FACULTY OF HEALTH
School of Applied Psychosocial Sciences
An investigation into whether there is a problem for
people with a Learning Disability accessing mainstream
Mental Health Services in particular reference to
Cornwall
Kate Smyth
Dissertation in part completion of the M.A. in Social Work
Executive Summary
Background
Whilst studying as a Social Work student in Cornwall across work placements in
Learning Disability and Mental Health I became aware of barriers for people who
required access to both services. This issue went on to inform the focus of aims for
my final year research project.
Literature Review
A Literature Review indicated the following points:
 People with a Learning Disability are more likely to experience Mental Health
problems than people without a Learning Disability.
 Focus of government agenda has been equal opportunity access to services,
however evidences suggests that services are still not meeting people’s
needs.
 The debate on types of service provided:
Pros
Cons
Mainstream Mental
Builds self-esteem and
Physical barriers
Health service
self-image having an
Communication issues
affect mental well being.
Staff knowledge and
attitudes.
Assumptions about
reactions and predictions
of a person’s behaviour.
Specialised Mental
Clinicians and
Stigmatisation
Health service
professionals felt a
Labelling
specialised service was
Negative attitudes
necessary.
Provides specialist
knowledge.
Some literature suggested a combination of services was needed where care
was provided according to the person’s clinical and social need.
 Improved joint working across organisations and across general and
specialised services is needed.
 Training for Social Care staff around the issues relating to dual diagnosis and
systems around Mental Health is infrequent, leading to staff uncertainty.
 Access to services can be open to interpretation and, combined with financial
constraints, people often fall between services.
 Issues around assessment and interventions; label of Learning Disability used
to explain problems that may in fact be related to Mental Health issues,
differing types of communication, inappropriate assessment and intervention
tools.
 A Health focus in current research.
Project Aims
 To identify whether there were any problems for people with a Learning
Disability accessing mainstream Mental Health services in Cornwall
 To identify barriers compromising access to services, areas of good practice
and areas that could be improved.
Research Approach and Methods
The research aimed to capture subjective and current experiences of a small sample
of Social Care staff working in a variety of different roles supporting individuals with a
Learning Disability using semi-structured interviews. Information collected was
qualitative. The aim was to engage with staff experiences and provide a strong idea
of their reality. Ethical approval was sought and approved by the University of
Plymouth and Cornwall Council Research Consultation. Interviews provided the best
approach to collecting exploratory data of people’s experiences and views. The
literature review provided a national overview and themes were drawn from this to
provide structure and a basis for the interview questions. A semi-structured approach
meant there was the option to modify questions and change the order of themes
discussed. The transcriptions were then imported to the computer software
programme Nvivo 8 and interview transcriptions were reviewed line by line to draw
out information which was then used to draw out findings.
Staff Sample
10 interviews were completed. 9 of the staff had over 10 years experience working
with people with a Learning Disability. 4 of the 10 participants were Approved Mental
Health Professionals (AMHP) working with people who were dealing with complex
needs and high risk. Other participants ran projects around involving people in
services, worked in Day Centres or in management of services across Health and
Social Care. The participants’ job role and the people they supported had a strong
influence on the responses given and where concern was focused. The variety of job
roles gave a wide overview of service requirements for a massively varied
population.
The staff interviewed all demonstrated great commitment to the people they worked
with and concern around the services people were receiving. There was clear
frustration and anger around trying to support people and this was expressed
through the language used and emphasis on certain areas through repetition. Early
in the interview process it was clear that issues around access were complex. The
data collected was large in quantity and rich in substance, it therefore became clear
during analysis that it was only possible to identify certain core points highlighted in
interviews and these were discussed in the findings.
Findings
1.
Is there a problem for people with a Learning Disability accessing
mainstream Mental Health services in Cornwall?
 The majority of the participants gave negative responses when asked this
question. All participants agreed to various degrees that there were issues in
Cornwall around access to Mental Health services for a person with a
Learning Disability.
 There was acknowledgement of some improvement in overall services for
people with a Learning Disability.
 Participants who gave a more positive response were not working with the
high risk groups of people and this may indicate that improvements have only
been made for people with less complex needs. The response from
participants who worked with higher risk in general highlighted little change
and in some cases deterioration in services for this group.
2.
Assessment and Diagnosis
A strong theme that ran through all interviews was around assessment.
 Participants identified that diagnoses or labels given to people early on in their
lives where inadequate assessment may have occurred could greatly impact
on access to services. It was thought that people who had been given a
definable diagnosis received a better service.
 Participants explained that if people did not fit a defined diagnosis of Learning
Disability or Mental Illness at assessment, they may be excluded from
services or fall between the two services, even if a need for services was
apparent. It was felt the current access criteria did not recognise the variation
in needs of different individuals using Learning Disability services.
 Often a person’s Learning Disability was used to explain problems that may
be related to other underlying issues (diagnostic overshadowing). Behaviour
that challenged further tested services’ capacity to assess and support the
person.
 Due to a gap in services for people with dual diagnosis and behaviour that
challenges (possibly related to closures of large institutions with no
replacement service created), people are assessed for access to psychiatric
units. This medical approach may not identify other issues relating to social
and structural factors, meaning other needs are not being met.
 Half the participants said that even obtaining a Mental Health assessment for
people with Learning Disability was a struggle. One participant highlighted the
only time they felt this assessment occurred was at a crisis point where
someone was being assessed under the Mental Health Act (1983).
 Some participants hypothesised that tight access criteria may be being used
to protect funding and resources rather than meeting the needs of individuals.
3.
What type of service should be provided?
 The majority of participants felt a specialist service was necessary especially
in regards to people who had complex needs. It was felt there was a need for
specialist skills to provide more effective care, however concern was raised
that this should not replace an emphasis on a generic understanding of how
to support anyone using a service. One person highlighted that some staff
who worked in Mental Health services might not have an expectation of
coming into contact with this group in a mainstream service, they felt this
highlighted a training need.
 There was questioning of the evidence base to indicate the need for a
specialist unit. One person hypothesised that the numbers of people who
would require the unit would be too small to sustain a service. Another
participant was concerned that beds in a specialist unit would be filled for the
sake of filling them even if people didn’t have a specialist need and people
would continue to be placed out of county. Instead they felt the focus should
be on improving current services to meet people’s needs.
 Participants referenced historical experience in Cornwall of specialist
treatment units. The feelings around this were varied:

Some felt this was a clear example of why more specialist treatment
units should not be created, stating concern around creation of large
residential units rather than supporting people with specialist needs.
They felt building separate services created fear, prejudice and
discrimination.

Others felt that although bad practice in closed units had been
unacceptable and needed to be changed, by closing down units and
not replacing these services with better services had left a gap for
groups of people with complex specialist needs, who were now sent
out of county to specialist units at high cost. There was concern that
people may be more isolated since these units had closed.
 When discussion centred on access to mainstream Mental Health services
some participants were able to provide examples of where this had been
successful however most felt that services needed to be improved. A more
person-centred approach was seen as integral to this with recognition of an
individual’s support requirements and the importance of this being appropriate
to enable access. The concept of citizenship was highlighted as some of the
reasoning behind improving these services. It was also highlighted that if
mainstream services are improved for people with a Learning Disability the
services would be improved for everyone.
 Concern was raised around risk of abuse in mainstream services. Some
participants felt that a person with a Learning Disability was at greater risk of
abuse in a mainstream service than someone without a Learning Disability.
However others pointed out that to some extent anybody going into
mainstream Mental Health services was at risk to some extent. Another
person also highlighted risk to staff working with people in the community,
who showed behaviour that challenged.
 Overall most participants identified a need for both specialist and mainstream
services. One participant who had initially favoured access through
mainstream services concluded that some extra support may be required for
people with complex needs in these services.
 Some people gave examples of potential service models;

One person described an experience of someone receiving support
from an external private care team in a mainstream hospital. They
worked with the staff on the ward to develop an appropriate care
package for the person’s discharge, although not without difficulties,
the person felt it was a good example of how services could develop.

There was suggestion of separate safe areas on inpatient Mental
Health wards for someone with a Learning Disability with access to the
main wards as an option to avoid segregation. Although agreeing with
this model other participants felt unsure that this service would be
offered due to a lack of resources and funds.

Another suggestion was to have a specialist nurse such as the
Learning Disability Memory Nurse or Liaison Nurses to provide
specialist knowledge and support to staff working in mainstream
services around Learning Disability. It was suggested that this person
should not have a case load, but instead provide a consultative,
mentoring service.

Others noted that in general health there were specialist areas for
example in dementia care and it was felt this could also relate to a
model for Learning Disability. It was felt this type of service provided
experienced staff who knew when to not intervene in a safe
environment. They further stated that this did not need to be a service
solely available for a person with a label of Learning Disability it could
be a service for anyone who met the need.
Conclusions
According to the sample of 10 staff who currently work within Social Care services
there is a problem for people with a Learning Disability in Cornwall accessing
mainstream Mental Health services. There has possibly been a little improvement in
general services for people with a Learning Disability.
The sample covered a variety of different job roles. Some participants had
experience of work with people who showed behaviour that challenged, with a
Learning Disability and who were considered high risk. Other participants worked
with less high risk situations with perhaps less challenging behaviour. It is therefore
felt that although the sample was small, this was a good indication that there is an
issue with access and is representative of a real problem in Cornwall.
Strong feelings and a wide range of issues were highlighted. This indicated the
complexity around accessing services. From rich and substantial data core points
were drawn out around assessment and provision of services.
In regards to assessment it was found that this was not led by the requirements or
needs of an individual but instead by the criteria for access to Learning Disability or
Mental Health services. Diagnostic overshadowing was an issue and inappropriate
assessment excluded people from services. Challenging behaviour was recognised
as a further complication in assessment of a person and there was varying
recognition of whether this behaviour may be attributable to a Mental Health
problem.
In discussion around the type of service provided, positive and negative aspects of
specialist or mainstream services were highlighted. In regards to specialist services it
was felt that these provided staff with specialist skills, knowledge and understanding
of how to support someone with challenging behaviour, Mental Health issues and a
Learning Disability. It was felt that the closure of specialist treatment units, although
necessary due to bad practice, had left a gap in services for this group of people.
Examples were given of current service models that could potentially fill this gap.
Negative points were mainly focused around the segregation of people caused by
creating specialist units and the move away from ideas of ‘normalisation’ and social
inclusion. Mainstream services were seen to be positive in that they offered an
opportunity for equal access as highlighted by policy and guidance but it was
recognised that this required good in-reach specialist support.