“It is a poor thing to enslave another. I would suggest you find yourself a different line of business”
The Sandman, Neil Gaiman
Scrolling through my social media feeds I’m coming across a lot of vitriol for the “care” workers of the hospital exposed on Panorama this week. There is anger, fury, sadness and disbelief. This is often followed by a graphic depiction of what medieval tortures the person posting the comment would like to inflict. This is an understandable response to witnessing people in power seemingly taking pleasure in inflicting pain and humiliation on those who are helpless. It was sickening to watch, and they should face justice.
It’s essential that our quest for justice does not stop there. The destination turned out to be awful, but perhaps this is a journey that should never have been embarked upon? After the Winterbourne scandal, Transforming Care emphasised the need for people to be supported in their communities. The Rethink #InSightInMind campaign highlights how those with mental health problems are often put in locked rehab wards many miles from home. Most are probably bored of me listing the enthusiasm of the NHS to send people diagnosed with personality disorder to long term locked rehab, which most could agree is an utter inversion of what NICE would recommend. Despite all these voices arguing against the use of long term compulsory detention far away it continues to happen. We need to ask ourselves why.
A common feature of those with complex needs (whether they be branded as learning difficulties, schizophrenia or personality disorder) is that they can worry those who feel responsible for them. There is a two pronged fear around what might be done to you (E.g. assaults, allegations) and what you might be blamed for. My MSc research and studies highlighted the impact of anxiety in organisations and how this can lead to a perversion of care. I’ll use the example of someone diagnosed with personality disorder (not a real person but an amalgam of many I’ve met over my 20 years in mental health working in and researching this area).
“a pressure developed affecting all levels of staff, managerial through to clinical, to ‘manage risk’…but this soon slipped into ‘managing risk to themselves…this is understandable, since the consequences of a faulty risk assessment were and continue to be quite horrendous” Independent Review of the Mental Health Act
There was a girl (it’s almost always a girl) who didn’t want to live. She didn’t necessarily want to die, but she felt the world was an awful place. After she had overdosed she felt unwell and went to A&E. She ended up getting admitted to an acute ward. On the ward she started to swallow things and to tie things around her neck. Here, she never sought help and it was up to the staff on the ward to save her. They watched her more and more. They took everything dangerous away from her. The things she did became even more dangerous. She stopped being allowed any leave. They took everything away from her.
We sat in a meeting and talked. Some people talked about how she was only doing this for attention. Some people recognised that since others had taken over “keeping her safe” she had become significantly more dangerous to herself. We could hear her saying loud and clear that she didn’t want to die, she just couldn’t cope with her living situation and the overdoses helped. We thought really carefully and came up with some different accommodation options. We thought about how we could provide therapy and support for her now and in the community. We all agreed that the NICE guidelines for her diagnosis told us that collaborative working, minimal use of the mental health act and treatment in the community were the ideal response. Then someone said “What if she kills herself?”. The rest of the meeting was about how the organisation could protect itself from blame. The solution that best met this objective was to send her to a private hospital for at least a year. Some of the people in the room believed that private hospitals were specialist places with experts and exclusive therapies. Some of the people in the room knew they were locked rehab wards with less therapy than was currently available in the community. She would be locked there, for years, with people with difficulties vastly different to her own.
Clinicians had “failed to rescue the patient, were uneasy at their failure, and were inclined to blame others, especially relatives, but sometimes colleagues. They were clearly worried by the patient’s distress, and wanted to rid themselves of their responsibility, with professions of goodwill. Concern for the patient was emphasised; impatience or hatred never.” Tom Main 1957
She had to wait a long time to go to placement. During this time she was never told that placement was the opposite of what was recommended to help her. She kept being told it was the answer, that this would fix things. Again some staff believed it. Others not so much. Different quotes were obtained from a variety of hospitals that all claimed they were special and could all provide intensive therapy. It turned out one didn’t even have a psychologist. 3 different quotes were obtained. One could say that the NHS made sure it got good value. One could also say that the opportunity to provide substandard care was auctioned off to the lowest bidder.
She went anyway. Her years stay slipped into two, then three. People visited but it felt more like the hospital told them what was needed rather than them holding the hospital to account. Eventually a different hospital was suggested for her. People talked again about how much more dangerous she had become since we had started keeping her safe. People pointed out how her care was the opposite of what NICE recommended. The answer was “What if she kills herself?” and she moved to another hospital. This one was further. Despite the label above the hospital gate the staff there knew there was nothing special about them. They knew they were working with those the NHS had given up on. Why else would they be sent 100 miles away to a ward where none of the staff had any specialist training? After allegations were made against the staff she was eventually brought home to a greek chorus of “She will kill herself”. She didn’t, but she had seen multiple people die in hospital with her. Every inquest said they should have been watched closer. None of them questioned why they were there in the first place.
There are 3,500 locked rehab beds in the uk with 2/3 of these in the private sector. It’s estimated 1,200 of people in them have a diagnosis of personality disorder. Locked rehab placements in the private sector last twice as long as placements in the NHS. The evidence for therapy delivered under coercion (if such therapy is available) is abysmal. There are a range of therapies that have been shown to help, but the evidence for all of them is in the community. Despite everything that good practice guidance recommends, the above treatment plan is still used all too frequently. The NHS is terrified of blame, and for a mere £200,000 a year that blame can be exported to the private sector.
Due to the recent coverage it’s very easy to focus on those diagnosed with learning difficulties, but the reality is that a trip to the modern asylum is a danger for any person who elicits anxiety in those who feel responsible for them.
“The need to believe in the hoped for magical solution prompts denial of the inadequacy of the solution achieved, notably again in the poor quality of the institutions” Isabella Menzies Lyth
Last week I was at a study day where 30 people from across the country looked at ways of avoiding the above happening. There are some trusts that do not use OOA placements and we studied what they did that made it possible. While the NHS is frightened the temptation is that we do not focus on the risk to our patients but instead the risk to ourselves. When we are frightened it’s understandable that we do what we can to get the things that frighten us out of sight and out of mind. When we stop thinking about people, unthinkable things happen to them. Many people will watch Panorama and feel that it should never happen again. It is happening today.
Keir works at Beam Consultancy helping organisations to avoid long term out of area hospitalisation via the provision of training, consultancy and intensive support. firstname.lastname@example.org