Practical multidisciplinary service delivery in complex community social care
Protocols, pathways, and necessary requirements
Dr Andrew Hider, 9th October 2024
• Policy History
• Service Overview
• Case
• System Requirements
• A Model for Provision
• Barriers and Challenges
• Flow Data: 5-year discharges
1971 – White Paper: Better Services for the Mentally Handicapped
•Focus: Closure of Long-Stay Hospitals and shift to community care for people with learning disabilities. (England only)
1983 – Mental Health Act
Introduced provisions for the detention of individuals with learning disabilities in hospitals under specific conditions. (Applies to both England & Wales)
1998 – Human Rights Act (HRA)
Incorporated the European Convention on Human Rights (ECHR) into domestic law, ensuring protection of fundamental rights, including those in care or detention. (Applies to both England & Wales)
2007 – Second Mansell Report
•Updated guidance, emphasizing the need for specialist services for individualswith learning disabilities and challenging behaviors. It reinforced community-based care over institutional care and addressed gaps in the delivery of care for those with more complex needs. (England only)
2001 – Learning Disability Strategy (Fulfilling the Promises)
Follow-up to the All-Wales Strategy, reinforcing the commitment to provide better support for individuals with learning disabilities in community settings (Wales only)
1983 – All Wales Strategy for the Development of Services for Mentally Handicapped People
A landmark strategy focusing on community care and supporting people with learning disabilities to live in their own communities, rather than institutions. (Wales only)
1990 – NHS and Community Care Act
Emphasized community-based care and reduced institutionalization, requiring local authorities to assess care needs. (England only)
Commissioning and Policy attention
Regulatory and statutory complexity
Clarity of service models?
Consensus re: sustainable policy responses?
2018 – MM Case
•Court of Appeal ruling that conditional discharge could not impose conditions amounting to a deprivation of liberty without lawful authority.
(Applies to both England & Wales)
2009 – Transforming Care: A National Response to Winterbourne View
•Developed in response to the abuse scandal at Winterbourne View, this policy aimed to reduce inappropriate institutionalcare and support community-based care for people with learning disabilities. (England only)
2004 – First Mansell Report
•Advocated for person-centered care for individualswith complex needs, including offenders, in community care settings (England only)
2014 – Care Act
•Major reform in social care, focusing on wellbeing and providing more control to individualsover their care. (England only)
2005 – Mental Capacity Act (MCA)
•Provided a framework for decisions on behalf of individualswho lack capacity, including those with learning disabilities. Introduced best interest decisions and Deprivation of Liberty Safeguards (DoLS) (Applies to both England & Wales)
1995 – Disability Discrimination Act
Ensured equal access to services for people with disabilities, including healthcare and social services. (Applies to both England & Wales
2015 – Building the Right Support
•Launched as a follow-up to Transforming Care, this policy focused on closing inappropriate inpatient facilities and increasing communitysupport services for people with learning disabilities and autism. (England only)
2007 – Amendments to the Mental Health Act
Expanded criteria for compulsory treatment, including for individuals with learning disabilities. (Applies to both England & Wales)
2016 – Social Services and Wellbeing (Wales) Act
•Shifted social care policy in Wales, emphasizing well-being,prevention and individualcontrol over care. (Wales only)
2019 – PJ Case
•Supreme Court ruling clarified the lawful use of deprivation of liberty in the community, affecting people with learning disabilities.
(Applies to both England & Wales)
2020 – Mental Health Units (Use of Force) Act (“Seni’s Law”)
•Aimed to reduce the use of force and restraint in mental health settings, especially relevant to those with learning disabilities. (England only)
2021 – Improving Lives Programme
•Welsh Governmentinitiative aiming to improve the livesof people with learning disabilities by focusing on person-centered care and independent living (Wales only)
2023 – Liberty Protection Safeguards (LPS) (pending)
•Expected to replace Deprivation of Liberty Safeguards (DoLS) and reform how deprivation of liberty is managed, particularly in communitycare settings. (Applies to both England & Wales)
• Residential Services: 105 individuals supported over 16 sites
• Supported Living: 167 individuals supported over 31 sites
• Cohort: 46 primary LD, 39 mental health
• Characteristics – majority previous secondary care, forensic needs, high impact behaviours of concern
• Clinical input variable according to need
• Sessional:
• Clinical Psychology, Psychiatry, Assistant Psychology, Positive Practice Workers (ICG-specific role)
• Complex trauma and mild learning disability
• +++ early neglect, modern day slavery, physical abuse
• Unknown to system in early years: homeless, ‘street kid’.
• H/O arson, assault, harassment
• Impaired empathy, lack of understanding and lack of concern for criminal justice management, minimal emotional regulation.
• Sufficient awareness of learning disability to use to claim lack of culpability of offending.
• Section 7 Guardianship, CoPDoL
• Many years of inpatient care
• Formulation – behaviour (verbal aggression, threats to public) a function of:
• need for attachment to a (lost) family system, and
• inability to regulate emotional states due to trauma plus cognitive impairment.
• Primary affect – shame / sadness
• Challenges with supported employment as theft had occurred in multiple placements
• Develops relationship with local business – achieves paid work
• Reviewed by MDT and safeguarding. Concerns about consequences of likely relationship breakdown
• Death of estranged mother reduces already minimal family contact
• Relationship with community breaks down due to behaviour:
• Threats of serious harm and arson
• Threats to staff
• Property damage
• MDT input increases to c. 8-16 hrs per week to prevent admission
• Multi-agency management – use of civil orders by police.
• Placed on civil community protection notice
• Admission avoided
• Remains in community
Responsivity Need
• Providing the right care, in the right place, at the right time is one way of describing reliability in healthcare service delivery.
• Reliable design will help to ensure that staff are getting things right first time. This can reduce delays for patients, save staff and equipment time, improve the safety and quality of care and free up resources.
• Another approach is to focus on the reliability of a clinical pathway. This focus helps promote the mindset of providing a ‘guarantee’ for patients. A reliable pathway means that resources are not spent tracking and pushing patients through the pathway just to meet specific national targets
• Governance Processes:
• Standardised Procedures
• Risk protocols (major events, clinical deterioration, public protection)
• Outcome Data that is used to review effectiveness and quality.
• Audit
• Signal detection (of system / service fragility)
• Staffing continuity
• Forward visibility of commissioning and clinical need
• Adequately cater to Risk and ensure Responsivity
• A model of care is a framework for running a health and social care system to ensure that it delivers the appropriate interventions for the people it looks after.
• The model should derive from a clear theoretical and evidence-informed understanding of the problems it is designed to support people with.
• Associated with the model should be clear, auditable clinical processes, systems for assessing effectiveness, systems for ensuring staff support and knowledge, and a structure for the governance of the system that the model will be used in.
• Clear focus on working with both consent and coercion with service users. Consent is necessary even if statutory coercion is present
• Clear focus on direct care staff:
• Capability (understanding of role)
• Values (supervision to support automatic moral reactions to offence histories)
• Support to see people in context (behaviour a function of environment and needs as well as intrinsic clinical factors)
• Clear focus on ‘non-clinical’ outcomes – engagement and functional skills
• Non-technical frameworks and non-technical language (particularly psychological formulation)
• “Multidisciplinary teams (MDTs) are … a structured forum in which practitioners from across health and social care can come together around the needs of individuals and communities.
• MDTs need to have a clear role and purpose, be well led and organised, have sufficient diversity of professions and disciplines, and be supported by an enabling infrastructure.
• MDTs must be pro-active in how they engage individuals and families in their discussions and decision making.
• MDTs should also connect with other services and teams in their neighbourhoods and place.”
• Multiple agencies in MDT (Police / Probation, Secondary Care)
• Clear communication processes within a geographically distributed MDT
• Adequate capacity for responsivity to manage crisis
• Adequate time flexibility (time demands are hugely variable)
• Adequate skill mix and experience:
• Experience of managing risk situations without use of hospital as a containment
• Awareness and experiences of deploying range of management responses – civil, criminal and clinical
• Ability to cope with anxiety and hold accountability
• Ability to work both probabilistically and responsibly
• Hierarchy imbalance (e.g. AC devaluing opinion of non-clinical social care staff who are reacting to appropriate risk signals)
• Expedient management – the availability of hospital can shut down clinical reasoning to solve the problem / manage the crisis in situ
• Fear of failure – not using inpatient admission when it becomes necessary because of fear of commissioning and reputational consequences
• ‘Offhanding’ – jostling between agencies for accountability (who was at the wheel when the car crashed?)
• Sedimentation – not asking for different opinions, tolerating clinically static or unacceptably risky situations
• Communication failure between agencies
• Staff capability re: forensic knowledge / understanding / ‘praxis’.
• Lack of concern for outcomes
• Inadequate data capture re: incidents and risks
• Decision makers unsighted on key risk signals
• Regulation not aligned with understanding of service requirements – so systems prioritise delivery of aspects of care not necessarily connected to effective management and support
• Commissioning not aligned with the dynamic nature of this cohort – e.g. removing resource too early in response to improvement
• Statute not aligned with the ultimate aims of the system.
• Presumption that care and support (general principles) can be reduced to specific interventions (e.g. CBT/DBT etc, or medication)
• Presumption that symptom management and short term behaviour change determine long term outcome
• Staff training insufficiently focused on applied principles of relational service delivery (and overly focused on complex psychological theory)
• Staff clinical / reflective supervision neglected in favour of administrative task management
• Unrealistic expectations of the timescales of improvement / change from services / commissioners
Clinical Nihilism
Clinical Complacency
• Nothing works
• Nothing will change
Recall an inevitability
Low expectations of MDT impact on person receiving care
Clinical Curiosity
• This is good enough
• We have tried our best
May remain in community but quality of life low,
Outcomes poor, low chance of stepdown
• How do we know things can’t get better?
• What have we not tried?
Systems around person realistic but hopeful.
Crisis managed with adequate resource and system effort
Initial assessment determines pathway
Primary mental health need: RISE (Recovery in Supported Environments)
Intellectual Disability: Building Better Lives (BBL)
Co-produced support plan:
RISE : Recovery Support Plan
BBL : PBS plan
RISE : Co / User produced goals plan.
CHIME framework
BBL : Active Support / Skill Building
RISE – REQoL
BBL – MANS-LD
Both – Service experience questionnaire (SEQ)
GHCS (Group Home Culture Scale)
