Читать книгу Mental Health Services and Community Care - Cummins Ian - Страница 12
ОглавлениеIntroduction
This chapter will explore a number of mental health inquiries that took place in the early and mid-1990s. It will argue that the media reporting – particularly that in tabloid newspapers – had a key role in undermining support for the progressive elements of community care. This is not to diminish the nature of some of the cases that led to the inquiries. It is, rather, to consider the way that this media reporting helped to construct a discourse around risk and mental health. This reporting played on a series of long standing, often racialised tropes about the nature of mental illness. One of the most important of these was the notion that there is a clear, identifiable and causal link between mental illness and violence. These are complex issues. However, complexity was drowned out by the dominant narrative that the community faced new dangers in the form of ‘psychokillers’. Alongside this, a theme in the reporting of such cases was that liberal mental health professionals were refusing to use their powers to intervene.
Before exploring the role of mental health inquiries in the late 1980s and 1990s, it is important to place inquiries in the broader policy and organisational context of New Public Management (NPM). NPM seeks to bring the so-called disciplines of the market to the public sector. According to Pollitt and Bouckaert (2004), NPM was an attempt to introduce some elements of the market, such as competition, to public services. This is part of a shift that saw the marketisation of the state (Hutton, 1996). Health and welfare services have seen huge changes in the funding and delivery of services since the early 1980s. These have included not only the sale of state assets but also the contracting out of services – for example catering, cleaning and other support services – to private companies. Skelcher (2000) outlined three modern models of the state: the overloaded state of the 1960s/1970s; the hollowed-out state of the 1980s/early 1990s; and the congested state of the late 1990s. There is something of a contradiction here as neoliberalism seeks to limit the role of the state to a ‘night watchman role’ but the role of the state has expanded. This is the case in the area of penal policy (Cummins, 2018) but also in other areas. The demands of late modern capitalism meant that a role was required for the state. For example, all advanced economies require an increasingly well-educated workforce. These demands will not be met by private institutions.
The inquiries that are the focus of this chapter took place in the period that Skelcher (2000) argued saw the ‘hollowing out’ of the state. This term covers the process where new arrangements for the audit and governance of public services were established. These new regimes included the creation of new regulatory bodies and inspection regimes for public bodies. For example, OFSTED became responsible for the inspection of schools, and subsequently children and families social work services. NPM requires what is termed a purchaser/provider split. In health and social care, this split was legally introduced by the NHS and Community Care Act (NHS and CC Act; House of Commons, 1990). The purchaser/provider split breaks up a monopoly of service provision. Social workers became care managers. The care manager role is a significantly different from the tradition social work role. A pure model of care management sees the care manager acting in a brokering role between service users and service providers. This was always an uneasy fit and the model did not transfer easily into the area of mental health social work. The NHS and CC Act (1990) and related policies were written in the language of consumer choice. One of the outcomes of NPM was the development of an audit culture. This involved the creation of bureaucracies to manage the data required to demonstrate how an organisation was performing against a series of Key Performance Indicators (KPIs). These changes have had a profound impact on the nature of the public sector. The inquiries that are discussed in this chapter have to be placed in the broader context of this development of a new form of organisational governmentality.
High profile cases such as the murder of Jonathan Zito by Christopher Clunis were reported in such as a way that they became to be seen as representative of the whole policy (Cummins, 2010b). The inquiry culture was part of the developing and ultimate dominant risk paradigm. The response to the failings of community care was a series of policies that were based on the auditing of professionals – marginalising relational approaches to work in mental health services. The media reporting of these inquiries had a particularly powerful impact in constructing a narrative that ‘community care has failed’. This phrase was used by the then Secretary of State for Health, Frank Dobson, when he introduced New Labour’s Modernising Mental Health Services: Safe, Sound and Supportive (Department of Health, 1999) – note the use of language here: supportive mental health services coming after safety.
Inquiry culture
Butler and Drakeford (2005) highlight the role that scandals have had in the broader development of British public policy. This seems to be particularly the case in the area of social work. Changes in social work practice and legislation have often been a response to high profile cases. In the area of children and families social work, a public inquiry in response to a high profile child death has been a recurring feature of the policy landscape for the past 70 years (Warner, 2015). In the area of mental health, a series of inquiries into institutional abuse played a key role in highlighting the abusive nature of the asylum regime. This is not just a recent phenomenon. One of the most famous psychiatric institutions in the UK – the York Retreat, established in 1796 – was a response to a scandal. In 1790, Hannah Mills, a local Quaker, died as the result of appalling neglect in the local lunatic asylum. William Tuke and other members of the Quaker community raised funds to establish the Retreat (Cummins, 2017). More recently the Ely Inquiry (Howe, 1969) into the abuse of patients at a large psychiatric unit outside Cardiff was prompted by allegations from a whistle blower. The allegations were originally made in a letter to the News of the World. The Inquiry was chaired by Geoffrey Howe, later Chancellor of the Exchequer, during the Thatcher administrations. The Ely report presented a picture of wider neglect – an institution that was representative of the wider isolation, geographical, psychological and professional of mental health services of the period. One part-time and two full-time doctors were responsible for the care of more than 660 patients. There were difficulties in recruiting staff to an institution whose buildings were over 100 years old.
There is something of a shift in focus in the mental health inquiries from the late 1980s onwards. There were inquiries that focused on institutional issues – for example, the Ashworth Inquiry headed by Louis Blom-Cooper (Department of Health, 1992) and the Fallon Inquiry (Fallon et al, 1999) into Lawrence Ward, the personality disorder unit at Ashworth. However, the majority of these inquiries and certainly the most high profile – the Ritchie Inquiry into the care and treatment of Christopher Clunis (Ritchie et al, 1994) – focused on cases of homicide committed by individuals either with a history of mental illness or recent contact with mental health services. The ‘Spokes Inquiry’ (DHSS, 1988) was established following the murder of Isabel Schwarz (1955–84), a psychiatric social worker based at Bexley Hospital. Schwarz was stabbed to death by Sharon Campbell, who was 20 years old. Campbell had previously been a patient at Bexley and had been discharged against her will. She had previously attacked Schwarz and made other threats against her. Schwarz was attacked when she was working at the hospital late one evening. The Inquiry highlighted a number of issues that became recurring themes of later cases – poor communication, lack of coordination between services and the failure to take a holistic view of the assessment of risk. Butler and Drakeford (2005) suggest that Schwarz’s position as a social worker and the contradictory status that it has meant that this awful case did not become a scandal. The Inquiry recommended there should be a register of the most vulnerable mentally ill patients living in the community and they should be appointed keyworkers to have a coordinating role in their care (DHSS, 1988). The Spokes Inquiry led to the Griffiths Report (1988), the forerunner of the NHS and Community Care Act (1990).
Moral panics
Social work and social workers are often caught up in the moral panics of the day (Butler and Drakeford, 2005). On one level, this given the nature of social work and its liminal position between individuals, families, communities and the wider state, this is not surprising. There was a moral panic about the perceived failings of community care in the late 1980s and 1990s. Community care, in this context, was specifically used as a shorthand for mental health services – other areas of provision were not subject to such scrutiny or detailed media coverage. Cohen’s (1972) notion of a moral panic provides a theoretical lens through which the responses to inquiries into homicides, committed by those with current or some previous contact with mental health services, can be explored. Policing the Crisis (Hall et al, 2013) is a classic study of the way that moral panics reflect wider social and political disquiet. Its discussion of the way that racialised narratives have a key role in many moral panics is important in the mental health field. Hall et al (2013) seek to explore how and why particular themes, including crime and other deviant acts, produce such a reaction. They argue that social and moral issues are much more likely to be the source of these panics. There are certain areas, for example youth culture, drugs or lone parents, where there are recurring panics. The response to this panic includes not only societal control mechanisms, such as the courts, but also the media becoming an important mediating agency between the state and the formation of public opinion.
There have been a series of moral panics following the deaths of children. Jones (2014) shows the role that the media played in demonising social workers in the aftermath of the death of ‘Baby P’. Warner (2015) highlights that politicians had a key, often inflammatory, role in the developing media coverage. David Cameron and Ed Balls both wrote emotive newspaper columns about the case. In these columns, both politicians made links between their own experiences as fathers and their disgust at the treatment inflicted on ‘Baby P’. Of course, one does not have to be a parent to be repulsed by neglect and abuse of a child. Cameron and Balls were doing this to side with ‘ordinary’ members of the public as opposed to ‘out of touch’ social workers who, in this narrative, had allowed these events to occur.
