Full Circle: The
future of services that support people with high support needs
The future of the service provider:
Services providers have become specalised in providing for a specific
group within the disability arena. They provide the knowledge base, the
skills and resources in supporting a particular group. As a result the
wider community supports these activities.
Any service or organisation that grows above
a certain size
(saturation point :
that the organisation can no longer function as an organisation, but
rather as a collection of mini organisations) is dependent on it's
departments in fulfilling their own roles
within the organisation. These
departments become specialised in providing a specific function within
the organisation. Just as a person becomes specialised in a specific
task, and the person looses the skills in other related tasks, the
departments within the organisation may become so specialised within a
other skills that are important
to the needs (overall health)
of the organisation, become less important than the needs of the
department. Each department may have budgets, performance criteria,
targets, assessment programs etc. that determine the efficiency of the
department, which means that the department becomes more concerned with
it's own performance rather than the overall health of the
organisation. Communication, cooperation etc. between departments
becomes slow, uncoordinated and sometimes nonexistent (have you ever
experienced the frustration of trying to deal with the government, a
large bank, internet service provider or any large multi national
Is this the future of services that support people with high support
(aged, severe disability etc.) ????
While asyulms were origionally a place of safety or retreat from
became places of hardship, deprivation and depravation. What started as
small hospital facilities soon became large buildings that supported
hundreds of people. Built around a medical model of care, a culture
evolved that enabled a small number of people to support a large number
of people. Social policy
was to hide these groups behind walls, where society was protected from
the activities that happened within those walls. There has been a great
deal written about the values, behaviours and attitudes of the system
that supported the residents of these buildings within society. Because
they were in long term institutional care, the term "Institution"
referred to the building, the culture and the outcomes of the building
and the culture. While the charasteristicts of this institutional care
was similar to other institutions, the outcomes were different. Today,
we see small services evolve into organisations that
support different groups within society. Organisations are getting
larger to cope with increased demand for
services. As an organisation gets larger, more resources are needed to
support the organisation. Things wear out and need replacing. New
equipment and technology
replaces old and outdated equipment and technology. Direct care staff
need to be increased to meet the needs of its clients, which means more
support staff are needed to meet the needs of the direct care staff.
organisation also has its own needs in fulfilling its
role in providing for the needs of people with disability.
service provider can not provide for its own needs or the needs
of its clients, the culture and institutions of the service provider
so that the basic needs of its clients can be met, and other
needs that are considered as not important are not met.
For example the normal staff ratio may be 1 staff to 4 clients. As the
service grows, and the service can not get the extra staff because of a
lack of funding, skills or available workforce, then the service has to
prioritise needs as well as ration resources. Because the service
provides direct intervention in supporting its clients there may be no
other service that can provide support. The result is that the service
may become the Asylum that Goffman, Wolfensberger
and others wrote about in the past.
This is most noticeable in nursing homes where costs increase and
suitable staff are scarce. The nursing home tries to cut costs and
ration resources and as a result the clients are not getting all their
needs met. Hospitals are also suffering from a lack of skills and
resources. People are not getting the proper care, patients are left in
corridors because of a lack of space, etc. etc. This also happens
within disability service organisations
where the needs of the organisation become more important than the
needs of the clients. Administration, OHS, payroll, maintain, staff
training, policy development, volunteer coordination, area
medical staff, transport, recreational, employment, direct support
staff, relief management, relief staff - just to name a few roles
may have - may mean that there are 200+ people supporting 100 clients.
(CLP) - SA
for example has approx 40 staff employed to
than 20 and up to 30 clients, of which approx 20% need 24 hr support.
Suppose this group was supporting 100 clients. It is not unreasonable
to suppose that the group would need a minimum of 80 to 150 staff to
provide the same quality of service. Imagine what the service would
look like if it was supporting 200 or more clients. What would the
service look like if it was supporting 600 clients, which could easily
happen in the future.
Activ employs more than
(management, staff support and direct support).
Provides direct support:
homes to 250 people,
assist another 82
their own homes and deliver respite care to 268.
jobs to 1045 people with disability
= 1645 who receive direct support (source:
= 1/1.83 staff/clients ratio
Would the service become the Asylum that Goffman, Wolfensberger
and others wrote about in the past (both literally and figuratively) if
the community did not have the skills and resources to look after their
was designed as a twentieth century service
provider that provided for the needs for 1200+ men and
Origionally a hospital
Was ahead of its time
Supported a large number of people with an intellectual disability
To provide for the needs
of people with
an intellectual disability
Provide a secure setting.
To protect society from this group.
Strict rules and regulations
Division of groups ... staff/residents, male/female
Residents basic needs are
Residents have the opportunuty to socialise with each other.
Low expectations of the
Large group of people seperated from the wider community.
Shift in public and Gov. oppinions, values and policy towards this
group has ment that the residents of the hospital were moved to other
The life of institutional living is described through the experiences
of a former resident (Howard Mitchell) as well as others that were
"How do we
make sense of what we
saw? The video tells the story of the hospital in dramatic tones: we
hear about a riot, escapes, punishment and drug treatment regimes. But
we also hear about football matches, dances and friendships. Even so,
they are only part of the story of 60 years and many hundreds of
people's lives. We saw several volumes of detailed records. What can be
learnt from so much information? How can Howard Mitchell begin to
organise all these facts and accounts?" (Lennox
In order to support 1200+ men and women today the facility would need:
Assuming a direct support
there would need to be 300 primary support staff.
Management and other support staff would probably be 50-100.
Which means that the facility would need to support 1600-1800 people
minimum, which is a lot of people.
Assuming a total staff/client ratio of 1/1.83,
there would need to be app 660 total staff + 1200 residents = app 1860
If you feel inclined to watch the videos that are at the site (highly
recommended) some other interesting questions may come to mind:
... What are the values,
expectations of the community towards people with an intellectual
disability as described in the video?
... What are the values, attitudes and expectations of your community
people with an intellectual disability today?
... What are the characteristics of
institutional life as described in the video?
... What are the similarities and differences between the
characteristics of institutional life as described in the video and the
characteristics of life in a service today?
... What are the outcomes of institutional life as described in the
... What are the similarities and differences between the outcomes of
institutional life as described in the video and the
outcomes of life in a service today?
The real tragedy in all this was a lack
of skills and resources available within society, and of a set of
activities, values, attitudes and
expectations embedded into that society (institutionalised) meant that
people with an intellectual disability were not fit to live a normal
family live and share normal loving relationships that we all take for
providing the most appropriate
care for people with high support
1) The community is not
person is living, but where the person participates, shares experiences
and has valued relationships with others.
2) People with high support needs (severe disability, aged
will always need support structures as a part of their lives.
3) The amount of participation in a community (living, education,
employment or recreation) is directly related to the skills and
resources of the person, and, the skills and resources of the community
that the person wishes to participate in.
4) Institutions are going to be around in one form or another
whether we like it or not, It is the way that they are used that is the
5) The institutions of a society towards a particular group determine
the way the group participates in society.
6) The institutions of a particular government department,
organisation, profession or service define the way the person is
supported within that society.
7) Facilities that support people with high support needs do
need to be the nursing homes or prisons in the sense that they are
today, but can become warm inviting community places that offer a range
of services to the community, as well as be a part of the wider
8) People with high support needs are a minority group in our
society, and will have the same problems as other minority groups in
being a part of society.