Community Intellectual Disability Services in the UK.

Ken Courtenay argues that the UK’s Community ID Services model can provide greater benefits than the hospital system to people with intellectual disabilities.

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  • Community services for people with Intellectual Disability (ID) are well-established in the UK.
  • There are multi-disciplinary teams that usually include Psychiatrists, Psychologists, ID Nurses, Occupational Therapists, Speech Therapists, Physiotherapists, and Social Workers.
  • Since 2003 there has been a move towards merging health teams with social care teams under one joint structure.
  • The advantages of joint health and social care teams is to bring professionals together who are working with the same group of people.
  • For people with ID and their families and carers, there should be a more efficient and smooth service.
  • The major issue affecting community teams is staff recruitment, especially to nursing posts.
  • Brexit poses a great threat in potentially cutting off the flow of EU citizens in to the UK health and social care workforce.

Background

Community services for people with Intellectual Disability (ID) are well-established in the UK, having a long history of providing support to adults and children with ID and their families. The role of community services includes providing direct care and supporting people with ID to gain access to the mainstream services to which they are entitled, e.g. GP services. Legislation and policy have been useful in ensuring progress is made to enable services and agencies to be more inclusive of people with ID living in the community (Equality Act 2010; DDA 1995).

Community Services

The models of community services in ID are essentially multi-disciplinary teams with a range of professionals that usually include Psychiatrists, Psychologists, ID Nurses, Occupational Therapists, Speech Therapists, Physiotherapists, and Social Workers with a complement of team managers. Historically, there have been health teams in the NHS and Social Care ID teams in local Social Services departments. Since 2003 there has been a move towards integrating services by merging health teams with social care teams under one joint management structure. In England and Wales, this has been achieved under legislative changes to the NHS where one agency is the lead agent in managing the combined services (Britain, G. 2006). The members of joint teams remain employees of their employing organisations, retaining their professional support and employment rights, but are managed on a day-to-day basis by a joint team management structure reporting to all provider organisations in the service. It is the role of Commissioners of services to fund those services – however, this model does not exist in all ID services since it is left to local choice to decide which model suits local need.

Benefits of Community Services

The advantages of joint health and social care teams is to bring professionals together who are working with the same group of people, allowing for more seamless care between the respective agencies. Mental health care is embedded in community teams with physical health care and social care. The services tend to develop their own identity, with workers identifying with the joint team more, perhaps, than with their employing organisation. Between professionals there is the potential for better understanding of each other’s roles and responsibilities, reducing disputes over who should do what. A single IT system facilitates collaborative working between professionals. Seeking the opinion of other professionals should be without difficulty, since colleagues are usually located in the same work space, allowing professional relationships to grow. Establishing clear eligibility criteria for services assists in services defining the people they work with and therefore the best and most efficient use of resources.

For people with ID and their families and carers, there should be less repetition of their stories when seeking support from a joint service. Equally, when problems arise for the person they can be dealt with efficiently through a team response, especially when working with people whose needs are great and for whom the risk of harm or placement breakdown is high. Joint teams can develop and co-produce collaborative, robust care plans, with input from a range of professions and carers to support the person. Combining health and social care budgets under one management structure  allows services to have flexibility on how funding is used, with the potential for creativity in employing staff and using resources e.g. respite care or enhanced support, when needed temporarily.

Challenges to Community Services

The model of Community ID Services is not perfect or universal in Adult or Children’s services. Children’s services are often the least developed compared with Adult services, in spite of childhood being a time when the benefit of family support is greatest. The ‘Transforming Care Programme’ following the scandal of Winterbourne View Hospital in 2011, is the greatest challenge to all services in the UK including in-patient and forensic services (NHS England 2015). The task is to reduce the 3,000 in-patient beds by half by 2019.

Community services are under pressure to meet the support needs of people who have often spent much of their adult lives in hospitals or restricted settings and need to adjust to living in the community. Finding local providers who have the skills and resilience to support people with such high needs is often a daunting task that requires creative thinking in planning and commissioning services. The risk of breakdown in the person’s care package is high without the right planning in place. Personally, I have witnessed some excellent transitions of people in to the community after years of in-patient care, demonstrating that people can live more independently in the community with the right support as outlined in NHS England’s policy ‘Building the Right Support’ (NHS England 2015).

The major issue affecting community teams is staff recruitment, especially to nursing posts. Training bursaries have been cut, making it less affordable for students to pursue their interest in training as ID nurses. Recruitment to all professional groups is difficult at present, for a variety of reasons, and that has direct impacts on delivering services. Brexit poses a great threat in potentially cutting off the flow of EU citizens in to the UK health and social care workforce.

Within joint teams, there are often cultural differences between organisations where a strong NHS culture among health staff meets an equally strong Local Authority culture. NHS staff value and adhere to their professional identities and practices, especially with regard to the application of Clinical Governance and Quality Improvement initiatives.

The role of IT should be to facilitate and enhance working together. However, health services and social care services often do not communicate with each other. Problems arise when people are admitted to hospitals that use separate IT systems to the community teams, and thus create a barrier to efficient and informed care; that could lead to inappropriate treatment or unnecessarily long admissions.

Conclusion

The model of Community ID Services works well with good workforce, good leadership, and competent management who have a clear vision for their services. Putting the person with ID at the centre of the work of community teams is essential in supporting people to live more independent lives in the community. The challenges to services include recruitment of staff, integration of supporting technology, and supporting people to live in the community. Overall, local community services in ID are more economic and more humane than hospital care, which is often provided at a great distance from the person’s place of origin. There are challenges to community ID services, but it falls to professionals and families to advocate for good responsive community support for people with ID.

References

Act, E., 2010. Equality Act. The Stationary Office, London.

Parliament, U.K., 2005. Disability Discrimination Act. Office of Public Sector Information.

Britain, G., 2006. National Health Service (Consequential Provisions) Act 2006: Elizabeth II. Stationery Office.

England, N.H.S., 2015. Transforming Care for People with Learning Disabilities – next steps. England, NHS England.

England, N.H.S., 2015. Building the Right Support: a national plan to develop community services and close in-patient facilities for people with a Learning Disability and / or Autism who display behaviour that challenges, including those with a mental health condition. NHS England, London.

KenKen Courtenay is Consultant Psychiatrist in Intellectual Disability at Barnet Enfield and Haringey Mental Health NHS Trust London UK. He is also Vice-Chair at the Faculty of Psychiatry of Intellectual Disability, Royal College of Psychiatrists UK. His interests include Mental Health in ID, Autism, Down Syndrome and Community Services.

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