Archive for December, 2007

Closing a Therapeutic Community

News this morning that the Henderson Hospital will close.  This is one of only a handful of therapeutic units in the UK treating people with severe mental health needs, offending behaviour or both.  Indeed, the Henderson Hospital specialised in people with Severe Personality Disorders deemed to be a risk to themselves and/or others.  Therapeutic communities do intensive work, addressing, confronting and challenging the user’s own behaviours.  The evidence suggests the impact of the work is significant and, while the evidence might be challenged, effective in comparison to other forms of care or treatment available.

But why should we care?  The unit is only small, with 29 beds and only 12 currently occupied.

This is a classic example of finances determining the nature of the public services provided.  Until recently, the unit was funded under a national contract so that referrals were made where appropriate.  Indeed, there was a waiting list until the funding changed.  Responsibility for payment has now passed to local Primary Care Trusts.  For them, the costs represent a much more significant outlay.  And in an area of health service provision often poorly understood, there is an inevitable reluctance on the part of some to pay out.

However, the evidence does suggest that therapeutic communities are both effective and, over the long-term, are cost-effective.  But this requires an holistic view of spending over time.  Organisationally and annually constrained budgets report a cost without any recognition of savings elsewhere, even in that same financial year.  And if the benefits are to be seen in 5 or 10 years time, what then?

For twenty or more years now, we have been changing public services to ensure that the financial incentives are there to increase efficiency, generally narrowly understood as a ratio of inputs against outputs.  Yet here we have an example of the sort of service area where we might need to review some of this thinking.  The incentives are wrong.  They do not deliver efficient or effective services.  Indeed, those services are put at risk by the very financial systems reformers have been focusing upon for the past twenty years.

I am not the first to say this, nor will I be the last.  But we have public services that are hampered by the organisational forms within which we organise them.  Indeed, these organisational forms have, in many contexts, become the purpose of public services.