Contributing factors to providing an effective community-based forensic service for people with a learning disability: a literature review

Anna Leonie Wark (Creative Support Ltd, Stockport, UK)

Journal of Intellectual Disabilities and Offending Behaviour

ISSN: 2050-8824

Article publication date: 4 October 2019

Issue publication date: 4 October 2019

Abstract

Purpose

Legislative guidance stipulates that people with a learning disability have the right to receive local provision of personalised support within the least restrictive environment. On these bases there is a growing emphasis on the requirement for local authorities to develop appropriate services for people who are currently in a hospital setting. The purpose of this paper is to examine the literature addressing factors influencing the provision of effective community-based forensic services.

Design/methodology/approach

The six articles were analysed separately using the evaluation tool – Currency, Relevance, Authority, Accuracy, Purpose. The six articles used divergent sample groups and employed both qualitative and quantitative methods to collate data. The articles shared a purpose of examining forensic community service provision with an aim to improve services.

Findings

There were three themes that emerged consistently across the literature these included: balancing risk management vs individual autonomy; multi-disciplinary and multi-agency working; service improvement. There is a growing emphasis on the need to replace long-term hospital placements with specialist, community provision, employing least restrictive methods and positive responses to crisis situations. In this climate, it is crucial that multi-disciplinary agencies from local authority, health and the charitable and private sector continue to work collaboratively on the integration of service provision in order to bring about the development of effective and responsive community services.

Research limitations/implications

Research limited to peer reviewed and published research papers focusing on the subject of community forensic services with publications specifically made within the time frame of the Transforming Care Agenda.

Practical implications

This paper looks to examine the practical solutions to providing effective community forensic services for a person with an intellectual disability and makes recommendations for research into improving service specific training for support staff.

Social implications

Following the Winterbourne View Hospital scandal (BBC One, 2011) instigations were made to make legislative change under the Transforming Care Agenda. Despite a renewed conviction in the rights of people to be a part of their local community without segregation or discrimination, professionals in the field continue to report a failure to reduce numbers of people in long stay hospitals and secure settings. With commissioning under pressure to make these intentions a reality it is a really good time to reflect on practice and evaluate service models to establish the factors that bring about positive outcomes for individuals enabling inclusion within community settings.

Originality/value

This review will focus on the literature evidencing positive intervention and outcome focussed methods of supporting people with a forensic history in the community. This is an entirely original piece of work analysing peer reviewed and published research.

Keywords

Citation

Wark, A.L. (2019), "Contributing factors to providing an effective community-based forensic service for people with a learning disability: a literature review", Journal of Intellectual Disabilities and Offending Behaviour, Vol. 10 No. 3, pp. 45-57. https://doi.org/10.1108/JIDOB-03-2019-0005

Publisher

:

Emerald Publishing Limited

Copyright © 2019, Emerald Publishing Limited


Introduction

Since the initial resettlement from long stay hospital throughout the 1970s and 1980s (Emerson, 2004) there has been a growing interest in providing effective services to people with complex behavioural presentation and a learning disability. The revised Mansell Report (Department of Health, 2007) promoted the commissioning of complex needs provision in a community setting and challenged services to provide person centred support, with better communication methods and a better understanding of behavioural intention. Although some services pioneered a community model (Benton and Roy, 2008), it is frustrating that community-based forensic and complex services were slow to emerge.

Following the Winterbourne View Hospital scandal (BBC One, 2011) and subsequent report (Department of Health, 2012) instigations were made to make legislative change under the Transforming Care Agenda. The aim was to review all hospital placements by 1st June 2013 and return people who were unnecessarily hospitalised, to community-based support by 1st June 2014 (Department of Health, 2012). This target was later revised and benchmarks moved for completion in March 2019 (NHS England, 2015). Despite a renewed conviction in the rights of people to be a part of their local community without segregation or discrimination, professionals in the field continue to report a failure to reduce numbers of people in long stay hospitals and secure settings (Health and Social Care Information Centre, 2013; Chester et al., 2017).

Although the initial Transforming Care Report (Department of Health, 2012) did not make specific reference to forensic, learning disability inpatients, this service user group has been included in the review of hospital placements (Chester et al., 2017). More recent recommendations made by the Royal College of Psychiatrists (2014) and NHS England (2017b) make direct reference to the development of community-based forensic services (CFS) under the Transforming Care Agenda. With commissioning under pressure to make these intentions a reality it is a really good time to reflect on practice and evaluate service models to establish the factors that bring about positive outcomes for individuals enabling inclusion within community settings. This review will, therefore, focus on the literature evidencing positive intervention and outcome focussed methods of supporting people with a forensic history in the community.

Methodology

The review began with an exploration of the grey literature and media coverage in order to get some background knowledge on some of the influencing factors on the development of CFS for people with a learning disability. Access to SOLAR and the search engine CINAHL was used to commence an advanced search using the terms – Learning dis*, Forensic and Services bringing up 82 articles. To further the search the Boolean phrase “AND” – community was applied. Using these procedures, 25 articles were returned. From this list, articles were selected based on their relation to the proposed subject, specifically making reference to CFS and written within the last 15 years. Throughout the process articles were downloaded and saved if they were relevant to this area even if they did not meet the full inclusion criteria. This allowed a full review of the subject matter historically and to the present day, identifying key legislative reforms, leading scholars in this area and key themes running through the literature.

Reading through these articles, further material was sought out by completing a search for specific articles that were cited in the reference list or as recommended reading. A snowballing method was used to seek out the most recent research. Shibboleth access was used to complete an advanced search of journals specific to the research area. Selecting articles that were written post-Transforming Care gave an option of 14 pieces of work specifically addressing the review of CFS.

Throughout the search an inclusion and exclusion criteria were applied to assist in the selection of articles. This literature review specifically aimed to focus on community services following the Transforming Care Agenda, therefore, articles older than 2012 were excluded. As the proposal aimed to look at a whole system evaluation of services, articles were excluded that had a focus on specific treatment and intervention, such as an evaluation of the Sex Offenders Treatment Programme or of risk assessment tools such as the Historical, Clinical, Risk management tool (Douglas and Webster, 1999) or the Individual Risk Mitigation Profile (Hutchinson and Dunn, 2016).

The inclusion criteria determined the selection of the six pieces of work to be analysed in the literature review. These pieces were selected on the basis that they were written in the UK, peer reviewed, specifically focussed on CFS, written post-Transforming Care Agenda and could offer constructive recommendations on service improvement. In the final selection the most recent relevant articles were chosen in order to explore cutting edge innovations that were making a difference in terms of positive outcomes for individuals.

Results

Article 1: Browning et al. (2016) a community forensic team for people with intellectual disabilities

This paper was published in 2016 examining case note data collated in 2013. Article 1 had contributing authors from the psychology department of the CFS, Birmingham Community NHS Trust. They sought no source of external funding and the project was approved by the Trust Clinical Governance Committee as a service evaluation to inform development and improvement.

The methodology used was a qualitative and quantitative analysis of case notes of a sample group of 70 people who were the entire population of people referred to the CFS in 2013. Although ethical approval was given, there was no evidence that any consultation had been carried out with the sample used. An approved data collection tool was used with the aim to categorise the type of people supported at that time, offence specific behaviour and rates of reoffending post-referral to CFS.

Although this article focuses on recidivism it is acknowledged that a reduction in offending behaviour brings about positive outcomes for individuals including increased independence and reduced hospitalisation. The focus of the report was on developing effective multi-disciplinary interventions in the community, creating effective discharge pathways, professional best practice and reflection on service outcomes. The authors also discussed the significance of a correlation between early trauma and abuse and offending behaviour and made recommendations for proactive strategy in the prevention of mental health decline through trauma counselling and support.

Article 2: Chester et al. (2017) discharging inpatients from secure to community services: risk assessment and management considerations

This recent article examines service development, identifying implications for risk management, however, making little reference to quality of life outcomes. The five contributing authors were from a range of disciplines including research associate, capital investment manager, psychiatrist, consultant nurse and neuropsychiatry. They were also employed by a variety of agents including an NHS foundation trust, CQC and Health Tech Solution Ltd.

The methodology used was a qualitative, semi-structured, open ended interview using five subjects in the sample group, all senior clinicians from community teams. Consent was sought and anonymity confirmed. Ethical approval had been given and Cornwall Partnership NHS Foundation Trust sponsored the project. A five stage thematic analysis (Braun and Clarke, 2006) was used to review the results of the questionnaire. The method of analysis was chosen as it is independent from theory and has a versatile application across disciplines.

The purpose of the research was to evaluate professional competence in the assessment of risk and transition processes using a self-efficacy scale. The results were analysed in order to establish the preparedness for receiving service users with a history of forensic risk, into the community.

The aim of the research was to promote service development and had a cautionary tone in relation to the complexity of managing forensic risk effectively. However, many of the references to serious case review cited within the article related to patients of mental health services rather than learning disability services. This could give a misleading view of the issues involved with managing risk on discharge from hospital, due to the difference in risk profile in a population that may have reduced capacity due to a learning disability. The themes emerging from the article included risk assessment and management, multi-disciplinary working, legal frameworks and holistic approach.

Article 3: Graham et al. (2016) resolve: a community-based forensic learning disability service specialising in supporting male sex offenders – our model approach and evidence base for effective intervention

This is a recent and relevant paper incorporating the principles of the Transforming Care Agenda. The aim of the paper is to address best practice in therapeutic approaches within a community-based forensic residential service in order to promote an innovative service model based on the attachment theory of Schofield and Beek (2006) and referred to as Total Attachment (Harbottle et al., 2014). The authors of the paper are registered service managers within the organisation. They have declared a conflict of interest and have stated that the research is partial rather than impartial due to the invested interest that the authors have in promoting their service model. The paper provides a case study intended to instigate future research into the reliability and evidence base for the application of Total Attachment in the successful support of adults with an offending history. Evidence for the current paper was based on qualitative accounts of positive outcomes derived from CQC reports and quantitative measures of staff and service user retention.

Themes emerging include positive outcomes for individuals derived from a whole system approach delivered by a well-appointed and well-supported workforce with multi-disciplinary contribution. There was an emphasis on mutual respect throughout the team and those within service and an understanding of the impact of childhood trauma on future offence type behaviour.

Article 4: Bamford and Benton (2015) gathering meaningful service user feedback regarding a community forensic service

House of Commons Health Committe to Health Care Commission (2007) indicated that service users should be engaged with national and local policy and with service and individual level care planning. There is a significant link between failure to consult service users and the failure of services as identified in the Francis Report (Mid-Staffordshire NHS Foundation Trust 2013). This article aims to obtain and analyse feedback regarding service user satisfaction of a CFS in Birmingham. The research was led by members of the CFS, however, an independent third party experienced in facilitating complex communication was used to conduct the interview process. It was acknowledged that data could be skewed by the power imbalance between service user and assessor leading to acquiescence in response. It was acknowledged that there were barriers to conducting an investigation of this nature including the maintenance of anonymity and ensuring effective communication. It was also acknowledged that individuals excluded from the sample group due to reduced capacity, mental health contraindications or lack of engagement may have been the individuals who would have given the most constructive feedback on services. The people who were able and chose to consent may have been the population of people who felt positive about the service as was reflected in the results. It was acknowledged that the methodology could be improved with future surveys.

Ethical approval was given by the Trust Audit and Governance Department. The data were collected using a survey that had been approved by the Speech and Language Team for easy access. The data were analysed using a quantitative approach to show that a significant per cent of the sample population were satisfied with services and then qualitatively analysing the answers to make recommendations such as improving information shared regarding care plans. Themes evidenced in the results include the importance of the Good Lives Model (Ward and Brown, 2004) in ensuring that service users are central to service planning; the benefits of providing a seamless whole service approach through effective multi-disciplinary working.

Article 5: Davis et al. (2015) Am i there yet? The views of people with a learning disability on forensic community rehabilitation

Seeking service user feedback, this research article specifically examines the potential for fulfilling individual autonomy and inclusion in line with government specification (Scottish Executive, 2004; Mental Health (Care and Treatment) (Scotland) Act (MHA), 2003) whilst at the same time maintaining risk management strategies. Similarly to Article 4, the themes emerging from the text include the application of the Good Lives Model (Ward and Brown, 2004), balancing autonomy with risk reduction, the power imbalance experienced by a person on a Community Treatment Order (Mental Health (Care and Treatment) (Scotland) Act (MHA), 2003) and the difficulties that staff have in maintaining the restrictions of the order whilst promoting independence and equality.

This research is conducted by a group of psychologists representing a number of different agencies. Article 5 states that this is the first piece of work examining compulsory forensic care from the perspective of the service user. In terms of an originality claim, Article 4 also reviews feedback from service users and was published one month prior to Article 5 in the same journal. Article 4 does not specifically state that their service users are under a Community Treatment Order (Mental Health (Care and Treatment) (Scotland) Act (MHA), 2003) or Compulsion Order (Mental Health (Care and Treatment) (Scotland) Act (MHA), 2003) despite being referred to FCS, so technically the originality claim is correct.

A robust methodology was used to ensure qualitative transparency in that a third party could repeat the same procedure and understand the outcomes. Consent was sought from all participants. Participation information and consent form were both designed in accordance with principles of accessible information (Change, 2016). The questionnaire used open ended questions followed by structured prompts. The data were analysed using the method of interpretative phenomenological analysis (Smith et al., 2009) resulting in the identification of groups of content and themes. It was acknowledged that anonymity had been compromised in some instances due to the close proximity of staff supervision. The project was subject to audit by the academic supervisor. The purpose of the article was to make future research recommendations that ensure that the voice of the service user is translated in to clinical practice.

Article 6: Clifford et al. (2018) “I don’t want to take a risk even if it’s gonna mean this service user is gonna be happier”: a thematic analysis of community support staff perspective on delivering Transforming Care

Article 6 was published in 2018 making it the most recent piece of research identified in relation to the topic of Transforming Care provision. The contributing authors included a member of the directorate of Integrated Specialist services in Nottingham and representatives from Health Psychology and Learning. In total, 13 participants were used following a selection criteria based on length of employment and experience of working within specialist, community services. Semi-structured interviews (Smith and Osborn, 2008, pp. 58-59) were used to gather perspectives from support workers and first tier managers and the resulting transcripts were qualitatively examined using a technique of thematic analysis (Braun and Clarke, 2006) to deduce concurrent themes. It was recognised that there were methodological limitations based on the professional relationships that existed between the lead researcher and service providers from which the sample group was sourced.

The research specifically aimed to identify barriers and facilitators to meeting the needs of people who come within the Transforming Care cohort. Two predominant themes were identified that had a significant impact on support staff confidence in the effectiveness of their care delivery. It was noted that staff were likely to experience a dichotomy of ideological expectations particularly in relation to risk taking and individual freedom. Staff feel compelled to balance both the expectations of facilitating the human right to freedom of expression (European Convention of Human Rights, 2010), autonomy and independence (Department of Health, 2001) with the requirement to evidence positive outcomes through audit, inspection and service validation. In effect staff teams are expected to balance the right of the individual to make independent decisions with a service expectation to facilitate safe and healthy lifestyles. The second theme identified as an amalgamation of subsets was the significance of multi-disciplinary participation in ensuring that staff felt equipped to deliver specialist support.

Discussion

The six articles selected for this literature review have all focused on the evaluation of services for people with a learning disability and forensic risk living in the community. All six articles make reference to the Transforming Care Agenda in being a significant factor in service development. All six articles have been written by a range of professional who are expert in their field of practice within learning disability forensic services. However, the articles diverge on their chosen sample group which ranged from large scale service user information analysis; a small sample of community professionals; a review of third party information to small groups of support workers and consenting service users. The divergent sample groups allowed the same topic to be examined from different perspectives giving a holistic overview needed for genuine reflection and improvement. It was also evident through analysis of the six articles that related themes could be identified across the research field.

Risk management vs individual autonomy

All six articles identified the challenge of managing risk effectively and at the same time creating an environment that facilitates choice and control.

Articles 4 and 5 made specific reference to the application of the Good Lives Model (Ward and Brown, 2004) as a means to readdress the power imbalance between service user and support team who may have the duty of enforcing legal restrictions. Within the Good Lives Model, Ward and Brown (2004) propose that successful forensic intervention focuses on treatment which is directly responsive to the individual’s needs and characteristics. This intervention model supersedes traditional models of risk reduction such as the risk-need-responsivity model (Aust, 2010). It is intended to fulfil the expectations of the person centred agenda (Department of Health, 2001; Department of Health, 2009b) whilst maintaining legal requirements to prevent dangerous and illegal behaviour. Olsen and Heaton (2011) have also proposed that an individual who is living a fulfilling lifestyle, in line with principles of Normalisation and Social Role Valorisation (Wolfensberger, 1972, 1983), will have their needs met by well adapted and appropriate means which will reduce the need to resort to maladapted and dangerous behaviour.

Articles 1 and 3 acknowledged a correlation between childhood abuse and adult offending behaviour in males (Spatz Widom, 2006) with 48.6 per cent of the sample group in Article 1 having been victim of abuse or neglect as a child. This statistic may support the proposition that distorted cognition brought about by negative experiences may contribute to the tendency for offending behaviour. From this perspective, addressing cognitive distortion through the development of positive, therapeutic engagement and mutual respect would support the application of less maladapted strategies.

Article 6 makes specific reference to the conflict between providing choice and control and managing risk in order to reduce negative outcomes. It is acknowledged that the Mental Capacity Act (MCA, 2005) with Deprivation of Liberty Safeguards (DOLS) provides some direction and a legal framework with regard to identifying the right to make unwise choices balanced against a duty of care to protect from negative consequences.

All six articles acknowledged that a responsive service meeting the needs of individuals would lead to positive outcomes, recidivism and a reduction in hospitalisation.

Multi-disciplinary and multi-agency working

All six articles strongly promoted the need for close multi-agency working in order to ensure robust service delivery. Forensic services have typically run parallel to generic health care services and this model has been compounded by the specialist hospital setting (MacMahon and McClements, 2015). However, MacMahon and McClements (2015) propose an integrated model of services which may be a more comprehensive model for supporting people with forensic needs in the community. The proposed integrated model would embed forensic expertise within a generic team with the aim of making this skill set more accessible to the individuals who may require specialist support and intervention. An integrated model supporting forensic specialist services, providing a link between inpatient and CFS is also supported by a tiered model of multi-disciplinary working (Devapriam and Alexander, 2012). An integrated and tiered model of multi-disciplinary working would support the application of the Care Programme Approach from the hospital to community setting (Department of Health, 2008).

The need for effective CFS with a broad range of contributing skill sets is upheld by the evidence provided in Articles 1 and 2. Contributing factors include therapeutic knowledge; risk management ability including the application of Multi-agency Public Protection (Ministry of Justice: National Offender Management Service, 2012) and Sex Offender Prevention Order (Sex Offences Act, 2003) arrangements; connections with police services and care providers. An emphasis on the importance on working in partnership with local and national resources runs through the Bradley Report (Department of Health, 2009a) and is the attributing force required to bring about the reform of forensic services.

Article 3 promotes a whole system approach to providing effective community services for people with a forensic background. Advocating for the model of Total Attachment (Harbottle et al., 2014), Article 3 evidenced the benefit of a non-hierarchical practice with specialist practitioners, support workers, managerial staff and service users being seen as a mutually respected whole system. The approach advocates the benefits of providing a nurturing environment that supports the practice of promoting individual self-esteem whilst maintaining safe boundaries.

Articles 4 and 5 both focus on the need for service users to be central to their care planning. Effective communication between the service user and relevant professionals allows the individual to feel informed and in control increasing self-esteem, increasing potential for engagement and increasing the effectiveness of the support delivered.

Article 6 highlights the need to equip support teams appropriately through multi-disciplinary allegiance and shared risk taking. It is recognised that complex provision may require long-term multi-disciplinary input as a proactive measure to crisis prevention. It was identified that providers may work in partnership with specialist colleagues from local authority and health, however, multi-disciplinary provision is more sustainable on a long-term basis when available internally from the provider organisation. If this is the preferred model of support for people with complex needs then there are obvious implications for the commissioning and cost of care packages as tender specifications will necessarily be required to include access to professional and specialist resources. Providers may consider the appointment of an integrated or specialist practitioner as an effective means of contributing to a multifunctioning specialist team. Knowledge and training in social work can be instrumental in instigating the commissioning, gatekeeping and contractual evaluation of services in accordance with legislative requirements and in line with professional standards (Department of Health, 2016); nursing experience can ensure the delivery of a therapeutic, holistic and person centred intervention plan in line with nursing standards (NMC, 2015). Practitioners are often asked to combine these skills both within their own practice and through partnership working.

Service improvement

All six articles stress the importance of seeking feedback, reflection on practice and a commitment to change. Articles 1 and 4 reviewed the same service in Birmingham suggesting that they have an ongoing commitment to reflect and improve practice. However, Article 4 looked at different outcome measures to Article 1 and was more focused on the experience of the individual receiving services.

All six articles make recommendations for advancing research in the area of forensic community support; highlighting the importance of providing a workforce that is well appointed, well trained and well equipped with access to appropriate resources. It was acknowledged that research methods could be improved by finding ways to include disengaged and hard to reach service users and by addressing power imbalance within research. There was very little focus on the therapeutic benefits of the service user/support worker relationships with many professionals viewing the support worker role as a barrier to gaining the views of the service user. Article 6 went some way to readdressing this outlook by recognising that the perspectives of support work teams provide a valuable source of information when working towards service improvement. There was no real discussion about the significance of the application of the MCA (2005) in the discharge from the Mental Health Act (1983), in circumstances where the person will continue to benefit from restrictions in order to prevent reoffending behaviour. O’Kane et al. (2017) highlight the fact that DOLS can only be applied in that person’s best interest and not to prevent them offending. A tribunal may refuse or remove DOLS arrangements when a person is assessed as ready for discharge, has capacity, meaning that best interest decisions cannot be applied and continues to pose a risk to themselves or others (O’Kane et al., 2017). This has specifically been seen in the PJ case law where by the Supreme Court has determined that a responsible clinician is not given the power under the Mental Health Act (1983) to impose condition within a Community Treatment Order which deprives a patient of his liberty (Welsh Ministers (Respondent) v. PJ (Appellant), 2018). In addition, the Supreme Court have determined in the case of MM, that conditional discharge for a capacitated patient cannot stipulate conditions that amount to a deprivation of liberty (Secretary of State for Justice (Respondent) v. MM (Appellant), 2018). From the conclusions of the Supreme Court it can be inferred that capacitated patients may experience longer detention in hospital than patients who are assessed as lacking capacity; where by, care plans amounting to a deprivation of liberty in that person’s best interest can be considered by the Court of Protection under MCA (2005). This debate provides a massive ethical and human rights (Human Rights Act, 1998) dilemma in the current climate of discharge from hospital to community (Alexander et al., 2015) and is one that would benefit from further academic analysis.

Comparatively, Freckelton QC (2016) has offered a detailed analysis of the USA case law emerging between 1989 and 2014 which has changed the view of culpability in relation to serious offences carried out by a person with a learning disability. In 2002 the case Atkins vs Virginia state resulted in a ruling that the death penalty could not be used to punish a person who was “intellectually retarded”. None the less, as Freckelton QC (2016) describes, Florida Supreme Court sentenced Hall to the death penalty in 2014 for murder despite an evident intellectual disability and horrific abuse throughout childhood. This judgement was later reversed in recognition that intellectual disability should be seen as a continuum with multiple factors and not defined by an IQ score. The progress of the law in relation to the death penalty in the USA, although alarmingly recent in its application, may be somewhat reflective of the development and application of the MCA (2005) in determining culpability and diversion from prison services in the UK.

In a climate where there is international recognition that recidivism is most effective when treatment and intervention programs are delivered in a community setting (Cockram, 2005; Haysom et al., 2014) there is a real possibility that the UK can lead the way in gold standard practice. Cockram (2005) concluded services need to be enhanced in order to reduce recidivism in a learning disability population in Western Australia. This finding was supported by research carried out by Haysom et al. (2014) who identified a high rate of aboriginal offenders in the Criminal Justice System in New South Wales, Australia and called for more effective diagnostics and diversion from court. However, there is a significant lack of international research evidencing the provision of CFS.

All six articles acknowledge that service improvement cannot be achieved without service user co-production or a clear understanding of how to be responsive to individual needs and wishes. Throughout all research projects there was an emphasis on the absolute need for commitment to funding both in the development of effective services and in the research that will ensure that evidence-based practice is applied within those services.

Conclusion

Whilst the Transforming Care Agenda as set out by NHS England (2015) in Building the Right Support aimed to finalise in March 2019 it is evident from National Statistics that there is still a long way to go to meet the identified targets. In March 2015 it was calculated that there were 2,395 people with a learning disability in a hospital setting with the numbers standing at 2,325 in the census of November 2018 (NHS Digital, 2018). It has been identified that these figures represent individual’s being discharged and admitted rather than a static population (NHS Digital, 2018). Although national figures evidence a small decline in the hospital population they do indicate that it continues to be necessary to remove people from their community setting in order to receive specialist treatment or intervention. These figures should, therefore, be further reduced with the continuing development of effective CFS (Sinclair, 2018).

Turner (2019) highlights how national initiatives such as Building the Right Home (NHS England, 2016) are designed to ensure that people who have complex needs can be supported safely and effectively within their own communities. Imbedding the principles of positive behavioural support (PBS Coalition UK, 2015) and the “Stop Over Medicating People” movement (NHS England retrieved, 2019) and providing community Care and Treatment Review (NHS England, 2017a) have ensured that community services can be increasingly responsive and person centred (Turner, 2019).

Moving forward, it is essential that the principles of the Transforming Care Agenda remain at the forefront of service planning and development for the complex needs and forensic cohort. With a commitment to service improvement, partnership working and a growing awareness of the requirements of a successful service model there should be an increased sustainability and success of the CFS approach.

Research recommendations

This paper highlights a number of areas of service performance that would benefit from further exploration within the academic realm in order to identify evidence-based solutions to improvement in practice. Through service user engagement strategies it has been identified that further work can be done to seek out the opinion of hard to reach individuals in order to gain a true perspective on service user experiences. This could be achieved through further practice-based review and service led proposals exploring the efficacy of a whole systems approach. Practice-based review would invite services to share good practice and further understanding of barriers and facilitator to establishing effective CFS. It would be interesting to examine successful services within the framework of Total Attachment (Harbottle et al., 2014) in order to further an understanding of the efficacy and reliability of this model.

All six articles identified the importance of establishing a well-appointed and well-trained workforce. As maintained in Article 3 a strong therapeutic and mutually respectful relationship between all tiers of the workforce and people receiving services is essential in order to achieve a responsive and holistic service. It is, therefore, essential that the support workers who are at the forefront of delivering complex forensic services are not only supported by a comprehensive multi-disciplinary team but are also adequately equipped to carry out their work. Where as the nurses, psychiatrist and psychologists who develop and deliver intervention within a clinical setting all come under a regulating body evidencing their qualification and training, there is no expectations of the support worker who arguably has a more challenging role of delivering therapeutic interventions in a community setting. Support staff have the essential task of facilitating therapeutic interventions, evaluating dynamic risk assessments and understanding the conflict between existing legal frameworks whilst putting the service user at the centre of all decision making.

As recognised under the MCA (2005) a person with complex needs who has been assessed as lacking capacity to understand the consequences of their actions may require substantial support and guidance in order to achieve a valued and positive community presence. In addition, the learning disability population may rely on an external locus of control to manage the principles of relapse prevention as evidenced in a small scale study by Rea et al. (2013). Rea et al. (2013) evidenced that service users showed 100 per cent compliance with their relapse strategies when supported by a trained member of staff whilst in the community. The community compliance rating reduced to 44 per cent when supported by an untrained community assistant. These results not only highlight the requirement for an external locus of control in order to modify behaviour appropriately but also the importance of the support staff being competent, trained and respected in their work.

Further research on the efficacy of service specific training would enable an evaluation of training content in relation to how staff values, attitudes and skill set can be improved through an increased understanding of how offending behaviour may develop under individual circumstances. An ability to improve understanding of offending behaviour in the context of trauma, comorbid mental health presentation and attachment would equip the support worker to deliver effective support within the principles of the Good Lives Model (Ward and Brown, 2004). A well trained and robust workforce would support enhanced service delivery across all three themes identified as contributing to effective CFS for people with a learning disability.

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Corresponding author

Anna Leonie Wark can be contacted at: anna.wark@creativesupport.org.uk

About the author

Anna Leonie Wark is RNLD based at Creative Support Ltd, Stockport, UK.