This is the ugly face of capitalism. There need to be far tighter controls on these fat cat firms. Matt Hancock, the health secretary, should stop mouthing platitudes and finally take action to end this cruel exploitation of vulnerable people. Even as I write this sentence, another email arrives from a despairing parent over her distressed daughter, stuck in segregation yet still able to swallow a latex glove. Strangely the Left, too, is largely silent on such profiteering from failure and misery. The unfortunate citizens stuck in cruel secure units where they are violently restrained, forcibly sedated and held in lonely isolation are second-class status.
Yet this issue does not just revolve around abysmal social care failures, nor even dismal private operators funded at great cost by taxpayers. (It can cost up to £730,000 a year per person in these secure units). For this latest CQC report raises a more profound question over our mental health system: why is our nation sending more and more of its citizens into secure psychiatric hospitals in the first place?
A few weeks ago I visited Trieste, which pioneered a very different approach to psychiatric care based on opening doors and embracing human rights. It dates back half a century to the actions of an iconoclastic psychiatrist named Franco Basaglia, who argued “freedom is therapeutic” as he unleashed 1,200 patients locked up in a huge asylum complex above the coastal city. His work — part-inspired by controversial ideas circulating in British psychiatry — led to an Italian law blocking admissions to public mental health units, which were replaced by beds in general hospitals and smaller community facilities. Five years ago, the country went further and phased out forensic mental health units.
His legacy in Trieste is impressive and moving. One British expert told me before I went that if he was suffering mental health problems, he would want to be treated in that city — and it was easy to see why. Teams of medics rely on discussion and persuasion, backed by local services open day and night, instead of chaotic institutions filled with stressed patients and overloaded staff. “We have open doors everywhere,” said Roberto Mezzina, who has just retired as director of the city’s mental health services.
“Our belief is anyone can live freely in the city with the right support. We have proved this over many years. There is nothing positive about coercion. There is no study showing it has worked anywhere in the world.”
The Trieste model is based on respect, treating patients with mental health struggles in the same way as if they had any other kind of sickness. Remarkably, this genial psychiatrist told me he had never used physical restraint in his 41-year career, relying instead on often-exhaustive negotiations with patients based on listening to concerns and understanding their anxieties. He joked about use of ‘gelato therapy’, taking stressed patients out for a walk, coffee or ice-cream to help calm them down.
Contrast this with our own country: the brutal techniques of restraint were used almost 100,000 times in English units in 2016/17, leaving more than 3,600 patients with injuries. Teenage girls have repeatedly told me of their terror at being held down by teams of adults, then forcibly injected with sedatives after being stripped.
It is naive to expect CQC inspectors to stamp out abuse in 22,949 adult social care settings, 234 independent mental health units and 55 NHS mental health trusts on their flying visits, even if the watchdog has belatedly gained a few teeth. But ponder a tale I was told by Mezzina in light of all the abuse exposed in our mental health system.
When he arrived as a young doctor in Trieste, he was tasked with helping to discharge the final batch of institutionalised patients, moving most back to live in the community. Their lives quickly improved as their rights were restored. Yet the impact on the nursing team was just as strong: they stopped abusing their charges after seeing their humanity. “I call this parallel empowerment — power should be bottom up and challenge everyone. You cannot change the system otherwise.”
Herein lies the key to what has gone wrong with our services. If you remove rights from people and detain them in secretive units, this can foster abuse — especially in a culture that looks down at people with autism, dementia, learning disabilities and mental illness. Yet we have seen rates of involuntary admission almost quadruple since the landmark 1983 Mental Health Act with a significant surge in recent years, which leads to increasing reliance on those private places run by multinational operators. Detentions rose another 2% last year alone. A debt-funded model relies on constant flow of fresh patients. Now more than half of mental health patients admitted are on compulsory basis — and almost four in 10 patients are then subjected to coercive measures such as restraint, sedation or segregation within four weeks of their enforced entry.
Politicians love to talk of ending the stigma of mental health problems. But our fear-ridden society views patients with such difficulties through a prism of danger. This demeaning attitude has been inflamed by reaction to high-profile murders by people with psychiatric problems, then intensified by funding shortfalls, slashed services and chronic shortage of beds. The result is that Britain, like some other countries, has ended up with a service that revolves around risk analysis rather than effective or more sympathetic treatment, with private firms soaking up gaps in services.
This approach is ethically and medically flawed. It is also fiscally foolish. Trieste’s open-door approach ended up costing only 39% of its old asylum, which needed more staff to guard patients round the clock. The most recent review of our mental health laws — sparked by a 40% rise in use of coercion over a decade — was scathing about people being detained for public protection when better and cheaper alternatives are available. Published 13 months ago, it highlighted the lack of respect for patients and how the environment in which many people are held “is now anything but therapeutic”. Many of those incarcerated people with autism and learning disabilities end up in a far worse state with severe post-traumatic stress.
These failings frequently prove fatal. A BBC investigation found unexpected deaths in mental health services rose 50% between 2012 and 2016, while I know of one hospital where 34 patients have died over the last nine years, highlighted by a father desperate to free his daughter.
Among the most appalling recent cases was that of Connor Sparrowhawk, a teenager with autism and epilepsy who drowned in his bath in 2013. Afterwards it emerged that the award-winning Southern Health trust had not even bothered to examine the deaths of some 1,000 patients with autism or learning disabilities, sparking a national review and showing once again the dismissive attitudes towards such people that plague our society.
We need far more than slogans to solve this health crisis, with an adult debate on everything from provision of decent, well-funded community services and rapid expansion of autism testing, especially for girls, through to candid discussion of the complex issue of euthanasia for suffering individuals seeking to end their own lives. But this discussion must be rooted in respect, not simply revolving around the detention of troubled citizens in secure units, out of sight from the wider public.
This is not simply an issue of privatisation, poor care and political failure. It is about power. And it is about the most fundamental of human rights — that of freedom from state oppression. Claire Greaves knew that she was severely ill, but wrote movingly on her blog of her dream to deal with her problems as an outpatient backed by a supportive mental health team. She wanted to work in a bakery, go to ballet classes and have a baby. It was her vision of “a life worth living” that she never managed to attain. So how many more must die before we see the real problem in our society?
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