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“New” public management of mentally disordered offenders:
International Journal of Law and Psychiatry 25 (2002) 15 – 28
‘‘New’’ public management of mentally disordered offenders: Part I. A cautionary tale Nancy Wolff * Health Care Policy and Aging Research, Institute for Health, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901-1293, USA
1. Introduction Rarely in public policy is there a consensus on the nature of a social problem. Yet, there is general agreement among policymakers, researchers, clients, and carers that services needed by persons with complex and multiple needs are haphazardly organised and mired in bureaucratic intransigence (Kahn & Kamerman, 1992; Mechanic, 1995; Webb, 1991). The problem, dating back to the 1960s in both the USA and UK, is attributed to the muchsupported policy of community care for persons with chronic and enduring health problems, including mental illness, as well as physical and mental impairments (Mechanic, 1995). Over the years, these governments have been remarkably effective at transferring people from one site (hospital) to another (community), but decidedly less effective in accommodating those who were relocated (Vandiver, 1997). This mismatch has produced a pastiche of unintended consequences: homelessness (Dennis, Buckner, Lipton, & Levine, 1991; Draine & Solomon, 1994; Rossi, 1989; Scott, 1993), criminalisation of the mentally disordered (Abramson, 1972; Fisher, Packer, Simon, & Smith, 2000; Lamb & Weinberger, 1998; Torrey et al., 1992), substance abuse (Kessler et al., 1996; Menezes et al., 1996), social exclusion and isolation (Link, Cullen, Mirotznik, & Struening, 1992), and overburdened family networks (Grad & Sainsbury, 1966; Reinhard & Horwitz, 1996; Tessler & Gamache, 1994; Wolff, Helminiak, & Diamond, 1995). Because the social problem and its unintended consequences are framed in terms of disorganisation, the most favoured solution is services or systems integration (Department of
* Tel.: +1-732-932-6635; fax: +1-732-932-6872. E-mail address: [email protected] (N. Wolff). 0160-2527/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 1 6 0 - 2 5 2 7 ( 0 1 ) 0 0 0 9 8 - X
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Health (DoH), 1998a, 1998b; Schermerhorn, 1975; Webb, 1991). In particular, Britain’s Labour government is implementing ‘‘new’’ partnership initiatives that are intended to replace the ethic of competition among public systems with that of cooperation (Le Grand, 1999). Better cross-system management is portrayed as the panacea; it is the public sector’s counterpart to Adam Smith’s invisible hand. If one reads the policy rhetoric, it appears that through the visible hand of cooperation the multifarious barriers between systems and services will be eliminated, allowing the free flow of clients and service innovation across organisational boundaries. The ensuing process is one in which public systems respond collectively (and cheerfully) to build a comprehensive and seamless system of care for those with chronic and persistent mental health problems. All for the better — if it works. This article is the first of a two-part series examining alternative approaches to integrating services for mentally disordered offenders. Part I takes a critical look at the issue of ‘‘if it works’’ in the context of Britain’s Labour government’s ‘‘modernising’’ effort to better manage public systems’ responses to persons with mental illness who have cooccurring offending behaviours. Part II provides a ‘‘new’’ holistic approach to integrating services for mentally disordered offenders. This new approach draws on economic and organisational theory to structure a whole system of care that is responsive to the whole person and accountable to society. Mentally disordered offenders are an interesting ‘‘integration’’ case study in part because their needs span the boundaries of health, mental health, social services, and law enforcement systems (DoH, 1992; Watson, 1997), in part because the complexity of their needs along with their difficult and sometimes dangerous behavioural traits combine to make them undesirable clients (Coid, 1996; Prins, 1993), and in part because the criminal behaviour of some of these individuals occasionally excites moral panic among the public, leading to a community care backlash (Wolff, 2000). Getting public systems to work for this group is simultaneously a social imperative and a major challenge. To begin the analysis, I review the evidence in Britain of systems and services dysfunction as it relates to mentally disordered offenders to establish the need for the integration of systems (or ‘‘systems integration’’) and the integration of services (or ‘‘services integration’’). The next section explores three barriers associated with achieving services and systems integration, drawing on experiences in the USA and the UK to overcome these barriers. This historical record suggests that incremental integration initiatives fail because they are not consistent with institutional arrangements or incentives.
2. Systems and services dysfunction: need for a better way Dysfunctional management of mentally disordered offenders is of two general types. Systems-level dysfunction concerns the mismatch between individual needs and system capacities. Prison management of mentally disordered offenders illustrates this type of dysfunction. Correction officials argue that prisons have become modern-day psychiatric institutions because the community-based system of care has not adequately responded to the needs of persons with mental illness (Home Office (HO), 1990; Torrey et al., 1992).
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Dysfunction at the systems level relates to the ‘‘bureaucratized, categorized, fragmented policy and program world that lacks capacity for holistic approaches to whole individuals . . . with complex problems’’ (Kahn & Kamerman, 1992, p. 7). Services-level dysfunction arises when services and individual needs are mismatched because there are administrative or management barriers that restrict the movement of individuals through service systems. Issues of service dysfunction are highlighted in cases of homicides involving persons with mental illness (Zito Trust, 1996, 1997). Dysfunction at the services level concerns the ‘‘absence of glue to hold together what few services and settings do exist in most communities . . . mak[ing] continuity of services difficult if not impossible’’ (Talbott, Bachrach, & Ross, 1986, p. 598). Evidence of these types of dysfunction is presented below. Part of the evidence for this section is drawn from interviews and site visits undertaken in Britain by the author during September 1998 to April 1999. Interviews were conducted with senior officials of the National Health Service Executive, Probation Service, and HO. Field research included site visits to and interviews with over 30 representatives of two regional secure units, a speciality hospital, five prisons, a bail hostel, and six court/prison liaison programs located in England. In general, the interviews focused on the policies and practices associated with the management of mentally disordered offenders and related cross-system interactions. The interviews with policy officials lasted, on the average, for 90 min. Site visits typically ranged from 1 to 3 days and included, whenever possible, shadowing prison and liaison professionals while they worked. 2.1. Systems dysfunction: prisons and mentally disordered offenders A person with mental illness who is engaging in some form of criminal or social deviance could be managed either by the mental health system or law enforcement system. It is, however, considered inappropriate and inconsistent with government guidance to use the prison service option for persons who only need health or social services (DoH, 1992; HO, 1990). Prisons, according to government policy, are not to be used as holding or treating facilities for persons who need specialised treatment, not punishment. Safeguards, such as court liaison schemes, have been put in place to prevent inappropriate placements (Staite, Martin, Bingham, & Daly, 1994). Although there are 200 or more liaison schemes in operation in England and Wales (HO, 1997), the majority of liaison workers and prison officials interviewed stated that liaison schemes have limited effectiveness in diverting mentally disordered offenders to treatment because ‘‘there are not enough hospital or crisis beds,’’ ‘‘hostels are too restrictive,’’ and ‘‘clients’, problems do not meet statutory eligibility criteria.’’ Nonetheless, prison officials noted that liaison schemes are useful because they ‘‘highlight’’ remand and sentenced prisoners who are in psychiatric distress or have histories of mental disorder. In spite of official guidance and the presence of liaison schemes, informants reported that there remains a tendency for prisons to ‘‘hold and treat.’’ Government guidance sanctions the prosecution of mentally disordered offenders when it is in the ‘‘public interest’’ (DoH, 1990). In these cases, mentally disordered offenders are
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the responsibility of the prison service, which may, at the direction of the Court or HO, result in their transfer to hospital for assessment or treatment. Yet, whether a transfer to hospital occurs still depends on the availability of a bed. Finding a bed for sentenced prisoners first requires finding the financially responsible health trust. Prison health care officers and prison liaison workers mentioned frequently and at length how difficult it is to uncover the inmate’s last area of residence—because some mentally disordered offenders are migratory. Because mentally disordered offenders can be both expensive and difficult to treat, trusts are known to challenge the prison’s definition of the responsible catchment area. Negotiating ownership can take months, as trusts charge and countercharge responsibility. Meanwhile, the prison is held fiscally responsible for multiple assessments (one by each trust’s clinical staff and maybe more if the negotiation spans several months) and clinically responsible for the inmate who is awaiting transfer to hospital. This process may be extended if the level of dangerousness is disputed by clinicians controlling access to medium and high security beds. Although the Reed Report standard for assessment and transfer to hospital was set at a maximum of 72 hours (DoH, 1992), most prison health professionals reported that transferring mentally ill inmates to hospital can take weeks and in some cases months. The most recent evidence on psychiatric morbidity in prisons in England and Wales indicates that roughly 10% of the 65,000 remand and sentenced inmates have some form of severe mental illness (e.g., psychosis or bipolar disorder), while virtually all other inmates are suspected of having at least one of the following four disorders: personality disorder, neurosis, alcohol misuse, and drug dependence (Office of National Statistics (ONS), 1998). Although the need for psychiatric treatment by inmates is evident, the supply is minimal and of questionable quality. Evidence suggests that prisons are not up to the task of managing the mental health needs of prison inmates. Prison health professionals reported unanimously that prison health care is underfunded, understaffed, medication focused, and either undermanaged or mismanaged by senior medical officers. Their views are consistent with evidence from 19 semistructured inspections of prison health care services, which found that ‘‘no prison had arrangements for all mentally disordered inpatients to be under the care of a consultant psychiatrist [the NHS standard ], and none provided a full multidisciplinary mental health team’’ (Reed & Lyne, 1997). Moreover, prison health professionals report difficulty acquiring clinical information about inmates from the NHS. According to one informant, it is possible to get information from the NHS if the inmate signs a release but ‘‘how fast you get the information depends on whether the person at the other end wants to make it easy or hard.’’ While it is expected that mentally disordered offenders will be released from prison with after care plans (DoH, 1992), this is rarely accomplished. Connections between the prison health unit and probation are variable; some prisons work closely with probation and have colocated a probation officer in the health unit, whereas others have more remote relations. Some prison health professionals report making efforts to connect inmates with community teams; however, these discussions are generally unproductive until a residence can be secured for the inmate services, which again, hinge on catchment area. Arranging for housing was described in terms of a ‘‘nightmare.’’ There is not enough suitable housing and what housing
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is available has restricted access. The criteria for eligibility typically exclude anyone suspected or convicted of arson (at any time), with a drug or alcohol problem, certain types of mental disorders, or considered high risk. Some inmates cannot access council housing because of prior tenancy problems. In some cases, the inmate is presented as homeless to the homeless unit. Completing an application for the homeless unit is arduous, and meeting the criteria of ‘‘vulnerable person’’ uncertain. Yet, even when successful, it only provides temporary accommodations in a bed and breakfast. Linking inmates with the Care Programme Approach (CPA)1 was mentioned as particularly difficult in part because only a small percentage of mentally disordered inmates was connected with a CPA prior to their index offence and in part because community teams ‘‘generally do not want information’’ about prison inmates because they lack the skills to manage them. Some prison health professionals mentioned their efforts to work together with community teams, including setting up formal meetings to discuss the sharing of information. Success in building communication bridges has been variable. For example, several informants mentioned efforts to build a communication link between the prison and statutory services. In one case, although the first interagency meeting was widely attended and attendees supported the idea of sharing information, no one from the outside agencies attended the follow-up meeting. Communication between the staff of prisons and CPA is frustrated by the administrative diversity among CPAs; each CPA has its own forms, procedures, eligibility criteria, and so forth. Because prisons oftentimes manage people from a myriad of catchment areas located around England, Wales, and Scotland, their staff may need to be familiar with protocols for a dozen or more CPAs. Administrative barriers between prisons and other service systems have two effects. First, because prisons have situational custody of mentally disordered offenders, they must assume health care management responsibilities for which they are ill equipped, inadequately informed, and insufficiently funded. Second, the needs of the mentally disordered offender may be poorly managed and inadequately addressed by prisons if prisons fail to internally produce or externally arrange for specialty care. Systems dysfunction is perpetuated by administrative barriers that prevent the movement of people to more appropriate service systems and of specialty services to people located in the prison system. 2.2. Services dysfunction: homicides and inquiries after homicides Of the roughly 500 homicides occurring each year in England and Wales, 50–60 per year are committed by persons suspected of a mental illness (Peay, 1996; Taylor & Gunn, 1999). NHS Guidance (Secretary of State, 1992) requires a confidential inquiry into the details of homicides by persons connected to mental health services. The purview of the inquiry expanded in 1994 (DoH, 1994) to require a mandatory formal, but impartial public inquiry
1
This program provides various levels of community care and support to persons with severe mental illness. Once referred, clients are assigned a care arrangement that matches their needs. Those with the highest priority are assigned a key worker and receive regular multidisciplinary reviews (DoH, 1990).
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into the local circumstances surrounding homicides committed by ‘‘discharged patients’’ with mental illness (Peay, 1996). The scope of these inquiries includes, but is not limited to, the quality and continuity of care leading up to the event, and the nature and frequency of interactions among statutory agencies, the police, and family networks regarding the offender’s behaviour or psychiatric distress in the months and weeks leading up to the offence. There have been approximately 40 inquiries into homicides published from 1994 to 1997 (Peay, 1996; Zito Trust, 1996, 1997). Four issues are commonly raised by inquiries. The first is the lack of interagency communication on issues regarding signals of relapse, including threatening and bizarre behaviour. The Ritchie Report noted how ‘‘sometimes the police make the decision not to charge a mentally disordered offender without the benefit of opinion from either an Approved Social Worker or the Duty Psychiatrist’’ (Ritchie, Dick, & Lingham, 1994, p. 124). Relatedly, poor communication between the units of the law enforcement system has been noted in the inquiries. For example, police officers failed to inform their counterparts in the prison service about their concern that Richard Linford (an arrested suspect who killed his cell mate) was ‘‘very dangerous’’ (Coonan, Blugass, Halliday, Jenkins, & Owen, 1998). The second issue concerns the lack of team work within the CPA. Information bottlenecks within the CPA has been attributed to poor personnel management, poor understanding of the CPA concept, disorganisation, and restrictive interagency confidentiality policies (Coid, 1994; Ritchie et al., 1994). Another reoccurring issue is the lack of supportive housing. Although most offenders had housing accommodations prior to the murder, their accommodations were often unstable and usually contentious. The Linford Inquiry report stressed the need for the ‘‘right accommodation . . . with the right levels of domiciliary support’’ (Coonan et al., 1998, p. 285), while the Newby Inquiry recommended that ‘‘housing should be regarded as an integral part of a care plan’’ (Davies, Lingham, Prior, & Sims, 1995, p. 54). The last issue is the lack of expertise and training of community-based staff (including the CPA staff, as well as police and prison staff) across the various public systems. In particular, the various inquiries have recommended building clinical and social competencies to manage the needs of the population (Heginbotham, Carr, Hale, Walsh, & Warren, 1994, p. 24) and interpersonal skills that ‘‘promote multidisciplinary working arrangements’’ (Woodley et al., 1995, p. 109). Training was recommended on mental illness (Ritchie et al., 1994, p. 127), the provisions of the Mental Health Act (Mishcon, Dick, Welch, Sheehan, & Mackay, 1995, p. 49), new medications (Howlett, 1998), risk assessment (Collins, Hill, & Taylor, 1992, pp. 36, 38; Harbour, Brunning, Bolter, & Hally, 1996, p. 70), and violence management (Lingham, Candy, & Bray, 1996, p. 77). Although the evidence regarding systems and services dysfunction reveal enduring and prevailing deficits within and between public systems, it is important to bear in mind that neither adequate services nor appropriate information can prevent all bad outcomes; instead, these episodes of dysfunction provide windows into the process of service delivery and systems interactions that hinder effective and timely responses to and monitoring of psychiatric and behavioural distress, which may eventually lead to violent events or other criminal behaviour.
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3. Barriers to integration and efforts to bridge them Government since the 1960s has heralded the importance of integration (Webb, 1991). Both the appeal of and political commitment to the process of integration defy explanation, as there is no evidence to support that it works. The simple fact is that systems and services remain fragmented in the UK, in spite of the nature of integration policies in operation: centralised planning in the 1960s and 1970s, joint planning and commissioning in the 1980s, and the blitz of ‘‘interagency approach,’’ ‘‘partnership building,’’ ‘‘building bridges,’’ and ‘‘working together’’ initiatives of the 1990s. Such policies have shared a similar fate whether they relied on exhortation —‘‘please, play together’’— or mandates —‘‘you must play together,’’ or whether new funding or resources were added to the public systems network. Moreover, system structure, conduct, and performance have remained unswayed by government’s appeal to the greater common good — everyone gains when an integrated service is provided (Webb, 1991). Mechanic (1995), in commenting on the integration experience in both the USA and UK, noted that There is sufficient experience to impress even the most optimistic that exhortation to work together cooperatively and appeals to goodwill achieve little improvement in a context where interest groups compete for scarce resources and where each bureaucracy has its own agenda and political constituencies. (p. 134)
In light of historical experience with integration policy in Britain, it is interesting that ‘‘New’’ Labour, a government that advocates the ‘‘what matters is what works’’ approach, would choose to continue a policy that has unequivocally failed for over 30 years. Because it is unlikely that integration policy will be abandoned any time in the near future, it is useful to understand the forces that work against it. This section looks at three barriers that impede systems and services integration and describes why they have persisted in spite of efforts to bridge them. The evidence in this section draws on research and policy experiences in the UK and USA. Like meta-analysis, pooling together cross-national evidence provides a clearer and more detailed picture of what works and has not worked in the area of integration policy. 3.1. Categorical funding Specialised bureaucracies are created and supported by a budgetary process that earmarks funding for categories of services, such as health, social, and criminal justice. Public systems become labelled and limited by their funding mandates. Although the single-problem typology that underpins public systems is a product of government action and is maintained for historical and political convenience, it is in direct conflict with the variable needs of persons with multiple cooccurring problems and diagnoses (Wolff, 1998). Systems and services are fragmented because funding is fragmented; integration is necessary because funding is not. The problem of fragmentation is compounded when system-specific funding is decentralised to smaller groups (e.g., local authorities, health trusts, and prisons) that have dissimilar catchment areas (as discussed earlier). Integration at the local level becomes more challenging when service agencies define the service world differently. Dividing large areas
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into multiple, nonoverlapping catchment areas creates opportunities to lose people to followup, frustrates efforts to join up disjointed service activities, and limits the ability to efficiently organise and produce speciality services that require a larger base population (Mechanic & Aiken, 1987). As part of Labour government’s partnership building policy, social service and health agencies are being granted powers to integrate their funding streams and service activities (DoH, 1998a, 1998b). Whether these new powers will be effective is unclear, but the research evidence from the USA is not encouraging. There have been two well-funded demonstration projects in the USA that sought to decategorise services through integrating funding. The Robert Wood Johnson (RWJ) nine-city project attempted to centralise administrative, fiscal, and clinical responsibilities within a single mental health agency and focused on coordinating mental health and housing services (Goldman, Morrissey, & Ridgely, 1990). The RWJ Child Health Initiative was a six-city project that attempted to coordinate and monitor children’s services by unifying the funding from health, social service, mental health, and developmental disability programs (Newacheck, Halfon, Brindis, & Hughes, 1998). Neither effort was successful in integrating funding, although there was modest success at a few of the sites (Morrissey et al., 1994; Newacheck et al., 1998). Bureaucratic politics and turf wars dominated the deliberations at most of the sites and consumed endless hours of negotiation. Newacheck et al. (1998) notes that ‘‘in hindsight, it is clear that accomplishing decategorization requires considerable time and a minimum of distractions’’ (p. 170). 3.2. Resource allocation There are two separate resource allocation issues that affect system dynamics: inadequate funding and inconsistent funding. First, public spending on housing, social, health, mental health, and correctional services are constrained by aggregate funding allocations. The availability and quality of services and accommodations are determined by these allocations, which may not be tied in any meaningful sense to need or demand. Because resources are scarce, agencies tend their categorical boundaries, limiting access to those who most closely meet their eligibility criteria. Access rationing is the direct result of resource scarcity, which is created by budgetary constraints. The incentive to tend their boundaries becomes more extreme when resources become scarcer. Second, adding new funding, to alleviate the pressures of scarcity, makes sense only if the funding is reliable. Over the years, the British government has targeted money to expand services for mentally disordered offenders. For example, funds have been targeted for the development of court liaison schemes (James, 1996; Secretary of State, 1992). This initiative, funded partially by the HO, DoH, and the Mental Health Foundation, led to the development of over 200 local models of court liaison throughout England and Wales (HO, 1997). Anecdotal evidence suggests, however, that a nontrivial number of these schemes, after their pilot funding ended, either scaled back or terminated because local funding was not forthcoming (personal communication with the Head of the Mental Health Unit, National Association for the Care and Resettlement of Offenders). Discontinuous funding has hampered their continuity and stability.
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As part of Labour government’s policy of modernising mental health services (DoH, 1998a), funding is being targeted to expand the production of ‘‘safe’’ services, including extra secure beds, new outreach teams, and new assessment and management techniques. Yet, it is important to note that government’s ambitious ‘‘safe, sound, supportive’’ service expansion agenda is limited at £700 million spread over 3 years. That is, mental health spending in each of the next three years is expected to increase by 5%. This amount of spending will slightly reduce the scarcity of the moment, but will have no lasting impact if the funding is time limited. Without continued funding, new capacity will crowd out existing capacity or new capacity will be lost. Capacity expansion is inextricably tied to funding expansion, as are related conditions of scarcity. 3.3. Bureaucratic intransigence Public systems have classical organisational characteristics. They have bureaucracies that are structured hierarchically, have formal lines of communication, are specialised in their function, and conduct business in strict adherence to formal rules and regulations codified through written policies and enforced by internal control systems (Weber, 1957). These types of systems are tradition bound. Whatever coordination exists has evolved slowly and is routinised to ‘‘preserve an entrenched division of labour’’ (Webb, 1991). Classical bureaucracies are known for their monolithic qualities, not for their flexibility or dynamism. Asking organisations with rigid structures to change or innovate is comparable to asking an accountant to be flexible — neither is very likely. Systems, organisations, and people work together when it is to their advantage. Whether cooperation is worthwhile depends on the calculus of benefits to costs. However, neither the costs nor benefits can be assessed objectively; they are themselves value laden and will be influenced by the decision maker’s attitude towards the concept of cooperation in general and the particulars of cooperating with a specific system or individual. Decision makers who are not inclined to work cooperatively can define the problem in such a way as to make it an undesirable proposition in terms of process or outcome (Whetten, 1981). Benefits of cooperation can be of two general types: internal and external. Internal benefits are those that directly enhance the economic or political welfare of the entity (i.e., system, service, or individual) considering a cooperative venture. Such benefits may include recognition and support from the political or system elite for complying with government mandates (i.e., political benefits) or expansion of the service resource base by either acquiring access to another system’s resources or gaining new resources through a granting process (i.e., economic benefits). Decision makers are likely to value political and economic benefits differently, with greater value assigned to economic benefits in times of extreme scarcity and to political benefits in periods of system crisis. In contrast, benefits are external when the primary beneficiary is not the entity creating the benefits. Systems may engage in altruistic activities because they value contributing to the greater social good, even though they do not have property rights to the benefits that result from these activities. Systems are most adept at measuring the costs of cooperation in part because integrating with another system has immediate and potentially long-lasting resource and funding
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implications and in part because partnerships by their very nature diminish each entity’s control over its budget and flexibility to act. How much cooperation will cost in terms of the loss in resources and control will depend on the size of the cooperative venture and the nature and details of the intersystem contract or agreement. Systems assess these costs in combination with the transaction costs of negotiating an agreement and monitoring its compliance (Croxson, 1999). The start-up costs of joint ventures are extraordinary high as they require negotiating the loss of authority, access to resources, and monitoring of compliance, all of which require vast amounts of legal and professional effort (Goldman et al., 1994; Newacheck et al., 1998). Entities work together when the benefits of cooperation exceed their costs. The lack of integration within the public systems network to date would suggest that systems, organisations, and people, if acting rationally, have determined that it is not cost effective to work together, even though it would improve the outcomes of the public systems network. To offset the current equilibrium against integration, it would be necessary to substantially augment the internal benefits perceived by the decision maker and/or lower the costs. However, there has been very little policy effort expended towards altering the distribution of costs and benefits. Government, however, has tried to affect the calculus in two ways. First, it has acclaimed the external benefits — the social good — associated with integrating systems and services. These benefits, however, do not appear to be great enough to offset the expected costs. However, appeals to altruism are likely to be ineffective not because systems are unmotivated to improve the performance and outcomes of the system or service network; but rather because the benefits emanating from the greater good are diffuse and intangible while the costs are highly centralised and direct. Systems cannot act in ways that promote the social good when they are constrained by systems-level budgets. Second, government has tried at various times and with different instruments to humour or order systems into compliance with integration policy. However, neither exhortations nor mandates are likely to get entrenched bureaucracies to integrate their service activities, and even rule-abiding bureaucracies may only marginally respond to directives. According to Whetten (1981), ‘‘if an organization’s staff members perceive that they are being forced to interact with an undesirable organisation and that this interaction will severely tax their resources, they will probably try to undermine their mandate’’ (p. 247). This suggests several things. First, it may be easier to motivate interactions between the health services and social services but more difficult to instigate relations between the criminal justice system (the ‘‘dark horse’’ of public systems and the keeper of the nation’s most difficult, complex, and needy (read: costly) citizens) and either social or health service systems. Second, resources are likely to be the key and deciding factor. Again, Whetten noted that one of the ‘‘critical components of successful mandated relationships’’ is ‘‘providing them with sufficient resources to maintain the coordination process in addition to their other responsibilities’’ (p. 247). Working together is costly (Goldman et al., 1994; Newacheck et al., 1998). It takes time to develop new technologies, negotiate relationships, responsibilities, and protocols for engagement, hire and train new staff, and manage intersystem conflicts. Finding the ‘‘slack’’ within systems to build partnerships is highly unlikely
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when the systems to be partnered experience tight external resource constraints and high service demand.
4. Conclusions: shaping the future by learning from the past The most prudent way to deal with the problem of institutional disorder is to learn from the failures of past policies and to gain from the experiences of other parts of the economy, which have successfully organised complex production relations. Learning from the past includes both acknowledging that disjointed integration policies have unequivocally failed and recognising that they failed because they were incremental in their design, ad hoc in their approach, and misfocused in their aim in that they avoided the real problem: funding patterns and levels. Not surprisingly, getting the solution right begins with focusing on the right problem. Much can be learned from the experiences of the private sector. Organisations producing complex products within the private sector have historically changed their boundaries to alter managerial behaviour and improve performance. Coordination of effort is the foremost concern of industry. Commenting on this issue, Follett (Drucker, Kanter, & Graham, 1994) said For a business, to be a going concern, must be unified. The fair test of business administration, of industrial organization, is whether you have a business with all its parts so co-ordinated, so moving together in their closely knit and adjusting activities, so linking, interlocking, inter-relating, that they make a working unit, not a congerie of separate pieces. (p. 183)
The mental health, social services, and law enforcement systems both in isolation and combination can best be described as a ‘‘congerie of separate pieces.’’ Separating systems by categorical funding mandates undermine policy efforts to organise the pieces around the whole person. Administrative barriers that have historically hindered systems and services integration persist because categorical funding streams define individualised systems and reinforce their independence. Building a system that works for mentally disordered offenders begins with understanding what does not work and what causes the dysfunction, from there, it is possible to create an integrated system that works for the whole.
Acknowledgments This research was supported by an Atlantic Fellowship in Public Policy funded by the British government. Earlier versions of the paper were presented at the Conference on Mental Health Services Restructuring and Public Safety in Midland, Ontario, Canada, June 1999, and the 21st Annual Research Conference of the Association for Public Policy Analysis and Management, Washington, DC, November 1999. The author would like to acknowledge the helpful comments of two anonymous reviewers, as well as those of Mark Schlesinger.
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References Abramson, M. F. (1972). The criminalisation of mentally disordered behavior. Hospital and Community Psychiatry, 3 (4), 101 – 105. Coid, J. W. (1994). The Christopher Clunis enquiry. Psychiatric Bulletin, 18, 449 – 452. Coid, J. W. (1996). Dangerous patients with mental illness: increased risks. Warrant new policies, adequate resources and appropriate legislation. British Medical Journal, 312, 965 – 969. Collins, A., Hill, O., & Taylor, M. (1992). Independent inquiry into the care and treatment of Kevin Rooney. London: North Thames Regional Health Authority. Coonan, K., Bluglass, R., Halliday, G., Jenkins, M., & Owen, K. (1998). Report of the inquiry into the care and treatment of Christopher Edwards and Richard Linford. Witham, Essex: North Essex Health Authority. Croxson, B. (1999). Organisational costs in the new NHS. London: Office of Health Economics. Davies, N., Lingham, R., Prior, C., & Sims, A. (1995). Report of the inquiry into the circumstances leading to the death of Jonathan Newby (a volunteer worker). Oxford: Oxfordshire Health. Dennis, D. L., Buckner, J. C., Lipton, F. R., & Levine, I. S. (1991). A Decade of research and services for homeless mentally ill persons: where do we stand? American Psychologist, 46, 1129 – 1138. Department of Health. (1990). The care programme approach for people with a mental illness referred to the specialist psychiatric services. London: Department of Health. Department of Health. (1992). Review of health and social services for mentally disordered offenders and other requiring similar services—final summary report. London: HM Stationery Office. Department of Health. (1994). Guidance on the discharge of mentally disordered people and their continuing care in the community. London: HM Stationery Office. Department of Health. (1998a). Modernising health and social services: national priorities guidance 1999/00 – 2001/02. London: Department of Health. Department of Health. (1998b). Partnership in action. London: Department of Health. Draine, J., & Solomon, P. (1994). Jail recidivism and the intensity of case management services among homeless persons with mental illness leaving jail. Journal of Psychiatry and Law, 20, 335 – 349. Drucker, P. F., Kanter, R. M., & Graham, P. (1994). Mary Parker Follett, prophet of management. Boston: Harvard Business School Press. Fisher, W. H., Packer, I. K., Simon, L. J., & Smith, D. (2000). Community mental health services and the prevalence of severe mental illness in local jails: are they related? Administration and Policy in Mental Health, 27, 371 – 382. Goldman, H. H., Morrissey, J. P., & Ridgely, M. S. (1990). Lessons from the program on chronic mental illness. Hospital and Community Psychiatry, 41 (11), 1212 – 1216. Goldman, H. H., Morrissey, J. P., & Ridgely, S. M. (1994). Evaluating the Robert Wood Johnson Foundation Program on Chronic Mental Illness. Milbank Quarterly, 72 (1), 37 – 47. Grad, J. C., & Sainsbury, P. (1966). Evaluating the community psychiatric service in Chichester: results. Milbank Memorial Fund Quarterly, 44, 246 – 278. Harbour, A., Brunning, J., Bolter, L., & Hally, H. (1996). The Viner Report: the report of the independent inquiry into the circumstances surrounding the deaths of Robert and Muriel Viner. Ferndown, Dorset: Dorset Health Commission. Heginbotham, C., Carr, J., Hale, R., Walsh, T., & Warren, L. (1994). Report of the independent panel of inquiry examining the case of Michael Buchanan. London: North West London Mental Health NHS Trust. Home Office. (1990). Circular 66/90 provision for mentally disordered offenders. London: Home Office. Home Office. (1997). Mentally disordered offenders: survey of inter-agency arrangements. London: Home Office. Howlett, M. (1998). Medication, non-compliance and mentally disordered offenders. London: Zito Trust. James, A. (1996). Life on the edge. London: The Mental Health Foundation. Kahn, A. J., & Kamerman, S. B. (1992). Integrating services integration: an overview of initiatives, issues, and possibilities. Columbia University: National Center for Children in Poverty.
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Kessler, R. C., Nelson, C. B., McGonagle, K. S., Edlund, M. J., Frank, R. G., & Leaf, P. J. (1996). The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. American Journal of Orthospychiatry, 66, 17 – 31. Lamb, H. R., & Weinberger, L. E. (1998). Persons with serious mental illness in jails and prisons: a review. Psychiatric Services, 49, 483 – 492. Le Grand, J. (1999). Competition, cooperation, or control? Tales from the British National Health Service. Health Affairs, 18 (3), 27 – 40. Lingham, R., Candy, J., & Bray, J. (1996). Report of the inquiry into the treatment and care of Raymond Sinclair. Aylesford, Kent: West Kent Health Authority. Link, B. G., Cullen, F. T., Mirotznik, J., & Struening, E. (1992). The consequences of stigma for persons with mental illness: evidence from the social sciences. In: P. J. Fink, & A. Tasman (Eds.), Stigma and mental illness ( pp. 87 – 96). Washington, DC: American Psychiatric Press. Mechanic, D. (1995). Challenges in the provision of mental health services: some cautionary lessons from US experience. Journal of Public Health Medicine, 17 (2), 132 – 139. Mechanic, D., & Aiken, L. (1987). Improving the care of patients with chronic mental illness. New England Journal of Medicine, 317 (26), 1634 – 1638. Menezes, P. R., Johnson, S., Thornicroft, G., Marshall, J., Prosser, D., Bobbington, P., & Kuipers, E. (1996). Drug and alcohol problems among individuals with severe mental illness in South London. British Journal of Psychiatry, 168 (5), 612 – 619. Mishcon, J., Dick, D., Welch, N., Sheehan, A., & Mackay, J. (1995). The Grey report: report of the independent inquiry team into the care and treatment of Kenneth Grey. London: East London and The City Health Authority. Morrissey, J. P., Calloway, M., Bartko, W. T., Ridgely, J. S., Goldman, H. H., & Paulson, R. I. (1994). Local mental health authorities and service system change: evidence from the Robert Wood Johnson program on chronic mental illness. Milbank Quarterly, 72 (1), 49 – 80. Newacheck, P. W., Halfon, N., Brindis, C. D., & Hughes, D. C. (1998). Evaluating community effort to decategorize and integrate financing of children’s health services. Milbank Quarterly, 76 (2), 157 – 173. Office of National Statistics. (1998). Psychiatric morbidity among prisoners in England and Wales. London: HM Stationery Office. Peay, J. (Ed.) (1996). Inquiries after homicide ( pp. 1 – 38). London: Duckworth. Prins, H. (1993). Offender-patients: the people nobody owns. In: W. Watson, & A. Grounds (Eds.), The mentally disordered offender in an era of community care: new directions in provision ( pp. 3 – 8). Cambridge: Cambridge University Press. Reed, J., & Lyne, M. (1997). The quality of health care in prison: results of a year’s programme of semistructured inspections. British Medical Journal, 315, 1420 – 1424. Reinhard, S., & Horwitz, A. (1996). Caregiver burden: differentiating the content and consequences of family caregiving. Journal of Marriage and the Family, 57, 741 – 750. Ritchie, J., Dick, D., & Lingham, R. (1994). Report of the inquiry into the care and treatment of Christopher Clunis. London: HM Stationery Office. Rossi, P. H. (1989). Down and out in America: the origins of homelessness. Chicago: University of Chicago Press. Schermerhorn, J. R. (1975). Determinants of interorganizational cooperation. Academy of Management Journal, 18 (4), 846 – 856. Scott, J. (1993). Homelessness and mental illness. British Journal of Psychiatry, 162, 314 – 324. Secretary of State. (1992). The health of the nation. London: HM Stationery Office. Staite, C., Martin, N., Bingham, M., & Daly, R. (1994). Diversion from custody for mentally disordered offenders. Essex, UK: Longman. Talbott, J., Bachrach, L., & Ross, L. (1986). Noncompliance and mental health systems. Psychiatric Annals, 16 (10), 596 – 599. Taylor, P. J., & Gunn, J. (1999). Homicides by people with mental illness: myth and reality. British Journal of Psychiatry, 174, 9 – 14.
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Tessler, R., & Gamache, G. (1994). Continuity of care, residence, and family burden in Ohio. Milbank Quarterly, 72, 149 – 169. Torrey, E. F., Stieber, J., Ezekiel, J., Wolfe, S. M., Sharfstein, J., Nobel, J. H., & Flynn, L. M. (1992). Criminalising the seriously mentally ill. Washington, DC: Public Citizens Health Research Group. Vandiver, V. L. (1997). Services to the severely and persistently mentally ill. In: T. R. Watkins, & J. W. Callicutt (Eds.), Mental health policy and practice today ( pp. 195 – 208). London: Sage Publications. Watson, A. (1997). Services for mentally disordered offenders in the community: an inspection report. HMSO: Department of Health. Webb, A. (1991). Coordination: a problem in public sector management. Policy and Politics, 19 (4), 229 – 241. Weber, M. (1957). The theory of social and economic organization. New York: Free Press. Whetten, D. A. (1981). Interorganizational relations. In: J. W. Lorsch (Ed.), Handbook of organizational behavior ( pp. 238 – 253). Englewood Cliffs, NJ: Prentice-Hall. Wolff, N. (1998). Interactions between mental health and law enforcement systems: problems and prospects for cooperation. Journal of Health Politics, Policy and Law, 23 (1), 132 – 173. Wolff, N. (2002). Risk, responses, and mental health policy. Journal of Health Politics, Policy and Law. In press. Wolff, N., Helminiak, T. W., & Diamond, R. J. (1995). Estimated societal costs of assertive community mental health care. Psychiatric Services, 46 (9), 898 – 906. Woodley, L., Dixon, K., Lindow, V., Oyebode, O., Sandford, T., & Simblet, S. (1995). The Woodley team report: report of the independent review panel to East London and the City Health Authority and Newham Council. London: East London and the City Health Authority. Zito Trust. (1996). Learning the lessons (2nd ed.). London: The Zito Trust. Zito Trust. (1997). Mental health inquiries published during 1997. London: The Zito Trust.
‘‘New’’ public management of mentally disordered offenders: Part I. A cautionary tale Nancy Wolff * Health Care Policy and Aging Research, Institute for Health, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901-1293, USA
1. Introduction Rarely in public policy is there a consensus on the nature of a social problem. Yet, there is general agreement among policymakers, researchers, clients, and carers that services needed by persons with complex and multiple needs are haphazardly organised and mired in bureaucratic intransigence (Kahn & Kamerman, 1992; Mechanic, 1995; Webb, 1991). The problem, dating back to the 1960s in both the USA and UK, is attributed to the muchsupported policy of community care for persons with chronic and enduring health problems, including mental illness, as well as physical and mental impairments (Mechanic, 1995). Over the years, these governments have been remarkably effective at transferring people from one site (hospital) to another (community), but decidedly less effective in accommodating those who were relocated (Vandiver, 1997). This mismatch has produced a pastiche of unintended consequences: homelessness (Dennis, Buckner, Lipton, & Levine, 1991; Draine & Solomon, 1994; Rossi, 1989; Scott, 1993), criminalisation of the mentally disordered (Abramson, 1972; Fisher, Packer, Simon, & Smith, 2000; Lamb & Weinberger, 1998; Torrey et al., 1992), substance abuse (Kessler et al., 1996; Menezes et al., 1996), social exclusion and isolation (Link, Cullen, Mirotznik, & Struening, 1992), and overburdened family networks (Grad & Sainsbury, 1966; Reinhard & Horwitz, 1996; Tessler & Gamache, 1994; Wolff, Helminiak, & Diamond, 1995). Because the social problem and its unintended consequences are framed in terms of disorganisation, the most favoured solution is services or systems integration (Department of
* Tel.: +1-732-932-6635; fax: +1-732-932-6872. E-mail address: [email protected] (N. Wolff). 0160-2527/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 1 6 0 - 2 5 2 7 ( 0 1 ) 0 0 0 9 8 - X
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Health (DoH), 1998a, 1998b; Schermerhorn, 1975; Webb, 1991). In particular, Britain’s Labour government is implementing ‘‘new’’ partnership initiatives that are intended to replace the ethic of competition among public systems with that of cooperation (Le Grand, 1999). Better cross-system management is portrayed as the panacea; it is the public sector’s counterpart to Adam Smith’s invisible hand. If one reads the policy rhetoric, it appears that through the visible hand of cooperation the multifarious barriers between systems and services will be eliminated, allowing the free flow of clients and service innovation across organisational boundaries. The ensuing process is one in which public systems respond collectively (and cheerfully) to build a comprehensive and seamless system of care for those with chronic and persistent mental health problems. All for the better — if it works. This article is the first of a two-part series examining alternative approaches to integrating services for mentally disordered offenders. Part I takes a critical look at the issue of ‘‘if it works’’ in the context of Britain’s Labour government’s ‘‘modernising’’ effort to better manage public systems’ responses to persons with mental illness who have cooccurring offending behaviours. Part II provides a ‘‘new’’ holistic approach to integrating services for mentally disordered offenders. This new approach draws on economic and organisational theory to structure a whole system of care that is responsive to the whole person and accountable to society. Mentally disordered offenders are an interesting ‘‘integration’’ case study in part because their needs span the boundaries of health, mental health, social services, and law enforcement systems (DoH, 1992; Watson, 1997), in part because the complexity of their needs along with their difficult and sometimes dangerous behavioural traits combine to make them undesirable clients (Coid, 1996; Prins, 1993), and in part because the criminal behaviour of some of these individuals occasionally excites moral panic among the public, leading to a community care backlash (Wolff, 2000). Getting public systems to work for this group is simultaneously a social imperative and a major challenge. To begin the analysis, I review the evidence in Britain of systems and services dysfunction as it relates to mentally disordered offenders to establish the need for the integration of systems (or ‘‘systems integration’’) and the integration of services (or ‘‘services integration’’). The next section explores three barriers associated with achieving services and systems integration, drawing on experiences in the USA and the UK to overcome these barriers. This historical record suggests that incremental integration initiatives fail because they are not consistent with institutional arrangements or incentives.
2. Systems and services dysfunction: need for a better way Dysfunctional management of mentally disordered offenders is of two general types. Systems-level dysfunction concerns the mismatch between individual needs and system capacities. Prison management of mentally disordered offenders illustrates this type of dysfunction. Correction officials argue that prisons have become modern-day psychiatric institutions because the community-based system of care has not adequately responded to the needs of persons with mental illness (Home Office (HO), 1990; Torrey et al., 1992).
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Dysfunction at the systems level relates to the ‘‘bureaucratized, categorized, fragmented policy and program world that lacks capacity for holistic approaches to whole individuals . . . with complex problems’’ (Kahn & Kamerman, 1992, p. 7). Services-level dysfunction arises when services and individual needs are mismatched because there are administrative or management barriers that restrict the movement of individuals through service systems. Issues of service dysfunction are highlighted in cases of homicides involving persons with mental illness (Zito Trust, 1996, 1997). Dysfunction at the services level concerns the ‘‘absence of glue to hold together what few services and settings do exist in most communities . . . mak[ing] continuity of services difficult if not impossible’’ (Talbott, Bachrach, & Ross, 1986, p. 598). Evidence of these types of dysfunction is presented below. Part of the evidence for this section is drawn from interviews and site visits undertaken in Britain by the author during September 1998 to April 1999. Interviews were conducted with senior officials of the National Health Service Executive, Probation Service, and HO. Field research included site visits to and interviews with over 30 representatives of two regional secure units, a speciality hospital, five prisons, a bail hostel, and six court/prison liaison programs located in England. In general, the interviews focused on the policies and practices associated with the management of mentally disordered offenders and related cross-system interactions. The interviews with policy officials lasted, on the average, for 90 min. Site visits typically ranged from 1 to 3 days and included, whenever possible, shadowing prison and liaison professionals while they worked. 2.1. Systems dysfunction: prisons and mentally disordered offenders A person with mental illness who is engaging in some form of criminal or social deviance could be managed either by the mental health system or law enforcement system. It is, however, considered inappropriate and inconsistent with government guidance to use the prison service option for persons who only need health or social services (DoH, 1992; HO, 1990). Prisons, according to government policy, are not to be used as holding or treating facilities for persons who need specialised treatment, not punishment. Safeguards, such as court liaison schemes, have been put in place to prevent inappropriate placements (Staite, Martin, Bingham, & Daly, 1994). Although there are 200 or more liaison schemes in operation in England and Wales (HO, 1997), the majority of liaison workers and prison officials interviewed stated that liaison schemes have limited effectiveness in diverting mentally disordered offenders to treatment because ‘‘there are not enough hospital or crisis beds,’’ ‘‘hostels are too restrictive,’’ and ‘‘clients’, problems do not meet statutory eligibility criteria.’’ Nonetheless, prison officials noted that liaison schemes are useful because they ‘‘highlight’’ remand and sentenced prisoners who are in psychiatric distress or have histories of mental disorder. In spite of official guidance and the presence of liaison schemes, informants reported that there remains a tendency for prisons to ‘‘hold and treat.’’ Government guidance sanctions the prosecution of mentally disordered offenders when it is in the ‘‘public interest’’ (DoH, 1990). In these cases, mentally disordered offenders are
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the responsibility of the prison service, which may, at the direction of the Court or HO, result in their transfer to hospital for assessment or treatment. Yet, whether a transfer to hospital occurs still depends on the availability of a bed. Finding a bed for sentenced prisoners first requires finding the financially responsible health trust. Prison health care officers and prison liaison workers mentioned frequently and at length how difficult it is to uncover the inmate’s last area of residence—because some mentally disordered offenders are migratory. Because mentally disordered offenders can be both expensive and difficult to treat, trusts are known to challenge the prison’s definition of the responsible catchment area. Negotiating ownership can take months, as trusts charge and countercharge responsibility. Meanwhile, the prison is held fiscally responsible for multiple assessments (one by each trust’s clinical staff and maybe more if the negotiation spans several months) and clinically responsible for the inmate who is awaiting transfer to hospital. This process may be extended if the level of dangerousness is disputed by clinicians controlling access to medium and high security beds. Although the Reed Report standard for assessment and transfer to hospital was set at a maximum of 72 hours (DoH, 1992), most prison health professionals reported that transferring mentally ill inmates to hospital can take weeks and in some cases months. The most recent evidence on psychiatric morbidity in prisons in England and Wales indicates that roughly 10% of the 65,000 remand and sentenced inmates have some form of severe mental illness (e.g., psychosis or bipolar disorder), while virtually all other inmates are suspected of having at least one of the following four disorders: personality disorder, neurosis, alcohol misuse, and drug dependence (Office of National Statistics (ONS), 1998). Although the need for psychiatric treatment by inmates is evident, the supply is minimal and of questionable quality. Evidence suggests that prisons are not up to the task of managing the mental health needs of prison inmates. Prison health professionals reported unanimously that prison health care is underfunded, understaffed, medication focused, and either undermanaged or mismanaged by senior medical officers. Their views are consistent with evidence from 19 semistructured inspections of prison health care services, which found that ‘‘no prison had arrangements for all mentally disordered inpatients to be under the care of a consultant psychiatrist [the NHS standard ], and none provided a full multidisciplinary mental health team’’ (Reed & Lyne, 1997). Moreover, prison health professionals report difficulty acquiring clinical information about inmates from the NHS. According to one informant, it is possible to get information from the NHS if the inmate signs a release but ‘‘how fast you get the information depends on whether the person at the other end wants to make it easy or hard.’’ While it is expected that mentally disordered offenders will be released from prison with after care plans (DoH, 1992), this is rarely accomplished. Connections between the prison health unit and probation are variable; some prisons work closely with probation and have colocated a probation officer in the health unit, whereas others have more remote relations. Some prison health professionals report making efforts to connect inmates with community teams; however, these discussions are generally unproductive until a residence can be secured for the inmate services, which again, hinge on catchment area. Arranging for housing was described in terms of a ‘‘nightmare.’’ There is not enough suitable housing and what housing
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is available has restricted access. The criteria for eligibility typically exclude anyone suspected or convicted of arson (at any time), with a drug or alcohol problem, certain types of mental disorders, or considered high risk. Some inmates cannot access council housing because of prior tenancy problems. In some cases, the inmate is presented as homeless to the homeless unit. Completing an application for the homeless unit is arduous, and meeting the criteria of ‘‘vulnerable person’’ uncertain. Yet, even when successful, it only provides temporary accommodations in a bed and breakfast. Linking inmates with the Care Programme Approach (CPA)1 was mentioned as particularly difficult in part because only a small percentage of mentally disordered inmates was connected with a CPA prior to their index offence and in part because community teams ‘‘generally do not want information’’ about prison inmates because they lack the skills to manage them. Some prison health professionals mentioned their efforts to work together with community teams, including setting up formal meetings to discuss the sharing of information. Success in building communication bridges has been variable. For example, several informants mentioned efforts to build a communication link between the prison and statutory services. In one case, although the first interagency meeting was widely attended and attendees supported the idea of sharing information, no one from the outside agencies attended the follow-up meeting. Communication between the staff of prisons and CPA is frustrated by the administrative diversity among CPAs; each CPA has its own forms, procedures, eligibility criteria, and so forth. Because prisons oftentimes manage people from a myriad of catchment areas located around England, Wales, and Scotland, their staff may need to be familiar with protocols for a dozen or more CPAs. Administrative barriers between prisons and other service systems have two effects. First, because prisons have situational custody of mentally disordered offenders, they must assume health care management responsibilities for which they are ill equipped, inadequately informed, and insufficiently funded. Second, the needs of the mentally disordered offender may be poorly managed and inadequately addressed by prisons if prisons fail to internally produce or externally arrange for specialty care. Systems dysfunction is perpetuated by administrative barriers that prevent the movement of people to more appropriate service systems and of specialty services to people located in the prison system. 2.2. Services dysfunction: homicides and inquiries after homicides Of the roughly 500 homicides occurring each year in England and Wales, 50–60 per year are committed by persons suspected of a mental illness (Peay, 1996; Taylor & Gunn, 1999). NHS Guidance (Secretary of State, 1992) requires a confidential inquiry into the details of homicides by persons connected to mental health services. The purview of the inquiry expanded in 1994 (DoH, 1994) to require a mandatory formal, but impartial public inquiry
1
This program provides various levels of community care and support to persons with severe mental illness. Once referred, clients are assigned a care arrangement that matches their needs. Those with the highest priority are assigned a key worker and receive regular multidisciplinary reviews (DoH, 1990).
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into the local circumstances surrounding homicides committed by ‘‘discharged patients’’ with mental illness (Peay, 1996). The scope of these inquiries includes, but is not limited to, the quality and continuity of care leading up to the event, and the nature and frequency of interactions among statutory agencies, the police, and family networks regarding the offender’s behaviour or psychiatric distress in the months and weeks leading up to the offence. There have been approximately 40 inquiries into homicides published from 1994 to 1997 (Peay, 1996; Zito Trust, 1996, 1997). Four issues are commonly raised by inquiries. The first is the lack of interagency communication on issues regarding signals of relapse, including threatening and bizarre behaviour. The Ritchie Report noted how ‘‘sometimes the police make the decision not to charge a mentally disordered offender without the benefit of opinion from either an Approved Social Worker or the Duty Psychiatrist’’ (Ritchie, Dick, & Lingham, 1994, p. 124). Relatedly, poor communication between the units of the law enforcement system has been noted in the inquiries. For example, police officers failed to inform their counterparts in the prison service about their concern that Richard Linford (an arrested suspect who killed his cell mate) was ‘‘very dangerous’’ (Coonan, Blugass, Halliday, Jenkins, & Owen, 1998). The second issue concerns the lack of team work within the CPA. Information bottlenecks within the CPA has been attributed to poor personnel management, poor understanding of the CPA concept, disorganisation, and restrictive interagency confidentiality policies (Coid, 1994; Ritchie et al., 1994). Another reoccurring issue is the lack of supportive housing. Although most offenders had housing accommodations prior to the murder, their accommodations were often unstable and usually contentious. The Linford Inquiry report stressed the need for the ‘‘right accommodation . . . with the right levels of domiciliary support’’ (Coonan et al., 1998, p. 285), while the Newby Inquiry recommended that ‘‘housing should be regarded as an integral part of a care plan’’ (Davies, Lingham, Prior, & Sims, 1995, p. 54). The last issue is the lack of expertise and training of community-based staff (including the CPA staff, as well as police and prison staff) across the various public systems. In particular, the various inquiries have recommended building clinical and social competencies to manage the needs of the population (Heginbotham, Carr, Hale, Walsh, & Warren, 1994, p. 24) and interpersonal skills that ‘‘promote multidisciplinary working arrangements’’ (Woodley et al., 1995, p. 109). Training was recommended on mental illness (Ritchie et al., 1994, p. 127), the provisions of the Mental Health Act (Mishcon, Dick, Welch, Sheehan, & Mackay, 1995, p. 49), new medications (Howlett, 1998), risk assessment (Collins, Hill, & Taylor, 1992, pp. 36, 38; Harbour, Brunning, Bolter, & Hally, 1996, p. 70), and violence management (Lingham, Candy, & Bray, 1996, p. 77). Although the evidence regarding systems and services dysfunction reveal enduring and prevailing deficits within and between public systems, it is important to bear in mind that neither adequate services nor appropriate information can prevent all bad outcomes; instead, these episodes of dysfunction provide windows into the process of service delivery and systems interactions that hinder effective and timely responses to and monitoring of psychiatric and behavioural distress, which may eventually lead to violent events or other criminal behaviour.
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3. Barriers to integration and efforts to bridge them Government since the 1960s has heralded the importance of integration (Webb, 1991). Both the appeal of and political commitment to the process of integration defy explanation, as there is no evidence to support that it works. The simple fact is that systems and services remain fragmented in the UK, in spite of the nature of integration policies in operation: centralised planning in the 1960s and 1970s, joint planning and commissioning in the 1980s, and the blitz of ‘‘interagency approach,’’ ‘‘partnership building,’’ ‘‘building bridges,’’ and ‘‘working together’’ initiatives of the 1990s. Such policies have shared a similar fate whether they relied on exhortation —‘‘please, play together’’— or mandates —‘‘you must play together,’’ or whether new funding or resources were added to the public systems network. Moreover, system structure, conduct, and performance have remained unswayed by government’s appeal to the greater common good — everyone gains when an integrated service is provided (Webb, 1991). Mechanic (1995), in commenting on the integration experience in both the USA and UK, noted that There is sufficient experience to impress even the most optimistic that exhortation to work together cooperatively and appeals to goodwill achieve little improvement in a context where interest groups compete for scarce resources and where each bureaucracy has its own agenda and political constituencies. (p. 134)
In light of historical experience with integration policy in Britain, it is interesting that ‘‘New’’ Labour, a government that advocates the ‘‘what matters is what works’’ approach, would choose to continue a policy that has unequivocally failed for over 30 years. Because it is unlikely that integration policy will be abandoned any time in the near future, it is useful to understand the forces that work against it. This section looks at three barriers that impede systems and services integration and describes why they have persisted in spite of efforts to bridge them. The evidence in this section draws on research and policy experiences in the UK and USA. Like meta-analysis, pooling together cross-national evidence provides a clearer and more detailed picture of what works and has not worked in the area of integration policy. 3.1. Categorical funding Specialised bureaucracies are created and supported by a budgetary process that earmarks funding for categories of services, such as health, social, and criminal justice. Public systems become labelled and limited by their funding mandates. Although the single-problem typology that underpins public systems is a product of government action and is maintained for historical and political convenience, it is in direct conflict with the variable needs of persons with multiple cooccurring problems and diagnoses (Wolff, 1998). Systems and services are fragmented because funding is fragmented; integration is necessary because funding is not. The problem of fragmentation is compounded when system-specific funding is decentralised to smaller groups (e.g., local authorities, health trusts, and prisons) that have dissimilar catchment areas (as discussed earlier). Integration at the local level becomes more challenging when service agencies define the service world differently. Dividing large areas
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into multiple, nonoverlapping catchment areas creates opportunities to lose people to followup, frustrates efforts to join up disjointed service activities, and limits the ability to efficiently organise and produce speciality services that require a larger base population (Mechanic & Aiken, 1987). As part of Labour government’s partnership building policy, social service and health agencies are being granted powers to integrate their funding streams and service activities (DoH, 1998a, 1998b). Whether these new powers will be effective is unclear, but the research evidence from the USA is not encouraging. There have been two well-funded demonstration projects in the USA that sought to decategorise services through integrating funding. The Robert Wood Johnson (RWJ) nine-city project attempted to centralise administrative, fiscal, and clinical responsibilities within a single mental health agency and focused on coordinating mental health and housing services (Goldman, Morrissey, & Ridgely, 1990). The RWJ Child Health Initiative was a six-city project that attempted to coordinate and monitor children’s services by unifying the funding from health, social service, mental health, and developmental disability programs (Newacheck, Halfon, Brindis, & Hughes, 1998). Neither effort was successful in integrating funding, although there was modest success at a few of the sites (Morrissey et al., 1994; Newacheck et al., 1998). Bureaucratic politics and turf wars dominated the deliberations at most of the sites and consumed endless hours of negotiation. Newacheck et al. (1998) notes that ‘‘in hindsight, it is clear that accomplishing decategorization requires considerable time and a minimum of distractions’’ (p. 170). 3.2. Resource allocation There are two separate resource allocation issues that affect system dynamics: inadequate funding and inconsistent funding. First, public spending on housing, social, health, mental health, and correctional services are constrained by aggregate funding allocations. The availability and quality of services and accommodations are determined by these allocations, which may not be tied in any meaningful sense to need or demand. Because resources are scarce, agencies tend their categorical boundaries, limiting access to those who most closely meet their eligibility criteria. Access rationing is the direct result of resource scarcity, which is created by budgetary constraints. The incentive to tend their boundaries becomes more extreme when resources become scarcer. Second, adding new funding, to alleviate the pressures of scarcity, makes sense only if the funding is reliable. Over the years, the British government has targeted money to expand services for mentally disordered offenders. For example, funds have been targeted for the development of court liaison schemes (James, 1996; Secretary of State, 1992). This initiative, funded partially by the HO, DoH, and the Mental Health Foundation, led to the development of over 200 local models of court liaison throughout England and Wales (HO, 1997). Anecdotal evidence suggests, however, that a nontrivial number of these schemes, after their pilot funding ended, either scaled back or terminated because local funding was not forthcoming (personal communication with the Head of the Mental Health Unit, National Association for the Care and Resettlement of Offenders). Discontinuous funding has hampered their continuity and stability.
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As part of Labour government’s policy of modernising mental health services (DoH, 1998a), funding is being targeted to expand the production of ‘‘safe’’ services, including extra secure beds, new outreach teams, and new assessment and management techniques. Yet, it is important to note that government’s ambitious ‘‘safe, sound, supportive’’ service expansion agenda is limited at £700 million spread over 3 years. That is, mental health spending in each of the next three years is expected to increase by 5%. This amount of spending will slightly reduce the scarcity of the moment, but will have no lasting impact if the funding is time limited. Without continued funding, new capacity will crowd out existing capacity or new capacity will be lost. Capacity expansion is inextricably tied to funding expansion, as are related conditions of scarcity. 3.3. Bureaucratic intransigence Public systems have classical organisational characteristics. They have bureaucracies that are structured hierarchically, have formal lines of communication, are specialised in their function, and conduct business in strict adherence to formal rules and regulations codified through written policies and enforced by internal control systems (Weber, 1957). These types of systems are tradition bound. Whatever coordination exists has evolved slowly and is routinised to ‘‘preserve an entrenched division of labour’’ (Webb, 1991). Classical bureaucracies are known for their monolithic qualities, not for their flexibility or dynamism. Asking organisations with rigid structures to change or innovate is comparable to asking an accountant to be flexible — neither is very likely. Systems, organisations, and people work together when it is to their advantage. Whether cooperation is worthwhile depends on the calculus of benefits to costs. However, neither the costs nor benefits can be assessed objectively; they are themselves value laden and will be influenced by the decision maker’s attitude towards the concept of cooperation in general and the particulars of cooperating with a specific system or individual. Decision makers who are not inclined to work cooperatively can define the problem in such a way as to make it an undesirable proposition in terms of process or outcome (Whetten, 1981). Benefits of cooperation can be of two general types: internal and external. Internal benefits are those that directly enhance the economic or political welfare of the entity (i.e., system, service, or individual) considering a cooperative venture. Such benefits may include recognition and support from the political or system elite for complying with government mandates (i.e., political benefits) or expansion of the service resource base by either acquiring access to another system’s resources or gaining new resources through a granting process (i.e., economic benefits). Decision makers are likely to value political and economic benefits differently, with greater value assigned to economic benefits in times of extreme scarcity and to political benefits in periods of system crisis. In contrast, benefits are external when the primary beneficiary is not the entity creating the benefits. Systems may engage in altruistic activities because they value contributing to the greater social good, even though they do not have property rights to the benefits that result from these activities. Systems are most adept at measuring the costs of cooperation in part because integrating with another system has immediate and potentially long-lasting resource and funding
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implications and in part because partnerships by their very nature diminish each entity’s control over its budget and flexibility to act. How much cooperation will cost in terms of the loss in resources and control will depend on the size of the cooperative venture and the nature and details of the intersystem contract or agreement. Systems assess these costs in combination with the transaction costs of negotiating an agreement and monitoring its compliance (Croxson, 1999). The start-up costs of joint ventures are extraordinary high as they require negotiating the loss of authority, access to resources, and monitoring of compliance, all of which require vast amounts of legal and professional effort (Goldman et al., 1994; Newacheck et al., 1998). Entities work together when the benefits of cooperation exceed their costs. The lack of integration within the public systems network to date would suggest that systems, organisations, and people, if acting rationally, have determined that it is not cost effective to work together, even though it would improve the outcomes of the public systems network. To offset the current equilibrium against integration, it would be necessary to substantially augment the internal benefits perceived by the decision maker and/or lower the costs. However, there has been very little policy effort expended towards altering the distribution of costs and benefits. Government, however, has tried to affect the calculus in two ways. First, it has acclaimed the external benefits — the social good — associated with integrating systems and services. These benefits, however, do not appear to be great enough to offset the expected costs. However, appeals to altruism are likely to be ineffective not because systems are unmotivated to improve the performance and outcomes of the system or service network; but rather because the benefits emanating from the greater good are diffuse and intangible while the costs are highly centralised and direct. Systems cannot act in ways that promote the social good when they are constrained by systems-level budgets. Second, government has tried at various times and with different instruments to humour or order systems into compliance with integration policy. However, neither exhortations nor mandates are likely to get entrenched bureaucracies to integrate their service activities, and even rule-abiding bureaucracies may only marginally respond to directives. According to Whetten (1981), ‘‘if an organization’s staff members perceive that they are being forced to interact with an undesirable organisation and that this interaction will severely tax their resources, they will probably try to undermine their mandate’’ (p. 247). This suggests several things. First, it may be easier to motivate interactions between the health services and social services but more difficult to instigate relations between the criminal justice system (the ‘‘dark horse’’ of public systems and the keeper of the nation’s most difficult, complex, and needy (read: costly) citizens) and either social or health service systems. Second, resources are likely to be the key and deciding factor. Again, Whetten noted that one of the ‘‘critical components of successful mandated relationships’’ is ‘‘providing them with sufficient resources to maintain the coordination process in addition to their other responsibilities’’ (p. 247). Working together is costly (Goldman et al., 1994; Newacheck et al., 1998). It takes time to develop new technologies, negotiate relationships, responsibilities, and protocols for engagement, hire and train new staff, and manage intersystem conflicts. Finding the ‘‘slack’’ within systems to build partnerships is highly unlikely
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when the systems to be partnered experience tight external resource constraints and high service demand.
4. Conclusions: shaping the future by learning from the past The most prudent way to deal with the problem of institutional disorder is to learn from the failures of past policies and to gain from the experiences of other parts of the economy, which have successfully organised complex production relations. Learning from the past includes both acknowledging that disjointed integration policies have unequivocally failed and recognising that they failed because they were incremental in their design, ad hoc in their approach, and misfocused in their aim in that they avoided the real problem: funding patterns and levels. Not surprisingly, getting the solution right begins with focusing on the right problem. Much can be learned from the experiences of the private sector. Organisations producing complex products within the private sector have historically changed their boundaries to alter managerial behaviour and improve performance. Coordination of effort is the foremost concern of industry. Commenting on this issue, Follett (Drucker, Kanter, & Graham, 1994) said For a business, to be a going concern, must be unified. The fair test of business administration, of industrial organization, is whether you have a business with all its parts so co-ordinated, so moving together in their closely knit and adjusting activities, so linking, interlocking, inter-relating, that they make a working unit, not a congerie of separate pieces. (p. 183)
The mental health, social services, and law enforcement systems both in isolation and combination can best be described as a ‘‘congerie of separate pieces.’’ Separating systems by categorical funding mandates undermine policy efforts to organise the pieces around the whole person. Administrative barriers that have historically hindered systems and services integration persist because categorical funding streams define individualised systems and reinforce their independence. Building a system that works for mentally disordered offenders begins with understanding what does not work and what causes the dysfunction, from there, it is possible to create an integrated system that works for the whole.
Acknowledgments This research was supported by an Atlantic Fellowship in Public Policy funded by the British government. Earlier versions of the paper were presented at the Conference on Mental Health Services Restructuring and Public Safety in Midland, Ontario, Canada, June 1999, and the 21st Annual Research Conference of the Association for Public Policy Analysis and Management, Washington, DC, November 1999. The author would like to acknowledge the helpful comments of two anonymous reviewers, as well as those of Mark Schlesinger.
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