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Solving the puzzle
of assessment and treatment units

Steve Scown shares his reasoning as to why assessment and treatment units mostly don’t work and what needs to happen to minimise their use.

It is sobering that data has revealed that, in December 2015, half of assessment and treatment unit (ATU) ‘inmates’ were already in that institution when analysis began in 2013.

So-called ATUs are designed to offer a short-term crisis intervention, allowing a swift return home. This data proves that they don’t. They incarcerate people for the long-term.

Social care professionals have, for years, been saying that ATUs are not an appropriate solution to a crisis. It’s an obvious vicious circle. Remove someone from their home for treatment (a quarter of ‘inmates’ were sent more than 100km away from home, family and friends) into an unfamiliar, sterile environment that regularly uses restraint and seclusion to manage behaviour. And, as soon as their behaviour gets worse, apply more of the same techniques. It’s a wonder anyone manages to leave.

Neither local nor national Government is listening. Local authorities are failing to create the community-based services that will largely prevent these issues in the first place and then treat individuals properly in the event of a crisis. And the Government’s recent Homes not Hospitals report makes yet another promise to get half of the ‘inmates’ released from ATUs. Half. Even supposing they deliver on this latest in a long line of promises, do we just forget about the other half? The 1,500 people whose lives are being wrecked daily. Whose families are powerless to get them out. Who would almost invariably be able to thrive in their local community with the right support.

There is a place for assessing and treating people who are going through a crisis. It is in their community, surrounded by their loved ones and those that know them. It is not incarceration in an alien institution.

This is not simply a protest. I propose a comprehensive solution.

Challenging behaviour

Most behaviours that challenge can be prevented, reduced or eliminated without the use of restrictive practices or restraint. Personalised support and a focus on ensuring the individual has choice and control over their lives are essential underpinning best practices that must be in place for all support for people with learning disabilities and autism.

Where challenging behaviour still occurs, we must first recognise that this behaviour is a form of communication, a learned response to someone’s environment. Understanding the root causes of the behaviour is key. In fact, behaviour support strategies that are based on such an understanding are twice as likely to be successful as those that are not. Behaviour support specialists should carry out a functional behaviour assessment.

Where people are at risk of admission, they should be placed on a regularly-monitored register, which provides people most at risk of admission with proactive, preventative support. Individuals with a learning disability or autism should be excluded from the Mental Health Act when there is no diagnosis of mental illness. They should not be sectioned purely based on their behaviour, unless it is likely to cause significant harm to themselves or others.

Government must be more ambitious in respect of people currently in ATUs. An ambition to get half of them out is not enough.

Community-based support

Supporting people with learning disabilities in their local community almost always produces better outcomes and is almost always less expensive.

People should not receive treatment and support in hospital if the same treatment and support can be safely provided in a non-hospital setting or in the community. All organisations – providers, commissioners, clinical commissioning groups, local authorities, the Department of Health and other bodies – must remain focused on ensuring all people with learning disabilities have the opportunity to move into personalised community services. This cannot be achieved by any one body in isolation.

Emphasis must be placed on preventing admissions. This will mean local authorities must ensure they commission providers with the necessary skills in the first place, such as providers who can demonstrate adherence to the Positive Behaviour Support model.

People should be supported in services that have the capability to support people with behaviour that challenges, where there is involvement from community networks such as psychologists, psychiatrists, behaviour analysts, nurses, speech and language therapists and social workers. Together with high quality support workers, they make it possible for people to live in their communities.

Best practice and commissioning

The NHS and commissioners must be mandated to follow the National Institute for Health and Care Excellence (NICE) best practice guidance – to involve the individual and their family in decision-making and procure services based on the suitability for the individual requiring support, rather than availability of provision.

The commissioning framework should cover the NHS, clinical commissioning groups and local authorities.

Local authority procurement must encourage service providers that deliver person-centred, evidence-based and innovative support. It must concentrate on outcomes set by the individual.

There must be a reduction in the number of in-patient settings through private sector closures. We want to see at least 50% of all in-patient settings closing, leaving a small number of spaces in each local area, as part of a local care pathway for short-term specialist support in times of real crisis.

Local government

Local Government must remove budgetary divisions, allowing resources to follow the individual, and transfer with them, when they move from one place to another. It should stimulate the specialist housing market, creating options (such as step up/ step down services) for people to be able to live in an appropriate environment.

It must be obliged to seek explicit and documented approval, or consent, from an individual to admit them to an inpatient setting. It must provide clear evidence that supports why an individual would be better off being admitted, than remaining in their own home and receiving treatment and support in the community.

Evidence should also be provided that discussions have taken place with the individual and their family, and decisions have been documented, particularly where there is disagreement.

A care plan must be in place on admission, which includes a date for discharge. This should be statutory. When people are placed in these services, the clear goal should be returning them to live in their homes. As such, clear and consistent thresholds for discharge should be defined. Individuals should be encouraged to request a transfer to a less-restrictive setting, a setting closer to home or to be discharged.

National government

National Government must modify funding arrangements between health and social care, so that there are incentives to move people from in-patient settings and discourage further development of large, impersonal facilities.

Regarding the proposed dowry arrangement, whereby the NHS funding automatically transfers to the local authority for people who have been in an institution for five years, the threshold must change to two years. The five year qualification may become an unintended disincentive for cash-strapped local authorities.

Government must be more ambitious in respect of people currently in ATUs. An ambition to get half of them out is not enough. We want to see a real commitment to developing local community-based services, which will require more funding and visionary thinking to acknowledge that this will save money in the long-term.

Take action

We are working with local authorities across England to help people with learning disabilities to find houses close to their families and friends, in communities they choose. We have the country’s largest team of behaviour support specialists and, together with highly-trained staff, can create a suitable service in the community for almost any individual.

Steve Scown is Chief Executive of Dimensions. Email: steve.scown@dimensions-uk.org Twitter: @SScown

You can read Dimensions’ full policy statement on ATUs at www.dimensions-uk.org/news-media/position-statements 

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