Caring Times: LD strategies post-Winterbourne

Last month, the Department of Health (DOH) published its final report into the abuse allegations in Winterbourne View.  The plan of action set out in the report is wide ranging and will escalate the pace of change in the way services are delivered to those with learning disabilities.  The trend of moving service users from residential and hospital settings to supported living is not new of course but the DOH sets out a timescale by which all service users will have to be reviewed.  It is anticipated that all service users should be in appropriate settings by no later than April 2014.  There will be a strong preference in favour of services near families and a strong presumption against residential and hospital services.

The intention behind moving service users to community settings is laudable.  The idea is that service users are closer to their families and communities, have their own homes and can easily change their support or care providers if dissatisfied.   However, it seems likely that supported living may be the next big scandal.  All things being equal, regulated services are likely to be safer than unregulated (or under-regulated) services.  It is a basic matter of incentives.  In much the same way as self-assessment for regulation was bound to fail because it provided a moral hazard (a perverse incentive) for providers to provide misleading information, unregulated services have a moral hazard to skimp on quality and safety.  Of course domiciliary care agencies which provide personal care are regulated by CQC, but the regulator has no right to access service users’ properties and historically inspections have been somewhat superficial.  Agencies which provide support that falls short of personal care are completely exempt from regulation.  It may not be too long before we discover that many service users in supported living are neglected.  Many more may be leading isolated lives with minimal interaction with other service users or the community that they have enjoyed in residential care.  In time, it can be expected that supported living will be regulated in a more robust way, but not before countless vulnerable people receive shoddy services.

The train of change will, meanwhile, continue to drive forward.   Several options are open to residential and hospital providers to meet the challenge.

  • Diversification – for example EMI (elderly mentally ill service users), ABI (acquired brain injury), LTC (long –term conditions services such as Huntington’s disease, Motor Neurone Disease and early onset dementia) and substance misuse and rehabilitation services.  Variations may be required to CQC’s registration if this option is selected.
  • De-registration – separating accommodation provision from care provision can mean that registration as a care home may no longer be required and the service can be marketed as supported living.  CQC has guidance on de-registration that should be looked at closely when exploring this option.  There are also technical issues around housing benefit that should be considered at an early stage.
  • Devising step-down programmes of fixed duration – commissioners may be interested in services that can prepare service users for supported living in the medium-term future.  Services could provide courses on areas that service users will encounter e.g. food preparation, self-care, basic home maintenance, interacting with community and engaging with services.

Each option has legal implications that should be resolved early in the planning stage.  The one option that promises to be disastrous is the ostrich approach.  Burying one’s head in the sand will mean less time to respond when commissioners begin to remove residents.  The learning disability service providers who are likely to not only survive but to positively flourish in the next few years are those which take the initiative early and offer the types of services that budget-holders want to buy in the new learning disability landscape.

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