Community is Richer When Everyone is Counted In

NDTi’s new report Close to Home is to be welcomed as a careful analysis of the facts about Out of Area Placements for people with mental health issues. People in crisis and people with longstanding needs are being sent miles away from their home and community, often for weeks and sometimes for years. In almost every case, this is really bad for the person and terribly expensive for the public purse. A few places have found a better way, and in so doing, they have opened up a new future for the person concerned, reduced distress and dislocation; and saved hundreds of thousands of pounds.

Minghella has made the case for optimism by showing how money that has been spent on buying the wrong type of care could be used to improve support. However, many frontline workers, whether commissioners, care coordinators or advocates find their path clouded by fog. Vollm and Braun’s authoritative account of research concerning the people who spend the longest time in the most secure conditions summed this up as ‘moving around rather than moving forward’. We can do better, but most services don’t. What’s more, almost identical points were made in the Mansell Report back in 1993 (revised in 2007), so this fog of confusion and lack of positive change has been engulfing services for at least twenty-seven years.

It is often the case that if the fog doesn’t clear quickly then someone or something is making the stuff. Fog making is usually accidental, unintended and unwanted, but nonetheless real. People want to do the right thing, but something in the everyday reality of working life adds to the fog rather than blowing it away. Here are some possible fog-making processes.

• People who are hospitalised far from home live with chronic uncertainty about when and how it will end, which erodes their capacity to plan, hope and recover.
• Families seesaw between being expected to do everything and being expected to do nothing, so find it hard to set out on a new journey in support of the person.
• Frontline acute services, bed managers and commissioners who have dangerously high bed occupancy levels wrestle with the fact that short term pressures are eased when there is somewhere to send people to, even if a few people have to be sent away to get the help they need.
• Budget-holders find it difficult in practice to support improvements that cost them money while yielding savings elsewhere, even if this would bring a nett benefit to the exchequer.
• The Ministry of Justice and politicians agonise over the balance between detention and freedom, especially when popular opinion loves a scapegoat.
• The costing model for private hospitals relies on long stays and few empty beds and even the best patient-centred service must balance its books.
• Social workers long for the opportunity to devise creative and experimental packages of care tailored to the individual but find themselves fogged by workload pressures.
• Commissioners are eager to develop new, multi-skilled community services that can divert people from admission and support them intensively on discharge, but they seek in vain for the start-up funds that would release savings down the road.

Beyond these things lie some even more challenging questions. Mental health services are panic spending, buying the wrong things and wasting their money rather than investing it rationally and in order to deliver the best return, perhaps because they have too many targets, too many demands on their purse and too little in it. After all, ‘spend to save’ is a rich person’s mantra, a morality that the poor simply cannot afford. Perhaps we need more money for mental health. But while that campaign runs, while we cannot provide everything that everyone needs, we should look most carefully at those who have the greatest needs, who cost us the most and who are most likely to be harmed by our current arrangements.

Then there is the whole question of culture. Minghella writes helpfully about risk in her report, but a close scrutiny will reveal that it is all about risks to the person – the risk of losing employment, friends and community, the risk of poor care and finally the risk of death by suicide after spending time out of area. Does this make her report naïve in its neglect of risks not to the person but from them? I believe that this is a deliberate pointer to the culture change that is vital to adopt across mental health services if we are to support people in their communities rather than out of them.

Minghella insists that we re-evaluate the humanity of the individuals that we currently exclude, and, as a result, insist that they should be included. This is perhaps the emphasis that has been strengthened in the years since the Mansell Report – the growing conviction that we should listen more carefully to the people receiving services and co-produce solutions. Skill, creativity and forgiveness will be needed on all sides, but fundamentally, community is richer when everyone is counted in.

Peter Bates previously worked in probation, the employment service, social services, the NHS and audit. Since 2011, he has also worked at the University of Nottingham promoting patient and public involvement in health research.