Tuesday, 30 September 2014

The best defence is a good offence

I know, I know (thank you for ongoing twitter tutorials @FindlayEquality and @rich_w), I do my best to take to heart the Antonio Gramsci mantra of “Pessimism of the intellect, optimism of the will”. But as the Sir Stephen Bubb group’s task nears completion, there’s a worry that’s increasingly on my mind as I see the public manifestations of the group’s thinking and Jeremy Hunt’s response to the excellent question on ATUs posed to him by @BendyGirl and @People1stEng.

My personal nightmare scenario runs something like this:

1) The original Sir Stephen Bubb plan only proposes to work with around 1,700 people currently in inpatient services. As I’ve set out (and as the Jeremy Hunt response also implies), I think this means that the plan is only going to work with those people who are not in forensic inpatient services (around 1,600 people in total, although the majority of these people are in low secure services and very few – 73 in the 2013 LD Census – are in high secure services).

2) So, the plan goes forward working to get the non-forensic group of people out of existing inpatient services. A network of purpose-built residential services springs up for this group of people across the country (maybe some existing inpatient services will change their remit to fit?).

3) In the absence of enough decent local support for people with learning disabilities and their families, new cohorts of people will continue to become highly distressed, and/or show ‘behaviours that challenge’ (who knows, maybe even some of the people in the new purpose-built residential services?)

4) So, if you’re responsible for local services, what do you do if your previous option of Friday afternoon crisis commissioning is unavailable to you? Could there be a trend over time of seeing these behaviours as potential offending behaviour rather than challenging behaviour (particularly if it includes aggression or destruction of property) and calling the police in?

5) This would set the person into contact with the criminal justice system – if convicted, increasing and improving liaison and diversion schemes (which partly exist for the excellent purpose of trying to reduce the number of people with learning disabilities in hostile prison environments) would mean that the person would not go to prison.

6) So where would the person go instead? Maybe an ever increasing number of specialist forensic inpatient services (another way that existing ATUs can repurpose themselves?)?

7) In 2025, will we have a national network of expensive, new residential services with people compelled to stay in them under long-term contracts, that will be seen as anachronistic (and sucking money out of supporting people into the pockets of private investors)? Will we also have an expanded national network of ‘specialist’ inpatient forensic services for offenders with learning disabilities (say, for around 3,000 people?)?

Solves a problem for local commissioners (problematic people out of sight, out of mind, and paid for by someone else). Keeps inpatient services in business. Keeps the prison population down. Creating a whole new class of people with learning disabilities without strong legal rights, branded as ‘dangerous’, in a whole new(ish) class of institution – never mind.

I know this is beyond cynical and I’m quite ashamed of my brain for going in this direction. I really want to be persuaded that this won’t happen.

Wednesday, 17 September 2014

Transforming Care Steering Group update

The latest batch of papers from the Transforming Care and Commissioning Steering Group, chaired by Sir Stephen Bubb, have been made available by NHS England at the bottom of this webpage http://www.england.nhs.uk/2014/08/01/community-support/

There are the agenda and notes from a meeting held on 18th August, a paper containing a draft of a ‘National Framework for Local Commissioning’ and a paper from Skills for Care on workforce development.

You will be relieved to know I won’t be going through these in depth – instead in a relatively short post I just want to make a few observations arising from my reading of these papers.

1) The social finance reference group. This group is supposed to be coming up with options for the social financing of the transforming care strategy. The person leading this group is the CEO of Social Investment Business. According to Debrett’s ( http://www.debretts.com/people-of-today/profile/24799/Stephen-John-Limrick-BUBB ), Sir Stephen Bubb has since 2008 been the Chairman of Social Investment Business. Furthermore, the meeting notes state that Social Investment Business and Big Society Capital are jointly funding a consultant to work on this. What is their expectation for a return on this investment?

2) The meeting notes also mention that NHS England have developed a draft stakeholder partnership proposal (this is not one of the papers published on the website). However, this proposal appears to have been knocked back by Sir Stephen Bubb (“SB noted that this is a proposal for extensive engagement and we must be careful not raise expectations unrealistically. The group has a discrete, time-limited task and finish activity to complete and we are not able to engage in full consultation.”). It would be good to see the proposal, but it sounds highly promising to me – why was it dismissed? This is particularly worrying, as the Steering Group are not managing to complete the very limited engagement goals they have set themselves (“SJ said that in either case he is finding it difficult to make contact with people we need input from on the Steering Group’s stakeholder engagement reference group.”).

3) The draft ‘National Framework for Local Commissioning’. The ostensible purpose of this paper is “To set out for discussion the key areas where clarity, work and contributions will be needed to develop a robust commissioning framework for community-based support for people with learning disabilities or autism”. The paper does indeed set out a number of fundamental questions to be addressed and the information that would be needed to inform answers to these questions. Why then, with so much uncertainty, does the paper only state one ‘preferred option’ when it comes to commissioning? “We need to agree criteria and work these through, but an attractive option (given the need to drive-up and assure quality, stimulate market development, secure good value for money, and enable genuine locally-led co-commissioning) could be a centrally procured, quality-driven nationally-procured framework from which local commissioners and users can call-off” (underlining in original). In terms of contract duration, the paper states “Needs to be long enough to enable investment to be re-couped and risk shared fairly and avoid frequent disruptive changes in providers – 7 years+?”. Why is this the only option on the table, why is it proposed before the fundamental questions in the rest of the paper are addressed, and what work is being done on alternatives?

4) The workforce development paper from Skills for Care. I would recommend you read this, as it takes a quite different approach to the Steering Group so far. Indeed, this paper states:

“Whilst we fully understand ACEVO’s remit, Skills for Care would argue that the contribution of all parts of the social care sector and specifically individual direct employers and small user led / family led groups and innovative PBS networks must be harnessed to achieve the outcomes needed.

We are aware that there is a belief in some parts of the social care and health infrastructure that the skills required to work with people in crisis or who may need very particular care and support can only be developed within health settings. This must be completely rebutted, We maintain that the skills can be developed anywhere so long as they are based around the individual people’s needs, hopes, situation and interests, and that the workers in question have been recruited for the values they hold.”

For fans of Freud, there is a revealing slip in the meeting notes. The action recorded in response to the workforce development paper is “All to send comments on commissioning framework proposal to HW and BR” – copied and pasted from the actions concerning the ‘National Framework for Local Commissioning’ and, of course, not referring to the workforce development paper at all. What, if anything is going to happen to this workforce development paper?

 In summary, it seems to me that the Steering Group is designed to enact the original plan put forward by Sir Stephen Bubb as soon as possible, with any good work that might challenge this being brushed aside. I hope I’m wrong.