مدیریت عمومی «جدید» مجرمین اختلال ذهنی: قسمت اول داستان اخطار

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).

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 and Webb, 1991. The problem, dating back to the 1960s in both the USA and UK, is attributed to the much-supported 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 et al., 1991, Draine & Solomon, 1994, Rossi, 1989 and Scott, 1993, criminalisation of the mentally disordered Abramson, 1972, Fisher et al., 2000, Lamb & Weinberger, 1998 and Torrey et al., 1992, substance abuse Kessler et al., 1996 and 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 and Wolff et al., 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 Health, 1998a, Department of Health, 1998b, Schermerhorn, 1975 and 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 Department of Health, 1992 and 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 and 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, 2002). 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.

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.