Visible asylums

Using freedom of information laws, the Guardian has found that a growing number of people – 435 -with mental ill health spent time in locked rehabilitation wards in 2018, with one patient locked in a Birmingham ward for more than 21 years. Over 100 were in Central and North West London NHS foundation trust alone. The average length of stay in a locked unit at Sussex Partnership NHS foundation trust was 602 days, almost two years.

Former Care Minister Norman Lamb told the Guardian: “They are like old-style asylums that have no place in modern Britain. What we are doing is a fundamental breach of people’s human rights. It is a complete contradiction in terms: locked rehabilitation ward.” Care Inspectors CQC in a 2017 report last year said that these wards have no place in modern mental health care.

When I called my book on creating a more human health and care system, Escaping the invisible asylum,  I was conscious that there are still some very visible institutions in our public service systems, as well as the less tangible but equally institutionalised spaces we continue to create and maintain through rigid and inhuman processes, systems and rules. The large hospital building remains the totemic symbol of our NHS, even as we talk constantly about ‘shifting care into the community’.

The mini-asylums of Assessment and Treatment Centres for people with learning disabilities who are considered ‘challenging’ or ‘complex’ (such as the infamous Winterbourne View) were on my mind when writing the book, but there are striking similarities to the way those services have sprung up in the gaps between more humanised and community-based services, and what appears to be happening in the mental health system. Rajesh Mohan, chair of the Royal College of Psychiatrists’ rehabilitation psychiatry faculty, suggested that the falling number of NHS rehabilitation services may have led to “people with lots of complex and enduring symptoms” ending up in private sector units “for long periods of time.”

We will always need, I suspect, some forms of locked-room care, for people who pose an immediate danger to themselves or others. There will be good people working in those services, in difficult circumstances. But there is too often something deeply insidious about the way we approach care that is necessarily coercive. Central and North West London NHS foundation trust told the Guardian, “We’re very different from old style asylums; our facilities are hospitals, modern and bright…” This may be true, but it is not the décor which makes a place and the life it offers oppressive or not. We dress up these “facilities” and “service settings” in jargonistic or bad-faith descriptions: attempting to minimise those elements which make us least comfortable. As CQC and others have pointed out, there is not always much assessment and treatment happening in Assessment and Treatment Centres. The locked mental health wards that the Guardian found are described as rehabilitation services, yet people can appear to be stuck there, the community getting no closer.

If we need to provide institutional care, we should be straightforward about its existence, the reasons it is necessary its impacts and side-effects. That way we are more likely to do everything we can to ensure that people spend as little time as possible in these places. We will focus on the risks of being inside a locked building, to balance staff’s fears about the risks they see in releasing people from them. If we don’t, asylums will continue to hide in plain sight.