I visited Cardiff earlier this year to see the Dr Who exhibition before it closed. On the Sunday morning we walked around the City to see some of the filming locations.
It was like a horror movie. We came across people collapsed in the streets, comatose, or overdosed. Those who were moving were staggering semi-concious.
This apparently is Spice, the synthetic cannabinoid, recently made illegal, which has moved from head shops to street dealers with devastating consequences. Seeing such a desperate situation was very disturbing. What was worse is that we have been here before, and haven’t learnt any lessons.
Back in the 1980s I lived in Liverpool, and like most students, lived in a fairly poor and run down area. At this time the Government was implementing the Care in the Community programme, and neighbourhoods like Toxteth were filling up with people recently released from long stay Mental Health services. I have no doubt that Care in the Community is one of the greatest Social Policy failures of my lifetime.
Care in the Community was driven by 2 forces. The Libertarian Right had long
argued that mental hospitals were effectively prisons, preventing a return to normal life. Enoch Powell, a former Health Minister had argued as early as 1961 for the closure of the “isolated, majestic, imperious, …… asylums which our forefathers built with such immense solidity to express the notions of their day”. Alongside this was a second force – a desire to move to a cheaper model of service delivery without the costs of inpatient Mental Health services.
The Griffiths report in the mid 80s had recommended changes to the model of Mental Health care, inspired by the belief that State provision was bureaucratic and inefficient. The Thatcher Government enthusiastically embraced this philosophy but ignored his recommendation to support the shift of Mental Health services in the community with a ring fenced budget for Social Care support.
Predictably Local Authorities, already strapped for cash, reacted badly to being transferred large numbers of NHS patients to look after, with no budget to do so. Rows between the NHS and Local Authorities about who paid for which service were widespread, and larger and larger numbers of former patients became non-compliant with treatment, homeless or both. Gaps in service became larger and larger, and because the individuals affected were not the most eloquent the gaps were easy to forget about.
The problems were exacerbated by policy changes elsewhere. Homeless services, for example, had long dealt with people with Mental Health problems on an informal basis. As they were closed down the range of options available to people shrank.
Not all former patients became homeless, many struggled on in poor quality rented accommodation in neighbourhoods like Toxteth. There was however a massive increase in homelessness – Shelter estimates that during this period homelessness doubled to over 400,000.
As more and more former patients became non-compliant with treatment self medication with drink and drugs became widespread, and groups of outdoor drinkers and drug users became a common feature in large cities. Often people who hadn’t been in long stay accommodation gravitated to these groups.
It is hard to write about violence by people with Mental Health problems without slipping into cliche, and it is important to stress that Mental Health patients are massively more likely to be victims of violence than perpetrators. However, within these groups of people , self medicating with drugs and drug, and with chaotic lifestyles, there were a number of people who were very dangerous and very violent. They found cover among the homeless and the Mentally Ill and largely preyed on them. From time to time they would attack members of the wider population.
By the early 90s we had come to accept groups of homeless people on our streets, many with visible signs of Mental Health problems, some drunk or high on drugs, as part of living in big Cities.
The turning point was the 1999 Mental Health National Service Framework, the first time the NHS had produced a detailed service specification for Mental Health services.
Mental health wasn’t the top priority in the early years of New Labour, but the NSF meant that local areas were audited on their provision. Gaps were identified, and many, but not all were closed. Services were expanded, and new services introduced.
The National Service Framework benefitted by being introduced at a time when the new New Labour Government was increasing spending on the NHS. In 1997/98 the NHS Budget was £33.5bn. But 2005/6 it had grown to £76.4bn, and by 2008 had hit £96.4bn.
To put this into context Boris Johnson claimed that leaving the EU would provide a one off increase to NHS funds worth £350m per week. In the early years of C21st the NHS budget got an extra £150m every week.
One of the new services that was established in the National Service Framework was Assertive Outreach. These were specialist Mental Health professionals, normally Community Psychiatric Nurses, who went out and tracked down people who weren’t engaging in treatment. This was an expensive solution but bit by bit individuals were found.
Some re-engaged with treatment, but for many years of neglect had left them damaged. The best which could be hoped for was to limit the harm. For many this meant being helped to access benefits that they were entitled to, and live less chaotic lives. We funded a worker based within our local branch of Mind who advised people with Mental Health problems to access benefits and housing.
More controversially from 2001 onwards a new initiative called the Dangerous Severe Personality Disorder (DSPD) Programme was established, which targeted individuals with a very high Psychopathy Checklist – Revised (PCL–R) risk score in the community.
Not all of these developments were welcomed by the Professions. The DSPD programme was incredibly unpopular with Psychiatrists. In many parts of the Country the new resources the Government provided were hoovered up by Acute Hospital Care and waiting list reductions, and Mental Health services struggled to meet the National Service Framework requirements.
What is true is that people did re-engage with treatment, and British cities no longer had large groups of outdoor drinkers and drug takers. Homelessness peaked in 2003 and then fell sharply through to 2010. We need to be careful not to conflate homelessness and Mental Health, but it is clear that vulnerable people with Mental Health problems are more likely to become homeless if they aren’t receiving the right treatment.
By this point I had left the NHS and I was working for a Crown Non-Departmental Public Body sponsored by Department of Work and Pensions when the Coalition government came in. I was in the unusual position of having worked at Department of Health, which gave me a different perspective on the incoming governments policy mix.
The policy agenda they were persuing was a jumble, just as it had been in the 1980s. There was a movement within the Conservative party led by Ian Duncan Smith and the Centre for Social Justice which wanted to emphasise personal responsibility, similar to the beliefs of Enoch Powell in the 1960s. IDS wrote the foreword to a collection of essays in praise of Enoch Powell in 2014:
https://www.amazon.co.uk/Enoch-100-re-evaluation-politics-philosophy/dp/1849547424
But this was secondary to the overwhelming policy commitment of the Cameron Government – Austerity. Whatever happened had to be cheaper. A lot cheaper.
I am forbidden from being too mean about IDS by a compromise agreement signed when I left the Civil Service. I am however able to criticise the Centre for Social Justice. In 2010 after 6 years of well funded policy formulation the Coalition government came into power with little or no actual policy ideas. Normally the problem with think tanks is they produce too much, with not enough thinking through. The Centre for Social Justice produced nothing of any value.
Despite the emptiness of the policy cupboard Cameron and Osbourne had a desire to appear reforming and meaningful, and not just cost cutters, but with little concept of how to achieve this. IDS offered them Universal Credits as a solution and they embraced it without really considering what it meant.
Universal Credits was originally designed as a Labour Party policy, and was proposed by James Purnell during his brief tenure as Secretary of State. Gordon Brown squashed it as too expensive and complex. Given Gordon’s willingness to sign off on expensive public sector change projects this decision should have sounded alarm bells for David, George and Ian.
Instead it was seized upon by the Coalition as a way to give them a focus for Welfare Reform while they cut benefits.
I’ve written previously about some of the existential design problems that have beset UC:
Deep House Victims Mini Bus Appeal
In truth I could write about Universal Credit design flaws and programme management mistakes every fortnight for the rest of the year and still not communicate exactly how bad it is. Gordon Brown might have made some mistakes with Public Spending over the years but scrapping UC was one of his best decisions.
At the same time the Coalition was filling up friendly newspapers with horror stories about people claiming benefits, doing nothing to find work, and sitting around all day drinking cheap lager. Mostly stories like this were made up, but in truth there were people, claiming benefits doing exactly that, although they weren’t representative.
The Government ordered a massive clamp down shiftless benefits claimants both imaginary and real, and Job Centres were set targets for sanctioning the benefits of anyone who was deemed to be insufficiently diligent in seeking work. I signed on to Job Seekers Allowance while I was setting up my current business in order to access DWP’s small business start up service, and I had my benefits sanction on a couple of occasions, for trivial reasons.
Before leaving the Civil Service I tried to explain to some of my DWP colleagues the work that the NHS had done in Assertive Outreach, and that for some people, particularly those who had suffered under Care in the Community it was better to leave them securely housed and claiming benefits, even if their attempts at finding work were negligible. I even tried to describe the DSPD cohort who lived in the Community and how important it was that they stayed where they were, in contact with Community Mental Health services.
Predictably I was ignored, and Job Centres targeted the most vulnerable for sanctions in order to hit local targets. Targeting poor people in this way has become so politically acceptable that the last Labour Manifesto banked £7.5bn of savings from benefit cuts and freezes to fund it’s spending plans, while promising a rather timid “review”.
Homelessness has risen every year since then, as this graph for Rough Sleepers shows:
UC is years behind schedule and only has 500,000 people on it – the original target was 8.5m by 2015. It is clear that it is making things much worse. Applicants have to wait up to 12 weeks before receiving any money, which is then paid monthly in arrears. When they do receive money cuts and freezes to the value of benefits have left too many people unable to afford housing. And then there is the Bedroom Tax.
This has left us with exactly the same problems we had in the 80s and 90s, and it is exactly the same groups of people being hit the hardest. I have no doubt that there are people who suffered under Care in the Community, who got their lives back together thanks to Assertive Outreach, who are being targeted again by Government Benefit cuts and Universal Credits. The only thing that has changed is rather than alcohol and heroin the drug of choice is now Spice. People living in Cardiff or Manchester will already know how bad things are.
The rest of us are about to find out.
While the Labour Party were recently asking for a pause in the roll out of UC with typical timidity the Centre for Social Justice were publishing a report recommending placing homeless people with problems like alcohol and drug abuse in permanent accommodation and giving them access to care and training. The approach, known as Housing First, had been trialled in the US and adopted by Finland with positive results. Conservative communities secretary Sajid Javid said he was “keen to examine the scheme”
No shit Sherlock.
References:
https://www.ifs.org.uk/bns/bn92.pdf
https://www.kingsfund.org.uk/projects/general-election-2010/money-spent-nhs
https://www.cps.org.uk/files/reports/original/111028104921-TheNHSSince1997.pdf
http://sticerd.lse.ac.uk/dps/case/spcc/wp02.pdf
http://www.lse.ac.uk/website-archive/newsAndMedia/newsArchives/2011/03/NHSreport.aspx
http://www.newstatesman.com/blogs/the-staggers/2010/11/universal-credit-purnell-brown