Leading change

Learning disability nurses at North Staffordshire Combined Healthcare NHS Trust led the development and implementation of an Intensive Support Team (IST) to support people with a learning disability either within the community or in-patient unit. This has significantly improved outcomes, experience and use of resources locally.

Where to look

NICE (2018) highlight that people with learning disabilities are now living significantly longer. Emerson and Baines (2010)  and others, have reported that people with learning disabilities have poorer health than the wider population and have differences in health outcomes that may be avoidable. The health inequalities faced by people with learning disabilities in the UK starts early in life and could be a result of barriers they face in accessing timely, appropriate and effective health care.

To support this Transforming Care: a national response to Winterbourne View Hospital (2012) highlighted that many people with learning disabilities or autism are staying too long in hospital or residential homes, and even though many are receiving good care in these settings, many should not be there and could lead happier lives elsewhere. Hospital admissions, it suggests, can be prevented for many people with learning disabilities if they receive appropriate support in the community.

Within North Staffordshire Combined Healthcare NHS Trust nurses recognised that people with learning disabilities were spending longer periods of time in hospital due to many reasons, such as placement breakdown in the family home, lack of available community placements and lack of specialist intensive community health support to prevent further deterioration. Recognition of this unwarranted variation in practice highlighted the opportunity to develop the offer for individuals with learning disabilities in order to improve their outcomes and experiences of services as well as use of resources within the Trust.

What to change

North Staffordshire Combined Healthcare NHS Trust is a provider of mental health, social care and learning disability services in the West Midlands. The Trust’s Assessment and Treatment Unit (A&T) provides specialist interventions for individuals with a learning disability who require short term support or in-patient admission due to an acute breakdown in their healthcare needs. It has five in-patient places offering short term assessment and treatment for a maximum of up to six months.

Upon further inspection, the learning disability nurses identified that closer partnership working was required to support people to move or return to a community setting appropriate to their needs and preferences, by reducing barriers (ill health, independence skills, behaviours that challenge or other risks) through specialist assessment, treatment, interventions and prompt discharge planning. A focus on enablement was also required to promote independence and social inclusion, and least restrictive conditions compatible with safeguarding were needed to support an individual to maintain their independence and have the best quality of life possible. The senior nursing team supported a change in ‘thinking’ and staff culture to enable this to happen in practice.

How to change

The change was led based on the values and beliefs of the transforming care agenda. Learning disability nurses worked in close partnership with other professionals, including an occupational therapist, a speech and language therapist (SALT) and Local Health Authorities, to form the IST. This was done through research into similar models, intensive support services and evidence based practice, a review of the Transforming Care programme (NHS England) and information from annual service reviews within community and inpatient settings. The team was established, based on multi-disciplinary working, consisting of different nursing grades, enablement workers, social workers, speech and language therapists, occupational therapist, administration staff and psychology.

The IST provide assessment, support and treatment to adults who have a learning disability and complex needs including severe challenging behaviour, autism and mental health needs. It supports people who are reaching crisis and may otherwise require an admission to hospital. The team work closely with the A&T and community care services, to support people with a learning disability who require additional support either within the community or within the in-patient unit. The IST also supports avoiding hospital admissions in line with transforming care and supports transition from hospital to treat people in the community. Integrated working between the IST and A&T wraps the service around the person with them at the centre of their care, promoting people with a learning to be involved in making decisions about their care, treatment pathway and to maintain choice and control regarding accommodation, care and treatment.

Review of evidence bases, as well as local guidance, identified that the optimal duration of the clinical pathway for the support service should not exceed 12 weeks, which was evidenced by Transforming Care for People with Learning Disabilities (2015), The Care Act (2014), Mental Health Act (2007) and Mental Capacity Act (2005).

To support this new policies and procedures were developed, which includes raising concerns when people are referred to IST from community care placements, and ensuring that A&T were involved if the person was at high risk of admission, however all areas of support from IST are utilised prior to considering admission.

Other changes included:

• Education and training was provided to future carers and robust transition planning;
• Development of standardised positive behaviour support (PBS) for patients;
• Implementation of individual and group psychological therapy sessions;
• Multidisciplinary team (MDT) meetings were widened to include the SALT service and social worker input.

Adding value

Better outcomes – Due to the success of the pathway as delivered by the service, delays in discharge have reduced with an overall reduction in hospital length of stays from 483 days (69 weeks) to 71 days (14 weeks). The transition between services is much smoother with better planning and patient involvement, ensuring services are now wrapped around the person and their family. Prevention of placement breakdown is now being seen routinely as care packages are planned more robustly which has led to a reduction in avoidable hospital admission or readmissions which is extremely positive. There is increased engagement, with activities in the community being seen as the team community presence is now embedded. Promotion of positive behaviour support (PBS) to support families and carers to manage a situation that may be deemed as challenging is now routinely offered and supports better outcomes for the people who receive it and there has also been a reduction in the use of unnecessary medication and people having to be transferred to accommodation ‘out of area’ which means family contacts are maintained much more readily. These factors have all had a positive impact upon patient’s quality of lives by avoiding hospital admission and supporting them to maintain their independence in the community. When admissions take place, close partnership working between IST and A&T helps to provide a smoother transition prior to admission and at discharge by providing continuous and constant support.

Better experience – The team work in partnership with families and carers to provide better person-centred care creating a better experience for service users, families and carers, and enables people with learning disabilities to have choice and control over their care and support needs. Outcomes are focused on time limited assessments and treatments.

Staff feedback includes, “One of the service users in our care was experiencing severe challenging behaviour, IST were very supportive to both the staff and the service user and supported the service user through the transition period. A great well-required service!”

Family feedback includes “The IST service was a life saver for us in our ‘hour of need’ 100% supportive to us all.”

Better use of resources – The service was developed on evidence based practice and has supported integrated care pathways, working together with other professionals. Individuals with learning disabilities are supported to stay out of hospital which is anticipated to have a positive impact upon resources across the organisation.

Many evaluations that have taken place are now being used to further shape the development of the IST including meetings with relevant stakeholders and colleagues, people who require their services and their relatives, carers and providers. Closer partnership working with other IST Clinical Leads within the Midlands will hopefully serve to provide a useful network for benchmarking, sharing good practice and some governance across the health delivery of Intensive Support Service interventions.

Challenges and lessons learnt for implementation

Challenges around culture change, working independently, not knowing the patients (new referrals), difficulties with working in family homes and trying to build good working relationships, having the courage to make a decision independently and as part of the team, and positive risk taking were all noted, but all expected as this was a significant change and different way of working for some. By acknowledging and taking time to address these the support can be gained for the change which will help it drive forwards.

Always follow the 6Cs (care, commitment, courage, compassion, competence and communication) and work in a value based person-centred way, always putting the patient at the centre of their care.

An MDT is not just about a meeting, it is about the way that skilled professionals work together on a shared caseload.  Having the different professionals within the team has had such a fabulous impact upon our ability to provide efficient and effective support to individuals without having to ‘refer in’ for support from other professionals.

Find out more

For more information contact:

• Sonia Goodwin RNLD (A&T Manager), Team IST and A&T, North Staffordshire Combined Healthcare NHS Trust, Sonia.Goodwin@combined.nhs.uk
• Katie Sherratt RNLD (IST), Team IST and A&T, North Staffordshire Combined Healthcare NHS Trust, katie.sherratt@combined.nhs.uk
• Chris Major RNLD (IST), Team IST and A&T, North Staffordshire Combined Healthcare NHS Trust, Christopher.Major@combined.nhs.uk