Transforming Care: A National Response to Winterbourne View Hospital.

Department of Health, 2012

The report sets out the government’s final response to the events at Winterbourne View hospital. It sets out a programme of action to transform services for people with learning disabilities or autism and mental health conditions or behaviours described as challenging.

Our link provides access to the final report along with a number of supporting documents including, a summary of the Government’s response to the report, a programme of action, good practice examples, and responses to a series of stakeholder events and workshops held during the review.

See below for a CareKnowledge summary of, and comment on, the report.

CareKnowledge Summary and Comment

Government has published it’s much anticipated response to events at Winterbourne View Hospital. The notes below provide more detail on the range of information published by Government, summarise the key elements of the planned programme of action, draw together some initial comments, and include links to a number of other relevant publications.

In addition to the core documents outlined in our CareKnowledge introduction, the DH pages to which our ‘View Document’ button will take you provide access to:

• A video of the Ministerial Statement on the Government Response
• The (earlier) interim report on Winterbourne View
• The Government’s progress report on social care funding reform
• The minister’s Parliamentary Statement on Winterbourne View
• The Government’s Response to the select committee report on public health

The core elements of the agreed programme, are set out in DH’s introductory page:

All current hospital placements are to be reviewed by spring 2013, and anyone found to be inappropriately placed will move to community-based support, as quickly as possible.

• Whilst I accept that this objective is set out in short-hand terms, and whilst I have no argument with the concerns about – or the intention to reduce – the use of hospital-based accommodation, I still think the language could have more clearly addressed issues of individual and family choice in all of this. A number of commentators have already referred to the programme as ‘removing’ people from these establishments.
• The concordat (the agreed action plan) does refer to reviews of individual care packages involving service users and their families – it’s just a pity that’s not made clear, right at the outset, in the highest level introductory material.
• I have a concern that if we appear to abandon the principle of individual choice, even where the chance of better outcomes may seem obvious to the professionals and most of the individuals and families involved, we risk sacrificing it in other circumstances, where we would wish it retained. And remember, many of the people concerned will have been in these units for some time (that’s part of the identified problem) and not all of them (or their families) will be unhappy with the current arrangements.
• That is not to say that the broad plan should not be as it is, just that some clearer signal should be given, throughout all of the publicity for the plan, that individual moves will be a matter of consultation and discussion; and that overall targets for moving people on may need to be flexibly applied in individual circumstances.

Below this in the presentation, the DH says that:

By April 2014, each area will have a joint plan to ensure high quality care and support services for all people with learning disabilities or autism and mental health conditions or behaviour described as challenging, in line with best practice and, as a consequence, there will be a dramatic reduction in hospital placements for this group of people.

Again, I find the time target on this, somewhat worrying. I know that the individuals who will move out of current hospitals placements, by next year, are only part of the overall group who need effective support in the community, but committing to their general move from hospital, ahead of joint service plans, must mean, in the first instance some cobbling together of resources; which, in turn will have an effect on longer-term strategic plans.

The department intends to set out proposals – again by April 2013 – to strengthen accountability of boards of directors and senior managers for the safety and quality of care which their organisations provide.

It will be interesting see how far these proposals go – which seem to me amongst the most important in the programme of action. That’s both because of their innate value in terms of improving accountability – especially where the ultimate ownership of care organisations may lie in commercial ventures at some distance from core social care concerns. But also because the exercise will raise interesting questions about how far such accountability measures will be taken.

The Care Quality Commission will strengthen inspections and regulation of hospitals and care homes for this group of people, including unannounced inspections involving people who use services and their families.

This approach seems, initially at least, at odds with the drift of the Department of Business’s recent consultation on regulatory systems in social care, which had, as part of its objectives, reductions in the costs of bureaucracy, including the impact of inspections.

A new NHS and local government-led joint improvement team will be created to lead and support this transformation.

It is quite clear that a powerful mechanism will be needed to drive the necessary programme of change. But it’s also part of this Government’s approach (as in this case) to delegate a large measure of leadership and general responsibility to other national organisations.

That approach raises some key questions. For example, what powers will the new team have… and crucially, will there be any access to additional resources? Whilst moving individuals out of hospitals will produce some cost savings, unless those hospital close, it seems likely that all (or most) of the individual cost-savings involved will be needed for replacement community-based arrangements – leaving little for the development of a new infrastructure of the sort that is implied by the term ‘transformation’.

In addition to the headlines above, the Government response includes:

• An expectation that joint planning will be supported by the use of pooled budgets
• The development of NICE quality standards on challenging behaviour and learning disability by 2015 and on mental health and learning disability by 2016
• The introduction, by 2014, of a new single assessment process and Education, Health and Care Plan to replace the current system of statements and learning difficulty assessments for children and young people with special educational needs
• The development of new statutory guidance on children in long term residential care (in 2013)
• The development, by January 2013 of national minimum training standards and a code of conduct for healthcare support workers and adult social care workers
• A review of statutory and good practice guidance in time for the implementation of the Care and Support Bill
• Work to improve the use of advocacy

I think there are a couple of more general problems with the response – and the publicity it has been given. It reads as if the major focus is on hospitals of the Winterbourne View type – that certainly applies to the plans for movement of individuals.

But the CQC assessment went much wider and focussed on hospital and residential care, finding examples of poor practice in both sectors. Whilst the ministerial introduction to the Government’s response indicates that people spend too long in residential care (as well as in hospitals) the headline action plan does not seem to address that concern.

This will be an important issue going forward. Abuse can happen in any care situation, even in community-based alternatives. We need a management and regulatory approach that is adapted to the different risks posed by care arrangements across the piece. For example, whilst large institutions bring recognised problems with group living and staff ethos, smaller-scale arrangements can be hidden from sight, or isolated, demanding a similar level, but different management, community and regulatory approach.

Finally, I think the response to Winterbourne View shows a robust intention to take positive action. And, the programme planned is wide ranging. It begins to impinge on the much broader policy issue of overall care arrangements for people with a learning disability. That being the case, the absence of an overall policy lead – as was the case with Valuing People – and the response’s failure to revise the approach across the whole system may prove costly in the longer term.

Additional Resources

CareKnowledge readers may want to access two new Think Local Act Personal resources designed to support better practice, post-Winterbourne View. The first deals with market development of services for people with very complex needs. The second looks at some practice examples of the way community-based services – to replace the Winterbourne Views of this world – can be developed.