Coming home: complex care needs and out of area placements 2018

7 Conclusions and Recommendations

7.1 Values and Principles

it is important to outline the values and principles on which all of this work is based. All recommendations made in this report should be viewed in the context of the following:

7.1.1 Human Rights

Fundamental to the values on which this report is based is that people with learning disabilities have the same human rights as anyone else, and that these rights are not reduced by the level of their disabilities or the complexity of their needs. It is clear that the experience of people with learning disabilities being unable to receive support to live within their local communities, but instead having to move far from home or even to live for long periods of time within hospital settings, is a denigration of their human rights. Any attempt to move away from the current situation and to create a new dynamic in how support is provided, must recognise that this is fundamentally a human rights issue and must be addressed with the urgency that that context indicates.

7.1.2 Maximising Choice and Control

All recommendations within this report are based on a commitment to maximising the control people with learning disabilities have over their own lives, and the opportunities they have to make choices. This commitment does not change when people have severe learning disabilities, complex needs, or communication difficulties. In the context of this report in relation to out-of-area and hospital placements, individuals having choice about where they live and who they live with, are particularly relevant.

7.1.3 Prevention and Early Intervention

Challenging behaviours are a key characteristic of people with learning disabilities who are described as having complex needs. All research evidence and practice-based knowledge demonstrates that challenging behaviours develop at an early age, usually in childhood. It is therefore imperative to have a focus on early intervention for children with learning disabilities, particularly those with additional support needs such as autism or significant communication difficulties, as these are the group most at risk of developing challenging behaviours.

7.1.4 A Whole Life Approach

Traditionally, services to people with learning disabilities have been siloed into adult services, and child services, with little interaction or joint working between the two. This applies to policy as well as service provision, throughout different agencies and services. Finding support solutions for people with complex needs will require a whole life approach, with a fundamental commitment to closer working between adult and child services, and a focus on future planning from an early age.

7.2 Theme One: Strengthening Community Services

It is clear that a simple focus on discharging people from hospital will not reduce overall numbers, if these individuals are replaced by new admissions. A key element therefore to the successful reduction of use of hospital beds, and to the reduction of out-of-area placements, is for the strengthening of services within the local community. There must be a focus on strengthening the capacity of the community to develop good quality, safe and resilient services, with the right kind of accommodation and staff with the right kind of skills, in order to reduce the need for hospital admission and out-of-area placements, and to reduce the length of admissions when these are necessary.

7.2.1 Crisis Support

An important requirement in having strong community services is that these services are able to deal with crises; to manage them when they occur and bring the situation back to a period of stability, where any longer-term support issues can be addressed. Developing stronger and more resilient community services that can be supported to work through crises without the need for admission to hospital or use of an out-of-area placement is fundamental to reducing the use of these placements over the long-term. Health and Social Care Partnerships (HSCPs) should consider making crisis support available to community services in order to strengthen and maintain these services. This is likely to require specialist support across a range of systems, involving close collaboration between services and agencies.

This crisis support could be provided in a number of ways, depending on local arrangements, and it may be possible for HSCPs to work together to develop this type of service, especially for the smaller HSCPs. It would require the ability to provide staff at short notice, who are skilled in working with people with challenging behaviours and other additional needs, such as communication difficulties or autism.

One option for this type of crisis support is that it could come from the local assessment and treatment unit, where inpatient health staff could be seconded on a short-term basis to provide crisis support to community placements. The costs for these staff would need to be considered, and could potentially be met by the HSCP for specific periods of time to bolster a struggling service.

Another option is that this support could be provided by integrated learning disability teams; this may have the advantage of providing staff already known to the individual. Any change in role from for learning disability teams would need roles and expectations defined differently, and would also require additional training to develop expertise to provide this type of crisis intervention. There may also be a role here for other HSCP resources to be used to provide support, or even specifically commissioned third sector teams.

Crisis support could also be provided by specially developed Intensive Support Teams. For some HSCPs this may be seen as the most appropriate model, and it is a model that is reported to have been successful in some areas in the past.

Whatever the model of the service, the input provided should be multi-disciplinary, with an emphasis on providing direct support, rather than being limited to advice, training, or consultation. Access should be 24/7, with the ability to provide direct support either in the family home or other settings such as social care services, schools, respite facility, or other community setting. The purpose of this support would be to provide a local alternative to admission to hospital, and must therefore be flexible and available outwith office hours.

The model of support provided should be Positive Behavioural Support (PBS), and the support must have the ability to respond to a sudden escalation of behaviour with a range of proactive and reactive strategies, including the ability to respond to the most physically challenging and high-risk behaviours.

7.2.2 Flexible Support Responses

In addition to strengthening community services in times of crisis, this report has also highlighted the need for more flexible support responses to be used in community settings, in order to avoid the use of out-of-area placements or hospital admission. This could be approached in a number of ways depending on local circumstances, but it is recommended that HSCPs take a flexible and creative approach to problem-solving individual situations in order to provide local alternatives to admission to hospital or out-of-area placements.

Flexibility in budgets, via a contingency fund, would allow for bespoke, person-centred decisions to be made locally. This type of flexibility could allow for creative options to be quickly explored at times of crisis, for example, to take someone away on holiday instead of being admitted to hospital, or if a family carer falls sick, then they are accommodated elsewhere, while support staff move into the family home to support the individual, thus minimising disruption to the person and minimising the potential for challenging behaviour leading to crisis and placement breakdown. Although it is acknowledged that budgets may be tight, there are some HSCPs which are already successfully adopting this type of approach in for specific situations.

Another option could be to develop the provision of short-term respite or 'places of safety'; these could perhaps be developed on a regional basis, to allow cost-sharing and flexibility of use. This would provide assessment if needed but primarily would be to give the full-time carers a break. This could also be used on a proactive basis, before things become fully at crisis point.

Intensive short breaks services may also prevent family placement breakdown, with an aim to keep children in their family homes and communities on a long-term basis. This would deliver intensive support for the child, provided by staff skilled and experienced in supporting people with challenging behaviours, and would give parents a break in order to better continue their caring role over the long-term.

7.2.3 Support for Family Carers

Although this project focused on adults from 16 upwards, there are a number of themes that have emerged in relation to children and young people; one of these is the need for increased support for family carers, particularly in relation to behavioural challenges and how best to work through these in a family setting. The NICE guidelines for people with learning disabilities (NICE, 2018) also recommend increased support for families and carers to reduce the need for people to move away from their homes and communities for care, education or treatment.

This is something that HSCPs should be considering in order to have the right support available. This support may take a number of forms; it may include help to keep people at home via respite, therapeutic short breaks, direct support in the home, and the provision of an out-of-hours support service. It may also include providing information and support for family carers via family networks, peer support, carer forums and advocacy.

Support for family carers may also be provided via offering opportunities for training, particularly in areas such as PBS, communication, mindfulness, and the safe use of physical interventions.

More availability of support from learning disability specific CAMHS services, would support a preventative approach aimed at reducing challenging behaviour at an early age, and would be helpful in terms of impact on future services, as well as on long-term outcomes for the individuals concerned. Early intervention is recognised as the most effective way of preventing long-term breakdown of family and service placements. There is a range of evidence available through good practice documents and also via research, that early intervention PBS in particular may prevent school exclusions, family breakdown, out-of-area schooling, and hospital placements.

7.2.4 Strengthening Social Care Providers

Social care providers are a key element of addressing the issues of hospital and out-of-area placements for people with learning disabilities and complex needs. If these providers can be supported to become more successful in supporting people with complex needs, regardless of behavioural crisis or escalation of challenges, then service breakdown will become much less common. In order to achieve stronger social care providers there are a number of factors to consider.

Recruitment and retention issues within social care are widespread and well-known, with many HSCPs and provider organisations commenting on the challenges they face in recruiting and retaining the number and quality of staff required. Many providers report this to be particularly difficult for complex services where the work may be more challenging, with higher risks to staff and greater skills required in terms of the support provided. This issue is currently being considered via a COSLA/ Scottish Government working group.

There may be a need to consider whether remuneration needs to be more reflective of more complex work, and to explore options for how this could be achieved. There could also be consideration of how social care providers evidence the training, support, and management oversight that they provide to their staff who work within complex services, as research indicates that staff who feel well-supported and receive effective practice leadership provide a better service, and are more likely to be able to work successfully with those individuals who have complex needs.

7.2.5 Risk Register

Better local monitoring of those at risk of admission, by people who know the person, who can make decisions, and have access to funding may assist in preventing admission, particularly where these people have some flexibility in how they problem-solve at a local level.

HSCPs, working with service providers, community health teams and families, should have local risk management strategies in place to identify those who are at risk of placement breakdown leading to hospital admission or out-of-area placement. This could be achieved via a risk register process. This should mean regular reviews and a link in to the development of crisis contingency planning, in order to avoid placement breakdown, and should be effective in providing better anticipatory care planning. Risk of admission should be viewed by HSCPs as a critical event in a person's life, resulting in prioritised care management.

7.2.6 Recommendations in Theme One: Strengthening Community Services

Recommendation 1: HSCPs should develop options for access to crisis services for people with learning disabilities and complex needs, with a view to providing direct support to service provider or family placements which are at risk of breakdown.

Recommendation 2: HSCPs should consider the role of flexible support responses, to be used when placements are experiencing significant difficulty. The need for these should be informed by the use of risk registers to identify individuals at risk of out-of-area or hospital placement.

Recommendation 3: HSCPs should ensure that greater consideration is given to family support for the family carers of people with learning disabilities and complex needs.

7.3 Theme Two: Developing Commissioning and Service Planning

The planning and commissioning of services for people with complex needs has been one of the significant themes in this report and there are a number of important conclusions in relation to commissioning.

7.3.1 Co-production Commissioning

Commissioning should be approached in a spirit of co-production; that is, commissioners working together with family carers to design services, a partnership approach between families and professionals; creating a team around the person, incorporating both multi-disciplinary professionals and family, so that people who know and care about the individual specify the care and support plan on which commissioning is based. This is essentially a person-centred approach to commissioning that focuses on outcomes for the individual, recognising that designing the right support for people is not about imposing a one size fits all solution, but is about listening to what each individual needs to live their own life, and building support based on those needs. It is a commitment to working in partnership with the people who use services and their families, in order to create a catalyst for change, in the belief that everyone is an expert on their own life and that everyone has something to contribute.

The recent NICE guideline on service design and delivery for people with learning disabilities and behavioural challenges (NICE, 2018) contains guidance to help commissioners focus on prevention and early intervention, to enable people with learning disabilities to live in their communities and calls for people to be able to have control over the support they receive and lives they lead. This may involve people with learning disabilities and their families sharing their lived experience of services and the learning for the future that can be gained from their experience; advising on new models of service to be developed locally or nationally; designing performance indicators for quality services; and inspecting or auditing services to advise on their suitability for people with complex needs. This may involve the use of advocates and those skilled in the use of alternative communication systems such as Talking Mats, in order to genuinely obtain the views of people whose verbal communication may be limited.

7.3.2 Commissioning for the Future

The evidence from this report suggests that complex support services are often developed in a reactive way, on a person by person basis. A longer-term approach to planning is needed in order to support commissioning for the future, for example tracking complex individuals from an early age, to have a better knowledge about what kind of support need is anticipated, and to be able to proactively plan appropriate services to meet these needs. This may include analysing information from schools and residential schools, in terms of exclusions and behavioural challenges faced in the school environment, as well as information from Children & Families Social Work teams. This includes focused planning for young people coming from school in order to map their future needs, and working with transition teams to achieve better transition support from child to adult services.

This is about understanding what we want from our market and shaping it; planning on the basis of systematic analysis of local data, population profiles, and user experience. This is a collaborative and integrated approach to commissioning across the whole system, to ensure strategic service change and improvement. Part of this may be about bringing together commissioning colleagues to share local knowledge and set local priorities and plan ahead, perhaps working together to commission regionally across local authority boundaries. People with complex needs are a comparatively small group and if HSCPs continue to commission individually, then there is a danger that services will continue to be piecemeal, set up on a one by one basis, with a lack of proactive planning.

It is clear that in many cases the current system focuses less on early intervention and spends more on crisis management. There are in some cases financial de-incentives to discharge; over time integration may change this, but so far this does not often appear to be the case.

7.3.3 Skilling up Commissioners and Care Inspectors

Good commissioning requires a whole-system perspective, with an understanding of the population need, of local resources and of best practice. Commissioners should be commissioning good lives, not just services; and services that isolate individuals from their communities should no longer be commissioned. Commissioners have the opportunity to be leaders of cultural change and to be the strategic leaders in achieving systemic changes in how services are commissioned.

It is recognised that the group of individuals referred to in this report have very complex needs and that specialist knowledge of their support needs can provide a challenge to commissioners, particularly as they are a small group for whom they do not regularly commission services. It may therefore be that training for commissioners to support them with complex needs commissioning would be helpful, as would the opportunity to share experience, skills and learning between commissioning teams across the country.

All commissioning activity should support the development of person-centred services and a sustainable model of care, with the necessary staff support and skills made available, and commissioning should focus on achieving outcomes for the individuals using services. There is a link here with the role of the Care Inspectorate; and it may be helpful for there to be support provided for Care Inspectors who are responsible for inspecting services for people with learning disabilities and complex needs.

This expertise in complex needs being provided to Care Inspectors may also assist in ensuring that social care providers are held accountable for their commitments made during the commissioning process. Creating a stronger link between contract monitoring and the original commissioning specification, with an emphasis on ongoing reviews for individuals with complex needs, may be helpful to support with increased provider responsibility.

7.3.4 Use of Assessment and Treatment Units

There is a need to develop a new understanding of the role and function of inpatient services, which goes hand in hand with development of community supports. Some people will continue to need high-quality inpatient services because of a genuine need for assessment and treatment of their mental health. However, challenging behaviour is not a reason for admission to hospital, and crises in relation to challenging behaviour should be addressed in other more proactive ways as already described.

Where possible, admissions should not be on a crisis basis, but should give the assessment and treatment unit staff an opportunity to get to know the individual at home in familiar surroundings, by working alongside the current provider for a period of time, and to carry out a range of assessments prior to admission, so that they are better placed to help plan and support discharge. Other than in an emergency admission, when admission is being considered, a review meeting should be held with all relevant individuals, including the person themselves if appropriate, and their family. It would be helpful for the discussion to also include a practitioner with expertise in complex needs and challenging behaviour who is not clinically responsible for the individual, in order to have an independent expert voice. Options other than admission should be comprehensively explored.

When an individual is admitted to an assessment and treatment unit, it is helpful if service providers stay involved in the person's support. This is partly to provide continuity of support and reassurance to the individual, but also because loss of placement is linked with a longer stay in hospital. This could involve continuing some aspect of support while the person is in hospital, in order to work towards maintaining the placement, keeping familiar relationships, and more proactively working towards discharge. Funding would need to be made available to support this, and it may need to become part of the contract at time of commissioning.

Discharge plans should be set from point of admission. Discharge for even the most challenging individuals, should be achieved at no more than 12 months after admission; this is to give sufficient time for assessment, time to plan and develop a new service. However, this does not imply that there should not be an aspiration to achieve discharge sooner than 12 months.

As part of the process of discharge for those with challenging behaviour, assessment and treatment units should adopt PBS as their model of support and ensure all staff are trained in its use, and PBS should be integrated into the broader pathway for discharge into community services.

An increased focus on delayed discharge within learning disabilities could be helpful in prioritising this group, therefore separate reporting for learning disability delayed discharge would be helpful.

7.3.5 Discharge/Repatriation Pathway

This report has highlighted the issue that for some people, once they are placed out-of-area or in hospital, there is a sense that they lose contact with local community services, and may appear to be forgotten about. Regular multi-disciplinary reviews should be held while the person is out-of-area or in hospital, perhaps using the Care Programme Approach, or equivalent; these should occur on at least a 6-monthly basis. In addition to family members, this should include all relevant professionals involved in the person's support (attending either in person or by teleconference), both in the current placement and in the funding HSCP. This would bring a level of regular scrutiny and accountability in terms of discharge and repatriation. As with reviews prior to admission, a practitioner with expertise in complex needs and challenging behaviour who is not clinically responsible for the individual, should also be included, in order to have an independent expert voice. The focus of these reviews should be in making the commissioning team accountable, and would give the person, their family and the multi-disciplinary group confidence that work is proceeding towards discharge/repatriation.

Transition out of hospital or back to their local community should be done on a person-specific basis, and best practice suggests that for those with challenging behaviour this should be based on a functional assessment of the person's behaviour and a full PBS plan to support their move back into their local community. Transitions may need to be lengthy and require to be funded appropriately to ensure the best possibility for success. This includes consultation about the physical accommodation, including anyone that the person will share with, as well as an understanding of the type and amount of support required.

It could be helpful for HSCPs to consider the creation of a role in each HSCP to lead on repatriation or discharge; this would assist with bringing a level of focus and attention to these individuals, and would also create a single point of contact for any work on discharge or repatriation. At the moment, there may be a lack of a line of sight for some individuals, where a range of professionals are involved but there is not a clear lead in terms of responsibility for repatriation/discharge. A complex needs repatriation/discharge pathway could also be developed locally by HSCPs and adapted as required for individual needs

7.3.6 Housing Solutions

Lack of suitable accommodation was described as the biggest barrier both for the priority to return group and also for those whose discharge is delayed, with it being the main barrier for around half the individuals in both groups. This indicates a new approach to providing housing is required, with some focused planning on the type of housing and service models that may be necessary to meet the needs of the most complex individuals.

Commissioners should work with local housing providers to plan how to meet the housing needs of individuals with a learning disability and complex needs. They should ensure that a range of housing options and models of service are available, which enable individuals to live in their local communities, close to their family members if they wish and that options are available in terms of whether people choose to live with others, or would be best supported to live alone.

Particular examples of good housing models discussed during the work of this project included modular builds to provide bespoke and robust housing solutions; and core and cluster models, which combine the opportunity for an individual person-specific service, within the security of a larger support team, allowing for back-up and opportunity to rotate staff where required. There was recognition that for some very challenging individuals, individual supported living packages could be a very difficult model to sustain, both in terms of isolation for the individual, and in terms of lack of back-up and emergency support for staff.

Consideration should be given to how joint commissioning plans can address housing for this group, and also whether housing contribution statements specifically for people with complex needs would be a helpful way forward.

7.3.7 Regional Models

In relation to those who are placed out-of-area inappropriately, and are priority to return, it has been difficult to present accurate financial costs for these services, due to incomplete reporting of figures across Scotland. However, even from the information received, it is clear that there are substantial sums of money spent on this relatively small group of complex individuals. Adding together the spending of HSCPs within health board areas, it can be seen that five health board areas are spending over two million pounds per year each, and another four health boards areas are spending over a million pounds a year each, on this small group of 109 out-of-area people who are a priority to return. Consideration should therefore be given to alternative models that could potentially produce cost savings over time and would offer better outcomes for the individuals concerned. It may be that HSCPs within health board areas, or within wider MCN (Managed Care Network) areas, could work together to consider regional solutions for their shared challenges.

This report found 79 people currently supported out of Scotland, of whom 47 were not there through choice and 17 of those who were described as requiring repatriation. This small group needs more focused attention; this is a group who are particularly challenging to support, with over 80% having challenging behaviour and over half being autistic. Although small, they are also an expensive group, with over half costing more than £200,000 annually. Consideration should be given as to whether a better solution could be found by HSCPs working together and rather than commissioning for each of these individuals separately e.g. whether development of a regional resource could not better meet their needs. A regional service may be helpful for those with the highest levels of need, who may require extremely high ratios of support and may benefit for a period of time, from a very robust and secure environment. This would avoid so many individuals being transferred to England due to lack of suitable services within Scotland, and it may also provide financial benefits for individual HSCPs.

7.3.8 Service Models

In relation to models of support, there are currently a range of different models used to support this group, and there are examples of good practice and successful support in each of these models. This report does not therefore recommend a particular model, but recognises that to offer a person-centred service, a range of models may be provided across Scotland, including residential services, individual supported living, core and cluster, and secure settings.

There may also be a need to consider hybrid health and social care models which may be a helpful option for some individuals, providing additional benefits from having health care staff as part to the support team, working alongside social care staff.

Clearly it is important that any models of support are selected on a person-centred basis, not purely as a means for cost savings or economies of scale. Large institutional services should not be seen as the way forward, and in particular former institutions should not be re-commissioned and badged as community living, unless that is what they genuinely provide. Any service model which restricts opportunity for community living should not be commissioned.

7.3.9 Recommendations in Theme Two: Commissioning and Service Planning

Recommendation 4: HSCPs should take a more proactive approach to planning and commissioning services. This should include working with children's services and transitions teams; the use of co-production and person-centred approaches to commissioning; and HSCPs working together to jointly commission services.

Recommendation 5: HSCPs should identify suitable housing options for this group and link commissioning plans with housing plans locally.

7.4 Theme Three: Workforce Development in PBS

Building a workforce competent in PBS is a critical step to improve support services to individuals with learning disabilities, and PBS training is a key element in achieving this. The information in this report indicates that the individuals who are the subject of this report would benefit from PBS-informed services; the group is primarily moderate to severely learning disabled and challenging behaviour is the biggest cause for hospital admission or out-of-area placement. This is therefore a group likely to benefit from PBS input, and a strategic approach to workforce development in PBS should be developed across services in Scotland.

7.4.1 PBS Training & Qualifications

This report found that on the whole, social care providers are poorly trained in PBS and there is a lack of clarity what PBS is, with some providers appearing to equate it with training from restraint providers. A programme of PBS training should be launched across the health and social care sector with a number of levels of training, including accredited and non-accredited. This training should be mandatory for providers wishing to support individuals with complex needs and challenging behaviours. Although there is currently no sector accredited PBS training, the PBS Academy suggested that there should be at least three levels of PBS training to reflect the PBS Competence Framework (PBS Academy, 2015). These levels are: foundation (those responsible for providing direct support); intermediate (those responsible for facilitating the implementation of PBS, in supervisory or clinical roles); and advanced (those responsible for embedding PBS into services and building capacity). In order to systematically introduce PBS into care provider organisations, all three levels of training are required.

PBS training should be sponsored by the Scottish Government, with training made available at reduced costs to social care providers for a period of time, in order to create a critical mass of PBS-skilled practitioners. The Scottish Government should seek partnership with a university in order to develop this training.

7.4.1.1 Delivery of Training

Training must be delivered in a way that promotes generalisation and maintenance, so that PBS skills learned can be used in a variety of contexts over a period of time, and there is a need to intersperse teaching with supported application via a longitudinal training format, which is combined with periods of practice in the service setting and supported by coaching and mentoring.

PBS expertise is essential for those leading PBS: it is important for those delivering training and leading on the implementation of PBS to be themselves professionally qualified and experienced in PBS (NICE, 2018). There is a lack of accredited training in PBS in Scotland, with the result that many Scottish services have very limited skills in providing PBS-informed services. PBS is used more widely in health services, and there has been PBS training at an introductory level delivered to some health staff; however, more in-depth PBS knowledge and experience is limited here also, particularly for those providing direct support.

7.4.1.2 Practice Leadership

There is also a need for practice leadership to take any PBS training from theory to practice. The use of strong practice leaders with a commitment to PBS is an essential support mechanism to successful and comprehensive implementation of PBS. Practice leadership ensures that PBS is genuinely incorporated into direct care staff's practice, so that PBS is embedded within day-to-day ways of working (Mansell & Beadle-Brown, 2012). Practice leadership has increasingly become regarded as an essential part of developing a PBS culture within organisations and practice leaders have a role in facilitating implementation of PBS via coaching, role modelling and providing ongoing support.

The wider literature on implementation science may also useful to consider here in terms of addressing translation gaps from training to practice. Implementation science promotes the systematic uptake of training into routine practice, and it stresses the role of on-the-job coaching and performance feedback. Within a practice leadership model, those leading on the implementation of PBS should observe staff regularly, model good support, and give feedback. Training in PBS should include teaching around practice leadership, so that participants are taught how to undertake a practice leadership role.

7.4.1.3 Whole-Systems Approaches

PBS is also a whole-systems approach and is most effective when not seen in isolation from the rest of the organisation; in order to be implemented at optimum level, it requires to be embedded into policy and practice, with comprehensive changes made to systems and structures, and with PBS knowledge and practice being introduced across organisations and within services. A range of literature over many years refers to the fact that building PBS capacity at organisational level is essential and PBS training should address capacity building, resulting in systems change, not just change for the individual (Mansell Report, DOH, 1993).

Denne et al (2015) suggested an approach to workforce development in PBS which included the need to create cultural change including policies and operational procedures that promote PBS, and contractual arrangements that require PBS. PBS training would need to be supported by the organisation's culture, infrastructure, policies and procedures. This is about building the capacity of organisations to implement PBS systemically, rather than merely delivering PBS training within a service or organisation where organisational support and buy-in are lacking. Developing local capacity and the competence of everyone involved in the delivery of support to people with learning disabilities is critical to the successful implementation of PBS.

7.4.2 Community of Practice

In order to strengthen the use of PBS throughout services, it would be helpful to establish a Community of Practice in PBS. Communities of Practice are a concept that have successfully been applied to a range of areas and support the promotion of specific approaches. It is felt that Scotland would benefit from a Community of Practice around the implementation of PBS which would be focused on developing national learning resources, coordinating and supporting the implementation of PBS, offering guidance on policies relevant to individuals that challenge, and providing best practice examples of PBS.

7.4.3 Recommendations in Theme Three: Workforce Development in PBS

Recommendation 6: The Scottish Government should seek partnership with a university to provide PBS training across the health and social care workforce in relation to people with learning disabilities and complex needs.

Recommendation 7: The Scottish Government should support the establishment of a PBS Community of Practice.

7.5 Next Steps

To address the issues outlined in this report will require transformational change across the support systems that are currently in place for people with complex needs. This needs whole-system change, multi-agency approaches, across government, and across sectors. The next steps are therefore pivotal in taking the findings of this report forward from paper to practice. Key to this process is the policy lead from the Scottish Government, and support for a strategic approach to implementation from the HSCPs around Scotland. As a refreshed framework for The keys to life is anticipated, this would provide a means to take forward the implementation of this report.

In order to achieve the transformational change described in this report, there are a number of recommendations which will require to be taken forward by HSCPs, in order to achieve a redesign of systems and services for people with learning disabilities and complex needs. HSCP Chief Officers should consider the findings and recommendations of this report, and nominate a local lead to address the recommendations, and to coordinate these recommendations being adopted into local practice.

It may be that HSCPs wish to work together, to create a local change management working group which could coordinate a range of work based on the themes of this report, i.e. strengthening community services, developing commissioning and service planning, and workforce development in PBS. This group would also be responsible for mapping out a timetable for change, with clear targets and timescales; this is important in order to ensure momentum is sustained. This would involve regular communication, and delivering consistent messages about progress so that all stakeholders know what is happening and how any changes will affect them.

Throughout this process there is a need to continue listen to the sector, to get commitment and create a shared ownership of ideas, through shared understanding of what we are doing and why. Building credibility and trust will be vital, and creating opportunities for dialogue and discussion. HSCP engagement with social care providers will also be essential as it is they who must step up to provide better community-based support which can support individuals with the most complex needs and challenging behaviours. This will require strong leadership throughout service provider agencies.

It is clear that there are many examples of good practice in support for people with learning disabilities and complex needs already in place around the country. There are also some HSCPs who have progressed further than others with their development of support for this group. It would be useful for these HSCPs to share their learning around solutions to common problems with other HSCPs across Scotland, and this could perhaps best be done under the auspices of the Social Work Scotland group. A series of good practice learning events, such as seminars or conferences could be considered, to address relevant topics, for example, commissioning complex services, developing suitable environments, providing local leadership and direction, and overcoming barriers.

Through the implementation of the recommendations outlined in this report, and with the sector working together, the ambition is to ensure better lives for people with learning disabilities and complex needs. In particular, this would ensure that those delayed in hospital settings or who are in out-of-area placements can come home to live in their local communities once more.