A recent exposé showed what seems to amount to unethical practice in accepting referral fees by psychiatrists. One stated he accepted payment on a daily basis for a patient who stayed in rehab for 18 months. There was outrage at the referral fee for this amounting to £40K+ over that time. The outrage is misplaced; it’s not the size of the fee, it’s the length of stay which is the outrage.
18 months in a rehab is clinically dangerous. There is no justification for this. It’s not my place to police financial practice, but it is my place to call out bad clinical practice.
In the UK as in most counties around the world, mental health services aim to avoid hospital admission and where it is necessary reduce the stay to the absolute minimum. This is based on overwhelming clinical evidence of superior outcomes in treatment for all classes of mental health problems where treatment is provided in a person’s own community and home.
The General Medical council will decide if the psychiatrists involved breached guidelines on accepting referral fees. But, I’d like to know who will question this clinic about allowing a patient to stay for that length of time? Are they still doing this? Why is this happening?
I began my career in mental health post qualification in the mid 90’s. I had worked in the field prior to that, but in ‘96 qualified as a specialist psychotherapist. My first job was in a team helping resettle people into their originating communities who had been in long term residential hospital care. All these people were highly institutionalised, had very odd behaviours that outside of the hospital ward made them look and seem very odd and scary.
The actual mental and physical disabilities these clients had were relatively straightforward to deal with. This is the case with most mental health issues and disabilities if the services for them are resourced and targeted properly. Problems occur where the resources are scarce or disjointed.
What was more problematic to deal with were the institutionalised behaviours and practices that these clients had acquired from long term inpatient care. The lack of everyday social skills, personal care skills, employment skills and so-on. These were chronic issues requiring intensive input over several years to deal with. It’s an extreme example but one made to demonstrate a point.
The point is people adapt to the environment they spend most time in. Moving from one environment to another can be a difficult experience which pushes us into a regressed version of ourselves. A version that is generally less able to cope.
In general life that’s not a problem, we move home or job and we know it’s going to be confusing and we might be upset but muddle through. We adapt eventually to the new situation, but the stress on our system is managed by us.
In recovery from mental illness or addiction it’s a central fact of treatment; the longer you keep someone in an inpatient setting the less able they are to adapt to real life upon discharge. And the greater the stress on the individual of the transitional phase post discharge. Stress is centrally implicated in mental health and addiction relapse.
In practical terms, we manage stress by having a support network around us. In mental health treatment the closer to actual lived life the treatment phase is, the better the clinical outcomes. For this precise reason, the treatment when it’s home and community based, builds this network, creating resilience to stressors. It builds it in situ. It also eliminates the transitional shock of leaving an institution. It allows for the practical testing in real terms of management techniques for the patient.
When I set my current company up I moved into the private sector exclusively and was horrified to find the type of clinical practice described at the beginning of this blog. One patient had been admitted for pretty standard depression. Under no circumstances would in-patient be used for depression of the type this person had as inpatient admission is pretty much guaranteed to make depression worse. They were ‘treated’ for three months then discharged without any home or community assessment. The discharge coincided with the health insurance running out. This was in the same company as the one that owns the rehab involved in the 18 month inpatient stay mentioned above.
Another example was a patient I was asked to meet in a private London psychiatric hospital. They had been admitted multiple times for addiction issues at treatment centres all over the globe and the treatments had all failed but, nevertheless, multiple hospitals admitted the patient for the same failed treatment regime. As they were ‘cash’ fee paying this could go on forever, with the company supporting the patient receiving fee after fee after fee. This despite clear evidence of treatment resistance, a well recorded issue in mental health where multiple admissions lead to someone becoming more difficult to treat.
There is and was no clinical justification for the cases I was involved in of this prolonged treatment and they are by no means isolated cases. In the years I’ve been operating in the field privately I have only had one occasion where a rehab refused to admit because they felt clinically it would harm the patient. And only two treatment services that offered short term work as standard rather than a completely arbitrary month, 6 weeks, or 90 days.
The real cost of this is not the financial bill given to patients for unnecessary and harmful treatment. The real cost is mentally ill, vulnerable people and their families are being asked to buy into a model of care which is actively harming them. Treatment resistance is what it says, with each admission for no good reason, that person becomes harder to treat. Which means they are being put at risk of death from their illness. Institutionalisation causes physical health problems, mental health problems, reduces life chances along every axis. Add that to the high risk mental illness the person has in the first place and you are effectively handing a loaded gun to them with instruction to pull the trigger.
It is only very recently that the QCQ who ensure fitness to practice for hospitals in the public sector, were brought into regulate the private sector. To liken it to Wyatt Earp stepping into Tombstone to clean it up is not going too far I feel.
Noel McDermott is a health and social care professional with over 25 years of industry experience. His areas of expertise include social care, mental health, child care, refugees, trauma, addiction and recovery, distance therapy, personal development and emotional health and wellbeing