Think small, act small

As part of this week’s brilliant 7 Days of Action campaign, I heard a service provider respond to criticism by saying they were working on 'sourcing a placement' for a man who has spent more than 15 years of his life locked in a secure unit. Those three words seemed to sum up everything that we have failed to learn since Winterbourne View.

Amidst the Transforming Care work that has developed post Winterbourne View, there has been a persistent conversation about developing the market (an appalling phrase I know but let’s go with it) to ensure that commissioners are able to source improved services and placements for people with learning disabilities and behaviours that can challenge.

People, families and some professionals called for individual support, however, the conversation seems to have focused on growing and improving the quality of existing provisions, or worse, developing more services that look like the ones that already exist. Using the market place analogy, this is rather like responding to a call for boutique corner shops by building more out of town superstores on remote industrial estates.

Over the last few months I've had the opportunity to listen to support providers, like C Change and Beyond Limits, who seem to be getting it right (or are certainly on their way) by working alongside people with learning disabilities and complex behaviours.

There are some very clear reflections on how they’re managing to achieve this…

• Everything starts with the person and their family, friends and community (not an empty bed or void) and a series of conversations that explore aspirations, history, control and fears. These become the foundation for developing an idea of where the person will live, how they will live and how they will be supported. On a personal level, this was a striking reminder that great planning with people is a human skill and rarely the result of an industrialised version of person centred planning.
  
• Its next to impossible to plan whilst in a crisis. Waiting until people are in an inappropriate facility or families are exhausted is at best thoughtless and at worst cruel. It takes time to find the right place to live and pull together a team of people who have the skills and passions to support that person. This would seem to be anywhere between six and eighteen months. Also, finding the right place to live and great support does not mean one provider controlling both – when did we forget that simplest of rules about separating housing and support?
  
• The people leading best practice come with a punch of passion, idealism and practical knowledge of what works. They sweat over community and support rather than bottom lines and procedures. This doesn’t necessarily make them easy to work with or commission but it does make them worth the effort.
  
• Organisations who are getting it right are small (or smallish) and, more importantly, think small. Structures are flat, the most senior people know everyone and staff support just one or two people. Inevitably there are pressures to grow and support more people but limits are set. From the outside, it seems that developing supports for more than 4 or 5 people a year would risk quality. Where we get it right, quality is not a process that relies on inspection visits. Because everyone knows the individual and their aspirations, everyone knows when things are going well or wrong. Families, friends and leaders are present in people's lives.
  
• Too many procurement processes seem to favour size and bank balances over desire and ability to genuinely respond to an individual as flexibly as possible. The families and great providers we have spoken to all talk about individual commissioners who work as partners, who understand how to make the system work and who understand the need to move at speed. This reminds me of a conversation that I had with Shaun Pickens from My Life My Choice after we had been listening to people trapped in ATU's endlessly waiting for their 'community placement' - it’s all too much like Einstein's twins’ paradox where two people (here the individual and the social worker or commissioner) experience time at completely different speeds. For one the clock ticks endlessly while for the other months fly past in a haze of cases and meetings.

To truly develop the market, we must accept that where great support exists, it doesn’t happen by accident – it takes a full commitment to being person-centred, local and aspirational.