The Traps and Detours of Deinstitutionalisation

Author: Sam Sly

A version of this article was first published in Learning Disability Today.

The final DH response to Winterbourne View (2012) states: 

All current placements will be reviewed by 1 June 2013, and everyone inappropriately in hospital will move to community-based support as quickly as possible and no later than 1 June 2014. 

This was fantastic and just what organisations like Beyond Limits were hoping for as a great start for 2013.

However, from my experience so far on moving people from hospital two of the phrases used in this statement give me concern that these dates will not be hit, people will not be discharged and even if they are people will just move on to live in some other form of mini-institution. 

The phrases are ‘inappropriately in hospital’ and ‘community-based support’. 

I believe that the first phrase may be used to prevent people being discharged due to the key decision-makers who have these powers making decisions based on limiting information about a person due to hospital environments that don’t always look at the whole person. This also provides problems for Providers once discharged because information given does not always give the whole story. The second phrase may lead to people being discharged to yet more mini-institutions instead of real homes of their own because of misinterpretation of community-based support.

Our project has first-hand experience of trying to get people discharged from hospital into homes of their own and we have been heavy curtailed by blocks to this process and the limiting nature of hospitals. Decision-makers still continue to say people are ‘appropriately’ in hospital even after 3-9 years of treatment.

Here are some of the blocks we have encountered preventing discharge and keeping people, we believe inappropriately in hospital:

• New case law that questions the legality of 24 hour support packages if deprivation of liberty is in question (Sec of State V RB and Lancashire Care Foundation Trust)
• Treatment plans in Hospitals that do not help people get ready to move into their own home, in fact often institutionalisation renders people less able to look after themselves than when they were admitted. Basic skills like cooking or money management have to be relearned because hospital environments do not allow the maintenance of these skills.
• In Hospital people do not go out regularly in the community so skills around being a citizen, living as a tenant, being a good neighbour and how to get on with people are again under-developed or not practiced meaning people are presented with many, sometimes overwhelming challenges, with few learned responses when they get home
• Being taken away from issues and difficulties and placed in a hospital instead of resolving them with support in the community or making changes in situ means those same problems usually arise again when they come home.
• Fitting back into a family can also bring challenges when someone has not been involved, or missed many of the social and life changing events like births, deaths and marriages that bind families together.
• We have found time and time again that people have been admitted to hospital because of reacting badly to living with other people. In hospital the same situation is replicated but they learn to survive because tough forms of punishment like seclusion and restraint can be used.
• Some hospital treatment plans are based on the eradication of certain behaviours, but this is hard to achieve if people don’t have meaningful goals like leaving to aim towards. Present institutionalised behaviours are sometimes used to evidence that a person is not ready to leave, when often they cannot see the point of the meaningless goals and incentives they are given so give up trying.

We were pleased to visit one hospital recently though that was taking into account the positive support factors in our care plan when agreeing that future risks would be lowered through them. It was the first hospital to see it that way.

Finally, the phrase ‘community-based support’ can, and has had, many interpretations positive and negative. In every hospital closure or change of policy that I have been involved with in the past the result has been a flurry of mini-institutional developments to resolve the problem of the need for swift mass accommodation supplied as cheaply as possible. These developments, in the long term, cannot usually provide the tailor-made person-centred service that is required for people with big reputations. I have already seen advertisements for new smaller community-based Homes of multi-occupation. These surely are no different than the larger treatment based Institutions, except for the size and location and more than likely a nice community name like ‘X Villa’ or ‘X Lodge’? 

We have to stop doing this, and sort out people’s problems when they arise in their local communities.

The publisher is The Centre for Welfare Reform.

The Traps and Detours of Deinstitutionalisation © Sam Sly 2013.

All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.