Lessons will be learned

Margaret Flynn and Vic Citarella – authors of the Winterbourne View Hospital serious case review – reflect on what has followed the screening of the BBC Panorama \’Undercover Care: the Abuse Exposed\’ five years ago in May 2011.
The serious case review was published by the South Gloucestershire Safeguarding Adults Board in August 2012. In response to the findings and recommendations, politicians asserted that lessons will be learned and that they would set in train a number of continuing efforts to ‘transform’ services.[1]It was apt that they should deploy such terminology since, for us, the lessons have been stark:
Now it is evident that the number of people with learning disability referred to assessment and treatment facilities stubbornly refuses to reduce. The lesson? Stop registering these facilities and stop using public money to fund placements. Neither do we need yet another review to confirm that the act of commissioning a review only begins to address the heart-felt search of families for justice and healing. It\’s what comes after a satisfactory review that matters;
Change is a hard, slow process. Transformation programmes, such as the Winterbourne View Hospital Programme Board, are known to fail two-thirds of the time:  A long, drawn-out project executed by an inexpert, unenthusiastic, and disjointed team, without any top-level sponsors and targeted at a function that dislikes the change and has to do a lot of extra work, will fail;[2]provides an extreme caricature of what has happened. The lesson? Spend scarce resources on making sure the dice is loaded towards the converse – or better still towards prevention;
Sustained austerity and cuts in services for people with learning disabilities and their families cannot address the support needs of children, young people and adults whose behaviour is bewildering, troubling, challenging and even criminal. The lesson? The NHS spent a lot of money on commissioning harmful and inappropriate services at Winterbourne View Hospital.  The expenditure continues and should now be unequivocally channelled towards user and family controlled organisations. The stakes are high and soaring;
There appear to be many professionals who believe that ‘full-body restraint’ is a necessary skill for health and social care workers supporting people with learning disability. They should be directed otherwise. The lesson? This form of restrictive physical intervention leads to death, physical and emotional pain and severe injuries. Although Castlebeck’s restraint policy seemed OK, it was wholly ignored by its employees!
Health and social care practitioners are punished for their poor practice. In contrast, service commissioners and business owners seem to have an unassailable alliance to misuse public money intended for the care of people with learning disabilities. The lesson? Even though negligence and manslaughter are corporate crimes, there were surely offences under trades descriptions legislation and unfair trading practices committed by the owners of Winterbourne View Hospital and by the commissioners as the agents of the consumers. Yet thus far, no money has been returned and our recommendation that the costs of the serious case review should be met by Castlebeck Ltd has been ignored.
In a private health and social care market, inspection of practice has to be complemented by the use of regulatory powers in the boardroom and beyond. The lesson? Winterbourne View Hospital has taught us that in such a market an enforceable code of practice in ethical investment is essential. Consumers have rights. Company directors have duties. Investors have responsibilities.   It cannot be a matter of profit or loss or pressure to meet impossible financial targets because these overwhelm restraints against dishonesty and are incompatible with the delivery of humane care.
Winterbourne View Hospital is a case study in institutional abuse. Its name is synonymous with all that we must never let happen again to people with learning disability and with associated programmes of \’transformation\’ and \’improvement\’. Regrettably however, the serious case review remains a blueprint for many lessons still to be learned; particularly in respect of the conflicts of interest that can arise from the commercial provision of services.

[2] Harvard Business Review, October 2005