Where can you get a bed for £540 a night? The Ritz? No. The answer is an independent sector medium secure unit (MSU). That’s towards the top of the range but not the most expensive.
That £540 becomes £15,120 a month and £197,100 a year. In the world of mentally disordered offenders (MDOs) and others with challenging behaviour, a patient’s stay is usually measured in months and years. Faced with such huge expense and the shortage of their own provision, no wonder primary care trusts and mental health trusts have started to build new (or expand existing) units. Figures from the Department of Health show that secure and high dependency services have had the largest percentage real increase in funding, at 81%, in the mental health sector between 2001-5. More is now spent on these services than on community mental health teams and it is the second highest expenditure behind clinical services.
Locally it would appear the focus of the NHS mental health services has switched back to direct MSU provision because of the cost of the independent sector, coupled with government and media concerns over high-profile tragedies. My impression is of a system of people warehousing, offering simple containment, without the facilities to meet so many complex needs, let alone move-on accommodation to free up space for people in prison awaiting an MSU bed. (It has been estimated that 3,000-plus inmates in prison health centres are so sick that they need immediate admission to psychiatric hospital, but there are no beds.)
A generalisation of my experiences in NHS and independent sector MSUs is that about half of the clients can eventually be moved on to conditions of lesser security. But the rest will need long-term, slow-stream rehabilitation or a “home for life” in varying conditions of security. Consequently the primary intervention will be addressing quality of life – something that many MSUs cannot or will not do due to financial or political implications or both. If patients do not have access to a range of therapies or facilities, it can prolong their stay and increase cost.
In the absence of a long-term strategy from the government and mental health organisations regarding MDOs and uncertainty about the purpose of MSUs, medium secure units will continue to be a financial and moral black hole. And the uncertainty cascades through every level of organisation, so that many ward staff wrestle with the dilemma of what they are there for: to contain or treat?
Terry Conway is a senior social worker