A little local difficulty: The management of difficult-to-place people in Oxford

Abstract

So far we have outlined the cloud rather than the silver lining; and it is true, for example, that instances of "shared care that worked" could be found. But in general, the situation appeared to be that a small number of people posed difficult problems, often linked with aggression, for a range of agencies. It was perhaps ironic that many of the most difficult problems were picked up by the voluntary sector, which might be characterized as "the only place left to go" when statutory agencies decided that individuals had become too difficult to cope with. Interagency action was certainly possible, and attempted; but structural problems in its organization and differences of perspective between psychiatric and other agencies led to problems of implementation and sometimes to bad feelings. Part of the problem seemed to be that agency workers, in identifying individuals' needs, talked about the kinds of organizations that would be able to cope with the individuals. This limited their horizons. Individual "packages" of measures, perhaps in the form of "shared care," seemed eminently suited to the situation, provided they could be flexible enough to cope with quickly changing needs and provided that many of the relatively trivial details were systematically attended to--such as ensuring that everyone involved in a "package" knew the others' holiday dates. But this would not, by itself, be enough. Developments on these lines would also require movement in two other directions: on the one hand, to institute "top down" measures in the sense that the heads of agencies agree on the ground rules within which they could happen, and on the other, the delegation of more authority to rank-and-file workers to accept or refer cases. In some ways, this is a question of rethinking the forms of accountability within our statutory agencies. There will probably always be, as we have noted, a "rump" of people who cannot be helped perhaps because they do not wish to be; but the possibilities of more effective help and support for the rest were there to be grasped.