The Bubb Report – Neither Right nor Wrong

To take the positive view first. With one exception (see below) the main conclusions and recommendations are broadly good and sensible.

To give some highlights:

• Creating an enforceable requirement that people placed in assessment and treatment units have access to an independent review and support to challenge the decision.
• Creating a mandatory NHS commissioning framework that starts from a human rights perspective.
• Toughening the CQC regime to drive out bad providers.These and other proposals will meet with little dissent (other than from providers who benefit from this trade in humanity) and indeed they are all things that the sector has been demanding for many years. The officials appointed to write the report have done a pretty good job at listening to wise voices. (Incidentally, my colleague Sue Turner, NDTi’s Programme Lead for Learning Disability, will be publishing a more detailed analysis of the report on our website later this week.)

Yet the report has significant flaws. For example, stating that whether a service is ‘supported living’ or registered care has no impact on quality completely contradicts its own starting point of a rights-based commissioning strategy - given that residential care means a loss of rights and people being moved around against their will. (Wouldn’t you behave in a ‘challenging’ way if someone told you that you had to move house when you didn’t want to?). Its call for Government-produced plans to close assessment and treatment units is misleading and raises false hopes. Governments have no powers to close private (and indeed voluntary) sector provision in this way. All it can do is encourage better commissioning so that the demand is turned off.

Two other significant faults are the failure to do other than pay lip service to the need to start addressing these issues in childhood, and the proposal to use social capital money to develop new housing – which as presently conceptualised risks taking us backwards. Yes, more housing is needed, but the report’s proposals are to “acquire properties and refurbish them if necessary, before leasing those properties to housing providers” and that this should be with a “small group of approved providers”. Whilst there is rhetoric about this being based upon need, this risks revisiting our past mistakes and building group homes to close the institutions that we absolutely know are not what most people who challenge services want or need. Bubb himself gave the game away on Radio 4 this morning by saying the fund would be used for “opening homes in the community”. What we need are individualised local housing solutions that are flexible and not tied into long-term contracts to repay the investors. Those who would benefit under these proposals chaired by the ACEVO Chief Executive are large providers, who are similarly the only organisations that could help deliver the financial incentive ideas elsewhere in this report.

However, the major problem with the report is the direct consequence of how the Bubb group was set up. There is nothing to be gained now from revisiting those arguments, but it is a simple fact the NHS cannot, on its own, develop a commissioning framework to address the demand for Winterbourne View type services. It is a failure of both social care and health care that creates demand. There has to be a joint framework that covers (and indeed is led by) local government. This group did not have the membership or remit to deliver that. The plans for an NHS commissioning framework are welcome, but without complete local government and DH sign-up to a similar approach, such initiatives are (to quote what I wrote in an earlier blog on this) like clapping with one hand.

Which takes us to the negative responses to the report. People are right to say there is an absence of action, timescales and things that will make a short-term difference. For example, rather than say (as it does) there is a need for support to commissioners to improve performance, it could have said that money will be immediately invested in providing that support, it will be targeted on those authorities that are sending people out of area, every CCG should have a plan to change commissioning and develop local provision in place within six months, CCG Chief Executives will be held personally accountable for these things happening – and so on. Without these things, and on its own, the report will make little if any difference.

However, (and this is where I differ with the absolute critics), the Bubb report was never going to be able to instigate decisive action. It was a report to NHS England, not a report by NHS England. Neither the group nor Bubb had any authority to agree what would happen in the future. In that sense I’m not disappointed by the Bubb report because it never could do what I and others knew was needed – announce and instigate a set of cross-sector actions with a timeframe and resources.

The key now is how the report is actioned. I suggest that energies should be used not in attacking the report (which contains many good things and has been written by NHS England officials who are trying to change things in a positive way), but in the whole learning disability sector coming together with one voice and saying ‘enough is enough’ and that the report has to be followed up by concrete action in the form of:

1. NHS England responding by Xmas with a set of costed and timetabled actions to implement those elements of the report that are within its powers to take forward.
2. DH and the local government sector (which of course effectively lacks mechanisms to apply and enforce collective action) similarly responding by Xmas, committing themselves to the local government side of this equation – pooled budgets, enforceable rights based commissioning frameworks, CQC processes strengthened etc. This to encompass action with children’s services as part of the SEND reforms.
3. Sending the housing proposal back for more thought.
4. The immediate commissioning of knowledgeable expertise to work alongside LA and NHS commissioners in those areas where people are being sent out of area, to improve their commissioning practice, develop local provision to prevent admissions, bring home those currently out of area and engage with people and families to make this happen.

Yes - the brief to the Bubb group and its membership were wrong, yes - the report lacks teeth, yes - the good ideas are not new, and yes - it has flaws, but it also has some good content. The challenge is to turn content into action.

Maybe, just maybe, if these things happen, we won’t have wasted four months and the report might yet prove a catalyst for something good.