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Making Transforming Care work
Experiences of moving people out of assessment and treatment units

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Q. Why have targets for the Transforming Care Agenda been missed? What can providers do to support people from assessment and treatment units and into the community?

A. Jackie Fletcher, Executive Director, Dimensions 


Every target set for the transforming care agenda has been missed. Numbers of people in assessment and treatment units (ATUs) are declining slowly – but at nowhere near the rate required to achieve the 3-year goal of halving their numbers. Indeed, at current rates the 3-year goal could easily become a 15 to 20-year goal.

So why? It’s certainly not for lack of goodwill, commitment or hard work on all sides. It is just a very difficult thing to achieve. Dimensions certainly doesn’t pretend to have all the answers. If all the answers existed, there wouldn’t be a problem in the first place.

With that in mind, we thought it might be instructive to ask some of those at the sharpest end – our supported living managers who have to negotiate and plan to get individuals out of ATUs – for their tips on what works well, as well as some of the pitfalls. The resulting information comes from a medley of expert voices.

If you are involved in Transforming Care as a provider, a local authority, clinical commissioning group, health professional or, of course, a family, there may be something here that can help you.

Making transforming care work better

When talking about making transforming care work better, there are five topic areas that should be addressed. In no specific order, these are:

  • Challenging expectations.
  • Funding.
  • Working with families.
  • Involvement and access.
  • Housing.

Challenging expectations

Many of the people currently living in ATUs have often had multiple failed placements back into supported living environments. A history of failure like this can label someone as unsuited to life outside of ATUs. However, the reality more often than not, is that it is the system which has failed those people.

It might be that clinical staff in the ATUs have little understanding of supported living. Or they may be inclined to share ‘horror stories’ about the individual, not convinced that the person will ever be able to live outside of the ATU environment. This can be a particular issue in ATUs that are running on high levels of agency staff who do not know the person well.

This is where it’s important to challenge expectations. As with anything else in life, if you don’t believe in what you’re doing, you don’t achieve success. It is critical that all those involved with an individual examine and tackle the reasons for past failures and enter a new placement process with optimism and commitment. Otherwise failure can become a self-fulfilling prophecy.

Funding is a key challenge

The central issue to moving people from ATUs is a commissioner’s ability to take a long view, especially with regard to funding. Sometimes there won’t be an instant saving, as people may come out of hospital with fairly high costs. However, with the right support, costs often then reduce quickly and significantly. This takes trust.

It is understandable that many funding authorities see things through the lens of cost and funding. But this approach will almost invariably cost more, and lead to worse outcomes in the long run. Let me give you an example.

We have recently supported two men, let’s call them Jim and John, out of an ATU and into a shared living environment. Having supported Jim and John for several months, and experienced their interpersonal dynamics, we now believe they need single person services.

Unfortunately, the process to secure funding for this is crisis-driven. No crisis, no funding. We’ve found that the system often demands a failure before it steps in to support appropriately. In the long run, of course, this is far more expensive as it will likely entail a return to ATU.

Jim is an autistic man with no expression recognition or ability to understand humour. He likes people to be pleasant around him, but jokes undermine his confidence. He takes it all extremely personally and simply cannot cope with a ‘jokey’ environment.

Housemate John is a natural, continuous joker. He’s a real fun-loving guy.

As a result of living in each other’s space for a while, Jim is now spending more time in his room. He thinks people like him less. But, fun-loving John is also spending more time in his room. He is cancelling appointments, struggling to motivate himself. Both men are starting to sleep through the day and stay up at night, a sure sign of stress and a habit which puts their support plans at risk.

Both men could undoubtedly thrive outside an ATU but, it turns out, not in each other’s company. Despite every strategy we employ, shared living isn’t achieving the desired outcomes at the moment and there is a real risk of a failed placement. Maybe next week. Maybe next month. Maybe a little longer. But unless something fundamental changes, it will happen.

Single person living is not always the answer. Very often it is beneficial for people to live together, and it is not always possible to anticipate when people will not get along. But where a situation is breaking down, the ability to make changes quickly – and not embark upon a multi-year ‘evidence gathering’ phase – is clearly in everyone’s interests.

The really good news is that nationally, we are beginning to see a shift in approach. More and more local authorities are finding ways to take a long-term view when it comes to Transforming Care rather than selecting the cheapest short-term option.

The role of families in achieving change

Families can be a massive asset in helping people to move out of ATUs. A family determined to see their loved one out of hospital is hard for the system to resist.

However, some families may be a little resistant. There is an understandable fear of change – of seeing a loved one moving out of a secure environment into supported living. What might this mean? Who will be responsible? Some don’t see the potential for their loved one to lead a self-determined life. If the family doesn’t want change, it can be hard (but not impossible) for the ‘system’ to move it forward.

It is essential to build a strong, trusting relationship with families – taking the time to engage properly. Invite them to visit and meet other people living in similar environments. Introduce them to other parents who have been in a similar situation. This will increase the chance of a successful placement.

Remember that it is tough for families. They may encounter lots of providers before coming to you, they may have experienced placement breakdown too. This means it can be difficult to win their trust due to previous experiences, encounters or barriers.

Involvement and access

In my experience, placements break down when the support provider has been brought in late. When housing, staff ratios and the other elements have already been decided.

The earlier a support provider can be brought into the process, the better. It works well when a provider is introduced before a plan for discharge has been made. In those circumstances, that plan will be much stronger as a result. It is essential for a provider to be able to understand a person properly – it’s the basic principle behind person-centred planning and it remains as true now as it ever was. The support provider can ensure close liaison between behaviour consultants, speech and language therapists, occupational therapists and other agencies as required. Support providers can work with registered providers of social housing on an appropriate housing solution. And, at the right moment, they can build direct relationships with the person and their family.

On that note, in our experience, some ATUs seem to find it difficult to allow potential support providers in to meet, build relationships with and shadow the person. This lack of access can be a real problem – after all, would you want to leave your room in an ATU to be supported by a bunch of strangers? For many people, it also takes a long time to build up trust. Lack of access creates stress for everyone, hinders recruitment of matching staff and directly contributes to failed placements.

The role of housing

Personalised housing can obviously make or break a move into the community. In my experience, a lot depends on the individual housing provider. A good housing provider, like a good support provider, will want to be involved early on in the assessment process. In cases where housing contributes to the breakdown of a placement, it’s important to consider that instances such as people damaging their property should be seen as a failure of the assessment and/or housing solution, not a failure of the person. Also, where the housing solution is mandated from the outset, such as an unsuitable council property that happens to be available, a failed placement becomes highly likely.

On the subject of damage – it is also important to pre-agree a pot of money for repairs, and responsibility for repairs beyond that pot. A damaged house can provide an undesirable day-to-day environment that makes a return to an ATU more likely.

The future

Dimensions has recently supported the second longest serving ATU inpatient back into the community, where she belongs and where she is thriving. For her, as for the many other former ATU inpatients, many elements need to come together to ensure a successful, sustained transition.

If you are working to help someone leave an ATU, tackling these issues proactively will give you a great starting point.

Jackie Fletcher is Executive Director of Dimensions. Email: jackie.fletcher@dimensions-uk.org Twitter: @DimensionsUK 

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