This case study forms part of the publication, Bespoke support for people with learning disabilities and autistic people, an evaluation on the impact consequence for local authorities and councils of delivering bespoke support to autistic people and people with a learning disability, including people who have been detained under the Mental Health Act (or at risk of being detained).
In this case study, the provider has shared their views and experiences of planning discharge for people with learning disabilities and autistic people with a forensic history.
First of all, it’s important to be clear what we are talking about when we refer to ‘forensics’. Many people with learning disabilities and autism find themselves admitted to medium and high-secure mental health inpatient units due to the perceived levels of risk to themselves and the public. Often, the police have been used as a way of managing the person’s behaviour because their current support provider have not had the skills or experience to support them positively, and the person has found themselves entering the criminal justice system without any support or reasonable adjustment to understand what is happening. Sadly, the police often don’t have the relevant skills or training to understand how to support people with learning disabilities and autism within their own systems and processes.
Some people may have been detained in this way because a secure inpatient setting was simply the only place where the person could be kept safe and prevented from causing harm to others. However, these inpatient settings were not designed for people with learning disabilities or autistic people, and the staff are unlikely to have received any specialist training in how to support them well in those settings. Environmentally, they are overwhelming, distressing and unsuitable for helping the person to return to ‘baseline’ and prepare for life back in the community.
Consequently, seclusion and segregation is used as a way of managing the person within the inpatient setting, and this can cause further trauma and an escalation in behavioural responses. In some cases, particularly in forensic settings, it may also create further victims. Effectively, the patient can become stuck.
There is a particular cohort of inpatients with learning disabilities and autism who are detained in hospital under the Mental Health Act due to offending behaviour. In these cases, a very specific area of the Mental Health Act framework applies, and there may be involvement from the Ministry of Justice in any plans for discharge due to the risk of re-offending.
The current forensic model works by responding after offending behaviour has occurred.
A proactive model would allow a response and intervention to early signs of offending behaviour, to prevent others becoming victims. The early signs within the offending cycle are identified and intervention prevents further crimes being committed. Funding for services and support seems to be sitting in the wrong place within the offending cycle."
The clear distinction in planning for discharge with a person who has a forensic risk history is that you are applying the principles of person-centred practice in the discharge planning, but the person at the centre of the process is the victim rather than the patient. Many of the same person-centred planning and thinking tools can be still applied for information, gathering and developing the person’s life plan, but the team carrying out the discharge planning work needs a clear understanding of the forensic model of community support.
The person’s wellbeing is still a central focus of the plan, but the plan needs to reflect that decision makers need to protect the community. In the provider’s experience, commissioners don’t always have forensic training or understanding of the difference in the approach when commissioning community support for people with a forensic history.
The forensic community support model needs to include shared risk and responsibility between commissioners and providers. There are far more safeguarding concerns raised in complex support settings. There should be transparency and an open forum to share information and review risk.
If safeguarding processes are used as a way to punish providers for incidents which have occurred, then no learning is done, and providers are not encouraged to be transparent about concerns they have. A shared risk approach enables a shared learning and proactive response approach to concerns."
Understanding needs to start with education. Very few learning disability nursing courses at Universities in the UK include any content around support for offenders with learning disabilities and autism, and the intersection with the Mental Health Act framework.
It’s a very specialist knowledge area, but often the forensic specialists in social care are the professionals who had to learn on the job. The problem with learning on the job is that you’re dealing with very high profile and potentially dangerous people, so you need to be educated before you go into the work.
Housing is another area of challenge in planning for discharge. It is extremely challenging to find housing for people with an offending history. Housing providers often place restrictions around offering properties to offenders. Support providers who are willing to provide social care support often get stuck due to challenges with identifying suitable properties.
Providers are often placed in a position where they are taking on all of the financial risk for securing housing for the person they are working alongside. There is often a challenge in marrying up the property and the support team being ready to start supporting the person at the same time. There is a financial risk to providers if they recruit and train staff before the property has been identified.
In terms of establishing robust and positive models of support in a community context, a real key to this is for providers to be able to supply high quality trained and skilled staff, who have good intuition and are able to work responsively.
The reality with the current social care workforce is that as providers we are asking people who worked in MacDonalds last week to come in on Monday and start being forensic specialists. People applying for support worker positions are effectively applying for minimum wage jobs. The work simply does not attract skilled and experienced practitioners unless you are able to offer a salary commensurate with the level of risk involved in the job role and the level of training and skill required. The model can work well, but only where the right resources, training and skills are applied in building the right support.
Unfortunately, in these type of high-cost support models, there is always pressure to reduce the cost of support as soon as the person supported appears to be doing well. Sadly, this often results in the person going back into crisis or re-offending and being re-admitted to hospital. This creates more patients, and more victims. There needs to be a longer-term view about cost-savings, rather than a narrow view of year-to-year budget management."