National policy may be against hospital-based accommodation for people with learning disabilities but not in the private sector, where commercial concerns come first, says David Brindle
When public services are outsourced, how do you ensure they adapt to policy change? What can you do when you pull a policy lever at the centre, but nothing happens down the line?
These questions have been thrown into sharp focus by a new report, funded by the Department of Health, on the highly topical subject of private hospitals for people with learning disabilities. Specifically, the report looks at how to encourage change in services delivered by such facilities.
The report was researched before the scandal at Winterbourne View, the learning disability hospital near Bristol that has been closed by its operator, Castlebeck, following revelations of systematic abuse by staff of people placed there by NHS and council commissioners.
In response to a consequent call from 86 organisations to run down use of such hospitals, David Cameron has replied that he was "appalled at the horrific catalogue of abuses uncovered" and that "a joint plan of action is needed both locally and nationally to drive improvements in services and determine how the lessons from Winterbourne View can influence future policy and practice".
There has been growing concern that private units like Winterbourne View are bringing back the worst practices in the former NHS long-stay hospitals – all now closed. National policy is clearly against the use of large-scale, hospital-based accommodation for people with learning disabilities, yet there has been a steady expansion of such facilities in the private sector in recent years – a total 1,150 beds in England in 2008 and certainly significantly more now – and people are routinely being placed in them by some NHS primary care trusts (PCTs) and councils.
The report, by the National Development Team for Inclusion (NDTi), a not-for-profit organisation promoting good practice in care and support services, is based on an 18-month project aimed at encouraging private-sector providers to change their services in line with national policy. And it doesn't make happy reading.
First, and tellingly, although every known private provider was invited to bid to join the project, and thereby take advantage of free development support, fewer than half responded and only two convinced the researchers that they were serious about making changes.
As it turned out, one of the two was prepared only to develop an alternative service model alongside its existing hospital provision, so NDTi cut short its involvement. Having aimed to work with three providers, the organisation completed the project with just one.
Second, the researchers found that national policy was "largely irrelevant" in influencing change. What was overwhelmingly relevant was the need for providers to show a return on investment to satisfy their shareholders and, critically, the banks that funded operations. Services designed on a smaller scale, closer to people's homes and with a more preventive approach, were seen as untried and complex to cost – especially at a time of fiscal uncertainty.
Other than the two organisations selected for the project, the report says, providers "saw themselves as running a business and the correlation between that business's 'product' and national policy did not seem to very much concern them".
So what can be done? As the report points out, a key problem is the weakness of commissioning muscle: one of the two providers the NDTi worked with had 11 different commissioners for places in one unit; the other had 16.
No one PCT or council had sufficient critical mass to enable it to drive change – even if it wished to. And with PCTs and strategic health authorities being axed in favour of GP-led commissioning consortia, that muscle is going to become even weaker.
The only way to encourage private providers to change, the report concludes, will be for someone to come up with a fresh initiative that offers them an alternative role in the service system that is commercially attractive and enables them to add value to the company. Over, then, to Cameron's "joint plan of action".
David Brindle is the Guardian's public services editor. He is also a trustee of NDTi
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Read the complete post at http://www.guardian.co.uk/public-leaders-network/2011/aug/30/outsourced-services-policy-learning-disabilities
Aug 30 2011, 10:29 AM
Healthcare Network | guardian.co.uk
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