This paper is prompted by the post-Winterbourne transforming care agenda and the ongoing criticism of the practice of placing patients out of area and away from families. The issues of placing people away from their families have been historically documented across various fields of research/study:
- Children (Cameron & Maginn, 2008; Department of Education, 2015)
- Mental Health (RC Psych, 2012; McNicoll 2013 & 2015)
- Learning Disabilities (Bonell et al, 2011; Mansell 1993 & 2007)
The authors of this paper have experience of working in an impatient ‘forensic learning disability unit’. Their aim is to discuss the variables that influence home visits. They propose that an audit of practice will influence how standards for future practice about how home visits are set.
The authors recognise the breadth of current literature citing the negative consequences of placing people ‘out of area’. These include; institutionalisation (Walsh et al, 2001) weakening family relationships (McMillan 2006) and how these can contribute to the presentation of challenging behaviour. When patients from out of area placements are asked about family contact, they communicate they want more frequent contact.
The authors additionally cite studies where in some instances family contact may have a negative effect on patients. They state that cited studies may fail to include this group of patients in their research, suggesting that the results need to be questioned further.
The study audited the number of home visits 63 patients in a forensic learning disability unit received over 1 year, and investigated recorded factors that adversely effected this.
All patients were detained under the Mental Health Act, the majority under criminal sections. The study was led by the Social Work department, focusing primarily on pre-arranged home visits, although patients were also able to make individual requests for visits relating to important dates for them and their family.
The audit was retrospective and covered 12 months. It recorded whether the visit was out of area and the actual distance travelled. In addition, visits by family to the patient and other forms of patient/family contact were also recorded.
111 home visits were recorded. 32% of the 63 patients had between 1-3 home visits, 22% had 4 or more and 46% had no visits. (54% had at least 1 visit).
With respect to visits from family, 44% received a visit and 44% received no visits.
19% of patients received no family contact at all, whilst the majority, 81% had some form of family contact (visits, telephone or written contact). Of these 59% had contact with immediate family, and the remaining with extended family.
Some individuals (6) had limited/no family contact due to issues of abuse/neglect. Recorded reasons for no contact included; no family, family conflict/negative relationships. Forensic/Mental Health reasons included MOJ restrictions, prevention orders and risk assessments. Only 2 patients had no contact recorded as ‘because of the distance from the hospital’.
Patients in locked rehabilitation had higher rates of visits compared to those in secure accommodation, although patients in secure settings had higher numbers of telephone calls and letters.
From 63 patients; 28 were recorded as being ‘within area’ (average of 90 miles away) and 35 ‘out of area’, average (164 miles). Using this measure the ‘out of area’ group received slightly more visits from family home than those within area.
The authors found that some in area patients families lived a greater distance than out of area. This was because some families had moved and some patients had also moved repeatedly.
The authors make a number of conclusions based upon the results of the audit:
- That patients in less secure accommodation receive more visits than those in more secure accommodation. One explanation of this is that as the patient positively progresses through levels of therapeutic security, so risk reduces and family relationships improve.
- That patients can benefit from a “home visit equivalent” to ensure that patients who are not in contact with their family also have a day out of the service.
- That it is important to not only record whether a patient is “out of area” (based on the commissioning authority), that the actual distance from the service to the family’s current address is also recorded.
- The authors recommend and proposed a number of future audit standards around home visits.
- That on admission detailed information on the patient’s family and important social contacts is recorded, along with with distances.
- There is a need for care plans designed to facilitate requested family contact.
- That there is a record kept of the number of home visits and the different types of family contact (with an aim for at least 4 a year) and for reasons ‘why not’ also to be recorded.
- The authors also make recommendations that future studies are needed; into the nature of how supportive family contact impacts on quality of life and treatment outcomes.
Strengths and limitations
In explaining why they recorded ‘out of area’ patients as receiving more family visits than ‘in area’ patients, the authors pay attention to the anomaly of how out of area patients are recorded as being so. The problem being that out of area status is officially measured based on the location of the original commissioning authority. Additionally some patients may have lived away from their ‘home area’ for most of their lives, and there may be reasons why a person chooses not to return ‘home’ or has exclusion criteria enforced upon them.
The authors make a valid point about the need to explore whether all out of area moves are as problematic for patients as research indicates. However the reasons why out of area placements are made is ‘sidestepped’ i.e. often due to a lack of appropriate community support and absence of local appropriate hospital beds.
This study does take a positive clinical approach to recommending that secure hospitals ensure there are agreed audit standards regarding home visits. As the authors state: ‘It is widely accepted that patients who experience positive family support are likely to experience a better quality of life.’ It could also be argued that regular and person-centred family contact should be an integral part of any positive service philosophy.
Although some patients may have increased levels of contact with families, how are they then prepared for a return to their local community if this is a great distance away? It can also be argued that the aimed for ‘4 visits a year’ is an ‘arbitrary’ figure, given that 46% received no family visit. In addition, given the rural setting of this hospital even ‘in area’ patients lived an average of 90 miles away from family; a 180 mile round trip.
The authors do acknowledge that there are some limitations to this study; that this was a single service audit (how generalisable?) and that due to the retrospective collection of data, further questions could not be asked.
In addition, although the hospital is recorded as a specialist forensic inpatient unit, a high percentage of patients (25%) were detained under a civil section, which could reduce the effect of criminal sections limiting family contact.
What is the paper saying that is different? Its findings indicate that the term ‘out of area’ needs clarification, particularly in relation to actual distance between the patient and their family due to a number of factors.
This study also questioned whether ‘out of area’ placements actually reduce levels of family contact. Whilst this may not be so in terms of total amount of contact. Given the rural setting of this particular unit, and the relatively longer distances ‘in area’ families needed to travel, the important reported findings need to focus on both the amount of, and the quality of family contact.
The research on people with a learning disability has identified that a loss of social support and family contact has a negative psychological effect, generally leading to feelings of loss, abandonment and isolation. Service users who do not have close family members to advocate for them appear to be especially vulnerable to this practice (Shankar, 2014).
Research has also cited that contacting care managers from placing (responsible) authorities is problematic in out of area placements (Beadle, 2005). The perverse incentives that exist that encourage out of area placements to be made, irrespective of individual need, have historically made such moves as ‘normal or ordinary’ and part of a historical ‘solution’ to move marginalised people away from their local community.
People can only exercise real choice about where to if local services develop the competence to support people near their homes, families and communities.
The numbers of ‘reasons’ as to why out of area placements are unsound emotionally, psychologically, morally and financially stack up (see previous elf blogs by Tomlin, 2011; Northfield, 2011 and Northway, 2015. Further to this, research has identified that the movement of persons with complex health needs into ‘out of area’ placements can also have a detrimental effect on local services (Mitra & Alexander, 2003).
In the wake of Winterbourne, there has been increased scrutiny of out of area placements.
This paper looks at the reported negative impact of such placements in terms of reduced family contact, but also indicates that there are instances where this is not the case and that setting audit standards of contact can be beneficial.
In reviewing particular research about the importance of family contact, the authors find that through a clinical audit of family contact within a secure unit, that family contact can be increased and that often levels of family contact can be improved upon if the hospital actively pursues a policy of home visit programmes.
In answer to the question in the title of this blog; yes, audits can help inform improvements in practice by recommending set standards of contact. The authors do raise the issue of ‘out of area anomalies’ which is valid, but this does (in my opinion) detract from the more relevant focus of the research; to investigate the specific outcomes of out of area placement in comparison with more ‘family centred’ community placements, given the documented negative impact of this practice.
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Bonell et.al. People with Intellectual Disabilities in Out-of- Area Specialist Hospitals: What Do Families Think? Journal of Applied Research in Intellectual Disabilities (2011), 24, pp. 389–397.
Cameron & Maginn. The Authentic Warmth Dimension of Professional Childcare British Journal of Social Work (2008) 38, pp. 1151–1172
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