The DH’s Interim Winterbourne View Report
For the first few minutes of reading the DH’s interim Winterbourne View report, I was almost excited. I was reading clear, robust statements about the inappropriateness of many assessment and treatment services, commitments to develop local services that prevent the need for admission and so on. Then I read on, and felt myself despairing.
If you haven’t read the DH report you might want to make a quick detour to: http://www.dh.gov.uk/health/2012/06/interimwinterbourne/ and read the Executive Summary so the rest of this blog makes sense. What I want to do is explain why after a year of deliberations by the DH, the resultant report will make little difference to what happens at a local level – and local change is, as the report says, the key issue.
My fundamental measurement is to ask whether the report’s contents will result in changed local behaviour and actions. Specifically, think about a local commissioner who has limited expertise/knowledge in commissioning individualised services for people who challenge, operates in a service system and culture that hasn’t supported innovative practice and, as a result, currently uses places like Winterbourne View. Will the report mean they will be doing anything different one year from now? What is there that will result in local areas developing new skills, competencies and approaches when they have chosen not to develop them in the past? This is where the DH report falls down – I cannot see things that will help these changes occur.
Let’s be evidence-based for a while. The general research evidence around achieving organisational change shows that four things are needed if change is to be successful:
- A belief that what is happening now isn’t good enough and so things must change;
- A belief in an alternative way of doing things – without which people will stick with what they do now;
- Resources, tools etc to help people make change, without which they will either (i) do nothing or (ii) make the change badly;
- Support to identify and take practical first steps, without which the change will seem too daunting.
The production of national guidance and exhortations to do better can only go so far in achieving these four things. Change management research shows that people left largely on their own, with only documents and papers to refer to and with occasional checks on how they are doing, will not make a success of implementation. These four characteristics of effective change are achieved when those leading the process have access to people who can advise, support and model news ways of working, as well as help interpret the expectations being placed upon them. This means that (in this case) the government needs to invest in practical, locally focused but nationally-led change support. Without that, the evidence shows that change will fail. The DH report fails to understand this basic tenet of change management. Instead it appears to come from a belief system that (i) Government and national agencies speak (ii) people understand and agree (iii) people know what to do and how to do it (iv) people therefore take successful local action. That is not the real world.
To place one person in one of these remote assessment and treatment units often costs in excess of £150,000 per year. For the cost of less than ten people in these institutions, the DH could have a resourced national programme that would use evidence on achieving change to:
- Enable local commissioners and their partners to learn from success elsewhere through sharing of best practice
- Support the translation of national best practice documents into local action plans
- Provide a ‘critical friend’ on proposals about how to develop local, skilled, community focused services to replace out of area units
- Provide a direct source of knowledge and intelligence to Government about progress in achieving its objectives
Why does the current report not propose anything like this?
Two other issues have been raised more than once in ‘behind the scenes’ discussions about the DH response – both of which need putting in their place.
Firstly, it has been suggested that the increased number of independent sector assessment and treatment beds has been caused by the campus closure programme. There is absolutely no evidence to support this claim. The better campus closure programmes actually used those resources to help strengthen their community based assessment and treatment services. The users of and the demand for remote A&T beds are coming from a different place.
Secondly, it has been suggested that, as a growth in A&T beds occurred during the Valuing People programme, this is evidence that a national support programme wouldn’t work. Now, I’m obviously going to be defensive about that programme as I led it for six years, but this completely misses the point. The fundamental problem with Valuing People was that it had no ‘teeth’. As National Director, the only people I could require to do anything were the excellent dozen or so people on the Valuing People Support Team. We had to rely totally on our powers of persuasion and the commitment of local people to effect change. Local areas could choose to ignore anything that came out through Valuing People – and some did. As a result, progress happened in places where local people wanted it to happen. Where they didn’t - little changed, and excessive use of bed based assessment and treatment units is one result of that. Delivery support programmes need to be given authority.
An anecdote illustrates this. When one SHA was making poor progress on long stay hospital closure, as National Director I persuaded the then Minister (Stephen Ladyman) to send me to meet the SHA Chief Executive to press for greater action. At the ensuing meeting it became clear that (at best) the hospital would be closed purely to meet the tick box requirement with little attention paid to getting the process right for the people who lived there. When I expressed concern about this, the Chief Executive justified his lack of action by saying “Rob, you know and I know that I won’t lose my job if I don’t deliver on the learning disability agenda”. I knew he was right. He wouldn’t and he didn’t.
Perhaps we won’t make progress on this current issue until senior people believe that they are at risk of losing their jobs if these things continue. That means that a delivery support programme, which evidence shows is needed, must be given authority to require local services to take action in ways that the Valuing People programme never could. If this happens, then two to three years from now many people presently living in these units will be achieving better outcomes in their lives through access to local, skilled support - and there will be a saving to the public purse. If there is no delivery support, or it has no ‘teeth’, then we almost certainly will be facing more Winterbourne View exposés – and costs will continue to spiral.
I know that Paul Burstow, the Minister, doesn’t want this negative outcome and neither do his civil servants – so why not invest in what we know can help change things?