‘Homes not Hospitals’ – Let’s Not Be Cynical
It would be very easy to just be cynical about the latest NHS England plan ‘Homes not Hospitals’, in response to the abuse over four years ago of people with learning disabilities at Winterbourne View.
After all, there have been so many false starts by the Department of Health, NHS England and Local Government Association that have taken us almost nowhere - why should this one be different? The trouble with cynicism is it never really takes anyone anywhere and it does seem to me that this latest plan is the most cogent response so far and therefore merits receiving some support. The proposals in it are far from perfect, but they do represent concerted work by some good people in NHS England to try and take us forward and leave the dog's dinner that was the Bubb Report behind us. The concept of fast-track, or demonstration areas to show what is possible and the provision of some national support to help them do that, matches what many of us were calling for four years ago. The closure of Calderstones NHS trust, a long-standing anachronism, is well overdue (provided its absorption into a different NHS Trust really does result in service change and closure).
One important step forward on this occasion is there appears to be recognition that closing assessment and treatment beds is not the objective. Siren voices have been stating that the closure of A&T was the main objective - but as I and others have argued that would be folly. A&T beds are being used at the moment because services have failed people with learning disabilities, usually over many years if not for much of their lives, and so have become an inappropriate and poor quality backstop when all else has failed people. The challenge, as always, is been to develop good quality community support, with skilled social care providers working in harmony with creative NHS professional staff and others to ensure people live good lives in their communities. This takes time to achieve.
The announcement of three-year targets for substantial reductions in A&T beds thus makes sense. Beds should close as a consequence of local community services supporting people in ways that make such beds unnecessary. Settings bed closure targets will result in local managers finding ways to hit the target, irrespective of quality – as we saw when the last Government introduced personal budget targets. We need to ensure these stated bed closure numbers become the measure by which success in developing community services is judged and not become the target in themselves.
A number of shortcomings from earlier initiatives remain in these proposals, most notably:
- It is almost entirely adult centric. We know services start failing people in childhood and early life, yet there appears to be no signup from either the Department for Education or the Association of Directors of Children's services. Unless we genuinely start addressing these issues in childhood, there will continue to be an inappropriate demand for poor quality assessment and treatment beds long into the future.
- It is positive that something akin to the old dowry system has been introduced for people who have been in A&T beds for more than 5 years. This transfer of money from the NHS to social care is utterly essential given the current parlous financial state of social care. However, without a similar arrangement for people who've been admitted less than five years, it is likely that those individuals will remain stuck in the assessment and treatment beds. Local pooled budget will not be the answer, unless specialised commissioning resources are delegated to a local level.
- It is very difficult to understand from the document how the learning from these five fast-track areas is going to be effectively shared across the rest of the country. Other areas cannot be allowed to just sit back and watch what the fast track places do, and think it is not their responsibility to be developing their community infrastructure and competence as well.
Underpinning this, of course remains the question of why the NHS is leading this. Learning disabilities became very clearly a local authority-led responsibility 15 years ago and the development of competent community services is a local authority lead responsibility - working in partnership with the NHS. Until we get a way of holding local authorities to account for achieving this, no widespread change will be achieved.
However, to use these reasons as justification for ignoring or rubbishing the new NHS England initiative would be shortsighted and do a disservice to the people who are currently inappropriately stuck in assessment and treatment beds. These proposals merit support, but unless the points outlined above are properly and rapidly addressed by government as a whole, then we will risk continuing to see another generation of people let down by the system.