Friday, 15 August 2014

A gilded cage? Part 2

“A glided cage is still a cage” (Lady Hale, in the Cheshire West case)

Warning - this one's really long (there's a brief summary at the end though, so feel free to skip to that if you like).

This is Part 2 of a double-header focusing on documents made publicly available concerning the NHS England “Transforming Care and Commissioning Steering Group”. Part 1 (available here ) focused on the terms of reference and minutes of the first meeting of the Steering Group. This post (imaginatively titled Part 2 will focus on the original ACEVO plan also made public on the same NHS England webpage as the ‘Scoping solution’ document (available here ).

As Sir Stephen Bubb’s initial blog is remarkably faithful to the longer plan, many of my initial observations from reading his blog (available here ) still apply. This post will ask some additional questions arising from some of the details contained in the plan. 

I’m also aware that as I’m writing this a bunch of excellent folks on Twitter are digging out very similar questions to me, so apologies when I’m repeating what someone else has already expressed more pithily than me.

The sections of the four page document are as follows, providing a handy guide in themselves to the plan’s preoccupations:
·         Addressing the problem
·         Commissioning appropriate local placements
·         Capital Implications
·         Revenue Savings
·         Long term contracts
·         A National Framework locally delivered
·         Future Considerations for the NHS

Addressing the problem

To paraphrase, this states that:
·         The Winterbourne View programme has failed (“out of a total of 2,615 patients, only 256 have a transfer date”).
·         The voluntary sector are the people to sort it (with the “capability and aspiration”, “deep knowledge and experience of this client group”, and “extensive operational expertise and national reach”).

In terms of a plan, the final point is the crucial one, stating that:
“The numbers of clients (estimated at 1,702) are not impossibly high to deal with (between them, the charities represented at the ACEVO meeting alone support tens of thousands of people each year, including with supported housing) and the sector is in a position to directly develop local services that meet the needs of children and adults with a learning disability and behaviour that challenges.”

This final point makes me doubt where the group as convened does have the “deep knowledge and experience” required to make the task a success:

First, I’m not convinced they know their numbers. The 2,615 “patients” number they mention is from the latest commissioning returns, but this is likely to be an underestimate as some people in specialist inpatient services aren’t known to commissioners and the overall number of people in specialist inpatient services is going up, not down (see ).

Second and more worryingly, I don’t know where the suspiciously exact figure of 1,702 “clients” comes from. In a relatively recent post (see ) I tried to present what we know about the number of people with learning disabilities in various types of specialist inpatient services under the broad label used by NHS England. I also tried to tease out the implications in terms of how many people, with the right support available in the community, did not need to be in inpatient settings. Looking at these numbers again, I wonder if this plan is ignoring all those people with learning disabilities in various types of forensic inpatient settings (perhaps all those commissioned by NHS specialist commissioners rather than locality-based clinical commissioning groups?). To my mind (and others too) this group of people absolutely needs to be included rather than excluded from a national action plan.

Commissioning appropriate local placements

Again, to my mind this section also shows a misunderstanding of some fundamental issues. I know it makes for a long post, but most of this section is worth quoting directly:
·         Regardless of the reasons why patients have been classified as not appropriate for transfer to the community, it remains the case that people have ended up in long stay, large-scale hospital services because appropriate local services have not been effectively commissioned.
·         This has increased and perpetuated the use of long term hospital placements which are poor value for money and far removed from home. This is a key stumbling block for successful transfer.
·         It has therefore the view of the ACEVO group that the key to transferring current patients out of hospital placements is the development of cost effective and sustainable local housing and support solutions as soon as possible.
·         This will help to overcome other barriers to transfer that have been identified.
·         We understand that the numbers are debated and that they may be higher than the stated position, especially as patients in crisis continue to be admitted. This is largely the case because there is no other crisis support available
·         That is why we propose that as well as commissioning local placements for existing patients, there should be a two pronged approach to ensuring that there are no more inappropriate admissions. This will involve:
o   1. Strongly linking the national transfer programme to a national closure programme. This has the added advantage of reducing the risk of double-funding placements;
o   2. Creating a national crisis support service that local authorities can draw on instead of inappropriately sending patients into ATUs. The model that we are most interested in developing is small scale emergency support and care homes specifically for clients with a learning disability who are in crisis.

First, understanding the reasons why people have been judged to be not appropriate for moving out is, I believe, rather fundamental to achieving a successful closure. This is a particularly resistant part of the system that many Winterbourne View Joint Improvement Programme local initiatives have foundered on, and it needs to be understood and measures taken to do something about it.

Second, the inpatient services for people with learning disabilities being discussed here are absolutely not “long stay, large-scale hospital services”. This is a really worrying misunderstanding – we’re not talking about closing big, old institutions here that were designed to (ware)house people for life. These inpatient services are usually small, often quite new (indeed purpose built, which we’ll come to later), and have an ostensibly assessment and treatment rationale. Some ‘lessons’ (gah!) from other closure programmes are transferable but in many respects the terrain is quite different.

Third, I agree that the lack of provision of appropriate local services is a major reason for people ending up in inpatient services. I’m unconvinced that the magic bullet for overcoming all the ‘barriers to transfer’ (an aside: the dehumanising language of this document is quite astonishing) is only the “development of cost effective and sustainable local housing and support solutions as soon as possible”. It ignores completely the role of commissioners, the interests of inpatient service providers and the crisis of resources within public services and the devalued role of people with learning disabilities within our society, and it raises the very obvious question to me of if it’s so straightforward, why hasn’t it happened already? I also wonder how phrases like “cost effective and sustainable” will play out in terms of people’s actual lives?

The two prongs of the proposal mention firstly a ‘national closure programme’. No more attention is given to what this should be and how it could be made to happen. The Winterbourne View Joint Improvement Programme has been trying to do this for some time and not succeeded on its own terms, and the DH Minister Norman Lamb has stated he doesn’t have the levers of power to force it to happen. So this issue seems worth more attention than a throwaway line that suggests the closure programme is someone else’s job.

The second prong is to create a “national crisis support service that local authorities can draw on instead of inappropriately sending patients into ATUs. The model that we are most interested in developing is small scale emergency support and care homes specifically for clients with a learning disability who are in crisis.” Erm, I hate to break it to you at ACEVO, but word for word this is a description of what Assessment and Treatment Units would say they are currently doing.

Capital Implications

In my reading, this section is largely concerned with how to raise £10 million for voluntary sector service providers to build housing for people with learning disabilities moving out of inpatient services. The rationale for such a capital investment programme in purpose-built housing is that challenging behaviour is “strongly influenced by their environment and how it is managed”. My understanding of “environment” in this context is that it is much more about interpersonal environments than a built housing environment, and it is very individual. This plan also ignores the mental health issues and traumatic life histories that some people will be carrying with them.

Based on this understanding I am unclear why purpose built housing is necessary (will housing designs be individualised to each person? What happens if they move house?), rather than finding existing suitable housing in a place where the person wants to live and will afford active engagement with people’s worlds beyond their house. And how big will these purpose built houses be? Will people be “allowed” to move house? And if there’s then an empty “bed”, will someone else be slotted in, old-school? These sound like group homes to me, ignoring the hard-won insights from supported living, person-centred planning and personalisation (of which there is no mention in this plan).

I’m struggling a bit to understand the money/social investment bit, and I’m more than happy to be set straight on this. Even with my limited/absent understanding, I’m not completely convinced of the maths on this:
·         So – Mencap raised a £10 million bond (in my understanding, a fancy name for a loan?) which they used to provide housing services for ‘over’ 137 people with learning disabilities.
·         On this basis, the plan concludes that it costs £10 million to develop housing solutions for 150 people (not 137 people?), it will therefore cost £150 million for capital investment to house 2,000 people [er, wouldn’t this be 2,250 people?].

The plan is to raise 90% of the money, so £135 million, from ‘social investors’ (apparently the Treasury’s Libor Fund will stump up 10%). My knowledge of social investment is restricted to some googling today, and my simplistic view is that in this context social investors have funds (like venture capitalists) which they would lend to fund the capital programme at an undetermined rate of interest? (if these services are provided by big voluntary sector organisations I’m assuming they wouldn’t want an equity stake in them?). As with any loan/mortgage, this would mean no big public investment up front, but at the literal cost of interest paid to the investor (of which a little more in a bit).

Revenue Savings

There are a lot of figures here, but I think it comes down to the assumptions in the plan that existing inpatient services cost £3,500 per week per person, and that the voluntary sector could deliver community-based, purpose built services for the same group of people 40% cheaper (not a great deal of evidence is provided for the second part of this assumption).

So on their assumptions there are 1,702 people (or is it 2,000 people, or 2,250?) to whom this would apply. Currently, they are costing £309.8 million per year (or £364 million? Or £409.5 million? – think the differences in assumptions are starting to stack up).

The plan states that services could be provided for £185.9 million (saving £123.9 million) (or £218.4 million, saving £145.6 million? Or £245.7 million, saving £163.8 million?).

And over the 10-year cycle recommended in this plan as necessary for the contracts (never mind the assumptions made here about whether the people in these services will want to stay in the same house for 10 years, or whether they might want to stay in their house while changing how and who supports them?), even without inflation we’re talking about savings of £1.24 billion (or £1.46 billion? Or £1.64 billion?)

These savings are crucial for the social investment model mentioned earlier. Remember that this plan relies on social investors to invest £135 million at beginning for building the purpose built houses. My understanding is that the return for investors will come out of this notional ‘saving’. If this is right, then a major problem I have with this model is that a big slug of public money that could be reinvested into better community supports at a time when they’re really needed, ends up in the pockets of social investors. If social investors expect a return of only 2% over 10 years, then they make £29.5 million profit on their £135 million investment; 3% gets you £46.4 million profit; 5% gets you £84.9 million profit and 10% gets you £215.2 million profit.

Perhaps the most crucial line in this section is the final one: “This is a cashable saving that would be prioritised for repaying investors’ capital, but in theory a portion could be returned to the NHS.” [my italics]. So perhaps the model for the social investor is to take all the savings?

Long term contracts

This section has just four points, which are repeated in full below:
·         A key principle for the success of this project would be commissioning for long term contracts of around 10 years.
·         This supports the development of partnerships, reduces risk to providers and maximises efficiency and effectiveness for commissioners.
·         A short-term approach will limit the potential for social investment and therefore reduce the financial savings that can be achieved.
·         The other major consideration is the stability of clients. The consistency and continuity of their care is paramount and would be put at risk if providers changed regularly.

Essentially, this insists on 10-year contracts jointly cooked up with commissioners and providers, with no flexibility or autonomy for the people with learning disabilities living with them. People may want stability, they may not, and there is no Plan B for what happens if the service is failing (unless the plan assumes that such failures cannot happen in the voluntary sector).

A National Framework, locally delivered and Future Considerations for the NHS

On my reading, the final two sections of the plan essentially park all the difficult issues that the operational elements of the plan have resolutely ignored, including issues of accountability, what to do about commissioners, local authorities and social care generally, and supporting people with learning disabilities so they stop going into these services in the first place. To me, this reveals the essential nature of the plan. When looking at all sorts of plans and policies, I’m increasingly asking myself the “Cui bono?” question. To whose benefit? I’ll stop there.

A quick summary (if I put this at the beginning no-one would read it!)

·         It misunderstands the situation of people with learning disabilities in inpatient services
·         It ignores a large group of people with learning disabilities in inpatient services who really need to be included
·         It shoves the thorny issue of how to actually close existing inpatient services elsewhere
·         It aims to partly replace short term assessment and treatment units with, erm, short term assessment and treatment units
·         It misunderstands the nature of challenging behaviour and proposes expensive and unnecessary purpose built accommodation will is likely to replicate some of the shortcomings of group homes
·         The social investment model takes large amounts of scarce public money out of supporting people with learning disabilities, rather than investing that money into better support for people with learning disabilities
·         The plan ties commissioners and providers into collusive 10-year block contracts, recreating some of the worst aspects of the current system to the detriment of people with learning disabilities

·         The plan parks, hives off or ignores most of the thorny issues that prevented the Winterbourne View Joint Improvement Programme being successful, while extracting a significant amount of public money over a long period of time towards large voluntary sector providers and social investment

PS: The unconscious is a strange and wonderful thing. Exodus by Bob Marley and the Wailers has just come on my headphones...


  1. Alarmingly the plan also seems to propose developing these long term contracts through some centralised body and then 'handing them over' to local authority commissioners. This runs completely counter to the acknowledged need to build up local skills and capacity.