Mansell 2Services for people with learning disabilities whose behaviour presents a challenge

Jim Mansell

OUT OF AREA PLACEMENTS

USERS, CARERS AND STAFF HURT

CARERS LEFT TO STRUGGLE ALONE

STAFF DEMORALISED INCREASED RI SK OF ABUSE

BAD CARE PRACTICES

CRISES AND PLACEMENT BREAKDOWNS

REI NSTITUTI ONALISATI ON ‘SI LTING-UP’ OF

SPECIALISED SERVICES

LESS CHOICE AND CONTROL OF SERVICES

LOWER EFFICIENCY PUBLIC CRITICISM

The hidden cost of failing to develop local services

Overview

• Analysis• Service models• Commissioning• Conclusion

Analysis

Typical problems

Community placements break down Out-of-area placements increasingly

used Poor quality institutional solutions

persist Care planning overwhelmed by crises Costs increase while quality declines

Reasons for these problems

Amount of challenging behaviour depends on service competence

Most placements can only support people without problems

There is not enough planning ahead for individuals

Action needed now Increase capacity of local services to

understand and respond to challenging behaviour

Provide specialist services locally which can support good mainstream practice as well as directly serve a small number of people with the most challenging needs

Replace low-value high-cost services with better alternatives

Avoid increasing the burden on family carers by reducing levels of service

Service models

Service models

Supporting people living with their family

Supporting people in other accommodation

Education, work and day opportunities Access to other health and social

services Specialist support to services

Supporting people living with their family Re-examine use of residential schools

away from people’s homes Provide practical support

Equipment Advice and training Staff support to work with the individual

Short breaks available to every family

Supporting people in other accommodation Best model likely to be support to

enable people to live in ordinary housing Direct payments and individual budgets

should be more widely available Stop using services which are too large

to provide individualised support; serve people too far from their homes; and do not provide people with a good quality life in the home or as part of the local community

Education, work and day opportunities Everyone should have access to

innovative day opportunities, further education, supported employment and other day opportunities

Commissioners should take the lead in developing a much wider range of alternatives to day centres

Access to other health and social services People have the same right of access to

mainstream health services as the rest of the population

Mental health services available to the whole community should increase their ability to meet the needs of people whose behaviour presents challenges and who have a diagnosed mental illness

Psychiatric hospital admission only for short-term, highly focused assessment and treatment of mental illness

Specialist support to services

Specialist multi-disciplinary challenging behaviour support teams are essential

Make commissioners, managers and professionals work together to ensure that advice is both practicable and is acted upon

Emergency support available 24 hours a day, seven days a week

Budgets to fund a much wider variety of interventions as an alternative to placement in special units

Commissioning

Commissioning

Commitment Agency responsibility Value for money Service development NHS role

Commitment

Cornwall demonstrates importance of focus and commitment

Reasons why this should be a priority These individuals have the greatest

needs for services Quality services achieve marked

improvement Failure to develop local services

threatens the policy of community care

Agency responsibility

Partnership working established in some areas

Problems remain: Unilateral withdrawal of NHS finance Reduction of Supporting People finance

for individuals with relatively high needs for support

Continued use of residential special schools a long way from home

Government improving coordination between departments

Value for money

Need a person-centred, comprehensive view of benefits and costs

Take account of hidden costs of failure to develop local services

Service development

Make sure every person whose behaviour presents serious challenges has a proper person-centred plan

Build capacity in the local system, rather than waiting until crises occur

Strengthen commissioning to combine expertise about challenging behaviour with the ability to actually develop the services needed

NHS role Keep contributing the money needed for joint

work Not undermine strategy by commissioning poor-

quality services themselves Continue to provide professional support to

sustain good practice in community Provide short-term psychiatric assessment and

treatment, but only as part of an integrated pathway of care for the individual that gets them back into the community

Enable fair access to health services for people with learning disabilities whose behaviour presents a challenge to services

Conclusion

The right strategy

Only commission services that prevent challenging behaviour developing or getting worse

Develop effective local services for people presenting the most severe challenges

Replace low-value high-cost services with better alternatives

Avoid increasing the burden on family carers by reducing levels of service

What should councils do now?

Replace procurement with service development

Combine expertise with authority to actually develop services

Think about people not units

Two examples 4 young men with mild

learning disabilities, mental health needs and substance abuse problems

From out-of-county placements in 2007 to individual flats supported by voluntary sector outreach support

Cost in first week £7400; cost 2009 £3970

2 young men with severe learning disabilities and serious challenging behaviour

Secure units in 2001 at c£2900 per week each

Now sharing a house with skilled staff support

Costs now £1175 per week

What works?

Building support and accommodation around people, not setting up ‘units’

Working with individual, family, service provider

Sticking at it over the long haul (working through difficulties)

Focusing on the quality of day-to-day support from well-matched and skilled staff

Conclusion

Critical factor is to change commissioning to build and sustain the capacity to meet the needs of people in each area