Published: 18/04/2002, Volume II2, No. 5801 Page 20
The place of learning disability services in the NHS has been hotly contested since the mid1960s, when a series of public scandals in NHS institutions revealed extensive ill-treatment and neglect in overcrowded surroundings.
The push for community-based services run by local authorities began with the 1971 white paper, Better Services for the Mentally Handicapped, and gathered pace with the then controversial 1979 Jay report, which called for an end to long-stay care in NHS hospitals.
As the vision of the Jay report gradually took shape over the 1980s and 1990s, the battle between the 'medical' and 'social' models of learning disability seemed to have been firmly settled in favour of the latter.
Things seem more confused now, however, with two policy imperatives pulling in different directions.On the one hand, the recent white paper on learning disability, Valuing People, is based on a set of inter-related principles which underpin a strong social model - recognition of rights as citizens, social inclusion in local communities, choice in daily lives and real opportunities to be independent.Achieving these aims is acknowledged to require a wide range of bodies to work in partnership - social care, education, employment, housing, leisure, social security and health among them.
The NHS, then, is merely one among many players in this approach - and by no means the most important. Indeed, where the health role is discussed in the white paper, it is more about appointing a health facilitator to deliver a health action plan than contributing 'specialist' services.
The policy pulling in the contrary direction is the encouragement, tacit or otherwise, to NHS trusts to strengthen their position as specialist providers of care for mental health and learning disability. Sometimes these will be existing NHS trusts which - with the loss of community health services to primary care trusts - need both responsibilities to remain viable, thereby once again creating confusion in the public mind about two distinct conditions.
To secure a critical mass, formerly separate trusts are also merging over a wider geographical area to deliver 'specialist' care, shifting decisionmaking further from where people live. And now the health secretary is urging the creation of more care trusts, with mental health and learning disability seen as suitable client groups to be placed under an expanding NHS umbrella. This contradiction is a nonsense. Clarity is badly needed, or people with a learning disability will be the losers.
If the primacy of the socially inclusive model is taken as given, the first implication is that a wide range of partners is needed, and these arrangements need to encompass all aspects of a person's aspirations - an education, a job, a home, a decent income, some close relationships.
The second implication is that the partnership must place the person with the learning disability at the centre. This suggests a complex web of organisations and individuals working together - not an oldfashioned partnership axis of health and social services - and certainly not an NHS lead.
Significantly, Valuing People gives local authorities the lead in ensuring partnership-working becomes a reality at local level - and given the scope of their planning, commissioning and providing remit, this seems appropriate. In principle, the learning disability joint investment plan (JIP) should provide the right sort of vehicle for pulling relevant partners' contributions together, though an evaluation of the first round of JIPs found many to have narrow partnerships limited to social services and the NHS.
1For the future, much will depend on the new learning disability partnership boards, for which councils again have been given the lead.The boards are expected to operate within the framework of local strategic partnerships - again, a local authority-led initiative.
Where specialist trusts exist, boards will have to play a part.
Boards will review the role of community learning disability teams and encourage staff to deliver support via 'managed networks'.
These strong collaborative requirements, the interlocking model of practice and the socially-inclusive values and principles make the very idea of specialist NHS organisations for learning disability look distinctly out of kilter.
Far better for NHS staff to move to PCTs, and from that base to be engaged in a variety of lead commissioning, integrated provider and pooled budget arrangements with other agencies.Anything less would be a step back to the 1960s. l
1Swift P. An Evaluation of Learning Disability Joint Investment Plans.
London: King's College, 2001.
Bob Hudson is principal research fellow, Nuffield Institute for Health, Leeds University.