Friday 10 August 2012

What can CCGs learn from the Winterbourne scandal?

What can CCGs learn from the Winterbourne scandal?:
Commissioners must monitor services and feedback to ensure services are being delivered to the right standards
The serious case review of the Winterbourne View hospital scandal has powerful messages for commissioners and providers of care in the reformed NHS.
The findings of the independent review conducted for South Gloucestershire council's adult safeguarding board are reminiscent of child abuse investigations in the 1980s and 1990s – overlapping authorities failing to spot warning signs or share evidence.
Even without witnessing the abuse taking place in the hospital, there were warning signs of poor care in NHS records. For example, patients ended up in A&E on 78 occasions, but there was no alert system in place to tell clinical staff about previous visits, so any evidence of a pattern of poor care was lost. Over three years there were 29 police contacts with the hospital and they successfully prosecuted a member of staff, while the council had received 40 safeguarding alerts.
NHS South of England's own investigation highlighted the absence of processes for commissioners to be told about safeguarding alerts – some commissioners were aware of concerns – and failures to follow up concerns when commissioners did become aware of them. Meanwhile strategic health authority oversight of primary care trust commissioning simply "did not work for Winterbourne View hospital patients", the serious case review concludes.
Proof of the extensive misuse of physical constraint was in the records, but the frequency with which some patients were being restrained, physically and chemically, was not shared with commissioners or South Gloucestershire's adult safeguarding board.
Patient records reveal casual neglect – there were widespread dental problems and "most patients were plagued by constipation". Many patients were being given anti-psychotic and anti-depressant drugs without a consistent prescribing policy.
The Care Quality Commission's failures, particularly not responding to a hospital whistleblower, have been well reported.
But the review's most damning criticism is rightly reserved for Winterbourne's owners, Castlebeck. The company failed to address clinical governance, staffing problems, why the police were called to the hospital or the "operational relevance of the hospital's statement of purpose". In other words, the promises the firm made to patients and commissioners bore no relation to the reality.
The review is a timely and powerful reminder to clinical commissioning groups of their responsibility to monitor the services they buy. It mirrors the warning from the Commission on Dignity in Care for Older People that commissioners need robust mechanisms in place to ensure dignified care is being provided, including feedback from patients, families and independent advocates.
They must also assure themselves that hospital management teams and boards are acting on the information. Robust action, including closing the service, may need to follow.
As the reformed health service prepares for more competition and increased use of the private sector, there are important lessons for commissioners. The serious case review says that on paper Castlebeck's policies, procedures, operational practices and clinical governance were impressive. Yet the reality of the way patients were assessed and cared for, how staff were recruited, trained, managed, led and disciplined, how complaints were handled and how records were kept came down to "arbitrary violence and abuses".
This does not mean, of course, that such practices are in any way representative of the private sector, and rotten cultures take root in the public sector as well. But the chasm between what Castlebeck promised and the reality means that commissioners had clearly failed to test the foundations of those claims at the outset or use them as a rigorous benchmark for monitoring performance.
A similar question arises in the commissioning of NHS services. They are more open to scrutiny and evaluation, but failure still happens.
The purchaser/provider split is intended to promote quality, drive up standards and ensure the interests of the patient are championed. But the scandal at Winterbourne View hospital demonstrates how far commissioning still has to travel before it meets its objective.
The new commissioning groups have a huge burden to manage in simply taking over the basics. One of the key tests of the reforms needs to be the extent to which commissioning reaches new levels of engagement with providers. It is difficult to see how that will be achieved by such lean operations.
Richard Vize is a commentator on public policy and management. Guardian Professional. 

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