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Sun 25 October 2020
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Alain Catzeflis investigates the impact of an explosion of US corporate money on Britain’s independent mental health sector

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Beth is an autistic teenager. Her story is shocking but far from unique. It serves as a parable for a rapidly-growing, for-profit, mental health sector with profound and systemic problems. 

Beth spent much of the past three years in solitary confinement in “behavioural health facilities” – private psychiatric clinics. Her father Jeremy says that she was sedated and locked in a cell measuring 10 feet by 16 feet with a mat for a bed. In one facility she was fed through a hatch. 

When he visited her, he frequently had to kneel and speak to her through a grille because she was thought too dangerous to have visitors.

“I could only just hold her hand,” he said. “Nearly three years of kneeling down to see her through this six by eight-hole.”

Jeremy says that Beth was regularly stripped naked to stop her using her clothes to harm herself. She was often forcefully restrained. 

Beth’s last day out, watching the Circus at Blackpool in 2016 with her father Jeremy, before she went to St Andrew’s Healthcare

She was held from the age of 15 at two private, secure units until her release earlier this year. First at the child and adolescent mental health unit in Northampton, owned by St. Andrew Healthcare. Second at the Priory Llanarth Court, Monmouthshire, part of the US-owned Priory Group, the UK’s largest mental healthcare provider.  

A serious case review, ordered by Health and Social Care Secretary Matt Hancock into Beth’s confinement at St Andrew’s, found that she was subjected to “profound restrictive practices”. 

In its most recent, highly critical, inspection report the Care Quality Commission (CQC) watchdog rated the facility ‘inadequate’, citing increased use of physical restraint, insufficient staff and a top management culture that belittled ‘significant concerns’. 

The Welsh Healthcare Inspectorate’s report into Llanarth Court in January 2019 found that ‘physical intervention techniques’ at the time were not appropriate. It identified ‘poor environmental conditions’ that impacted negatively on patient privacy and dignity. A more recent report has found improvements.  

Beth and many like her are subjected to treatment reminiscent of Victorian asylums, failed by a state-sponsored system that seems incapable of dealing with complex conditions humanely. Her care workers – paid little more than the minimum wage – were insufficiently skilled to understand what being autistic meant or how to support her with empathy.  

Beth is now living independently with the right support after a vigorous political and publicity campaign by her father. 

“She was transformed within hours of her release,” he said. 

Beth on a trip out within days of moving to her new setting in December 2019

A spokesman for the Priory told Byline Times that at Llanarth Court – the unit in which Beth was held – “staff are attending to patients 24 hours a day, sometimes on a 3:1 or more basis, and no patient is in ‘solitary confinement’. Sometimes a patient is segregated from others or secluded where absolutely necessary to protect them from hurting themselves, other patients or staff.”  

“All decisions concerning the care of patients are made by a multidisciplinary team,” the spokesman said “led by a consultant psychiatrist alongside others, including registered mental health nurses, health care assistants and other professionals such as therapists and social workers, with family members consulted and kept informed throughout.”


ASTRONOMICAL COSTS

The cost of care in an assessment and treatment unit (ATU) ranges from expensive to astronomical: it averages £3,000 a week or £150,000 a year. Beth’s care cost around £750,000

Britain’s independent mental health sector is growing fast. Its main client – its paymaster – is the NHS, either through national commissioning or local commissioning groups. This accounts for 90% of its income. The sector would not exist if the NHS had not been cut to the bone.  

Three factors have driven the NHS into the arms of private mental health providers: a relentless four-decade of cuts in NHS capacity; the lack of community-based provisions; and the prohibitive costs of building more facilities. 

Providers such as the Priory have the bricks and mortar to offer the beds the NHS needs. Because of the acute shortage of alternatives, the NHS has nowhere else to go: it is a captive client.  

The CQC has been highly critical of the sector. It says too many people are held in solitary confinement, that many are distressed, wards are not fit for purpose, staff lack necessary skills, too many people are subject to ‘prolonged segregation’, that physical restraint is routine, and management does not listen to concerns.   

In its 2020 State of Care report the CQC states: “Since October 2018, we have rated as ‘inadequate’ 14 independent mental health hospitals that admit people with a learning disability and/or autism, and put them into special measures. Our inspectors are seeing too many mental health and learning disability services with people who lack the skills, training, experience or clinical support to care for patients with complex needs. This is an unacceptable situation.”

The Priory trades heavily on the reputation of its £5,000-a-week flagship Roehampton hospital, a high-end addiction and depression clinic known for treating celebrities. Most patients are either rich enough to self-fund or their treatment is paid for by private health insurance. 

Individual facilities are vetted by the CQC. While many in the private sector receive a rating of ‘good’ or occasionally ‘outstanding’, those branded ‘inadequate’ or placed in ‘special measures’ remain stubbornly high at between 15 and 20%. 


DASH FOR GROWTH 

In a few short years, the Priory has gone from being a respected, niche player with just one clinic to become – through an aggressive takeover strategy – Britain’s largest mental healthcare business, heavily dependent on NHS funding.

This coincided, unsurprisingly, with a time when most new contracts to provide NHS services were going to private companies under the ‘Any Qualified Provider’ policy promoted by the then Health Secretary Jeremy Hunt. 

The business model groups such as the Priory operate depends on two things to make big profits. ‘High-value’ residents – people with complex needs like Beth whose care, usually state-funded, is expensive; and keeping staff costs down. 

The hunt for expansion-led profits at the Priory began in earnest in October 2014 when its then chief executive Tom Riall announced that the group was planning a significant expansion into the ‘mental health community services market’. The group, he said, would be using its “considerable commercial bidding expertise” to become the “overflow provider of choice” for the NHS. 

In 2016, a vastly-expanded Priory Group was sold to Tennessee-based Acadia for £1.3 billion – a huge mark-up on previous valuations. The new Priory group made an operating profit of £62 million in 2017, the last year for which results are available. The majority of this came from the NHS and social services.


SCANDALS

Many NHS-funded Priory units receive a ’good’ score from the CQC. But some have been the subject of repeated safety scandals and closures:

  • In 2015, the coroner in the inquest into the death of 17-year-old Sara Green, who died in the Priory Royal in Cheadle the previous year, said she would have been safer at home.
  • In 2016, the Priory and Solent NHS trust admitted liability for the death of 15-year-old George Werb while on home leave. The coroner said his assessment was “incomplete, inaccurate and did not reflect the actual situation”.
  • An ITV documentary in 2019 exposed further serious safeguarding issues at the Priory Ticehurst clinic in East Sussex. This included a number of cases of unchecked self-harm. It also featured a teenage girl who had spent weeks covered only by a blanket. 
  • Also in 2019, the group was fined £300,000 for health and safety violations after 14-year-old Amy El-Keria, who had known suicide tendencies, was found dead in her bedroom in 2012 at the Priory Ticehurst with a ligature around her neck. 
  • In February 2019, the Priory announced that it would be closing its hospital for teenagers in High Wycombe after failing an inspection. Karen Bennett-Wilson, the CQC’s head of hospital inspection, said it had identified a number of serious problems concerning patient safety and the quality of care. “It was a matter of some concern that, at a specialist unit, some of the staff could not demonstrate the knowledge or specialist skills needed to care for teenagers who had learning disabilities or autism,” she said.

A Priory spokesman told Byline Times: “There is no basis whatsoever for any suggestion that we put profit before safety and we strongly refute any allegation that we ‘cut corners’ in an attempt to achieve ‘adequate levels of profitability’. We invest heavily in staff recruitment and training including £9 million annually on a quality improvement team of over 100 staff who provide constant support across our portfolio such that 86.2% of our healthcare sites in the UK are rated ‘good’ or ‘outstanding’.” 


THE US CONNECTION

As Britain negotiates its post-Brexit deals, International Trade Secretary Liz Truss has repeatedly said that the NHS is not for sale. But defunded NHS services are already experiencing rapid backdoor privatisation through extensive outsourcing. It is likely that American companies are eyeing Britain’s lucrative health sector. 

The Priory is owned by Acadia, a large American mental healthcare group quoted on the New York Stock Exchange (NYSE) with a troubled record. Serious concerns have been raised about allowing what the Financial Times described in 2016 as a “deal-making spree” in the sector. Between them Acadia and The Priory have more than 800 facilities housing vulnerable people in the US, the UK and Puerto Rico. 

NASDAQ-traded Acadia Healthcare, the Priory’s US parent, has been repeatedly investigated in America for poor care, neglect, abuse – including physical and sexual assault – runaway patients, a failure to guard against suicide risks, and fraud.  In May 2019, Acadia agreed to pay $17 million to the federal Government and the state of West Virginia to settle allegations of a complex Medicaid fraud. US Attorney Mike Stuart said: “This is a strong message and a massive penalty… a deterrence to other would-be fraudsters.”

The US company employs more than 40,000 people. A private investigation into the group was recently launched by the former Attorney-General of Louisiana Charles Foti. His law firm – Kahn, Swick & Foti – said in March 2020 that Acadia appeared to be in financial difficulties. The law firm added that Acadia was being investigated elsewhere for “alleged systematic instances of patient abuse and neglect at dozens of the company’s US facilities” but would not comment further. 

Acadia Healthcare, will not comment on specific facilities or individuals but has said that the company delivers superior outcomes. It points to the fact that its facilities have never been decertified by any government health programme or lost a license.


OTHER US HEALTHCARE COMPANIES

Acadia is not the only US-owned healthcare company with problems operating in the UK’s booming mental healthcare market. UHS (United Health Services) listed on the New York Stock Exchange has 324 facilities worldwide of which 133 are in the UK, following a number of buy-outs. 

In 2019, police arrested 10 workers from UHS-owned Cygnet Healthcare’s Whorlton Hall hospital following a BBC Panorama documentary which showed physical and psychological abuse at the facility reminiscent of a previous scandal at Winterbourne View. Whorlton Hall has since closed. In a statement at the time, Cygnet said that it was “deeply shocked” by the allegations.

Whorlton Hall was not the only Cygnet facility with serious problems. In 2019, nine Cygnet facilities were rated ‘inadequate’ or placed in ‘special measures’.  One Cygnet hospital in Coventry was placed in special measures by the CQC in May this year following the death of 25-year-old mental health campaigner, Claire Greaves. An inquest into her death found multiple failings and that inadequate staffing levels “probably caused or contributed” to her likely suicide. 

In January 2020, following the revelations of abuse at Whorlton Hall, the CQC took the unusual step of issuing a special report on the management of the company. It identified concerns “linked to the provider’s leadership and governance arrangements”. 

Meanwhile, Cygnet’s chief executive Dr Tony Romero had his pay increased from £508,000 to £925,000 in 2018, according to the latest accounts on file. Frontline mental health support workers at Cygnet facilities earn between £8.64 and £9 an hour. 

A spokesman for Cygnet told Byline Times: “As one of the largest and best quality providers in mental health care services in the UK, Cygnet Health Care’s focus is always on the best outcomes for those who use and commission its services. This is reflected in independent assessments of Cygnet’s facilities, 85% of which are rated as ‘good’ or ‘outstanding’, above the national average.”

One of the more troubling allegations levelled in lawsuits against corporations such as UHS in the US is that high-value residents are kept in their facilities for longer than they need to be there – to cash in on the significantly higher fees paid by federal and state authorities through Medicaid.  UHS reached a $127 million settlement with the US Department of Justice this month following a long-running criminal investigation into fraudulent billing practices by the company. The US authorities accused UHS of admitting patients that did not need to be admitted while keeping ones that had recovered for longer than they needed to be. 

UHS has denied wrongdoing. It has said: “UHS unequivocally disputes any allegation that it engaged in wrongdoing of any kind and the agreement is not an admission of liability but merely a resolution of a civil claim.” 

The concern about overcharging is mirrored on this side of the Atlantic. Anne Longfield, the Children’s Commissioner for England, highlighted what she called “perverse financial incentives which keep children in hospital” in a scathing report in May 2019. She said that, despite Government assurances that children with autism would be moved into community settings, the numbers are actually rising. The report also found “shocking evidence of poor and restrictive practices and sedation leading to trauma while parents were left powerless to intervene.”


INVESTING IN CARE

Labour MP Barbara Keeley, a member of Parliament’s Health and Social Care Committee and a former Shadow Health Minister, told Byline Times that an urgent review “of all contracts the NHS have with private institutions” should be conducted.

“Nearly a decade after the Winterbourne View scandal, it is a disgrace that thousands of autistic people and people with learning disabilities or mental health conditions are still being held in these inappropriate institutions. 

“Rather than continuing to pay exorbitant fees to private providers who often provide substandard care, the Government should invest in community provision which allows people to live independently.”

The mental health watchdog, the Citizens Commission on Human Rights (CCHR), wants tighter regulations and greater criminal and civil penalties for persistent violations of patient care. It also wants tougher penalties for fraudulent billing practices. 

“When patient care takes a backseat to corporate profits it is the patient who loses out,” one lawyer involved in a lawsuit against a mental healthcare company observed.

Years of savage cuts by successive governments have left the sector severely under-funded. Staff are insufficiently skilled, holistic care is notably absent. The use of powerful sedatives and physical restraint is pervasive. 

Supporting people with learning disabilities, autism and mental health problems is not easy. Each case is different. But, as Beth’s starkly demonstrates, the answer is not necessarily to throw money at the problem. 

Is this really what we want for our vulnerable citizens? Is the mental healthcare sector to be treated just like any other commercial enterprise? Or should it be subject to fresh guidelines that acknowledge its special responsibilities to the sick, the elderly and the disabled, and to the taxpayer?           

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