Are Institutions Still With Us?

Author: Sam Sly

A version of this article was previously published in Learning Disability Today.

This month, I pause to reflect on the work of Jim Mansell (CBE), sadly no longer with us whose work inspired us at Beyond Limits and the Health Commissioners at NHS Plymouth to take accountability for stopping the commissioning of placements for people with Learning Disabilities out of area and to work together as commissioners and providers to improve services locally.

I was fortunate to meet Mansell in 2009 in Plymouth when he was rolling out his revised report Services for people with learning disabilities and challenging behaviour or mental health needs and he told me that it would be the last report he would write on the subject as he was tired of repeating himself and not seeing anything change. He believed there was only one real solution and that was to stop commissioning places that took people away from their families and communities and instead invest money locally.

Commissioning is without doubt the driver for good quality support, especially for people with more complex needs. The recent learning disability scandals in Cornwall and Bristol would have been prevented by good planning, insightful joint commissioning and robust quality monitoring especially if Commissioners had involved families and people using the places.

Mansell (2007) believed the answers to good quality commissioning for people who challenge services lies in:

• Individualised, local solutions providing good quality of life not those too large to provide individualised support, too far from their homes, and providing good quality of life in the home and as part of the local community.
• Direct payments and individual budgets always to be considered and to be more widely available.
• Closer co-ordination between the commissioners paying for services, the managers providing services and the professional specialist advising on the support people need to ensure advice is both practicable and acted on.
• Commissioners should allocate a budget to be used to fund a much wider variety of interventions as an alternative to placement in a special unit.

To give further weight to changing Commissioning being the only solution findings from a DH funded NDTi project ‘Incentives for Achieving Change in Private Sector Learning Disability Hospitals’ (2011) stated that despite the offer of free development support to achieve change few Private Hospital providers wished to embark on a reduction of Hospital beds and alternative service models. 

Change was made even more difficult by Private Hospitals having a large number of Commissioners from across the Country purchasing beds meaning they found it difficult to work together to change practice and with no national steer or direction the problem was compounded. The major obstacle the NDTi found was Provider’s primary obligation to achieve financial returns to their shareholders and demonstrate financial viability to their debt funders (banks etc.) who in times of economical difficulties need demonstration of short term profitability rather than taking a longer-term financial view. So in summary we cannot look to Private Hospitals to change.

This month, the end of the first year of our project with NHS Plymouth, sees us in a series of workshops run by Dr Simon Duffy starting to think, with our partners in Health and Social Care, about Commissioning for continuity of support to enable the people we are working with to have a life that makes sense to them in the long-term; without having to jump through unnecessary hoops when they, inevitably, move across from Continuing Health Care to Social Care funding as their health needs diminish. 

This may not be an easy transition when Health and Social Care currently work very differently, the project is set up to support people very flexibly and people’s Individual Health Budgets will have to transfer into Social Care Frameworks that have been set up for a market not so used to flexibility. We will have to consider how to work together to make sure people remain in the community long term in a system that sees funding currently yo-yoing back and forth from Social Services to Health if people’s behaviours that challenge deteriorate. One wonders about a system where there is no incentive (other than moral of course) for Social Services to maintain high cost support packages when if they fail the outcome is a transfer back to full Health funding in a Hospital placement.

On a different subject I’d like to leave you with a few questions that are mystifying me recently. 

We are told the ‘Long Stay Hospitals’ are all closed now and therefore people no longer have to live in Institutions for long periods of their lives: 

• So why then in 2012 have I met people with Learning Disabilities who are still spending from 3-14 years of their lives in Specialist Learning Disability Hospitals? 
• Is ‘Recovery’ ‘Treatment’ and ‘Therapy’ not supposed to be a short-term intervention? And at what point does short-term become Long Stay? 
• Have we really moved very far from the days of Long Stay Hospitals for some people?

The publisher is the Centre for Welfare Reform.

Are Institutions Still With Us? © Sam Sly 2012.

All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.