Purpose of this guidance
This publication sets out the essential components that help autistic people and people with a learning disability to live good, meaningful lives in their communities. It is designed to support local systems plan and deliver this support across all ages.
NHS England has engaged with around 300 people with lived experience, as well as families and professionals, to understand what needs to change.
The publication draws on this insight, alongside policy, research and best practice. It is also intended to help prepare for changes to the Mental Health Act, which will place greater emphasis on community-based support. This includes addressing the significant health inequalities experienced by autistic people and people with a learning disability, including poorer physical and mental health outcomes, and the systemic factors that drive these inequalities.
A coordinated, whole-system response across health, education and social care is required, including strengthening post-diagnostic and intensive community support to reduce escalation and crisis. Other organisations will provide guidance on services outside the NHS’s direct scope. The components described here relate to neighbourhood and community-based services delivered wholly or partly by the NHS.
Applying this guidance
To deliver the principles and core components set out in this guidance, local systems will need to:
- review existing support offers
- identify gaps and priorities for improvement
- align commissioning with local population needs, using tools such as the local integrated care strategy and joint strategic needs assessment to model the provision required
- plan community provision with other partners, including (but not limited to):
- social care
- housing
- police
- education
- voluntary, community and social enterprise (VCSE) sector
Key principles for community support
Regardless of age, support for autistic people and people with a learning disability should be:
- person-centred and holistic
- co-produced with people who have lived experience and their families
- inclusive, promoting equality of access and care through reasonable adjustments in all services
- local and community-based, delivered using a neighbourhood health approach, as well as ensuring full participation in community life
- needs-led, not diagnosis-driven
- rights-based, delivered in line with statutory duties and human rights principles
- joined up across sectors, including education, health, housing and VCSE and minimising unnecessary reliance on specialist services where mainstream provision can meet needs
Core components of effective community support
These components describe what should be in place to ensure autistic people and people with a learning disability can live well at all ages with improved health outcomes, quality of life and reduced inequalities.
Health and wellbeing
Integrated care boards (ICBs), working with partners, should ensure:
- timely access to healthcare that:
- meets the person’s physical and mental health needs
- includes reasonable adjustments in all settings (including neighbourhood health centres and urgent treatment centres)
- is adapted to meet people’s sensory needs and communication preferences
- includes health facilitation
- promotes medicine optimisation
- is in line with health improvement best practice guidance
- annual health checks for people aged 14 and over with a learning disability, and adults with a severe mental health condition
- timely access to diagnostic services
- support for people on waiting lists (known as “waiting well” approach) recognising that delays or gaps in access to timely intervention and support can significantly impact experience and outcomes for people and their families
- autism assessments follow the national framework to deliver improved outcomes in all-age autism assessment pathways
- access to support both before and after assessment and diagnosis
- access to planned mental health community services for children and young people and adults, including:
- services designed for autistic people and people with a learning disability
- services adjusted for autistic people and people with a learning disability
- access to planned community services which have expertise in supporting autistic children, young people and adults, and those with a learning disability (including those with behaviours of distress, or which challenge services)
- access to support (whether for mental health or behaviour needs) to help people to avoid a crisis while in the community
- keyworkers for autistic children and young people or those with a learning disability who may be at risk of admission to a mental health hospital or who are in a mental health hospital
- access to support during times of crisis for children and young people and adults; this should include:
- reasonably adjusted mainstream crisis and emergency centres, including crisis assessment centres
- intensive and enhanced support, for example, through intensive support teams (ISTs) access to short-term accommodation alternatives to hospital admission
- 24/7 support, for example through the NHS 24/7 neighbourhood mental health centres
- people have the opportunity to understand the Dynamic support register and Care, (Education) and Treatment Review (C(E)TRs), with flexible support provided to those at risk of admission to a mental health hospital and high-quality support to discharge those admitted to a mental health hospital
- people have support with transitions:
- from children’s to adults’ services
- between different agencies and services
Education and training
ICBs, working with partners, should ensure:
- people have support to access education and training; this could include:
- access to health-offered interventions at school or for schools, including mental health in schools teams (MHSTs), Early Language Support for Every Child (ELSEC) and Partnership for Inclusion of Neurodiversity in schools (PINS)
- support through special educational needs and disability (SEND) support in school or via an Education Health and Care Plan (EHCP) for some children and young people
- support for young people and adults to develop vocational skills and access employment opportunities; this could include:
- reasonably adjusted services, such as Individual Placement Support (IPS) and the Job Centre
- specific employment services for autistic people and people with a learning disability
Home and living well
ICBs, working with partners, should ensure:
- access to support and guidance to navigate the system, for example:
- advocacy services
- working with children and young people‘s keyworkers identifying, assessing and supporting the wellbeing of carers and their families
- access to care and support in the community when needed, including:
- short breaks, delivered through high-quality organisations
- personalised offers from well-trained staff based on the relevant core capabilities framework either for supporting people with a learning disability or supporting autistic people
- access to support to build and maintain new and existing relationships, for example, through age-relevant peer opportunities
- access to practical housing support; this could include:
- accessing Disabled Facilities Grant
- being supported by resources such as Brick by Brick and Learning Disability England’s Housing Guide
- for children, young people and adults living in the family home, the family has access to support, such as:
- peer support
- carers assessments
- short breaks
- access to support to reduce the likelihood of offending or reoffending, including:
- information about the criminal justice system
- access to a forensic support team when needed, for example, through community based forensic support functions or community forensic child and young people mental health service (FCAMHS)
- opportunities to co-design and plan services in their area; this could include:
- youth representatives or forums
- partnership boards
- use of data from the Dynamic support register
Background and further information
This guidance builds on Building the Right Support (2015), as well as the principles outlined in the Service Model and Developing support and services for children and young people with a learning disability, autism or both.
Alongside this publication, we plan to update related service models published in 2017 and provide more detailed guidance for specific NHS-commissioned functions, including:
- accommodation-based alternatives to hospital
- enhanced or intensive support for autistic adults
- enhanced or intensive support for children, young people and adults with a learning disability
- community-based forensic support for adults
Publication reference: PRN02155