By an adults’ social worker
It’s a break in the usual routine of an adults’ social worker to visit a person with learning disabilities who is cared for a long way from home, ‘out of county’. A long car or train journey provides unusual time to sit and think. In my early days of social work these journeys were filled with anticipation for the highly specialised place I would find at the other end, with their fees of between £3000 and £6000 a week.
But this anticipation has faded with a series of, at best, underwhelming visits. These days I mostly wonder why there is nowhere closer along my route of up to 300 miles that is deemed able to meet the needs of the person I’m going to see.
Arriving at the final destination provokes a variety of feelings. If the visit is to a secure hospital, the towering electric gates provide a stark reminder of the containment occurring within. My own depersonalisation, as I am instructed to leave ‘contraband’ in a locker (the list is so long I leave everything), is an echo of the depersonalised world of the patients. The use of the word contraband itself is a symbol of the institutionalised setting, the parallel with prison is no coincidence.
There is precious little space in these hospitals to be a social worker. You’re shepherded into a meeting room and the patient arrives at a carefully planned time to participate in the part of the meeting professionals feel is appropriate for them. Families may also have made the long journey to attend. Each professional presents a report. The psychiatrist, psychologist, nurse and occupational therapist are the staples. There may be a hospital social worker, but they tend to be spread thinly.
‘What really happens here?’
I want this person to be back in their community. Some have ‘lived’ in these hospitals for 10 years or more. Professional expertise about them has faded from their home community team and been transported here, to these people, in this room. Families, though, are my experts of choice. The rich history of the person (not the patient) is ingrained in the family’s hearts and minds. Their knowledge is no dusty archive, no mishmash of paper files and notes across multiple computerised systems.
In these meetings, I am me, a lowly social worker among the high brow medical professionals in the room, often the sole representative from my local area, grappling with these reports and my gut instinct. To what extent can I confidently challenge the psychiatrist’s view? Or the psychologist’s?
What I want is to spend time on the ward. Talk to the people who really know. Spend time with the person, the health care assistants, the cleaners. What really happens here? I need health colleagues from my community to be here, engaging with their peers in this private hospital, meaningfully probing how their work with the person is leading to a life back in their own community.
There should be no pecking order, I know, and I should not describe my social worker role as lowly. I am secure in my social work practice, but I am not a psychiatrist and the truth is that in this room, and others like it, they wield the power. I will discuss the meeting with my local psychiatry colleagues in our next multi-disciplinary team meeting when I return, but really this person needs their home community psychiatrist looking this one in the eye, taking the lead. Owning their care, and their return.
‘A very different agenda’
The government’s Transforming Care policy, launched in the wake of the Winterbourne View scandal, is working towards closing beds in hospitals and moving people into the community. The premise of our conversation around this table should be that we are all working together to achieve that. However, as the 7 Days of Action report, A Trade in People, recently pointed out, only NHS beds are being closed, the private sector has spotted this and is moving in to fill the gap.
One US-based healthcare company, for example, has been snapping up hospitals for people with learning disabilities in the UK. This seems quite a niche interest for this organisation, but a look at their website offers some clues about this. It states that they ‘build or acquire high-quality hospitals in rapidly growing markets, then invest in the people and equipment needed to allow each facility to thrive and become a dominant healthcare provider’.
I will forgive myself, then, for being distracted in the meeting by thoughts of how this aggressive ambition of market dominance can be reconciled with Transforming Care, my own role and this person’s life and human rights. How can I wield the power here, in the face of contradictory corporate intentions, to get this person home? I don’t want to doubt the professionalism of the people around the table, but these are not my colleagues and we are ultimately not on the same page. Their paymasters have a very different agenda.
‘Step up to the plate’
We file out. I hope I’ve helped move things along, challenged where I should. I’ll hang around for a while. See the person on their own. Try to get into the ward itself. Have a chat with the staff who support hands on, day in day out. I’ll meet the family in more familiar surroundings, another time. Then I’ll go back to my team, urge commissioners to source the accommodation and support the person needs. I won’t let it drop.
But it’s not enough. Under Transforming Care we now have Care and Treatment Reviews, but we all need to step up to the plate, all of the time. Let’s not kid ourselves that we’re commissioning care in these private hospitals (where are the commissioners, the contracts, the holding to account, do we even know what we’re paying for here?), we’re stumbling into this for want of the will to do better in our communities. And the private sector know it.
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For three grand a week you could pay for rent on a 2 bed flat and 24 hour professional care and support in the community, where this person lives. This goes for people with severe and multiple disabilities and even those with ‘challenging behaviour’. It’s ridiculous that all Transforming Care seems to be doing is more outsourcing to private, for-profit providers who have a clear incentive to keep people in secure units for as long as possible.
Keep talking back to the medical professionals! You are the only one in that room with any deep understanding of what the social model of disability really looks like, who is not diagnosis-led and the only one with genuine commitment to enabling that person to have a full life: one which includes seeing family and friends daily, which means being a part of your community, not just the next door along on the ward.
100% agree. Challenge all the way when appropriate.
Agree fully with everything you say, Emma.
Community care, please please more articles like this please to highlight the barbaric treatment of these members of our society
Emma you are so right. Sadly this not only applies to hospitals but also the learning Disability large homes still exist – perhaps partitioned off in to a series of smaller units around and old facility. We still come across them all to often and they cry “wolf” when our trainers challenge the practice. In reality often little has changed for many people.
I agree. Psychiatrist psychologist OT and nursing. I find it impossible to get a sense of the person. Just professionalised perspectives which can be dehumanising.
But when I have challenged I feel I have been respected for doing so. I really agree with Emma. Advocacy, strengths and personhood. Medical teams are not against these, and a social worker can be good at raising them.
Such a well written article that gets right to the heart of things. It beggars belief that we have this conflict of interests where hospitals rely on heads on beds to make their huge profits. There is zero accountability courtesy of the Mental Health Act. These places charge an extortionate amount of money to provide a non service using a totally inappropriate model and all at the expense of some very vulnerable people.
Well said Julie. Often the behaviours are perpetuated by the environment these people are incarcerated into.
This is why we need to get the Mental Health Act changed – it appears to be a real doddle to detain and keep people with learning difficulties and autism in psyctratric hospitals. All that needs to happen is to provide no support for families, inappropriate, inexperience or no support for disabled adults with LDs and ASC whilst living at home or in any forms of accommodation. Wait until these people get frustrated or angry because their human needs and rights are not being satisfied or fulfilled by the state and their agents – wait until they display abnormally aggressive or serious irresponsible conduct (against social norms defined by neotypical people) and bobs your uncle they get sectioned under the MHA 1983. No need to consider anything other than whether the person displays certain forms of behaviour…… Also there is a conflict of interest of the hospital provider having the power to continue sectioning someone who is a patent in their “care” – LAW needs to change – both MHA and Care Act giving disabled people enforceable rights to what they need to live independent lives as set out in UNCRPD Article 19 and social model of disability.
As a lay person it seems to me that part pf the problem is that in mental health services if you need care for more than a short time the choices are either low secure or rehab ((often locked). There are no long term beds for people who don’t get well quickly enough unless they have an eating disorder or personality disorder. So if you have a mental illness and don’t recover fast enough you are doomed to spend months on an acute ward where the expectation is that people will be gone within a month. Has the time come to accept that some people, who don’t need to be in secure services, still need long term care and treatment?
I would highlight though that often these people get detained under section 2 because their community placements were inadequate. I’ve worked on both sides and the real issue is there are providers in the community who claim to be specialist etc but don’t actually know what they are doing. Seen it happen too many times. Commissioners need to be stricter on who they commission in the community and have more regulation around what is required
Interesting. For psychiatrists it is actually the social worker who holds the power. The social worker is the one we ask for emergency respite care so that we can diffuse a difficult situation in the community (e.g., carer exhaustion) and avoid having to prescribe meds. The social worker is the one who tells us that there is no emergency respite. The social worker is the one who puts pressure on the psychiatrist to section people because they cannot find anywhere else for them to receive care. The social worker is the person we need to help find places/put together care packages so that we can discharge people. The social worker is the one who tells the CTR they cannot identify an alternative place of care, leaving us with no possibility of discharging the person.
Hi Anne-Marie
Yes, power is a complex and ever-shifting thing and, depending on the situation, may be concentrated in the hands of medical professionals or with the social worker. However, if your experience has been that the social worker cannot find emergency placements for people it’s clearly a larger problem they’re facing within the local authority and available providers. A rock and a hard place for all concerned.
My interest lies in whether and how this balance of power changes according to how the service has been commissioned. If it’s a private company with a profit incentive, how does that change the discharge rate and quality of care? If it’s a charity, does that make any difference?
Another factor is if the service is funded by the local authority rather than the NHS: this changes the incentives for the social worker too, who would be under more pressure to move their clients to less expensive, community placements if the secure placement sits within their team’s social care budget and is not shared by health.
Have you found any difference in how people are supported as a result of these contexts?
Excellent so true.Cannot stress enoughthe importance of talking to staff on the ground and the cleaner if possible at CTR’s.Rarely present
This is exactly my experience of many secure / rehab / ATU places. The large US firms are buying community residential as well as hospitals to create a monopoly situation. CEO of NHS England used to be very senior in same US giant – the marketisation of our disabled loved ones is really advanced and mostly disguised by brands in the private ‘health’ sector.
a well written paper that brings many good points but I have never found OTs following a medical role and as stated in some of the other replys it is the Social workers that have the power , all the folk around that table are just people doing their job no more no less than each other if you feel lesser it is yourself that is making that assumption and the subjective statement that all others work to a medical modle makes clear that you have not had clear communication with any OT’s as they usually make the best allies to get folk out and as indedependant as possible. Value your proffession or give it up
So why is everyone ignoring AnneMarie’s comments?!
Blair when a person is in the care of a specialist provision and being funded by an authority the social worker has certain powers, however if the company employs its own psychiatrists, as they mostly do, they can decide to section a person, the social worker does not hold all the power, they can certainly raise concerns but these need to follow a chain of events through the funding authority before over turning certain decisions made. This I know as has happened to families that I know personally.
A very insightful article. I often wonder if my daughters social worker feels this way. I find myself as a parent to a young lady with autism and severe learning difficulties, who is supposed to be receiving specialist care in a private residential placement, by a large company who specialise is mental health and autism education and care, having to move my daughter further away from me because my daughter is not receiving the right level of care, she is simply £££ to the company. It is shocking how the company is managed and the way they take hundreds of thousands from local authorities promising to meet the needs of the service users they take on, but don’t deliver, even having some people sectioned that should not be sectioned. The state of the care industry generally in the UK is dreadful and the options for finding the right care providers is limited, often leaving very vulnerable young people in unsuitable institutions. I fear for my daughters future I really do.. these big companies who fail need to be held to account, our vulnerable people are “people with needs” not money making instruments!!!