Transcript What do we need to do after Winterbourne View? Supporting

The future of services for people with
learning disabilities who have offended
post the Winterbourne View Report
Tony Holland
Cambridge Intellectual and Developmental Disabilities
Research Group and NIHR CLAHRC for Cambridgeshire and
Peterborough
Outline
• Winterbourne View
• What happened
• What is now happening
• What are the main lessons
• In-patient services
• Local services
• What is required of ‘hospital services’
• What is required of ‘community services’
Sequence of events
• Panorama investigation at WV May 2011
– WV hospital closes June 2011
– Interim report (D of H) June 2012
– Independent serious case review August
2012
– CQC inspected 150 LD hospitals and homes
– Criminal proceedings -11 prosecuted and
sentenced – August 2012
– Castlebeck Care under receivership March
2013
Winterbourne View hospital
• Independent hospital owned by Castlebeck Care Ltd –
opened 5 years ago
• For the purpose of assessment and treatment and
rehabilitation of people with LD
• 24 places 73% detained under the MHA
• On average cost £3500 per week
• 48 patients referred to WV by 14 different LAs – 13
within 20 miles, 12 between 20 to 40 miles, 14 between
40 to 120, and 9 > 120 miles
• Nearly 50% referred because of a crisis – average length
of stay 19 months, some for 3 years at time of closure
• Very high number of recorded interventions, numerous
safeguarding alerts
Key points from review
• Patients at WV not listened to
• No one organisation, such as South
Gloucestershire Council, had lead responsibility;
• Serious failure of management, high staff
turnover, lack of leadership;
• Opportunities missed by Managers of WV, Local
services, CQC, MHA commissioner, Police, A &
E;
• Whistleblower not listened to – and so on..
The message of Winterbourne View
A failure of local services
• Local services are failing some children and adults with
LD and complex needs;
• Local services need to be able to respond appropriately
when someone with a LD presents with challenging
behaviour;
• Out-of-area placements need to be avoided
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Away from families and familiar environments
Quality of care cannot easily be monitored
Re-settlement back in area problematic
Expensive and very difficult to control costs
• All services for people with LD need to have strategies in
place that minimise the risk of challenging behaviour
• All services need to have access to the necessary
expertise for this to happen
Other issues
• Pooled budgets
• Services for children
• Community is the norm for all of us – there
needs to be a clear reason for admission
• Need for continuing relationship with
hospital when admission is genuinely
needed in order to ensure questions are
addressed and discharge is planned;
• Review of care plans – family involvement
What is happening?
• Government mandate to the NHS Commissioning Board
to work with LAs to ensure every person with an LD
receives safe, appropriate and high quality care etc
• A program of action to transform services so that people
no longer live inappropriately in hospital but are cared for
in line with best practice..
Action
• Department of Health Implementation Group established 2013
• Every service will be asked to review those people with LD
presently in hospital placements to be completed June 2013 –
anyone inappropriately supported moved no later than June 2014;
• To work with CCG and LAs to ensure the necessary local services
are in place – by April 2014 each area locally agreed joint plan
• CQC strengthen inspections
• Concordat agreement to achieve fundamental change (RCPsych)
• Re-evaluate outcomes
What are the messages for ‘out-of-area’
IP services?
• Your work is under close scrutiny
• You need to be clear what is it that you
offer that is both required and generally
not provided at a local level
• If someone is placed in a hospital
placement away from their home there
must be a clear purpose and justification
• You must establish and maintain a close
working relationship with local services
What are the messages for local
services?
• What should local services be able to do?
• What should local services look like?
• How should local services function?
• Test your service by asking – how would
the service respond in this situation?
People with LD
• Complex, varied group – majority with life
long support and communication needs;
• Health inequalities - different pattern of
causes of death and illness;
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Mental health and challenging behaviour
Malnutrition, aspiration, choking, etc
Epilepsy
Syndrome-related
• The importance of the interface between
health and social support.
Some examples
• A man with autism and severe learning
disabilities aged 23 recently moved from
the family home now engages in
aggressive and self-injurious behaviour.
• A man with Prader-Willi Syndrome
severely damages property following a
temper outburst – the police are called –
staff at his home refuse to work with him..
Some examples
• A man with mild learning disabilities is said
to be a risk to others following an
allegation of a sexual assault on another
service user.
• A women with moderate learning
disabilities becomes aggressive towards
the public saying that people are being
rude about her – she has become tearful
and withdrawn.
Questions?
• With each of these examples:
• do you have the expertise to respond to these
potentially complex needs in your area?
• where does such expertise ‘sit’?
• how readily available is this expertise to those who
need it?
Key points
• Meeting complex needs can be complex!
• Needs the necessary skills and services
structures in place
• It needs partnerships between key stakeholders:
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People with LD and their families
Those providing social support (support living/residential)
General practice and other health services
Specialist community teams for children/adults with LD
• It requires:
• understanding of the individual and the context within which
they live
• the application of accepted and tested models of
understanding and intervention
What response is required?
• When someone presents with challenging
behaviour what is required:
– The ability to identify the developmental, biological,
psychological and social factors that might predispose
to, precipitate, and maintain such behaviours;
– To develop an understanding of that individual within
the context of established models of understanding
that are based on empirical research;
– To develop and apply interventions in partnership with
the different stakeholders and determine outcomes.
What do we need to do after
Winterbourne View
• To ensure we have the local services and expertise in
place to be able to respond to the needs of people with
LD who present with complex difficulties such as
challenging behaviour;
• To be committed to, and have the ability to support,
people with complex needs locally;
• To support the necessary positive partnerships between
different agencies that acknowledges the different
cultures and roles of different organisations within the
network of services (emphasis on partnerships!)
• This is not fundamentally about money, it is about vision
and commitment – a place at WV cost £3000+ per week!
– What should the services look like and what should it do?
Specialist adult LD services
The Cambridgeshire LDP (established in 2001)
• The commissioning of day and support services
• Residential care
• Supported living (personal budgets)
• Supported employment, social firms etc
• Managing the community teams for adults with
LD
• Care co-ordination
• Specialist health support (employed by CPFT*)
Two in-patient services (mental health) (Cambridge and
Peterborough) directly managed by CPFT
*CPFT Cambridge and Peterborough Foundation NHS Trust
Function of specialist LD services
• To provide care management and specialist health
support to meet specific needs of people with LD –
interface with various stakeholders and particularly
supporting primary care
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Access to generic services
Health screening
Safeguarding
Advice (employment, social support, specific health etc)
To enable access to social support (eligibility criteria)
• To support people with LD and their families and
those that provide support with respect to:
• Total communication environments
• Skills development
• Sexuality and other matters relating to adult life
Function of specialist LD services
• Specific focussed roles:
– Mental health and challenging behaviour
– Assistance with eating and drinking
(aspiration, choking, malnutrition etc)
– Assessment and treatment of severe epilepsy
(in collaboration with neurology services)
– Matters relating to offending and the CJS
SPECIALIST SERVICES FOR ADULTS WITH LD
STRUCTURES (CAMBRIDGESHIRE LDP)
Social support
providers
People with LD, families and
others who support them
City, East, Fenland,
Huntingdon, South
General Practice and
primary care services
Generic secondary
care services
Five integrated community
teams for adults with LD
Two intensive
Assessment and
Support Service
(IASS) (in-patient)
Cambridge
Peterborough
Intensive Assessment
and Support Service
(IASS) (community)
Regional secure services
Norwich
Map of Cambridgeshire Area
Estimated population
of Cambridgeshire in
2011 (aged 18-64):
619,400**
Team base
Emerson & Hatton
(2004)* showed that
roughly 20 people in
every thousand have
an ID. 4.6 of these are
likely to be known to
local health and social
services, but these
numbers vary with
age.
Fenland
Huntingdonshire
East
Cambridgeshire
Cambridge
City
South
Cambridgeshire
Estimated number of
people with an ID:
12,388*
And the number
known to local
services:
2,849*
**Projecting Adult Needs
and Service Information
(PANSI)
www.pansi.org.uk
Other issues
Where does the expertise for this sit?
• Interventions in childhood aimed at improving
long term outcomes
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Education
Children’s services (family support)
CAMHS
Children’s Disability Team
• Interventions in services aimed at minimising the
risk of challenging behaviour (prevention)
• Physical and mental health
• Structure and informed support
• Communication strategies including visual timetables etc etc
Design
• The need for an agreed vision as to what
the service is there to do;
• A recognition of the complexity and
relational aspects of care and that good
health and social support are closely
linked;
• A recognition of the practice and cultural
differences between health and the LA
and a partnership between agencies to
address these issues
Key messages for LD services post WV
• People with LD may engage in challenging behaviour, this will be for
varied reasons. May result in contact with the CJS;
• There must be local capacity to respond to such behaviour through
providing expertise to people with LD & local social support
providers;
• Local capacity must ensure the ability to respond in different settings
and circumstances and must include the skills of various disciplines
reflecting the varied and complex reasons that lead to such
behaviour and to its continuation over time.
• Local community teams who provide that response need access to
other resources in order to meet the range of short-term and longer
need. Possibly the following:
• Local, small, expert, IP facility
• Additional ‘intensive’ team
• Quality support providers
Questions?
• To what extent do these issues reflect your
experience in the service you work in?
• Is there a convincing case for specialist services
for adults with LD – if not, what are the
alternatives?
• If yes – do you agree with the proposed tasks for
the teams?
• What should a specialist service look like?
• Would your service be able to respond to the
range of clinical demands to be expected?