The ‘locked rehabilitation’ paradox
Assistant Psychologist Paige Butcher on how lack of funding and recruitment difficulties are impacting on the experience of rehabilitation, for both staff and service users.
27 March 2023
Imagine someone you love has struggled with their mental health and has endured a severe emotional breakdown. Or maybe your loved one was born with significant learning difficulties, growing up in an unsupportive and overstimulated environment, leading to increased negative behaviour, potentially causing them to commit a criminal offence. What would you want for them?
Here are some options:
- A short stay in A&E while experiencing psychosis. Being discharged without immediate support in place. Becoming another number on a never-ending waitlist before receiving support to readjust.
- A prison sentence, whereby their sensory or social skills are not a priority for their rehabilitation back into society safely.
- A place of monitored safety and robust support, targeting recovery and readjustment?
That last option, 'locked services', has been described as "outdated and sometimes institutionalised care" (Marsh, 2019). The Care Quality Commission (2017) expressed the view that the model has no place in the modern healthcare system.
There have been several cases where a stay in such environments has resulted in abuse (Winterbourne) and even death of service users (Connor Sparrowhawk). You cannot help but wonder if these services are merely expensive residential homes for those whom society does not know what to do with.
However, speaking with those in respected positions about their interpretation and intention of these services, they share that locked rehabilitation is to provide useful and meaningful work such as short-term assessment and treatment, as well as creating recommendations for future care. This can be hugely beneficial for fulfilling the Transforming Care Agenda, where the focus is on reducing the time needed in a hospital environment.
As an assistant psychologist within the NHS, I experience a variety of valuable 'placement' roles. I have met so many wonderful staff and service users alike. I have always felt the experience and wellbeing of the service user is the most important goal for all those involved in their care.
Here, I reflect on those experiences of working within both private and NHS-locked rehabilitation units, acknowledging how limited funding and continued reduction in recruitment may overshadow the services, to the detriment of staff and service user experiences of rehabilitation.
Held back by lack of funding
I am not an expert in the financial structure of the NHS. However, I have repeatedly seen how a lack of clear direction can impact the suitability of a service being delivered. Rajesh Mohan, chair of the rehabilitation and social psychiatry faculty in The Royal College of Psychiatrists, has said 'the facilities appear to be defined by having a locked door rather than the specific type of rehabilitation service they offer' (Salman, 2019). Without quantifiable outcomes for a service to report on, the 'rehabilitation service' offered is left vague and open to interpretation.
One story that I often hear is that individuals are on these wards due to 'having nowhere else to go'. As a service, it can be hard to create a 'case' without reliable and valid data. It's an uphill challenge to request further funding, creating a barrier to improvement and development.
A continued lack of funding means a continued reduction of 'rehabilitation therapeutic' opportunities – welcome to the locked rehabilitation paradox. A clear direction and a robust effective pathway seem to rely heavily on funding to achieve this, and vice versa.
Around 10 per cent of new referrals to secondary mental health services need rehabilitation (Killaspy et al., 2015). In my experience, a stay within a rehabilitation setting tends to be lengthier than most hospital placements due to constant care needs, which amounts to a major resource pressure for NHS and social services.
The lack of available services within the NHS following the Transforming Care Agenda – whereby it seems, those who would mostly benefit from rehabilitation services are now in overstretched community services – has led to referrals being made to the independent sector, which relies on remaining profitable to exist.
Speaking with Clinical Psychologists colleagues, they have shared that there needs 'to be more insight about the true scope of reduced placement since Transforming Care, and how we seem to be ineffective for those who are in hospital at the minute'.
Commissioners should examine if this represents value for money between increased costs of beds compared with expanding the rehabilitation sector within the NHS (CQC, 2018). An expansion within the NHS would allow for a smooth and supportive pathway of care for people to receive appropriate and continued care.
In my experience, common views of a successful pathway of rehabilitation include the importance of frequent community access, continued structure, and routine within the 'real world', supporting Salman (2019) when they share that 'you cannot rehabilitate someone if they are locked up'. However, I have found that you cannot offer 'rehabilitation' without the resources to provide this therapy.
For instance, I have picked up on a shared feeling of disappointment in the wards that there are limited opportunities to facilitate group therapies due to a lack of training, an inability to support the service users to seek volunteering or job opportunities, or being unable to offer rehabilitation kitchens or 'step down' flats.
When these desires for change are raised, they seem to be met with comments such as 'the budget doesn't stretch', 'we don't have enough staff' or 'buildings are too outdated or expensive to adapt'. Without being able to invest in the staff or the services for the future, it is felt services are 'forgotten about'.
With a clear direction, more available services, and more rehabilitative therapeutic activities, the hope is that we will be able to support people to independently manage their health and wellbeing through access to services, rights, and opportunities when back in a community setting (Epidemiol, 2014).
How does the lack of funding and recruitment impact the staff?
I consistently hear that the desire from staff is to provide the best care possible for their patients, setting realistic goals and creating robust care plans. This relies on the 'therapy budget' to provide suitable assessments and interventions which in my experience does not seem to stretch far enough to offer very much.
During reflective practice sessions, staff have shared that without the appropriate numbers and qualifications of the staffing team, the quality of experience for the service users can suffer. On reflection, it was noted how this can further impose a negative emotional impact on the staff team themselves, leading to emotional burnout.
Figures from the 2021 NHS Staff Survey suggest that less than half of staff feel enthusiastic about going to work, less than half feel confident about making positive changes in their workplace, and less than half feel there is sufficient staffing to fulfil the job roles.
Through discussions with the staff team, the common fear emerges that too much complacency, and an 'it's just easier this way' attitude, could lead to inconsistent care, boundaries becoming blurred, decline in patient safety and deterioration in teamwork, as found in recent research (Garcia, 2019).
When discussing what staff feel would help promote better job satisfaction, a common theme is 'the chance to progress', 'implement new creative ideas', '…have more staff. This way, we can focus on spending more valuable time with the service users, without feeling there are a million other things to do'.
Yet here's that cycle again – due to the limited funding for extra resources, or a lack of recruitment and retainment of new staff, it becomes harder to implement these things. Higher levels of support staff are associated with better outcomes, shorter lengths of stay in hospitals, fewer re-admissions and higher service user satisfaction and safety (Aiken & Sloan, 2020).
Therefore, a focus on improving staff satisfaction through progress, training, or ability to implement changes through additional funding, could have a dramatic effect on the experience of staff, and their commitment to stay within the services.
Breaking the paradox
As a team, we reflect on the unspoken promise of what we might achieve from the admission. The experience should be goal-directed and positive for our service users. On initial planning, we discuss future discharge and interventions vital for future success. But very often within the 12–24 month timeframe of rehabilitation, we seem to have run out of time to complete all that needs to be done, due to limited funding or recruitment setbacks.
I have often heard service users speak about their experiences as like 'life within a small prison'. When prompting what this means to them, they reflect on limited activities, feeling bored and often having feelings of uncertainty of when they will be discharged. During these discussions, I can't help but wonder what effect these feelings must have on an individual regardless of their situation.
Can we really blame our service users for their 'unsettled' behaviour associated with frustration when hearing 'low staffing levels' or 'we cannot afford to do that'? Ultimately, one prominent message I receive from service users is feelings of being 'trapped' within services, while as staff we continue to feel 'disappointed we can't do more'.
While acknowledging the realities of extra funding and recruitment, there are several important changes that I feel could support these services.
- Clear guidance on why Locked Rehabilitation is different from Low Secure Service. What are the clinical needs required to begin the transition to more community-based rehabilitative intervention? Has enough scaffolding around the service user been built to successfully engage within therapeutic adjustment into community services? Structured outcomes of what we are expected to meet and why ensured services can meet the threshold for community readjustment. This can allow for robust pathways to be implemented, leading to reduced stays in services and more availability for the demand of rehabilitative services in the NHS.
- Funding for mandatory, appropriate, and applicable training for current and future staff. This can aid in creating group therapies or offering in-service low-level interventions and improve job satisfaction.
- Sufficient placements for the 'gap' between locked rehab and community, such as rehabilitation flats or more 'core and cluster' accommodation which combines the services and supports of a traditional refuge with the independent living facilities of transitional accommodation. These will support those who are deemed too risky to move into the community without support or minimal support from community services while maintaining the fluidity of movement within hospital services.
References
Commissioning guidance for rehabilitation (england.nhs.uk)
'Locked rehabilitation': a need for clarification - PMC (nih.gov)
'You can't rehabilitate someone into society when they're locked away' | Learning disability | The Guardian (Salman, 2019)
Mental health patients detained in hospital wards for up to 21 years | Mental health | The Guardian (Marsh 2019)
Karatepe, O. M., Uludag, O., & Menevis, I., Hadzimehmedagic, L., & Baddar, L. (2006). The effects of selected individual characteristics on frontline performance and job satisfaction. Journal of Tourism Management, 27(4), 547–560.
National results across the NHS in England | NHS Staff Survey (nhsstaffsurveys.com)
Why did Connor Sparrowhawk die in a specialist NHS unit? | Social care | The Guardian
20180301_mh_rehabilitation_briefing.pdf (cqc.org.uk)
NHS Sickness Absence Rates - April 2021 to June 2021, Provisional Statistics - NHS Digital
BJPsych Bull. 2016 Feb; 40(1): 1–4. doi: 10.1192/pb.bp.114.049726 'Locked rehabilitation': a need for clarification Stephen Dye, Lucy Smyth, and Stephen Pereira
Aiken LH, Sloane DM (2020) Nurses matter: more evidence. BMJ Quality and Safety. 29, 1, 1-3. doi: 10.1136/bmjqs-2019-009732
Walker & Dye - A-national-survey-of-psychiatric-intensive-care-low-secure-and-locked-rehabilitation-units.pdf (researchgate.net)
Helen Killaspy, Louise Marston, Nicholas Green, Isobel Harrison, Melanie Lean, Sarah Cook, Tim Mundy, Thomas Craig, Frank Holloway, Gerard Leavey, Leonardo Koeser, Paul McCrone, Maurice Arbuthnott, Rumana Z Omar, Michael King (2015). Clinical effectiveness of a staff training intervention in mental health inpatient rehabilitation units designed to increase patients' engagement in activities (the Rehabilitation Effectiveness for Activities for Life [REAL] study): single-blind, cluster-randomised controlled trial (core.ac.uk). Lancet Psychiatry, 2, 38–48. Published Online December 16, 2014 http://dx.doi.org/10.1016/ S2215-0366(14)00050-9
J Epidemiol Community Health 2014; 68:1102-1108. The effectiveness of community-based rehabilitation programmes: an impact evaluation of a quasi-randomised trial | Journal of Epidemiology & Community Health (bmj.com)
Rehabilitation: how can services meet demand? - NIHR Evidence
Garcia CL, Abreu LC, Ramos JLS, Castro CFD, Smiderle FRN, Santos JAD, Bezerra IMP. Influence of Burnout on Patient Safety: Systematic Review and Meta-Analysis. Medicina (Kaunas). 2019 Aug 30;55(9):553. doi: 10.3390/medicina55090553. PMID: 31480365; PMCID: PMC6780563.
