Why does NHS commissioning go so badly wrong?

Emma Bundleson,* who has experience working alongside NHS commissioners, was not surprised to see the Dispatches programme exposure of inappropriate placements in mental health services. She gives a disturbing insider view of how clinical commissioning decisions are sometimes made.

Quote 1

“Once someone with a learning disability falls into the world of mental health it often goes horribly wrong.”

Quote 2

“The CCGs are highly reliant on the Care Quality Commission to deal with any issues and do not consider quality monitoring to be their responsibility.”

The appalling findings in the Dispatches programme (Under Lock and Key, Channel 4, 2 March 2017) are sadly not a surprise to me. Placements in these big semi-secure/secure institutions continue to be made by Clinical Commissioning Groups (CCGs) despite it being widely acknowledged that, regardless of their health needs, anyone with learning disabilities must be supported with that need the primary focus.

Social care staff, families and specialists in learning disabilities all know that even those with the most challenging of needs benefit from having support in a smaller, local residential setting. With case management being provided by local teams we can ensure that family views are taken seriously, support can be sensibly monitored by independent GPs, help can be given from local nurses and there can be input from voluntary sector staff who work alongside the home to give a rounded service. Or, as I like to call it, offer someone a decent life.

Mental health model

In my experience, once someone with a learning disability falls into the world of mental health it often goes horribly wrong. The problem is that Clinical Commissioning Groups do that and only that – they commission. Many CCG Learning Disability commissioners have little or no knowledge of, or interest in, the actual person. The CCGs are highly reliant on the Care Quality Commission (CQC) to deal with any issues and do not consider quality monitoring their responsibility. They will rarely tolerate contact with families and typically use a mental health model to make placement decisions, as many have no experience of working with people with a learning disability. They use language such as ‘patient’ and ‘unit cost’ and there’s still an assumption in the CCGs that the more challenging the person, the more secure the accommodation needs to be. I have found that there appears to be little room for creativity in CCG commissioning, no incentive for good behaviour management to limit medication use and a very limited understanding of the complex nature of the support needs.

I haven’t found care staff in secure hospitals to be any better trained (or better paid) than those working in care homes or in supported living placements. Generally, good quality care staff at all levels who really understand how to work with people with learning disabilities, will opt to work in a home setting. In this environment, they can work freely with people to understand their individual behaviours and triggers and enjoy being part of the infrastructure that will help people grow and develop.

Although funding for social care is being cut from all sides, the strong links between commissioners and the social work teams continue. The teams may have different agenda but both will be aware of placement agreements, costs and any service issues. Social work teams are usually skilled at working with families and aware of the fact that, for those supporting people with learning disabilities, it’s been a lifetime of struggling, battling for everything and advocating for someone’s rights. CCGs must take a lead from skilled social care staff and be more willing to consider creative, community-based options if we are going to avoid such distressing mistakes in the future.

Noise and chaos

A CCG learning disability commissioner once asked me why I was so adamant that someone shouldn’t be moved from a bespoke residential placement to a cheaper option in a bigger, more secure service. I said: “Because there’s no way that they’ll cope with the noise and chaos of that service They’ll be sectioned and moved again within a week.” He shrugged and replied, “Oh well, at least that would get the cost out of my budget. I don’t pay once they’re
on a section.”

* Emma Bundleson is a pseudonym