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

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

2. Overview • Analysis • Action needed now • Conclusion

3. Forward and backward at the same time

4. Analysis

5. Typical problems • Community placements break down • Out-of-area placements increasingly used • Poor quality institutional solutions persist • Costs increase while quality declines

6. 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

7. 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

8. 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

9. 100 Need Capability 80 60 40 20 0 Services Placement competence • Dominant model of care is unskilled minding • Treatment rhetoric perpetuates this • Commissioners purchase mainly low-competence services

10. 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

11. 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

12. Action needed now

13. 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

14. 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!

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

16. 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

17. 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

18. 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

19. 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