Tuesday, 15 July 2014

Deja vu all over again

Deja vu all over again

Words fail me (short blogpost, huh?). Just a week after Bill Mumford resigned as lead for the Winterbourne View Joint Improvement Programme, the following blogpost began circulating (http://bloggerbubb.blogspot.co.at/2014/07/the-winterbourne-view-concordat-and.html ). It’s by Sir Stephen Bubb, Chief Executive of ACEVO (the Association of Chief Executives of Voluntary Organisations). It’s worth reading in full, but my take on a summary of the main points within it are as follows:

1) Simon Stevens, CEO of NHS England, asked Sir Bubb to come up with a plan to sort out the Winterbourne View debacle.

2) Sir Bubb invited an unknown number of voluntary sector organisations providing residential services to people with learning disabilities to breakfast.

3) On the basis of this breakfast, Mark Winter, Sir Bubb’s ‘multi-talented’ Head of Health Commissioning, wrote a Plan (as yet unseen by the wider world), which Simon Stevens has accepted.

4) Sir Bubb has been asked to Chair the Steering Group to guide the development of the plan, sorry, Plan.

5) The essential features of the Plan as described in the blogpost are as follows:

which we characterised as a "national framework, locally delivered".

In essence this envisages the closure of most or all of the current inpatient facilities and the transfer of clients to appropriate community placements near their families . This will require investment in buildings,  converting houses or building new. However social finance can cover this on the back of sensible commissioning i.e. 10 year contracts.  With will,  it is entirely  doable. And if we all share the interests of the 3,250 clients we need to move into better community settings we will do it. Of course with any such task there will be a multitude of views and interests but I've been pleased so far that we all seem to be on the side of sorting it out : and that means being client focused.

Apparently some time after the blogpost was published, NHS England produced a press release about the plan, which you can find here, and again it’s worth reading in full http://www.england.nhs.uk/2014/07/14/learning-disability-support/

This press release states:

NHS England has asked Sir Stephen Bubb, the Chief Executive of charity leaders network ACEVO, to head a new group of experts and advisors to develop a national guide for how we provide health and care for those with learning disabilities.  The group will also include healthcare, charity and voluntary sectors, as well as with people with learning disabilities and their families. It aims to design more innovative and integrated local commissioning of healthcare and housing to best support people with learning disabilities at home and in their communities, reducing reliance on hospital care.

The key objectives of the group are to:
·         develop models for local implementation that meet the needs of people with learning disabilities and autism
·         develop funding models for new services
·         identify potential sources of social investment
·         identify the best way for funding to meet individual needs
·         seek input and guidance from partners working in this field.

The group will provide a final report by the end of October 2014 to inform commissioning.

And Sir Bubb is quoted in the press release as saying:

While I am delighted that Simon Stevens has asked me to help create a plan to support the Government meet that pledge, I am also determined to bring the experience and strength of the third sector to help transform care for people with learning disabilities

I have some questions…

Is there a plan that has already been accepted or not? If so, can be it made publically available, and if there is a draft plan can this be published now so the public can see what changes are made as a result of the group’s work?

Where are people with learning disabilities, families and allies, in any of this process? Certainly not at the heart of decision-making and power here, which is absolutely essential if we’re not all going to take another ride on the Waltzer of Crapitude. A cursory look at the #justiceforLB #107days campaign, or conversations with any number of superb self-advocacy and human rights organisations led by people with learning disabilities, makes the centrality of this so clear. While people with learning disabilities and family members are glancingly mentioned in the NHS England press release, the nearest we get in Sir Bubb’s blogpost is a nod to “being client focused” – the fact that I have to write that this isn’t the same as “Nothing About Us Without Us” shows the total inadequacy of the starting point.

What on earth is the relationship to the current work of the (currently leaderless) Winterbourne View programme and the good work that is already being done to help individuals get out of ATUs? Is this supposed to stop while the Group deliberates? Even if not, it’s clear that existing commissioners, local authorities and service providers aren’t going to take this work seriously, while they wait for “Bubb’s Challenge” (not my words) to complete its work.

Why the focus on providers, and voluntary sector providers at that?
  •  First, do voluntary sector providers (and large residential ones at that) have a monopoly on good practice in this area? If voluntary sector providers were so transformative, why haven’t services for people with learning disabilities been transformed already? What if the people round the breakfast table were CEOs of similarly sized private care organisations, for example?
  • Second, surely one glaringly obvious lesson from the iterations of the Winterbourne View programme so far is that focusing on providers doesn’t work. Commissioning is weak and providers run rings round them already, and many commissioners and current providers have been resistant to the radical changes needed. Where’s the national strategy for closure, and the national strategy for ensuring that such places will never be thought to be needed?
  • Third, another glaringly obvious lesson is that without a strategy for addressing why people go into ATUs in the first place (as the ‘need’ is often purely a function of the failure of local community supports) and stopping this happening, they will stay open for business.

Why the focus on buildings and long-term contracts? To my mind, this is exactly the wrong direction to be going in on all counts:

  •  As we have seen so many times, institutional spaces are not a function of the type of building. Certain characteristics of buildings and their locations can make abuse and neglect more likely, and helping people live a fulfilling, meaningful, healthy and connected life much harder, but institutions are a set of practices, not an arrangement of bricks.
  • This Plan strikes me as building yet another set of proto institutions – where people are encased in an all-encompassing service with precious little by way of rights and self-determination. The central insight of supported living is the separation of housing and support – people should be able to live where they choose, with legal rights as tenants or owners, and have the power to sack their support if its rubbish without having to move home.
  • Absolutely the last thing we need are more, in essence, block contracts that lock people into a service for 10 years. Commissioners need to be disentangling themselves from these types of contract to allow for the nimble commissioning of support that people actually want and need from a much wider range of organisations (the voluntary sector is vital here, but the interests of the voluntary sector as a whole are not necessarily the interests of the CEOs of the big organisations round the breakfast table).
  • And surely this flies in the face of NHS England’s commitment to large-scale implementation of personal health budgets?

Why do we need a Group to answer the questions outlined? Many excellent ideas for fundamental changes to the system, including a new settlement with people with learning disabilities, family members and allies, are out there (I won’t list all the ones I know of as this post is long enough). There is good evidence on how all people with learning disabilities can be supported in their own homes to live meaningful, fulfilling and self-determined lives. We have the examples of successive waves of institutional closure programmes for people with learning disabilities in the UK and internationally to draw on (surely more relevant than the mental health institutional closure programme mentioned by Sir Bubb). Why not apply these?

Finally for now (this blogpost is long enough), why is this only about health services? Are these Bubbplexes going to run in splendid isolation from their local communities? Where does education fit in, or local authorities? Locking people into 10-year stretches as ‘health’ clients patients residents (err, can I just say people?) is a recipe for institutional recreation all over again.

No big conclusions, just two quotes:

It’s like déjà vu all over again” (attributed to the baseball player Yogi Berra)

If you build it, they will come” ((almost) Kevin Costner, Fields of Dreams)


  1. Agree Chris - we need a single plan (to rule them all), developed with all stakeholders and a serious issue is stopping people entering these facilities (which is about local capacity) as well as getting people out.

  2. Mindset of Learning Disability = Health is deeply depressing.

  3. Thank you Chris - very helpful. It would be good if the joined up working described in Transforming Care could be modeled from the top


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