Locked up

Secretary of State for health and social care, Matt Hancock, has ordered the Care Quality Commission to instigate an immediate thematic review into “the practice of prolonged seclusion and long-term segregation for children and adults with a mental illness, learning disability or autism in secondary care and social care settings.”

This follows another distressing case of a young woman with autism kept in solitary confinement in an Assessment and Treatment Unit (ATU): a kind of mental health institution. The only contact she is apparently allowed with her father is via a hatch. The use of restraint in ATUs, including seclusion, medication and physical restraint, has almost doubled in the last two years to more than 26,000 incidents of restraint in 2017. NHS England believes this may be due at least in part to better reporting, but it is nevertheless an extraordinary number and worrying trend. ATUs are intended to be a short term measure, but instead the average length of stay is well over five years, and one young man was in an ATU for 18 years.

There can be no excuse for keeping disabled people in solitary confinement for long periods, without any hope of release and the Secretary of State is right to order a full investigation by CQC. That thematic inspection is unlikely to find anything new: the problems with housing people for long periods in institutional settings are well known. Decades of research have shown that institutions tend towards abuse, but even where there is no behaviour which is found to be abusive, the very nature of such institutions is abusive: people are confined away from friends and family, with little opportunity for an ordinary life. The logic of the institution takes on its own momentum: each “incident” is a reason for confinement, restraint and medication. The unhappiness which results from that malign trinity, in turn feeds more incidents.

Can a young woman who has been convicted of no crime really be so dangerous to warrant a kind of solitary confinement which prisons hesitate to use with hardened criminals? Her support no doubt will be costing taxpayers thousands of pounds a week: is that money not enough even to pay for the staff needed to manage any risks of more human contact?

A CQC review will help to remind us of how wrong the current system is. That is necessary, because we forget so quickly people kept out of sight and mind. But the opportunity for change lies in investing the public funds currently paying for expensive, low-outcome institutional care, in providing wrap-around support to make family and community care viable for people whose behaviour can be risky or ‘challenging’. We have developed ways in which Shared Lives could be combined with other support models to make it more viable for people considered challenging. Ultimately, any community care model requires us all to see risk differently: recognising that while the risks of ‘challenging behaviour’ matter, so does the risk of long term incarceration.

We all need to insist on change, and to be willing to make it happen. Personally, I would like to hear from clinicians and commissioners with the creativity and capacity to work with us, Shared Lives carers, and other like-minded people and organisations to make that change happen.

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