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Lost in the too difficult zone


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Thursday, 25 August 2011

Lost in the too difficult zone

It’s unlikely that embryonic clinical commissioning groups are thinking about the needs of people with learning disabilities.

It’s a safe bet that other priorities are way ahead on the agenda: getting CCG members to talk to each other, working out where they are going to get commissioning support and how they can pay for it, casting spells to turn GPs into leaders, that sort of thing.

But commissioning care for people with learning disabilities is one of about a million things that could catch clinical leaders with their corduroys down if they’re not careful.

Remember Winterbourne View? You may have seen it on Panorama becoming another one of those things that must never happen again.

Minimising the chances of a repeat of these depressing events is not just a regulatory issue but a commissioning one.  Some of the people in the “care” home should never have been there in the first place and would not have been if adequate local services had been available.

The investment in more suitable local provision would be modest and the savings more than enough to pay for it.

It cost £3500 a week to keep an individual at Winterbourne. On the basis of that figure alone it would be hard not to make a business case for better accommodation.

But will business cases like this be made? The numbers of people involved are relatively small and viewed from the perspective of a local GP or commissioner may not appear terribly significant. One of the drawbacks of scaling down commissioning units is the loss of the bigger picture. A couple of people on the practice list, a few tens at CCG level maybe. That’s where the business case starts to fall apart.

Examples like this will test the ability of CCGs to scale up on their own account, and work together on a risk sharing basis to provide services it may be uneconomic or otherwise impractical to commission individually.

Given where most of them are today, it is difficult to believe that these thoughts will appear on the radar any time soon.

Of course, until the NHS Commissioning Board is running at full steam, we don’t even know where decisions like this will sit. Commissioning for people with learning disabilities falls into the too difficult zone between the CCGs, the board and the local authority along with children’s services and others.

So it may not turn out to be a problem for CCGs. But until the gap between the commissioning board and local commissioners is closed, it will be nobody’s job to consider these issues until another one of the things that must never happen again happens again.

Before angry commissioners write in to rail against the hopeless oversimplification of articles like this, there is another cost to consider. It is not just the damage to the reputations of the NHS, local authorities, regulators and the individual managers who find themselves in the firing line when things go wrong. Nor is it the much more serious damage to the individuals who find themselves, through no fault of their own, in the wrong kind of care.

Low level commissioning issues that turn into high profile news stories have an unpleasant effect on politicians, turning mild mannered ministers into bloodthirsty vigilantes.

They also result in endless rounds of reviews and enquiries and reports and recommendations, the cost of which runs into millions of pounds – money that could have been invested in avoiding the problem in the first place.

rmiller says:
Aug 26, 2011 08:19 AM
This article reflects the concerns that many of us who have worked within learning disability services have regarding the lack of discussion regarding how the modest but important improvements in services for people with a learning disability will be maintained in the new commissioning landscape. What needs to be added though is that there does not only need to be an emphasis on developing local specialist services but also in ensuring that maintstream health provision is responsive and accessible to this disadvantaged group - without this we are not only in danger of another winterbourne but '6 more lives' ruined through inadequate and discriminatory health care.
janetcobb says:
Aug 26, 2011 10:23 AM
Help for commissioners is available at http://www.improvinghealthandlives.org.uk/publications
and also via learning disability networks at
mcannon says:
Aug 26, 2011 12:35 PM
I don't think this is an oversimplification at all and millions is wasted as a result. Much of what you say goes to the very heart of the challenge the NHS needs to face. The most profound irony we uncover is that everyone in the system spends vast proportions of their time collating patient information and updating systems and yet the root cause of all the damage we do to people is that we know nothing about them. http://www.vanguardinhealth.blogspot.com
alisongs@btinternet.com says:
Aug 26, 2011 06:40 PM
Thanks for posting about this issue. You're absolutely right to point out the need for robust commissioning. This needs to start with really good information about your local population, including the small number of people in it who really challenge us about how to support them imaginatively. I do hope that the new commissioning arrangements, as they evolve, don't detach planning for these "low volume, high cost" people from the commissioning of competent local services. If this happens, we risk the "out of sight, out of mind" attitude that has allowed people to be marooned for years in out of area placements.
twray says:
Aug 27, 2011 11:09 AM
Too little is spent in this area on research.
Large Example FASD Uk Births ?? 7000 pa .
Social / health in Economic cost estemated at
£2.5 in One childs life time, yet we are some 30 years
behind other develped country's, with good interventions and awareness cost would be minimal in this and other area's ,
see www.fasdoutreach.ca as an example also www.fasaware.co.uk.
mike.adams@devon.gov.uk says:
Aug 30, 2011 10:07 AM
It is good to see some commnets on this subject. But I'm a bit confused. Over the years LD has been both in and out of the NHS. The emphais now seems to rest with LD Parnerships but wiht more attention being paid to the health needs. However the area which will cuase big probllems are the high costs of delivery of complex long term care, some I believe of up to £3,500+ a week. How is this going to be commissioned? For a long time local services have beeen closed down that is why we see places like Winterboourne View taking people who are long distances from thier home area.
As for pure health services people are now referred to and seen by in the same places as everyone else, this has been of enormous benefit to the patient and as an educational tool for the public and professions.