On Monday the government published its serious case review into the Winterbourne View abuse scandal. Winterbourne View was a specialist private sector hospital for learning disabled and autistic people – people who were sectioned and could not fend for themselves – “vulnerable” in the jargon. The BBC Panorama programme filmed some spectacular cases of staff abusing patients. A closer look didn’t make things look any better – abuse had being going on for years, and the hospital was not remotely doing the job it was being paid to do. This is laid bare in the report. All sorts of people fell down on the job – the hospital’s owners, police and other services, and the Care Quality Commission. This should not distract us from the central lesson which the report makes clear – the commissioning of these services was seriously deficient.
The report was published on a day when the news was dominated by the Olympics and by the Coalition spat over Lords reform. Perhaps it is a pity that this meant it did not get the public attention it deserved. But it may be just as well. In the hands of the usual top news journalists and editors, the wrong lessons would have been drawn. Instead the coverage has been a bit more balanced and considered – I have even been able to pick up mature and balanced coverage from BBC’s Radio 4. Even so, I’m not sure if the right messages are getting through to the people that matter. There are some big red herrings.
The first red herring is the use of private sector providers to deliver care. The report and headlines made much of the hospital owner’s pursuit of profit as being the reason they failed to provide a proper service, in spite of being paid quite well. But this is nothing new – and there are plenty of shining examaples of good practice in the private sector. The problem was that they were not being held to account. Terrible things happen in public sector organisations too, if nobody is asking what they are getting for their money.
Which leads to a second red herring. An early “lesson” was that the Care Quality Commisssion’s inspection regime was too light touch, and that inspections by this national body should be more frequent and more thorough. But we mustn’t rely on these big inspectorates, who often fail to understand local nuances and issues, and can end up being excessively confrontational. At best they can guarantee a certain level of mediocrity.
And thirdly there is the role of family. The patients at Winterbourne were often from a long way away, which meant that it was much more difficult for the family to stay in touch. This was condemned as being part of the problem. This is right up to a point. Public service commissioners are far too casual about sending people a long way from where they have their roots. I am uncomfortable with the NHS reformers’ constant refrain of creating fewer but bigger specialist facilties for everything – though they always point to statistical evidence. But while family can and (usually) should be an important part of somebody’s care, the system should not depend on them.
No, the real issue is with the commissioners of public services, within the NHS and local authorities. They should take more responsibility for the services they commission and devote more time to holding them to account. At this point it is very easy to be swept away by a debate over structures, procedures and responsibilities, seeing this as simply an exercise in public procurement, as one might outsource street cleaning, for example. But again, that is not the important point.
At the heart of the commissioning of social and health services should be the client or patient. Their individual requirements should be assessed, treatment individually tailored and their progress followed with human interest. The patients of Winterbourne were sent there by commissioners who thought their job was done by just placing them there. What was supposed to assessment, treatment and rehabilitation, a process implying progress towards a goal, turned into warehousing. That should be almost as outrageous to us as the abuse itself. If the commissioners had been following their patients, they would have picked up their lack of progress, and either worked with the hospital to improve it, or simply taken their patients elsewhere.
This isn’t rocket science. My wife is a care manager at a local authority, dealing with drug rehabs. Her authority takes an interest in their clients as individuals, and this invovles meeting clients at the rehab facility from time to time to check on progress…and cutting out facilities that aren’t up to standard. The problem is that some public sector managers take a more industrial view of things, trying to drive efficiencies by doing things in bulk and treating problems and performance indicators rather than people. This can give rise to some short term cost savings, but it quickly becomes self-defeating, as processes that fail to take account of people as individuals fail to solve their problems, and you end up with warehousing on a minimum cost basis. But it is not value for money you keep adding to the workload.
Unfortunately in this aspect of public services, not much much can be learnt from the private sector. Private sector techniques (lean management, business process engineering) can lead to a more people-centred approach if applied properly – but ultimately the private sector answer to difficult clients is either to pass them on to somebody else, or turn them into dependents and warehouse them for a fee. Warehousing problems rather than solving them can be a lucrative business, as the owners of Winterbourne, Castlebeck Ltd, clearly saw.
I hope that the government’s ideas for GP-led health commissioning, and integration between local authority and NHS care, will lead the commissioning process to the right place, as they should in theory. But the bureaucratic obstacles are huge. It would help to have a clearer vision from on high.