Acting on the lessons of Winterbourne View HospitalBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f18 (Published 09 January 2013) Cite this as: BMJ 2013;346:f18
- 1Lancashire County Coucil’s Safeguarding Adults Board, County Hall, Preston, UK
- 2BMA, London WC1H 9JP, UK
Panorama’s broadcast of Undercover Care: The Abuse Exposed during May 2011 made “real” the abusive treatment of patients with intellectual disabilities and adults with autism at a private hospital owned by Castlebeck Care (Teesdale) Ltd, which had become their “home.” The BBC’s undercover reporting enabled millions to watch the degradation and distress of patients as nurses and support workers exercised merciless power. Viewers witnessed the cruelties endured by patients and heard the shallow rationales of support workers and nurses as they encouraged each other to use considerable force. They covered patients’ heads, laid across patients’ chests, put their arms across patients’ throats, and generally immobilised patients with bodily weight and objects.
The Department of Health in England’s final report on the Winterbourne View scandal was recently published.1 It recommended rapidly reducing the number of people with challenging behaviour in hospitals or in large scale residential care, particularly those away from their home area. It also recommended improving strategies to deliver integrated care so that individuals could stay at home or close to their homes.
The serious case review commissioned by South Gloucestershire’s Safeguarding Adults Board was published after the trial of 11 support workers and nurses. It asserted that business opportunism after the hospital closure programme and the failure to commission the local services recommended by the Department of Health and its advisers led to the situation at Winterbourne View Hospital.2 The review found that the healthcare provided at Winterbourne View Hospital was inadequate, as was the ongoing monitoring of patients’ health status. Extensive dental problems and constipation were common. Many patients without a diagnosis of serious mental illness were prescribed antipsychotics and antidepressant drugs. Furthermore, in a specialist hospital, commissioners should have expected a psychiatrist to prescribe and monitor drugs, but this was left to a local general practitioner.
Such abuses—where patients were placed and forgotten, as in long stay institutions—have occurred in the past in NHS hospitals and around the world. In the United Kingdom, long stay institutions were officially closed in 2009, but privately run hospitals have been stealthily replacing them.3 What makes the failings in care at Winterbourne View Hospital even more appalling is that, unlike the long stay NHS hospitals, it was not starved of funds. Its average weekly fee was £3500 (€4315; $5689) per patient, with one primary care trust paying almost £10 000 a week for one patient.
The Department of Health’s final report acknowledges the serious failure of commissioning and advises that when children, young people and adults need specialist support, including crisis support, the default position should be to put this support into the person’s home.1 It asserts that people should not live in hospitals, and it sets out timetabled actions for health and local authority commissioners with a view to transforming care and support for people with intellectual disabilities or autism who also have mental health conditions or behaviours viewed as challenging. The report was influenced for the better by the concerns of people with intellectual disabilities, their relatives, and health and social care professionals.
Any large scale reduction in the number of vulnerable adults cared for in institutions away from their home will require the parallel development of a range of local services to prevent admissions to hospitals or other large institutional settings.3 4 5 For more appropriate care to be delivered to people with intellectual disabilities who are cared for in the community, mental health services will need to make reasonable adjustments. Commissioners are expected to work together to draft and agree a joint plan to ensure high quality care and support services for all people with challenging behaviour. Such integrated care should be based on the needs of individuals and designed to help people stay in their communities. The Department of Health will shortly commission a wider review of the prescribing of antipsychotic and antidepressant drugs for people with challenging behaviour. There is already a compelling case for GPs and psychiatrists to review all drugs prescribed to patients with intellectual disabilities and autism and to ask questions about the use of antipsychotics and antidepressants.1 6 7
There are lessons to be learnt from the Winterbourne View scandal for all clinicians, not just specialists, and implications for clinical care. In sourcing patients from all over the country, Castlebeck Ltd weakened essential relationships between patients and their families, friends and support structures, particularly GPs and other primary care professionals. Primary care practitioners must pay careful attention to patients whose communication may be compromised. Emergency doctors also have a role to play in transforming adult protection through concerned and careful questioning at each encounter.
There is no case for the delegation of the ordinary health and social care needs of patients with intellectual disabilities and autism to an imagined, all purpose specialism. All doctors must be comfortable and competent to attend to the routine needs of people with intellectual disabilities and autism in their own branch of practice. Achieving effective, non-discriminatory and skilled clinical practice will require some new educational initiatives. Participatory development activities with patients, family members, and advocates is increasingly recognised as crucial in educating practitioners and monitoring service provision.8 9
Taken as a whole, the scandal of Winterbourne View Hospital requires us to face the insistent themes of neglect, exclusion, exile, and punishment. The healthcare of patients with intellectual disabilities and autism is at a crucial juncture if these themes are not to prevail.
Cite this as: BMJ 2013;346:f18
Competing interests: Both authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; SH’s son has an intellectual disability and uses services; she chairs Beyond Words, a charitable organisation that publishes picture books on topics relevant to the editorial; MF chaired the serious case review into Winterbourne View Hospital. She has a brother with a learning disability.
Provenance and peer review: Commissioned; not externally peer reviewed.