Services for people with intellectual disabilities and challenging behaviour: the Mansell Report Jim Mansell

Overview  Analysis  Action needed now  Conclusion

Forward and backward at the same time

Analysis

Typical problems  Community placements break down  Out-of-area placements increasingly used  Poor quality institutional solutions persist  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

The potential challenge Vulnerable people  Between 10 and 46% of adults have additional mental health needs  12-15% have significant impairment of sight  8-20% of hearing  27% have autistic spectrum disorders  At least 45% have significant impairments of communication Vulnerable situations  Low level of staff support in residential homes (about 9 mins/hour)  Less facilitation (1-4 mins/hour)  Communication often doesn’t match person’s needs  High staff turnover and low levels of training  Treatment for challenging behaviour hard to get

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

Placement competence  Dominant model of care is unskilled minding  Treatment rhetoric perpetuates this  Commissioners purchase mainly low- competence services

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

Not enough planning ahead  Children sent to residential schools out-of- area  Care planning overwhelmed by crises Not enough care managers Cost pressures reduce proper planning Placements obtained at last minute, often in crisis Increasing burden of care on families

Action needed now

 Increase capacity of local services to understand and respond to challenging behaviour  Avoid increasing the burden on family carers by reducing levels of service  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

Increasing local capacity  Good advance planning for individuals  Personalisation – tailor services to individual  Partnership with good service providers  Incentivise good services  Don’t just buy what is there – make something better!

Support family carers  Prevent service withdrawal  Provide practical help  24/7 not 9-5  Treat families as experts  Plan ahead

Replace low-value high-cost services with better alternatives  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

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

Provide local specialist services  Use specialists to help managers lead their staff  Identify responsibility for extra help to get failing placements back on track and development of replacement homes  Encourage provider cooperation/ mutual support to enhance resilience  Replace ‘one-stop shop’ of challenging behaviour units with range of tailored options  Clarify responsibility for case co- ordination, decision-making and resource allocation

Conclusion  Challenging behaviour is not just an individual treatment problem, it is a service design problem  The key to better support is to build capacity in the local system, rather than waiting until crises occur  This requires coordinated action across a range of areas – ie planned service development with a view to investing for the future