Jim Mansell is Professor of Learning Disability at the Tizard Centre at the University of Kent and a commissioner for the Commission for Social Care Inspection. In 1993, he published key guidance on services for people with learning disabilities and challenging behaviour or mental health needs. This month, he published revised guidance looking at progress since 1993. He spoke to Community Care’s deputy news editor Maria Ahmed about the current issues facing services for people with learning disabilities and challenging behaviour.
What has changed since 1993?
The institutions are almost gone and we now have a service system largely based on smaller settings in the community. However, many of these services are not good at supporting people whose behaviour presents a challenge and some of the services are relatively institutional. Proper planning of services for individuals has become dominated by reacting to crises and placement breakdowns. There is not enough service development to build up the capacity of local services to meet the needs of local people whose behaviour presents a challenge.
What needs to be done?
Councils, as the lead agencies for services for people with learning disabilities, need to strengthen their commissioning. They need to bring together people who combine expertise about challenging behaviour with expertise about service design and development, to plan services for individuals through a process of proper person-centred planning, and to give them authority to actually develop the services in partnership with service providers.
The Department of Health says no extra resources will be provided for the implementation of your revised guidance and says it is not mandatory. Would you like to see some of your guidance become statutory and if so what would you prioritise? How can this guidance be best be enforced, given that, 14 years on from your last report, services for people with learning disabilities with challenging behaviour are “lagging behind”?
The key thing we have to do is strengthen the voice of the person needing support in the allocation and use of resources. Circles of support and individual budgets or direct payments look promising ways of doing that for individuals, and partnership boards and new legal obligations are important at the policy level. Active campaigning at local and national level is going to be more important in the future.
Have you got any estimate of whether your recommendations, including emergency support for people with learning disabilities and challenging behaviour, can be achieved within existing resources? If not, do you have any estimate of how much would be needed?
Authorities currently funding good practice are doing so within existing resources, so this question may be more about commitment and priorities than absolute levels of resource. It is noteworthy that in Cornwall and Sutton and Merton (where scathing reports by inspectorates detailed poor practice and institutional abuse), the responsible bodies have responded by redirecting resources to learning disability from within their budgets.
You say the role of the NHS is to keep contributing the financial resources needed to sustain the transfer of specialist learning disability services to councils. Are enough NHS trusts doing this?
I say in the report that there is clearly a problem in the perception that NHS finance has been unilaterally withdrawn in some places where there are pressures elsewhere in the NHS. I hope that the current discussions on transferring the responsibility for commissioning specialist learning disability health services to local authorities will lead to a situation where all the resources available can be secured and used in the best way to support people with learning disabilities.
Is there any estimate you can give on forecasting the amount of new housing, day opportunities and support, staffing and training needed for the years ahead?
Some attempt to do this has been made by Emerson and Hatton, who suggest an increase of 12000 residential places needed over the period 2001-2011, principally due to changes in the age-structure of the population of people with learning disabilities. In relation to people whose behaviour presents a challenge, what is needed is, in the main, not different kinds of services but more skilled support in ordinary services.
You say that in your first report you argued that challenging behaviour was an “acid test” of the policy of community care. In the light of this report, has community care failed?
It is not community care that is failing, but our ability to deploy the creativity, imagination, competence, commitment and resources to make it a reality for people with complex needs such as challenging behaviour.