Thread by @TheSmallPlaces

I went to the @britishlibrary yesterday to look at some market reports on mental health and social care, to gather data for a book I'm writing. I can't stop thinking about them.

It was like listening at the keyhole to a conversation you weren't supposed to hear. The reports are (I assume) aimed at investors. If I were an investor I would definitely want a copy, they are extraordinarily detailed descriptions of the care 'market'.

But I can't stop thinking about the images and language in the reports. The opening sentence of the mental health report reads "At the time of writing the independent mental health hospital is enjoying robust demand".

The care of older people report has this extraordinary image: a symbolic depiction of two older people (like you get on road signs - 'elderly people crossing'), with "£15.7bn, 2016 market value" stamped across them.

Declining rates of dementia are a "counter-driver" of demand, as is the 'compression of morbidity' at the end of life.

Preventable deaths in MH detention are 'factors tending to increase demand' for supported living, whereas pre-birth screening for genetic abnormalities decreases 'demand'

And if you're wondering why we can't get people out of ATUs into the community, you need to read these reports. Hospitals are a 'robust' business model, the investment market for supported living is 'challenging' - too many providers competing. Low pay a key feature of the market

'Clustered' supported living is preferred. Strengths of this business model include 'Longevity and 'stickiness' of service users', permanent on site staff facilitates easier staff supervision and rota planning, and has 'synergies with adult specialist care home operation'

Threats to the business model are liabilities for back pay for sleep ins (interestingly, and incorrectly, the report predicted the COA would not overturn the Mencap sleep-in ruling). And liability for under-occupancy when providers have 'sole rights' to place SUs in these schemes

Sole rights. That doesn't sound very in keeping with regulatory requirements for supported living to provide accommodation separately to support...?

A great graph showed declining rates of learning disability hospital "beds" since the 1990s (also in NHS England's Building the Right support). Milestones like Valuing People and the Mansell reports take on a different light in investment reports: lost market opportunities.

The descriptions of law and policy were also fascinating. The modern de-regulatory landscape of CQC. Austerity is a problem for care markets as well as care service users (reports note declining numbers receiving formal care services since 1990s). NMW laws are a problem.

Of the MHA 2007 the report notes, 'Developments in mental health law and its application may sometimes also have a significant impact, sometimes unintended, on how demand for mental health services is expressed.'

Human Rights Act coverage of the care market (or gaps therein) is noted. Oddly, no reference at all to the MCA or the DoLS, suggesting care home and hospital investors do not regard these as significant liability concerns, nor affecting 'demand'.

I'll leave you with the profit margins: For MH hospitals, profits range between just under 5% to just under 35%; for supported living/homecare, profits don't exceed 20% but sometimes losses are reported; profitability of care homes declining due to 'exposure' to state paid fees.