Pathways into and out of secure services for people with learning disabilities: report of a pilot study

Background to the Study
The research described in this report has been commissioned by the North West Secure Commissioning Team to inform the development of policy and future research. The core objectives are:

• To explore professional perspectives on the service related factors that
(a) contribute to people with learning disabilities being admitted to secure services and that
(b) shape decisions about discharge.
• To consider the genesis of these factors and in particular the extent to which they are recent or enduring features of the NHS/public sector.
• To assess methodologically and analytically the viability of a broader study into this field being undertaken.

This research was designed as a pilot study and therefore draws on only four cases. It should not be considered descriptive of the broader picture in secure services, nor predictive of how pathways may be followed in the future.

The four case studies were selected from a list of recent admissions and discharges provided by senior staff at the participating secure unit. Of the four that were selected, two were admissions (one male, one female) and two were discharges (one male, one female). For each of these, around four to six people involved in the admission/discharge process were interviewed. They fell into three groups: clinical staff, family members and social workers.

Research Findings
• A number of interviewees indicated there is a gap in community service provision for persons who are just below the legal age of adulthood and who exhibit challenging behaviour. It was suggested that this can result in ‘inappropriate’ placements with the potential to further destabilise the individual’s behaviour and wellbeing.

• Some social workers suggested that legal decisions regarding under-age clients who had offended seemed a little arbitrary and could inadvertently increase the instability of those clients’ lives. One interviewee considered that magistrates may be treating women and men differently when considering detention.

• It appeared that Social Services and clinical staff conceptualised the clinical assessment processes for admission and discharge differently from one another. Social workers considered the methods to be obscure. It is suggested that this could cause friction and misunderstandings in the course of the decision-making process.

• It is a concern voiced of all the professional workers interviewed that when a client is resettled into a new district, there are serious grey areas regarding supervision. If a Section is requested that requires a responsible medical officer (RMO) to take responsibility for the client’s welfare, there were thought to be insufficient guidelines on how this should be done, or by whom. This could delay the discharge process itself.

• All interviewees spoke of funding disputes between health Social Services and Health Services as being potentially damaging to any resettlement programme, but also as a fact-of-life. During negotiations regarding who will pay for a resettlement, the placement can be lost.

• The discharge process is understood to present risks to the client (e.g. risk of a period of instability) and from the client (i.e. in the event that the client may re-offend). It was considered by clinical staff that most risks can be reasonably assessed but the impact of the discharge procedure itself cannot. Clinical staff conceded that to set an exact and workable discharge date is very difficult given the many contingencies involved, even though this lack of certainty can unsettle the client. Consequently, when each discharge/resettlement process begins, a significant degree of ‘grey area’ manifests regarding how things might ‘turn out’.

• Family members and social workers voiced concern that secure unit may be seen as being more punitive than clinical in nature. This can impact upon interactions with the unit, or prevent those interactions outright.

• Some social workers and family members clearly viewed the RMO as being ‘in charge’ of admission and discharge procedures, and of acting unilaterally. This had serious ramifications for the interactions these people have with other members of staff, and the manner in which they approached the secure unit on the broader scale.

• A key part of this study concerned the perceptions of admission and discharge as processes. It was demonstrated that conflicting perceptions of either process can impact negatively on the process itself. Different approaches to the same problem sometimes became impasses because the motivations and priorities were not communicated.