Transforming care following Winterbourne: learning disabilities Anne-Maria Olphert

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‘closed and punitive’ culture had developed—families and other visitors were not allowed access to the top-floor wards and patient bedrooms, offering little chance for outsiders to see daily routines at the hospital. (DH, 2012)

Commissioners’ role Following the Serious Case Review (Flynn, 2012) one of the expectations of commissioners was to ensure all patients with learning disabilities placed in acute hospital settings were reviewed, and there would be an end to any inappropriate placements by 2014; every person with challenging behaviour would get the right care in the right place. This target has been widely missed and nationally 2615 patients were still in inpatient settings on 1 April 2014 (Samuel, 2014). The analysis of these patients shows that as at 31 March 2014: ■■ Only 35% of patients that were in hospital on 1 April 2013 had been transferred ■■ In total 256 patients had a transfer date (182 of these were before 1 June 2014) ■■ Owing to a clinical decision preventing it, 1702 patients did not have a planned transfer date. Many of these people had very complex needs. Some may have been too ill or possibly a danger to themselves or the public. A total of 534 patients were in high or medium secure services and most were subject to a Ministry of Justice order ■■ Of the people admitted in the 12  months after 1 March 2013, 88% did not have a transfer date ■■ A total of 81% of people who had not had a formal review in the previous 6 months had been in hospital for over a year (British Institute of Learning Disabilities, 2014). The commitment from NHS England is to ensure that more than half of this number of patients are transferred to more appropriate settings by March 2015. In order to achieve this, a Transforming Care and Commissioning Steering Group has been established, and Jane Cummings, NHS England’s Chief Nursing Officer, is the senior responsible officer for learning disabilities. The steering group has set out six priorities to look at:

■■ Making

sure patients are on the patient register ■■ All patients should be recorded as having a care coordinator ■■ Estimated transfer dates and care plan reviews, ■■ Patients who have not been reviewed for 26+weeks ■■ Patients without estimated transfer dates ■■ Patients (non-secure) held in hospital settings for 2+years. (NHS England, 2014a) Regional teams, area teams, specialised commissioning and Clinical Commissioning Groups (CCGs) are responsible for the delivery of these priorities. As well as this Transforming Care and Commissioning Steering Group, Sir Stephen Bubb (Chief Executive of the Association of Chief Executives of Voluntary Organisations) was asked to provide recommendations on the shape of a national commissioning framework for local implementation. This, together with other actions, such as pooled budgets, the right to request a personal budget, active decommissioning of inappropriate institutional care and closures of such institutions, would support the discharge of patients from inpatient settings and increase the capability of community providers (recognised as a necessary part of improving care) (NHS England, 2014b). His recommendations formed part of the report, Winterbourne View—Time to Change (Transforming Care and Commissioning Steering Group, 2014). The main point from the report is that community-based alternatives to inpatient care should be boosted through the creation of a mandatory commissioning framework requiring local authorities and NHS CCGs to pool health, social care and housing budgets. A social investment fund, backed by £30  million of government or NHS England funding, should also be set up to leverage up to £200 million capital investment in community services. The report also calls Anne-Maria Olphert Chief Nurse and Director of Qualtiy, Erewash Clinical Commissioning Group, Derbyshire

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n 31 May 2011, an undercover investigation by the BBC’s Panorama programme revealed criminal abuse by staff of patients at Winterbourne View Hospital near Bristol, a secure setting for patients with learning disabilities and autism. After its broadcast Winterbourne View closed, with the remaining residents placed in other settings. South Gloucestershire Safeguarding Adults Board began a Serious Case Review (Flynn, 2012). In addition, the police launched their own investigations, with 11 criminal convictions (Department of Health (DH), 2012). The Care Quality Commission (CQC) inspected all hospitals and homes operated by Winterbourne View’s owners (Castlebeck) and conducted a wider ‘health check’, inspecting 150 learningdisability services across England (CQC, 2014a). The Government set up its own review, led by the DH, to investigate the failings surrounding Winterbourne View, understand what lessons we should be learning to prevent similar abuse to explore and recommend wider action to improve quality of care for vulnerable groups (DH, 2012). Drawing on the Serious Case Review (Flynn, 2012), as well as reports from the police, the CQC and the local NHS, the DH review drew the following conclusions: ■■ Patients stayed at Winterbourne View for too long and were too far from home—the average length of stay was 19  months and almost half of patients were more than 40  miles away from where their family or primary carers lived ■■ There was an extremely high rate of physical intervention—well over 500 reported cases of restraint in a 15-month period ■■ Multiple agencies failed to pick up on key warning signs—nearly 150 separate incidents including A&E visits by patients, police attendance at hospitals, and safeguarding concerns reported to the local council— which could and should have raised the alarm ■■ There was a clear management failure at the hospital with no registered manager in place, a substandard recruitment processes and limited staff training

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commenced across all CCGs (NHS England, 2014b). What has been recognised sinceWinterbourne is that across the full range of health and social care services delivered or commissioned by the NHS or local authorities in England, people who present with behaviour that challenges are at a higher risk of being subjected to restrictive interventions. Many restrictive interventions place people who use services and, to a lesser degree, staff and those who provide support, at risk of physical and/or emotional harm. Because of this in April 2014 the DH produced guidance: Positive and Proactive Care: reducing the need for restrictive interventions (DH, 2014).

Learning Disability Census The Learning Disability Census is an annual audit of data on provision, placements and lengths of stay in learning disability services and is a mandated collection under the Health and Social Care Act 2012. The aim of the census is to gain a snapshot of learning disability services. It first took place in 2013 and was repeated a year later in September 2014 so that any changes and progress could be assessed. After this, it will become part of the Mental Health and Learning Disability Data Set (CQCb, 2014). NHS and independent hospitals that provide mental health and learning disability services will need to submit data. The Learning disabilities in England census

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British Institute of Learning Disabilities (2014) Responses to the abuse of people with learning disabilities and autism at Winterbourne View. http://tinyurl.com/ob9lnmo (accessed 11 December 2014) Care Quality Commission (2014a) Our action since Winterbourne View. http://tinyurl.com/l6tlt5n (accessed 11 December 2014) Care Quality Commission (2014b) Learning Disability Census. http://tinyurl.com/pydchq8 (accessed 11 December 2014) Department of Health (2012) Winterbourne View Summary of the Government Response. http://tinyurl. com/mfgrgeo (accessed 11 December 2014) Department of Health (2014) Positive and Proactive Care: reducing the need for restrictive interventions. Guidance for all those working in health and social care settings: commissioners of services, executive directors, frontline staff and all those who care for and support people. Summary of key actions. http://tinyurl. com/knd3pku (accessed 11 December 2014) Flynn M (2012) South Gloucestershire Safeguarding Adults Board. A Serious Case Review. Winterbourne View Hospital. http://tinyurl.com/9zrylfm (accessed 11 December 2014) NHS England (2014a) Delivering the ‘Transforming Care’ Concordat. Update on progress and recommendations for further partnership working. http://tinyurl.com/ k99p5hh (accessed 11 December 2014) NHS England (2014b) NHS England: Transforming Care for people with a Learning Disability.. http://tinyurl. com/k48q3fq (accessed 11 December 2014) McNicholl A (2014) Latest plan to end inappropriate learning disability care revealed, following failure to meet Winterbourne target. Community Care. 26 November. http://tinyurl.com/mcyjg8o (accessed 11 December 2014) Samuel M (2014) Minister to consult on changing law to transform learning disability care post-Winterbourne. Community Care. 26 November. http://tinyurl.com/ qblvas7 (accessed 11 December 2014) Transforming Care and Commissioning Steering Group (2014) Winterbourne View—Time to Change. Transforming the commissioning of services for people with learning disabilities and/or autism. http://tinyurl. com/qjrlplr (accessed 11 December 2014)

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Julie I Swann

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Promoting independence and activity in older people

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on the government to create a ‘charter of rights’ for people with learning disabilities and their families to underpin all commissioning decisions, including rights to personal health budgets and to challenge admissions in inpatient care. (McNicholl, 2014). The Transforming Care agenda is now subject to an intense level of scrutiny and assurance. CCGs are required to submit weekly assurance to their area teams, through regular teleconferences, weekly data return, and attendance at regular Area and Regional programme boards. In addition, each individual CCG will be required to provide a narrative on progress on Transforming Care including the delivery of the Discharge and Independent Care and Treatment Review (CTR) targets as well as an understanding of the position on each patient without a discharge date. A CTR will be required for all inpatients from the original cohort, where there is no planned discharge date before 31 December 2014. These reviews will be undertaken by team of four people including a clinical expert, independent expert (advocate or expert by experience), social worker and a CCG commissioner.The reviews will include the patient and, where the patient is lacking capacity, his or her appropriate representative. They will take a full day and are offered to provide constructive challenge to clinical teams regarding the appropriateness of the current placement. The CTRs have

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