Only connect…

The “overuse” of hospitals by homeless people highlights a huge
problem: the failure of government and its agencies to communicate
effectively with each other, says Conrad Russell.

Shelter’s report on the use of hospitals by homeless people is
called Go Home and Rest. In that thoughtless piece of
medical advice much of the difficulty of multiple deprivation is

The street homeless overuse hospitals because they have peculiar
difficulty in registering with a GP. That is not because GPs are
heartless, though the increasing tide of violence in surgeries
worries most of them. It is much more because of the perverse
incentives to refuse registration to the homeless created by the
performance indicators on which practices are remunerated. Homeless
patients do not score highly on immunisation rates. Homeless
patients also overuse hospitals because of the direct effect of
their homelessness. Hospitals give out large amounts of Ventolin
inhalers to homeless patients to do what a home would have done
better. The NHS drugs bill goes up and patients do not recover.

When students with serious psychiatric problems are referred for
treatment, they often also have acute financial problems. The
effect on a patient with a tendency to paranoia of wrestling with a
system of support they often perceive as being set up to make them
fail can be devastating. Persecuting a paranoid person is not an
effective method of treatment. Yet the psychiatrist is often
unaware of, or not interested in, the financial aspects: that is
someone else’s problem.

Similarly, the tutor who wrestles with the financial
difficulties may be unaware of the psychiatric dimension, or not
interested in it because it is someone else’s problem. We are all
overworked and, often for good reason, hesitant about poking our
noses into someone else’s difficulties. The result is that
solutions that are well-designed for one problem may exacerbate the
other, and end up doing more harm than good.

This pattern may be repeated all round the field of social work.
A family with difficulty in coping may be thrust down below the
level from which they can fight back by a decision by the Benefits
Agency to disentitle them to benefit. Bet that decision will be
taken by rule of thumb, without any attempt to weigh up the
circumstances or tailor the response to the people on whom it is to
be imposed. The treatment of women who have suffered domestic
violence runs up at every turn against rules designed for quite
different situations.

For example, the social security verification framework demands
the production of documents as a protection against fraud. This is
a perfectly proper and, superficially, logical response. Yet one
can imagine the effect on a woman who left home bleeding, in her
nightdress, of being told she can have no support until she
produces documents which are in a place that is no longer safe for
her to go to.

Some of the problem arises from the division of ministries in
Whitehall. Each makes legislation, regulations and guidance for its
own purposes, and ignores the effect on other ministries. It ought
to be for parliament to make the connections.

More regularly, the need is for the different disciplines of the
caring professions to connect with each other, to exchange
information, and consider the person with multiple deprivations as
a whole person. It is the old injunction, “only connect”. There is
a constant need to consult and confer.

Yet to ask for this is to ask for the moon. It is not just the
obstacles arising from the fear of a discipline in which we are not
expert, the preference for our own explanations over those of
others, and the tendency to regard the handicap in our own field as
the worst of the lot. The real problem, as always, is time. I get
on extremely well with King’s College’s psychiatrist, to take one
example. Yet the times we are both free to talk probably add up
only to a few minutes each week.

If we miss those few minutes, we may, with the best will in the
world, fail to make contact until it is too late. That pattern is
repeated all round the public services, and pressure for
“efficiency” (treating more cases for the same money) makes it
worse each year. Getting over this sort of problem would involve
far higher staffing levels, less obsession with performance
indicators that necessarily take no account of the needs of any
other discipline, and an end of the culture of blame social workers
know so well.

Conrad Russell is Liberal Democrat social security spokesperson
and professor of British history, King’s College,

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