Black box thinking and the role of assessment and treatment units in the lives of people learning disabilities and challenging behaviour.
I’ve been reading Matthew Syed’s book “Black Box Thinking”. As a matter of principle I don’t normally read pop science, but Matthew had got a very complimentary mention in a parliamentary working group’s report on patient safety so I thought I’d give it a go. Anyway the book is about safety, risk and achieving high performance, and it was quite a relief for me to read that apparently failure is often a pre-requisite to success. It is a very good book and if you have ever failed or succeeded at anything it’s definitely worth a read and like most good books the important thing about it wasn’t just what I read, it was what it made me think once I started reading it.
At the moment apart from caring and developing a resource to support an organisation in its implementation of a new set of government standards , I am working on a website to support families who are trying to get their sons and daughters out of Assessment and Treatment Units. For those of you who don’t know, an Assessment and Treatment Unit is the name given to what is effectively a secure unit for people with learning disabilities, who also have behaviour that is usually described as challenging, but which might more accurately be described as behaviour that puts themselves or others at risk. But for the rest of the article I’ll stick with the term challenging although I will come back to the issue in another blog.
Anyway the idea behind ATUs is that people go into them for short periods of time so that packages of treatment and support can be put into place that will then allow them to return to their communities. The reality is somewhat less rosy. The average length of time that a person stays in such a unit is over 5 years, there is widespread use of drugs and physical restraint to manage behaviour and significant numbers of residents or detainees are considered to be impossible to place anywhere else.
Now you might say that this is unfortunate, you might view the existence of ATUs as a necessary component of provision for people with learning disabilities and challenging behaviour. Alternatively you might want to view the placement of a person with learning disabilities in an ATU as something else. You might see it as a denial of human rights. You might see it as an indicator of a failure of support; both the failure to support an individual and the failure to support a family and you might even see it as institutionalised abuse and on occasion assault.
The idea of the Assessment and Treatment Unit as part of a spectrum of provision is pretty much the status quo. The argument is that some people have needs that are so “complex” (click on the link to read an excellent blog by Chris Hatton on what is meant by the word complex) that they cannot be met within their communities, regardless of whether their normal “home”, is a home with their family, is one of their own, or is a group home with a number of their peers. In this world view the Assessment and Treatment Process is separate from everyday life and is usually a great distance from the communities in which people have lived. It is intrinsically medical and dependent upon medication and intensively behaviourist interventions to manage behaviour. The justification for it is the assessed threat that these individuals pose to themselves and the people around them.
But what if we view a person’s placement within an ATU as an injustice and a failure. What if we treated the placement of an individual in an Assessment and Treatment Unit as a kind of personal black box incident? A failure that requires thorough investigation and the best efforts of all concerned understand, to learn from and to remedy. This is the approach that the government adopts towards patient safety so lets take the same approach and use it on the quality of the services that they provide. If we do that then the drive and impetus to get people out of Assessment and Treatment Units will be all the greater and will make it more likely that we will be able to overcome the current inertia that seems to be hampering current initiatives to get people back into their communities. But if we accept that the placement of an individual in an ATU is a failure how do we go about assessing and measuring that failure and through that assessment identify how such failures might be avoided in the future.
Fortunately many of the indicators required for assessing failure have already been identified. They exist in the form of the “The New Service Model” from the government’s policy “Building the Right Support” which is part of its Transforming Care Programme. The New Service Model comprises of a set of nine principles – well actually they are sets of principles and they actually add up to over 34 – but I guess nine sounds much easier for people in Trusts and Local Authorities to implement. Either way they provide us with a perfect starting point in developing a framework with which to assess “the placement of an individual in an ATU as failure “. It’s important to note that most of the principles outlined in Building the Right Support should already be in place from previous initiatives.
Building the Right Support’s – Nine Principles – the building blocks of success or indicators of failure
Using the Nine principles as the basis of good practice it is reasonable to identify their absence as indicators of failure.
So where Principle One of Building the Right Support identifies:
- A Right to a Good and Meaningful life based on:
- Inclusion in activities and services
- Education, Training and Employment
- Relationships with people
- Support to do things
The failure to provide these things would be expected to be indicators of failure – the same would apply to the other eight principles.
- A Person-centred care and support plan based on early and pro-active intervention that is key-worked to ensure effective co-ordination.
- People should have choice and control over how their support needs are met with information provided in a range of formats, with personal budgets and access to independent advocacy
- Support to my family and paid staff including:
- Support and training for families and carers
- Short break/respite
- Alternative short-term accommodation
- Trained support and care staff
- Where I live and who I live with
- Choice of housing and who I live with
- Security of tenure
- Strategic housing planning
- Mainstream health services
- Annual health checks
- Health Action Plans & Hospital Passports
- Liaison workers
- Quality Checkers
- Reasonable Adjustments
- & 8 – Specialist Multi-disciplinary health and social care support in the community
- Specialist health and social care support for people
- Intensive 24/7 function
- Specialist forensic support
- Inter-agency collaborative working including with mainstream services
- Liaison and diversion
- Integrated with Community Services
- Admissions based on a clear rationale
- Discharge planning
- Reviews of Care and Treatment (CTRs)
Building the Right Support p.26
So when we start building the website for families one of the things that I think that we should do is build a quality checklist, based on the indicators of the New Service Model and others. We would use it to evaluate the extent to which individuals and families were, and are being provided with the kind of support that the government itself believes is required to support people with learning disabilities and challenging behaviour within their communities. We will also base it on existing legislation and legal responsibilities. So that families will have a clearer picture of their legal position set within the context of a local authorities wider performance.
If we do this we will be able to develop a detailed picture of the reasons why an individual has had to go into an ATU and also challenge trusts and authorities that are failing to put sufficient support in place to get people out. We will be creating our own “black box” with which to challenge individual and systemic failure.
Building the Right Support promises to make things different and that is a bold promise – well if it doesn’t we’ll be the first to let them know.