A REPORT from the British and Irish Group for the Study of Personality Disorder (BIGSPD) highlights the problematic practice of moving patients out-of-area to so-called “specialist” personality disorder residential units in the private sector, with massive costs and no oversight, that could be better diverted to improve local NHS mental health services.

Far too many patients on mental health wards who have the contentious catch-all diagnosis of borderline personality disorder are still being moved hundreds of miles away into residential and sometimes locked placements in the private sector they are told are “specialist” personality disorder units.

Concern about this practice has been raised by the Care Quality Commission (CQC) and Rethink, among other organisations. 

Now, experts from the BIGSPD have released a report about how these patients get treated, many of whom spend months and sometimes years on these units.

The contents of the report contributed to a BBC Radio 4 File on Four today, with interviews with some of the patients and authors who contributed to the report. 

The government promised out-of-area units would be closed but there is no sign of such action for these personality disorder units. 

By 2021 there were 7,145 placements, with a cost to the taxpayer of £112 million between February 2020 and February 2021. Ninety-nine per cent of such placements are in the private sector.

On residential rehabilitation placements, The CQC estimates £535m is spent annually with these out-of-area placements accounting for two-thirds of all expenditure. It is an estimate as nobody knows how many are in these units and for how long they have had to stay.

With local mental health services starved of funds, the cost of these private, out-of-area units is hard to justify. It might be easier if there was a noticeable improvement in the mental health of patients recently discharged. 

Instead, these “warehouses” result in many patients feeling considerably worse, with the added trauma of what they have experienced on the unit.

The investigation found a lack of transparency, with no way to judge the performance and monitor the care given to their patients. 

Basics such as quality standards were missing, making it impossible for commissioners and patients to make an informed choice. 

The lack of competition means there are no market forces that could push up the quality of the services and make them more cost-effective.

How patients diagnosed with a personality disorder get treated generally is a concern. After all, it’s the only mental health diagnosis where they are “blamed” for being attention-seeking or manipulative, even though many of these patients are dealing with the trauma of childhood abuse. 

In terms of these “specialist” units, it is likely this negative view about personality disorders and the lack of oversight contributes to the delivery and quality of care — with violent, restrictive and degrading treatment a daily reality for some patients.

It doesn’t take much to find individuals who have been harmed by their time on one of these private units.

Ella spent just over two years in a “specialist” unit, discharged just before she turned 18. Like many with a BPD label, she also had another diagnosis — in her case an eating disorder. 

Her parents said the unit only did what it needed to in order to keep her alive, by often restraining her to put in place a nasal gastric tube. Bar some dialectical behaviour therapy sessions, it did nothing for her mental health.

Her father said: “The unit did unimaginable harm with constant restraint both physical and chemical. She learnt self-harm techniques from other patients. She was put on Haloperidol for 15 months and as a result developed tardive dyskinesia. She has constant flashbacks and has been left with scarring on her head, arms, and legs. They did nothing to help her and after two years she was far worse than when she was admitted.”

Like the experiences of Ella, the report contains what patients have experienced in these so-called specialist units, with shocking accounts of unethical treatment that worsened their original distress.

One patient highlighted how the staff chose to humiliate patients: “I had to wear an anti-ligature dress and was denied access to my underwear. This meant I had to wrap a blanket around my waist whenever I sat down, despite there being the option of a two-piece garment.”

Another patient told the authors of the report about the relentless and inexplicable violence they were subjected to each day: “I was restrained daily and could be injected with a sedative medication up to three times a day, usually without the option of oral medication, or even the chance to discuss why I was feeling so distressed.”

Keir Harding, one of the authors of the report, speaking independently, said: “This group of people has already suffered from people not paying attention to their distress in life. 

“We can’t compound that by putting them into systems that aren’t monitored or regulated nearly enough to ensure quality. 

“We need genuine criteria for units to meet so that the title of specialist means something, but we also need to see local expertise available so that people are not needlessly compelled to go to hospital for years.

“If the ethics of this situation doesn’t convince people of the need for action, I’d hope the need to ensure that half a billion pounds of Treasury money is spent effectively would be a good motivator.”

With nothing to indicate these units are “specialised,” as they claim to be, it would be far better if there was a system of quality standards and accreditation in place. 

The NHS only provides a fraction of these beds, so it might be the case that this needs to increase.

Better still, rather than the money spent locking such patients up, out of sight and out of mind, we could instead spend it on improving local NHS mental health services, where the quality and outcomes of a service can be properly monitored and where patients can be closer to the support of family and friends. 

The report can be found here: bigspd.org.uk/bigspd-ooa.

Ruth F Hunt is an author and freelance journalist.