The virtual asylum revisited

Early in my career as a consultant, I took responsibility for the psychiatric care of a group of men who had been resettled in a community facility after decades as residents in a distant mental hospital. One man sticks in my mind. Ernie had diagnoses of learning disability and chronic schizophrenia. He was mute. He had no known family or friends. In his new home, with a lot of coaxing and support, he became happier, more active and eventually he starting speaking again. It turned out that his name was not Ernie. It was Eddie. It appeared that people had started calling him Ernie twenty years earlier, when Benny Hill’s record “Ernie (The Fastest Milkman In The West)” was Christmas number one. An unkind tease had come to signify his total loss of personal identity. It astonishes me that there are still pockets of nostalgia for large mental hospitals. Whilst acutely ill patients often did well and the staff were generally well intentioned, these institutions damaged their long-term residents.

For fifty years a great, optimistic movement dominated developments in mental health care. It challenged assumptions about ‘treatability’ of chronic psychosis, personality disorder and other persistent mental health problems. It played out in different ways in different places, and there were set backs from time to time, but a wide range of people with an interest in mental health were happy to march together under the banner of de-institutionalisation.

De-institutionalisation is a clumsy word for a complex idea. The closure of large mental hospitals had numerous effects, some of which were anticipated and some unintended. It was the engine of much creative thinking and fresh ideas. De-institutionalisation led to the development of therapeutic communities, psychiatric rehabilitation and a whole range of complex innovations in treating people in their own homes. Not only were the new ways of caring for people with mental illness less damaging and more humane than old-fashioned asylum regimes, a series of rigorous studies showed that the patients did better in their own homes and in more ordinary environments, with treatment strategies that included social and psychological intervention alongside skilled use of medication.

A minority of people with psychosis show poor or slow treatment responses. As the mental hospitals closed, only limited attention was paid to the needs of ‘new long stay’ patients. In this century, NHS outsourcing of care for people with persistent severe mental illness has led us to a system that is a wasteful mess. The impetus to develop mental health services in the first place arose from concern over mistreatment of people with chronic psychosis. It is shameful that they are sometimes neglected at great expense in modern programmes of care. It is particularly unfortunate that 21st century provision replicates some of the damaging features of 19th century asylums.

I first became aware of how dysfunctional the new system of care had become back in 2002. Tony Ryan, Alison Pearsall and I reviewed a group of patients from one locality who were scattered across the country in out of area placements. All of the patients we saw were far from home and isolated. The physical environment in these long stay units was certainly much better than in the “back wards” of mental hospitals where I trained. We saw some private sector facilities that were providing excellent treatment. We also saw some that were not. In one memorably awful establishment, a highly articulate patient with severe mobility problems had had his wheelchair removed, allegedly as part of behaviour modification regime. No one could tell us what he had to do to get his wheelchair back. He begged us to do nothing that would lead to his transfer away from the facility because, he said, it was much better than previous placements.

The cost of placements was high, no one seemed to know how such provision should be commissioned and monitored, and care appeared poorly co-ordinated. Some of the mental health staff caring for patients in out of area placements were frustrated because they had problems moving them on when they made progress. We felt that the system was a virtual asylum, dispersed and invisible. We approached the BMJ and our editorial The NHS, the private sector and the virtual asylum was published a few weeks later. The tone of indignation upset some private sector providers, but the article did not condemn private hospitals. It criticised the lack of co-ordination, planning and monitoring in the system of care. Two consultant psychiatrists responded with a letter in the BMJ saying that there were very similar problems in learning disability services.

We concluded:

“The virtual asylum is ripe for a destructive moral panic, which would be likely to focus blame on service users, clinicians, and purchasers. If the private sector were discredited, the cost of reproviding services in the NHS would be prohibitive. The main victims of this scenario would be patients and their families, rather than the policy makers and politicians who inadvertently created the virtual asylum.”

The moral panic did eventually happen, in 2011 with the scandal over care at Winterbourne View. Political responses proved clumsy, as we had anticipated.

Since 2002, Tony Ryan has led research that has tracked the continuing problems in the virtual asylum. I have been a co-author of some of the papers (see below). Nothing has improved very much. Tony has convincingly demonstrated that substantial amounts of NHS money is wasted on providing people with inappropriately intensive care long after they have ceased to require it. The entire system moves very slowly. It appears that, in many places, between 15-18% of NHS acute mental health beds are occupied by people who are waiting for specialist placement and rehabilitation. Whilst this is only one factor in the shortage of acute beds, it is certainly an important one. The consequences of the wasteful and inefficient nature of the virtual asylum are felt far beyond specialist rehabilitation psychiatry.

The NHS is facing the worst funding crisis in its history, and the community of campaigning mental health interest groups will have to cooperate and fight hard to maintain services. There is no mental health system in the world that provides adequate care to people with mental illness exclusively on a for-profit basis. Campaigning is difficult when it is prolonged, and emphasis on the needs of one group can leave other groups behind. There are significant problems across the UK in acute mental health care and in services for people with common mental disorders, and these matter too. Nonetheless, if people with chronic psychosis are not considered first, they are rarely considered at all. Whatever other messages we want to deliver, the problems of people with chronic psychosis must have prominence.

Organised psychiatry has had success in getting investment in liaison psychiatry, in part because there is evidence that this eases problems and expenditure in other part of the health system. A similar case now needs to be made about the virtual asylum. It is hard to reject the argument that NHS should spend its money on less expensive, more appropriate care. In the new age of unreason, we have to fight for rationality and evidence in mental health policy.

References

Ryan T, Pearsall A, Hatfield B, Poole R (2004) Long term care for serious mental illness outside the NHS: a study of out of area placements. Journal of Mental Health, 13, 425-429.

Poole R, Ryan T, Pearsall A (2014) Delayed discharges in an urban inpatient mental health service in England. Psychiatric Bulletin, 38, 66-70.

Ryan T, Carden J, Higgo R, Poole R, Robinson CA (2016) An assessment of need for mental health rehabilitation amongst in-patients in a Welsh region. Social Psychiatry & Psychiatric Epidemiology, 51 (9), 1285-1291.