Winterbourne View

Earl Howe Excerpts

Tuesday 30th October 2012 Lords Chamber

[The Parliamentary Under-Secretary of State, Department of Health (Earl Howe)]

My Lords, I shall now repeat as a Statement an Answer given earlier today by my honourable friend the Minister for Care Services in another place on the safeguarding of former Winterbourne View residents. The Statement is as follows:

“The review into the abuse at Winterbourne View Hospital established by my right honourable friend the Member for Sutton and Cheam set out 14 actions to transform care and support. Central to the review is ensuring the safety and well-being of these very vulnerable people. I shall publish the final report before the end of November.

When Winterbourne View closed, NHS commissioners put in place independent clinical and managerial supervision and commissioned an independent assessment of every patient. The Care Quality Commission worked with commissioners to relocate Winterbourne View patients to suitable alternative placements.

The Department of Health review team commissioned NHS South of England to follow up the 48 patients who had been in Winterbourne View in March and September of this year. That revealed that 19 former patients were the subject of safeguarding alerts. In response to this, officials asked commissioners to take the appropriate action and confirmed that a follow-up would take place in six months’ time.

I was concerned to be informed that this follow-up had revealed that there are current safeguarding alerts for six former patients. I am assured that these are all being followed up to ensure the safety and well-being of the individuals concerned. Furthermore, the September follow-up exercise revealed that 32 Winterbourne patients were now living in the community in their own family homes, supported living or a residential care home; 16 were still living in hospital settings.

The priority is to improve commissioning to develop the good local services which will prevent people being inappropriately sent to hospital. We are working closely with the NHS Commissioning Board, the Local Government Association and directors of social services on what support local services need.

While a small number of people will need hospital treatment, we expect to see and indeed must see a substantial reduction in the number of in-patients. We intend to strengthen safeguarding arrangements to prevent and reduce the risk of abuse and neglect of adults in vulnerable situations. Where there are safeguarding concerns, the local safeguarding of adults boards need to be closely involved. These boards will be placed on a statutory footing, ensuring a co-ordinated approach to local adult safeguarding work.

This Government will put the necessary legislation for safeguarding adults boards, and local councils should bring clarity to their roles and responsibilities. But it is the responsibility of the care provider to ensure a culture of safety, dignity and respect for those in their care, including stopping abuse before it happens. Those providers must be held to account for the care they provide”.

My Lords, that concludes the Statement.

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[Earl Howe]

My Lords, I am grateful to the noble Lord, Lord Hunt, for his comments and questions. Turning, first, to the very distressing programme that was shown on television last night, we know that some of the people who were at Winterbourne View hospital are now receiving good-quality personalised care in community settings that is appropriate for them. However, it is deeply concerning that some people have been so affected by what they experienced at Winterbourne View that they have had to go into more secure settings. Equally, we are very concerned that others continue to experience poor-quality care.

The Government take this very seriously, and that is why Department of Health Ministers set up a wide-ranging review not just into what happened at Winterbourne View but into the state of care and support services for people with learning disabilities or autism who may have mental health problems or behaviours described as challenging. We have heard a lot from people who have experienced the services, as well as from their families. We have been working across the health and care sector to identify what needs to be done to make sure that vulnerable people get the care and support that they deserve.

I make no apology that that has taken some time. We are determined to treat this issue very seriously and bring forward a firm programme of action to really make a difference. We will publish the final report of the DH review shortly, together with a concordat setting out the commitment for change and inviting external partners to sign up to specific actions to deliver that change.

The noble Lord asked me about commissioning. In general terms, in our perception commissioning has been too remote from the patients whom it is intended to serve, and I think that the noble Lord’s remarks reflected that point. Clinical commissioning is intended to push decision-making much closer to patients and local communities with the aim of ensuring that local people are able to hold commissioners to account more effectively for what they achieve. Commissioning decisions will also be better informed by local clinical knowledge and insight.

The noble Lord asked whether all families have been given full information about the alerts. In essence, that is a matter for the local commissioners but I can tell him that the Department of Health has reminded health and care bodies of their responsibilities in that area.

The noble Lord called into question the capacity of the CQC to take on as much work as we are requiring of it. He will know that the department has undertaken a performance and capability review of the CQC. The resulting report was published back in February. It found that the CQC had made significant progress in the previous nine months, and I believe that it is continuing to make that progress. It has shown, in particular, a new focus on its core purpose—to protect patients by concentrating on essential standards—and in strengthening its operational base. The review has already made recommendations to strengthen the board of the CQC and board structures, including changing the board, so that instead of comprising only non-executives, it becomes a unitary board of majority non-executives, with senior executives on the board where they can be better held to account. It also recommended that the CQC needs to review and reinstate the board support and development programme and strengthen capability at executive team level. The department will oversee the implementation of these recommendations.

I share the noble Lord’s confidence in David Behan as chief executive of the CQC, having got to know him quite well during my time in the department. The noble Lord raised the issue of skills and training. We have had a number of debates on this subject over the past few months and, as he will know, the department has commissioned Skills for Health and Skills for Care in partnership with unions and employers, regulators and educators, to produce by January next year national minimum training standards and a code of conduct for healthcare support workers and adult social care workers.

I would just say, however, that to my mind the skills required in looking after those with learning disabilities and challenging behaviour are of a different order from the skills needed in other settings and we need to nuance the standards to ensure that the right skills are being imparted to the right people. Commissioners need to encourage hospitals and assessment and treatment units for adults with these disabilities to make sure that their employees are signed up to the proposed code of conduct that we plan to put in place and the minimum induction and training standards for unregistered health and social care assistants. We are working with the National Skills Academy for Social Care to explore how registered managers can get better support, which includes regular monitoring and supervision. Indeed, Skills for Care is developing a framework of guidance and support on commissioning work for solutions to meet the needs of people with challenging behaviour.

Finally, the noble Lord asked me whether I was satisfied that Postern House represented a safe and secure environment. Following the programme last night, my officials are pursuing that matter with urgency, as we speak, and once I have an assurance to give him about the current state of affairs at that care setting, I shall be happy to pass it on to him.

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[Lord Laming]

My Lords, the Minister has made it plain that it has been the Government’s position for some time that people with learning disabilities should be enabled to live with local personalised services, supported in the community. The fact that some former residents of Winterbourne are now living with their families is an indication that this policy has been implemented all too slowly. There are too many units like that around the country. Will the Minister tell the House what levers are being employed to speed up this policy so that people have a range of local services designed to meet their personal needs?

[Earl Howe]

My Lords, I am absolutely in agreement with the noble Lord, Lord Laming, that it is really important that people are held to account for making change happen. We have indicated what we think that change should be, and that is why we have developed a concordat with key partners to get them to commit to the actions they will take. We also plan to strengthen the learning disability programme board, in particular to make sure that key delivery partners—such as the NHS Commissioning Board, the CQC, ADAS and the Local Government Association—are core members. The board will review progress on implementing the action set out in the final departmental report and the concordat. We have tried to address the issue that the noble Lord homed-in on—which is speed of action—but the core of his point was that there are too many people currently in specialist in-patient learning disability services, including assessment and treatment units, and that they are staying there for too long. This is often due to crises which are preventable or which can be managed if people are given the right support in their own homes and in community settings. That is the agenda that faces us.

[Baroness Jolly]

My Lords, what action can be taken against partners that fail to comply with the concordat?

[Earl Howe]

My Lords, I think that part of this involves defining roles and responsibilities. There is no single answer to my noble friend’s question. However, the transparency of the delivery of care, measuring outcomes and measuring the quality of commissioning in local areas are all important. It is also important to ensure that systems are in place to expose poor practice when it occurs. The problem with Winterbourne View is that, for too long, people did not know that those dreadful things were happening. Therefore, levers such as the introduction of local Healthwatch, the promotion of the new elements of the NHS constitution and ensuring that the CQC focuses its attention on where risk may most strongly lie, all have to be considered in the mix. I can tell my noble friend that this very subject will be covered in the report that my department will be publishing by the end of next month.

[Lord Elton]

My Lords, my noble friend is right: the care of people with learning difficulties requires a different order of commitment, compassion and patience. The Government are putting some weight on referring and sending people with learning difficulties out of institutions and into private homes. Can he give us reassuring news about the ease or difficulty of supervising the quality, consistency and continuity of the care which can be given in circumstances where these people are dispersed and each individual needs some kind of monitoring allocation of their own?

[Earl Howe]

My noble friend is absolutely right: this is not a simple matter. That is why we believe that commissioning should not be remote from those for whom care is commissioned. There needs to be regular monitoring by commissioners of the quality of the service that has been commissioned. Equally important, commissioners need to satisfy themselves on the suitability of the placement in the first instance. Best practice and guidance are clear: people with learning disabilities, autism or behaviour that challenges should benefit from local, personalised services and should be supported to live in the community wherever possible. The creation of clinical commissioning groups and health and well-being boards will encourage that local dialogue and insight to make sure that the services available in an area are appropriate and of a capacity for those who require them.

[Baroness Donaghy]

My Lords—

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[Baroness Donaghy]

Is the Minister satisfied that not a single senior manager or owner went to jail as a result of the Winterbourne View scandal? Given that, how on earth is a culture change going to be promoted in these organisations? Can he assure the House that the responsibility and any judicial changes will be considered as part of any review?

[Earl Howe]

My Lords, the noble Baroness makes an important point. We have been clear that those who lead organisations where people suffer abuse or neglect should be held accountable. We have made it clear that there is a gap which needs to be addressed. A range of options is available through regulation; for example, by barring people from running care homes or hospitals ever again or, indeed, through criminal sanctions. As I have mentioned, very soon we will publish our final recommendations on what more can be done to prevent abuse and protect those who are in vulnerable situations.

[Baroness Emerton]

My Lords, I thank the noble Earl for his response in terms of support workers, and particularly on challenging behaviour. My past experience nearly 20 years ago of decanting hundreds of patients from large institutions satisfactorily into the community was due to the fact that the psychologists made an independent assessment of each individual of their clinical and environmental needs, and thus the training needs of the support workers. Can the Minister assure us that a holistic approach in terms of multi-professional involvement will be taken, and that it will particularly be led by evidence-based psychologists who understand challenging behaviour?

[Earl Howe]

I agree fully with the noble Baroness. The aim and aspiration for this group of individuals is that they should benefit from personalised services. What that means is that their needs should be individually assessed professionally by multi-disciplinary teams. The noble Baroness did not do this, but there are some who suggest that we need to get rid of in-patient services altogether. There are individuals who will continue to require in-patient services, but these should be used only in very limited cases. We need to aim towards a situation where no one is sent unnecessarily into in-patient services for assessment and treatment. We know that that has not been happening. For the small number of people for whom in-patient services may be needed for a short period, the focus has to be on providing good quality care that is safe, caring and open to the community, which is another important aspect, and that people can move on from these services quickly. Planning starts from day one to enable people to move out of the in-patient setting into more appropriate care as quickly as possible. That comes back to intelligent commissioning.

[Baroness McIntosh of Hudnall]

My Lords, is it not the case that a great many workers in this sector are extremely low paid? Does the Minister think that there might be any correlation between the fact that they are low paid and the quality of care they deliver? I do not mean to imply that there is any excuse for the sort of behaviour that was revealed in the “Panorama” programme, but could any form of pressure be applied by regulators and commissioners to the commercially driven organisations that provide this care so as to prevent them continuing to employ people on very low wages to do such sensitive work?

[Earl Howe]

My Lords, there is more than a nugget of truth in what the noble Baroness says. Many of us have been troubled for a long time that work of this kind is insufficiently valued by society, and that is reflected in the rates of pay. That is why I am a firm believer in raising skills in this sector as a reflection of the value we place on care workers. The programme that we have in train over the coming months should steadily deliver that. To come back to the commissioning question, I am also a believer in ensuring that commissioners should be satisfied that the settings to which they send individuals have an appropriate mix of skills to look after the people concerned. That has not always happened. There is no single answer to this, but I identify myself with the particular point she has raised about remuneration.

[Lord Cotter]

My Lords—

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[Lord Cotter]

My Lords, I very much welcome the mention of training once again today. It is so important that support workers are trained. One issue that has come to my notice quite frequently is that through a lack of training, support workers question the trained professionals an awful lot. The management also need to be trained to back up the professionals who are trained in their job as a vocation, so that the less well trained support workers respect their decisions.

[Earl Howe]

I agree with my noble friend. Where supervision is required, it is the job of the manager to ensure that it takes place, and that the supervision, staff ratios and so on are appropriate. We come back to the question of the responsibility placed on the shoulders of managers and proprietors of care homes. As the Statement made clear, this is very much a responsibility of providers, who need to be held to account for the quality of care that they provide.

[Viscount Tenby]

My Lords, I declare an interest both as a trustee of an organisation dealing with women with learning disabilities and also as a father of someone in that category. Although everyone can applaud the move to independent living within the community—nothing could be better—this has considerable financial implications, at a time of great financial stringency and rationing within the NHS. Can the noble Lord assure me that sufficient funds will be found and made available for this most important development?

[Earl Howe]

My Lords, the commissioning of this type of care will, in the future, be the joint responsibility of clinical commissioning groups and local authorities. We are encouraging as much close co-operation as possible at a local level. The noble Viscount will know that across-government funding is tight. However, we as a Government took the decision to protect the health budget, which is in fact rising in real terms every year of this Parliament. That does not reduce the pressure placed on the budget, because historically the pressures on the health budget have been higher than the rate of inflation; nevertheless, in protecting the health budget, we are also supporting local authorities to the tune of more than £7 billion over the spending review period to ensure that their social care services are not seriously depleted or damaged. It would be idle of me to say that there is no problem, but the funding available should be enough to support these services over the medium term.

[Lord Clinton-Davis]

This is not a simple matter. Does the Minister agree that an interim report will not provide all the answers and that this matter ought to be kept under constant review by Parliament in due course?

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[Earl Howe]

Yes, my Lords, I agree with that. We must not take our eye off the ball. Once this report comes out, we have to ensure that its recommendations are carried through and constantly monitored. It will be, in part, the job of the NHS Commissioning Board to hold the ring and ensure that local commissioners are supported with the proper guidance, and held to account for the outcomes that they achieve, across the whole NHS but particularly in this area. That focus on outcomes is important when we consider how the service is held to account. We will be publishing very shortly the final version of the mandate that the Secretary of State gives to the NHS Commissioning Board as the means by which the board will be held to account by Parliament and the public.

[The Earl of Courtown]

My Lords, I declare an interest as a patron of a home providing residential care for adults with autism spectrum disorder. What we have all heard, read and seen about the Winterbourne View care home has been quite terrible. Does my noble friend the Minister agree that there are many homes out there providing a very good service to people suffering from these problems?

[Earl Howe]

My Lords, I am very grateful to my noble friend because it is all too easy to sink into a state of despair over these services. He is absolutely right: many, many good examples of excellent care are being delivered to those with learning disabilities. The challenge is to ensure that best practice is spread, but I am grateful to him for reminding the House of that important fact.

[Lord Elton]

My Lords, learning-difficulty patients are extremely aggravating at times and their carers have enormous power over them and can be tempted to abuse it—hence the results we have seen. The same can be said of prisoners and prison officers. When I was Minister for the Prison Service many years ago I was aware of the problem of the abuse of prisoners by prison officers who had a tendency to bully. I commissioned work on identifying the psychological profile of potential bullies, which was useful in reducing that invasion of human rights in prisons. Will my noble friend look into a similar approach when it comes to the way in which carers are recruited?

[Earl Howe]

My Lords, my noble friend makes an important point. The thing that shocked us all in the context of the BBC programmes was the extent to which restraint and physical abuse occurred in care settings, which was clearly inappropriate and also extremely distressing and damaging to the individuals involved. We are working with the DfE, the CQC and other stakeholders to drive up standards and promote best practice in the kinds of areas my noble friend is no doubt thinking of, particularly in the use of restraint. We believe that there should be a set of core principles to govern restrictive physical interventions. We think the guidance needs to be updated and that there needs to be improved training in this area. We will particularly consider in our review what additional guidance is needed for specific groups, including people with learning disabilities and behaviour that challenges.