By Jonathan Beebee
Today CQC announced the release of their State of Care report. Learning disability support was a leading headline. The key points were that learning disability hospitals are continuing to fail people, going from 1% being inadequate last year to 10 % this year. Additionally, the declining numbers of learning disability nursing was leading to a decline in skills in the workforce. They describe these two components as the “perfect storm” for an impeding crisis in learning disability support. For many of us, these issues are not new news but it is much appreciated that CQC are adding their weight to this now. I wanted to share a few thoughts on what is happening in my view, and what I feel the solution should involve.
Have hospitals declined in their quality in the last 12 months?
In May of this year we saw the release of the BBC Panorama programme about Whorlton Hall. When we had all stopped crying that nothing had been learnt from Winterbourne View, CQC (again) received a lot of criticism about this documentary. There was a high level of inspection occurring at this hospital immediately before the documentary. A CQC inspector also disclosed that he had wrote a damning report on his inspection where he found failings at this hospital, but it is alleged this was discarded and the hospital was rated “good”. It is likely that CQC inspections of these hospitals are under greater scrutiny, and therefore that the inspection regime has tightened up.
I am in no way a supporter of long term, meaningless hospital admissions where the model of support is an abuse of human rights. However, I cannot support a view either that all hospitals are bad. The world is not that binary despite how the media portrays it. Yet, if you work in a hospital setting, good or bad, the messages that have been portrayed in the media today have been prevalent since Winterbourne View and are universally applied. News reports today described hospitals as torture and barbaric. I am not denying that for some this has been true, but it is not a universal picture.
Can you imagine being a nurse working in a hospital? These messages are describing you. You aren’t going to speak with pride in the pub about what you do because this is the common view. This then impacts upon recruitment and retention. This then impacts upon our ability to attract the Learning Disability Nurses of the future. And this all impacts upon the quality of the hospital environment.
I don’t feel it is any surprise that the number of hospitals rated inadequate has increased 10 fold.
So what is happening with the learning disability nursing workforce?
We have known for a long time now that there has been an impeding crisis in Learning Disability Nursing. For years we have spoken about an ageing workforce and challenges with recruiting student nurses. The media portrayal of learning disability support certainly has not helped.
The RCN Connect for Change report has demonstrated how the NHS has had a severe decline in the number of RNLDs (Registered Nurses in Learning Disabilities) it employs. At the time of the report it was reported there was a decline of 1/3 over the 5 years the report covered. Now the RCN are reporting the cut has been 60% in 10 years. Some of this has been the closure of hospital services for people with learning disabilities, but if you speak to any community learning disability team they will tell you how austerity has led to their teams being reduced also.
The Transforming Care programme has largely been criticised for focussing on discharges from hospital but little focus on what community services are needed to promote discharge or to prevent hospital admissions in the first place. The news today was glossed with spin about how there are plans of investment in community NHS services. The State of Care report itself states that part of the problem is intensive NHS community support services aren’t available in every area. These teams ARE available in many areas, and many areas will tell you that the staff in these teams barely touch the the losses they have experienced through austerity. They are more a juggle of the cuts than an investment.
For the Learning Disability Nursing workforce, I feel the powers that be have done the opposite to the principles of good Positive Behaviour Support (PBS). Good PBS focusses on reinforcing what you want to see with less focus on reducing what you don’t want to see, as this will reduce naturally as the good things increase. For Learning Disability Nurses there have been clear messages about where the powers that be DON’T want us to be working, but there has been no clear vision and direction for where the workforce needs to develop and thrive.
Since the 70’s, the support of people with learning disabilities has had a welcome move from a medical care model to a social care model – and Learning Disability Nurses have been at the forefront of advocating for this. We all do not want people to “live” in hospitals. We want people to have the same rights as everyone else to an independent life in their own home with whatever level of support they need to achieve this. It is poor social care that has often led to admissions to hospital, and it is poor social care that has prevented timely discharges. It is poor commissioning that has created cheap frameworks where providers race to be the cheapest to “bid” for people through corporate tendering processes that fail to encourage a skilled workforce.
If we want skilled social care we need to value the role of Learning Disability Nursing in social care settings and further define the role RNLDs play in providing highly skilled social care.
I feel PBS4 has begun paving the way in demonstrating this. We are by no means the only social care provider to value the input of Learning Disability Nursing. However, we, and others who value RNLD input, have been doing so without being asked to or supported in this. We do it because we value the skills Learning Disability Nurses bring and sometimes the only way to achieve the change is to demonstrate that it works.
At present PBS4 supports 27 people. We employ 4 Learning Disability Nurses. We also employ a General Nurse (RGN) and 2 Board Certified Behaviour Analysts. We successfully support people to be discharged from hospital and create bespoke support solutions for people to live in their own tenancies avoiding hospital admission. The skilled clinical leadership we employ is an essential element of our support.
To me the answer is clear. The perfect solution to this imperfect storm is to develop a clear vision for the future of Learning Disability Nursing. We need explicit expressions of commitment to our value in social care provision. People with learning disabilities with complex support needs have traditionally been failed by social care, so then ended up being further failed in hospital settings. If we genuinely want to achieve stopping people with learning disabilities needing hospital admissions we need the skilled workforce to be available in their own homes. We need to switch our attention from what we want to stop towards what we want to achieve instead. People with learning disabilities don’t belong in hospitals. Neither does the future of Learning Disability Nursing.