The government’s NHS reforms left it powerless to make sure local health and social care commissioners met a target to end inappropriate hospital placements for people with learning disabilities in the wake of the Winterbourne View abuse scandal, a review has found.
The government left it to NHS England and local health and social care commissioners to deliver the Winterbourne View concordat’s commitments to shift more care into the community. A review of the failed scheme published today by the National Audit Office found that the government’s approach was in line with its Health and Social Care Act 2012 but ultimately left ministers unable to compel those responsible to implement the necessary changes.
Failure to meet key target
The concordat was established in 2012 and was the flagship policy for an improvement programme backed by £5m of funding from NHS England and the Department of Health. The policy was expected to deliver on a vow to end all inappropriate learning disability placements by June 2014 – the government’s key response to the Winterbourne View scandal.
The concordat failed to meet this key target despite being backed by 51 organisations, including professional bodies and sector leaders from both health and social care. Official figures released last week revealed that more than 3,000 people with learning disabilities or autism were in inpatient units as of September last year. The concordat has since been superseded by a new ‘transformation plan’ led by NHS England.
The NAO’s review found that ministers had “underestimated the scale and complexity of the challenge” involved in discharging so many patients into the community. The government’s ability to meet its targets had been “further weakened” by the fact that individual local authorities and NHS commissioning groups were not signed up to the concordat, the review found. It also highlighted the fact that the Department for Communities and Local Government did not sign up to the commitments.
The report said: “[The Department of Health] devolved how the commitments would be met to NHS England, and local health and social care commissioners. The government did not, therefore, have the traditional levers to achieve the commitments. It had no national monitoring, mandatory guidance, pump-priming, pooled budgets, dedicated funding, or accountability arrangements from providers to the government.”
It added: “The government did not ask clinical commissioning groups, local authorities and mental health hospitals to sign up to the concordat. This further weakened the government’s ability to meet the commitments. These are the main bodies upon which discharging patients, and expanding and operating community placements, depends.”
Lack of local progress
The review also found that local NHS groups and local authorities had been slow in developing commissioning strategies to cut reliance on inpatient services. It pointed to the fact that the concordat had assumed that health and social care commissioners would work together to pool budgets but, despite this not happening in the majority of cases, the DH failed to challenge it.
Another key factor in the Winterbourne programme’s failure was the fact that that funding did not follow the patient. With around half of inpatients funded directly by NHS England there was no financial incentive for local areas to bring patients home, as doing so would mean local health and care commissioners could face “substantial extra costs” to meet their community care needs. The review also found that some community learning disability teams – key services in offering a community alternative to inpatient care – had been “run down” as the pressure on CCG and local authority budgets hit.
Concerns over new ‘ambition’
In August 2014, NHS England said it had identified 2,600 inpatients and set out a new ambition to transfer more than half of them out of hospital by March 2015. But the NAO raised concerns that local authorities, clinical commissioning groups and hospitals were unaware of the new target.
“It can take up to 18 months to plan a patients’ discharge. There are therefore limited prospects for significantly increasing the rate of sustainable discharges by 31 March 2015,” the report said.
Care minister Norman Lamb said the government was redoubling its efforts to ensure people were cared for in the right setting.
“Winterbourne View shocked us all and shone a light on the way people with learning disabilities are sometimes treated. We know that the scale and complexity of the issue is a challenge and, although there have been some improvements; we have not gone nearly far enough fast enough,” he said.
“I am looking at legislative options to give people with learning disabilities and their families a stronger voice and more rights and I’m looking at how we can increase specialised housing options, so that more people can live independently but with the support that they need.”
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Excellent analysis from the NAO. However, if we consider the government’s true motives in NHS reform, this outcome may be consistent with their aims. Is what they’re looking for is disentanglement and deniability of NHS actions and outcomes, effectively taking this out of debate as a political issue? When ministers can essentially look at a development and say ‘Gosh, this really is terrible, what are agencies doing? Perhaps they should try harder?’ with every indication of belief in their role of bystander or disinterested commentator, without any indication of ownership or acknowledgement of responsibility in terms of funding cuts, the aim of the reforms is achieved.
There is still not enough appetite for change at local level. Some CCGs would still rather pay vast amounts for a hospital bed rather than think creatively about community solutions.
Norman, sweetie, my little woolly-headed Lamb, people don’t need ‘specialised housing’. They need homes of their own, on ordinary streets, with adaptations as necessary and with absolutely rock-solid security of tenure. Then they can start to build a life.
It won’t happen until either (a) you put your hand in the Government’s pocket for the investment or ((b) you force the NHS and local authorities to shell out from theirs, for the upfront funding needed to make the change.
When an institution serves a purpose and is used, that purpose and use cannot simply be wished or willed away. Despite all the regulation and inspection, and professional standards and good practice guidance, and declarations of good intent by all the organisations surrounding it and placing people there, Winterbourne View served a purpose and was used. It was so useful that it was worth £3,500 of public funds a week to encarcarate people there. It was closed because of the scandal, but it soon became clear that there were many other Winterbourne Views serving the same purpose and being used.
The minister – and many well meaning organisations – believed (naively) that they could wish away this particularly gross symptom of the system they maintain. They apparently didn’t know that they had to work on the whole system and start by understanding what had created the need for Winterbourne View and other such places, and caused decent social care professionals to think there was no alternative to these cruel placements.
We should always be wary when government and organisations start signing righteous concordats, commitments and resolutions to do what they were meant to be doing in the first place. It may be temporarily comforting but it doesn’t change why they are not doing what they were meant to be doing in the first place.
Good comments here about whole system changes needed, proper community care being on offer (and of course that costs albeit taking place on ordinary streets and enabling people with disabilities to have access to ordinary community services and resources), lack of creative thinking (especially by medics – SWs more open to these ideas?), and lack of funding (altho much money will be saved of course). One issue is the way these services for people with learning disabilities who have been labelled as having challenging behaviour (much of which is engendered and fostered by the institutions themselves) have been privatised. It is not to the advantage of these profit making organisations for their ‘patients’ to be moved, so they are presumably doing little to enable this to happen and putting barriers in the way of change.