A comment on the BBC Panorama 'Undercover Hospital Abuse Scandal' Documentary aired 22nd May 2019
The BBC Panorama documentary, which reported abusive practices in a hospital for people with intellectual disabilities and autism, has highlighted a broken system of support for society’s most vulnerable. The earlier 2012 Winterbourne View documentary was the first of many to expose a pervasive model of support that both is damaging and not therapeutic.
What Do We Know?
The children’s commissioner Anne Longfield identified that there were 1,465 children in England securely detained in 2018, of whom 873 were in held in youth justice settings, 505 were in mental health wards and 87 were in secure children’s homes for their own welfare. The cost of these placements was over a staggering £300 million per year. The situation in our adult mental health services is also concerning. Staff in NHS mental health hospitals deployed restraint on patients 22,000 times last year, almost 50% more than the 15,000 occasions in 2016. A File on Four investigation identified the number of such patients living in inpatient units in England has only fallen from 2,600 to 2,400, while the number of under-18s being cared for has almost doubled. We are spending huge sums of money supporting people with very complex behaviours quite literally miles from their homes and communities.
These are just the financial costs. The human cost of managing people in highly medicalised environments is also incalculable. I do acknowledge that the vast majority of this poorly trained and underpaid workforce are trying their best to deliver optimum care. However, in my opinion, our current system is flawed. We criticise people for the large number of individuals in this type of care, yet we do not adequately resource specialist community resources to support these people. In my opinion, there needs to be both a top-down and bottom-up approach to changing these services.
Deeds Not Words
The challenge for us is to have real and honest dialogue about how we begin to fix these problems. The usual sweeping statements from politicians and officials after such documentaries can be both full of vigour and quickly forgotten. We must begin to follow a simple message. My old school motto, ‘Facta Non Verba’, means ‘Deeds Not Words’. So, what are we going to do about it? I am very aware that complex issues such as these need to be reduced to basic principles. Let’s move away from targets and start to figure out who these people are and how we return them to their homes and communities. In the spirit of keeping things simple, the following short list should be seen as a ‘snapshot’ guide:
1) When people require support, it should be close to their homes Sending people hundreds of miles away from their family and supports places them in a form of isolation. This reduces the likelihood of visits, which is an important factor in the external monitoring of abusive practices. Local services can help to reduce the lengths of stays in specialist placements, and also encourage continuity of care. The mantra should be to 'keep people in their communities'.
2) We need to change our crisis training models to reflect an approach that genuinely makes restraint a last resort. Restraint may be required to keep people safe. On the other hand, when it is repeatedly used, it just demonstrates a traumatising approach which is a by-product of a larger failure to understand and meet a person’s needs. It is too easy to train people in narrow crisis management responses that often contain limited de-escalation strategies. Surely a better use of these pre-crisis skills would reduce the need for repeated use of restraint methods?
3) Commissioners of services must be held more accountable Placements are expensive, and often long in duration. The level of scrutiny needs to be much higher. Authorities that place individuals must move towards a system of visits which do not give prior warning to services. There should also be a mandatory funding threshold of one year in any placement. After this period, funding should only be extended by six-month periods, with commissioners’ agreement. The emphasis needs to be on returning people locally. Where a stay is determined to be long-term in nature (likelihood of greater than 2 years), the individuals should be moved to services locally.
4) Create a new national clinical audit team Greater scrutiny of placements should occur after 1 year. A national therapeutic, multidisciplinary team should assess all individuals in placements for their therapeutic needs, goals and outcomes. They should consider the therapeutic pathway for individuals and consider the following three areas:
· What supports and resources are needed to return home?
· A service specification for an individualised service for those individuals deemed to need long-term supports.
· Individuals that remain in placements must have a clear therapeutic pathway that is reviewed by this team. All individuals with monthly or greater levels of physical restraint or seclusion must have an agreed and binding restraint reduction plan.
5) Increase therapeutic resources to local community resources. Critical to returning people home is the need for local supports from specialist practitioners and agencies. The emphasis should be on strengthening these resources. Increased community supports should also prevent the need for specialist placements.
Conclusion It is our considered view that the core driver of change must be returning people to their local communities wherever possible, and developing local services to support these individuals. There needs to be a mindset change which emphasises that 'local is best'. What we are to learn from this documentary and Winterbourne View is that we need to ‘bring people home’.
Professor Andy McDonnell,
Studio 3, CEO