Another week passes and another scandal involving the mistreatment of people in Out of Area Placements hits the headlines. At the Yew Trees hospital in Essex residents were apparently “dragged, slapped and kicked”. “Didn’t I see a Panorama program about that?” I hear you ask. No, that was a different private unit a year ago. I wrote a blog following the Panorama program saying that the incidents documented weren’t isolated, they were happening elsewhere right now. Despite all the call for monstrous staff to be sacked and for health care assistants to be regulated, I want to remind us again that we are in a system that makes these abuses more likely. Don’t believe me? Let’s hear from British Medical Association Lead for Mental Health, psychiatrist, Dr Andrew Molodynski…
“As seen in the cases of Whorlton Hall and Winterbourne, the ‘cut-off’ nature of these institutions can be a breeding ground for the development of harsh and abusive cultures.” (NDTI 2019)
I wrote in the Lancet earlier this month about the push for the NHS to export those it finds troubling into the private sector. A perk of this process is that risky people become risky elsewhere. While it’s easy to blame the private sector for the quality of provision, I’m mindful of a training session Hollie Berrigan and I did with a leading mental health provider a few years back. It would be fair to say that the cohort of people were the least engaged we had worked with. Some played on their phones in front of their manager, some didn’t answer a question throughout, others came late and left early. Why were these staff so disengaged from the topic of “personality disorder” when they worked in a specialist personality disorder unit? It turned out they had only become a specialist unit a week before. It was a job none of them had sought or applied for, none of them had any enthusiasm about and where none of them had any hope of being able to help people. In contrast the staff group seemed fully aware that they were not there to provide a specialist service (they were all too aware of their lack of rudimentary knowledge, let alone specialisation), they were there to contain those that were sent out of sight, out of mind. People were coming from hundreds of miles away with little follow up or interest from their local services. Now I struggle to believe that anyone is born sadistic or abusive, but if I wanted to turn normally ethically sound and morally upright people into those capable of dehumanising others, this is the system I would use.
This leads me on to some training I was doing with Hollie recently with a trust keen to reduce its use of Out of Area Placements. Before we’d arrived one of the members of the trust had raised some reasonable points about why a private company with a vested interest in avoiding placements was coming to lecture them. Surely a private provider would like the chance to come and evangelise the virtues of inpatient treatment?
The critique took 3 forms –
1 – We are a private company.
Yes we are. As an Occupational Therapist within the NHS I found it impossible to influence the use of placements locally. The roles that could influence placements were reserved for other professions. The thousands of pounds the NHS invested in my MSc education was utterly wasted and clinicians went off to placement avoidance meetings while my research on how a team ceased the use of placements was never asked about. The only way I’ve found to get the knowledge the NHS paid for into the NHS has been to go private. It is very frustrating but while it’s frustrating for me, let’s not get started on the NHS use of Lived Experience Practitioners. Hollie also had the frustration of working in the NHS and seeing people who responded dangerously to restriction being moved into higher levels of security. In the private sector people see her as an experienced consultant and listen. In the NHS her skills and experience were squeezed into the box of a peer support worker (banded less than a support worker) who’s voice couldn't be heard and wasn’t allowed to write notes herself. Being private is not our priority, effectively advocating for the client group we care about is.
2 – We are anti-placement.
Yes we are. Emphatically and unapologetically. We do recognise that sometimes they are needed but nothing like to the extent they are currently used nor the duration they are used for. We are certainly not alone in having concerns about the use of OOA placements. By my reckoning, we stand alongside Rethink, the Royal College of Psychiatrists, NHS England, the Five Year Forward Plan, the Nation Development Team for Inclusion and the Care Quality Commission. It can be useful to judge people by the company they keep, and I see few organisations that could claim to be independent lining up to defend the current or increased use of placements. Further, our resistance to placements is based primarily on our experience. It is a heart-breaking thing to see someone who in one part of the country would be supported at home compelled to move 100 miles away. They often lose their accommodation. The distances and expense mean it’s easy to lose their family. It’s harder to accept this when those arranging placements acknowledge it isn’t in the patient's best interests but do it anyway. We’re in a fantastic position now where we work with some very creative and dedicated commissioners who recognise the repeated lack of value they gain from placements and who are keen to explore other alternatives.
3 – All the placements currently arranged fit with NICE guidelines.
This made me raise my eyebrows. There are many ways in which placements are incompatible with what NICE recommends (Is anyone interested in that blog?) but perhaps the most obvious one for me is “ensure that when, in extreme circumstances, compulsory treatment is used, management on a voluntary basis is resumed at the earliest opportunity”. I think you have to work very hard to convince yourself that this fits with a compulsory placement of a year or more.
At the end of the training 100% of the people attending said they’d be less likely to argue for placements in future. That was a reassuring day. Later in the week I was at a tribunal where the same theme of every tribunal I’ve ever part of came to the fore. The person is coping in a way that is more likely to lead to death since we started restricting them, so we must continue to restrict them or restrict them more. Obviously this wasn’t enough to convince a tribunal panel to maintain someone’s detention, but I worry about how few people get to make this case. I worry about staff who don’t know better evangelising about the benefits of placement (and I’m terrified by the staff who do know better doing it) and I worry that the desire to place those who trouble us far away means that we spend a lot of money giving people contraindicated care.
So back to Yew Trees. It’s awful and we can blame the people who worked there but let’s remember that the residents of this hospital arrived there due to the system of care that currently operates. Not one private institution has abducted a patient from the streets. Every resident had their place sourced by the NHS and theoretically monitored by the NHS. We will not get decent community services while we fund “care” like this. We will not stop the abuse of the vulnerable with the system we have.
This has been a long blog and in many ways it’s the same as the one I wrote last year. If you were to ask me what it’s about I’m not sure I could tell you, only that it was cathartic to write it. The sad thing is, I know it won’t be another year before events in the news push me to write another similar one. At 250k per person per year, the cost for this model of care is too high financially. For the most vulnerable people in our society who are “dragged, slapped and kicked” in a ‘specialist unit’ by those who are supposed to care for them, the cost is incalculable.