Tuesday, 30 September 2014

The best defence is a good offence

I know, I know (thank you for ongoing twitter tutorials @FindlayEquality and @rich_w), I do my best to take to heart the Antonio Gramsci mantra of “Pessimism of the intellect, optimism of the will”. But as the Sir Stephen Bubb group’s task nears completion, there’s a worry that’s increasingly on my mind as I see the public manifestations of the group’s thinking and Jeremy Hunt’s response to the excellent question on ATUs posed to him by @BendyGirl and @People1stEng.

My personal nightmare scenario runs something like this:

1) The original Sir Stephen Bubb plan only proposes to work with around 1,700 people currently in inpatient services. As I’ve set out (and as the Jeremy Hunt response also implies), I think this means that the plan is only going to work with those people who are not in forensic inpatient services (around 1,600 people in total, although the majority of these people are in low secure services and very few – 73 in the 2013 LD Census – are in high secure services).

2) So, the plan goes forward working to get the non-forensic group of people out of existing inpatient services. A network of purpose-built residential services springs up for this group of people across the country (maybe some existing inpatient services will change their remit to fit?).

3) In the absence of enough decent local support for people with learning disabilities and their families, new cohorts of people will continue to become highly distressed, and/or show ‘behaviours that challenge’ (who knows, maybe even some of the people in the new purpose-built residential services?)

4) So, if you’re responsible for local services, what do you do if your previous option of Friday afternoon crisis commissioning is unavailable to you? Could there be a trend over time of seeing these behaviours as potential offending behaviour rather than challenging behaviour (particularly if it includes aggression or destruction of property) and calling the police in?

5) This would set the person into contact with the criminal justice system – if convicted, increasing and improving liaison and diversion schemes (which partly exist for the excellent purpose of trying to reduce the number of people with learning disabilities in hostile prison environments) would mean that the person would not go to prison.

6) So where would the person go instead? Maybe an ever increasing number of specialist forensic inpatient services (another way that existing ATUs can repurpose themselves?)?

7) In 2025, will we have a national network of expensive, new residential services with people compelled to stay in them under long-term contracts, that will be seen as anachronistic (and sucking money out of supporting people into the pockets of private investors)? Will we also have an expanded national network of ‘specialist’ inpatient forensic services for offenders with learning disabilities (say, for around 3,000 people?)?

Solves a problem for local commissioners (problematic people out of sight, out of mind, and paid for by someone else). Keeps inpatient services in business. Keeps the prison population down. Creating a whole new class of people with learning disabilities without strong legal rights, branded as ‘dangerous’, in a whole new(ish) class of institution – never mind.

I know this is beyond cynical and I’m quite ashamed of my brain for going in this direction. I really want to be persuaded that this won’t happen.


  1. I agree that_Jeremy Hunt's comment was very discouraging. However, if you look at the Royal College of Psychiatrists' 'Guidance for commissioners of forensic mental health services' it says there should be a pathway to get people out of these secure units and talks about community forensic teams.
    So I am not sure that the psychiatrists that J H has been talking to represent the view of the College on best commissioning.

    Only half way through reading it :)

  2. Thanks Liz. I think this is a really good point, and there are some really good people working with this group who are absolutely committed to least restrictive community-based options. Even the ones who I've spoken to, though, are often frustrated and feel like they have their hands tied by commissioners. Problem with commissioners is that wherever you place a boundary between what different groups of commissioners do, some of them will try and shunt costs on to someone else.

  3. Hi Chris, In the cash- strapped public services cost be comes the deciding factor in most commissioning decisions. I think the anomaly in forensic mental health service funding is stopping the integrated care pathways, intended to gradually rehabilitate and get people back into the community, from working.
    While NHS England fund secure units and CCGs are supposed to fund step-down services and community forensic services then there is no incentive for CCGs to provide services locally to keep or resettle people in the community.It says in 'Guidance for commissioners of forensic mental health services' that community forensic teams are still rare.
    I think that , either NHS England should also fund step-down units and community forensic services or all services (except maybe high secure services) should be funded jointly by NHS England and CCGs. If there isn't a fundamental change like tthis then plans to get people from secure units into the community will continue to come up against the wall of no funding and no local services.
    Hope I have understood this dilemma OK. What do you think?

  4. Good Information.