Saturday, 29 June 2013

Sec.117 Aftercare: A Brief Guide for Patients and Relatives

I quite often get emails from relatives of people with mental illness asking questions relating to Sec.117 of the Mental Health Act 1983. From the information they give, it often appears that the regulations and guidance relating to Sec.117 are not being adhered to, or patients and relatives are not being kept in the loop when arrangements for aftercare are being made. I thought therefore that it might be helpful to lay out the basics relating to Sec.117 for the benefit of the consumer, so to speak.
What is Sec.117?
Sec.117 lays down a duty for the local authority and the NHS to provide services for people who have been detained and then discharged from certain sections of the Act. The most common section is Sec.3, where a patient has been detained for treatment. There are some other sections of the Act relating to people who have committed criminal offences for whom Sec.117 also applies. These are Sections 37, 45A, 47 and 48. Detention under these sections is much less common.
A patient who has only ever been an informal patient, or who has only ever been detained under Sec.2 (for assessment) is not entitled to aftercare under Sec.117. However, this does not mean that someone with mental health needs, but who has never been detained for treatment, is not entitled to services.
What is Sec.117 Aftercare?
The Code of Practice to the Mental Health Act says:
“After-care is a vital component in patients’ overall treatment and care. As well as meeting their immediate needs for health and social care, after-care should aim to support them in regaining or enhancing their skills, or learning new skills, in order to cope with life outside hospital. (27.5)”
Before anyone detained under the relevant sections is discharged from hospital, there has to be a meeting involving any relevant professionals or others, including the patient, relatives, and carers. There’s an extensive list in the Code of Practice as to what should be considered (27.13). These include: the psychological needs of the patient, as well as their family and carers; their physical healthcare; daytime activities or employment; appropriate accommodation; identified risks and safety issues; social, cultural or spiritual needs; assistance in welfare rights and managing finances; contingency plans and crisis contact details. There are many other things to be considered as well.
Once the patient is discharged, there have to be regular reviews in the community.
Will I have to pay for aftercare?
The most significant aspect of Sec.117 is that any aftercare provided under this section cannot be charged for. The MHA Reference Guide observes: “Because the Act provides no power to charge anyone for after-care services provided under section 117, they must be provided free of charge.” (24.18) Therefore, the patient cannot be charged for the cost of day care services, or residential care, for example, as long as it is specifically to meet the mental health needs of the patient.
Are there any exceptions to this?
There are some things that are not covered by Sec.117 aftercare. These are things which are considered to be basic needs, and not needs arising from the person’s mental health problems. These things include food and clothing, and rent for a flat. It may also be considered that if someone had mental health problems and a physical disability, needs arising from the physical disability might not be covered, and might therefore be chargeable, subject to an individual’s personal resources, of course.
I am the nearest relative of someone who has been detained in hospital under Sec.3 MHA. What can I expect to happen?
There should be regular Sec.117 Aftercare planning meetings. These take place while the person is an inpatient and well before they are discharged, and also periodically, usually at 6 monthly intervals, once they have been discharged.
At the meeting there should be the patient, their nearest relative, a representative of the local authority (for instance, a social worker), the patient’s Psychiatrist, a nurse, and then anyone else who might be involved in providing their aftercare, for example, someone from a day centre or a care home.
This meeting should set out what the patient’s mental health needs are, and what services are required to support them with these needs once they are discharged. The aftercare plan could be very simple, for example, stating that the patient will see a mental health professional regularly, that they should have regular outpatient appointments and that they should take specified medication. However, an aftercare plan may also entail placement in a residential care home, attending a day centre, the involvement of other professionals or care providers, etc.
Is Sec.117 aftercare time limited?
Sec.117 aftercare has no time limit. As long as the patient continues to require aftercare, even at a basic level, such as periodic outpatient reviews with a psychiatrist, then Sec.117 aftercare rules will continue to apply. Sec.117 aftercare can only cease if both the mental health service and the local authority are in agreement that it is no longer necessary, and they have to make a formal decision about this.
If someone has been detained under Sec.3 once 10 years ago, but since then has had a number of informal admissions, or admissions under Sec.2 alone, the subsequent admissions do not invalidate or strike out Sec.117. There should still be Sec.117 aftercare planning meetings even for someone who is an informal patient, no matter how long ago it was that they were detained under Sec.3.

Sunday, 16 June 2013

Origins 7: My First Caseload: Aggie and Mother

Part 7 in an occasional series about my early years as a social worker in the 1970’s and 1980’s. Written down before I forget.

Aggie was in her early 60’s. She lived with her 97 year old mother on a smallholding in a particularly remote part of the Charwood Social Services catchment area.

The smallholding consisted of about 10 acres of small fields and meadows enclosed by hedges, an oasis in the midst of the vast, open, intensively farmed fields of an industrial style farm.

To reach her home, you had to drive a couple of hundred yards along a track across one of these huge fields, ploughed over in the winter, and swaying with wheat, or barley, or oats in the summer.

Once through the gate of Aggie’s smallholding, you had to park up and walk the rest of the way through meadows full of wild flowers, where her small herd of cows grazed, until you reached what she referred to as the farmhouse.

It took a leap of imagination to see this structure as a “farmhouse”. In reality, it was a single storey timber clad barn with a corrugated iron roof, a few small windows, and a dilapidated door that led into what passed as her kitchen cum living room.

It had been built by hand about 50 years previously by her father, who had a little money after serving in the 1st World War. He bought a few acres in the tiny hamlet and decided to raise his family there. He had died many years previously, but his daughter and wife still lived there.

Aggie and her mother lived in the most primitive conditions imaginable. They had no electricity or running water. All their water was obtained from a well just outside the back door. There was a tiny corrugated iron outbuilding which contained a plank of wood with a large hole in it and a bucket underneath the hole.

The interior of the “farmhouse” consisted of the kitchen cum sitting room, which contained an ancient and inefficient coal fired range that was kept alight all the time. It was the only heating or cooking facility they had. In the winter, the temperature rarely rose above 10C.

Unaccountably, the room was furnished with a range of fine antique furniture, all of it now very dilapidated and wormy. There was also a piano, and on the walls, in the dim light, could be seen huge Victorian oil paintings, some of them reaching from floor to ceiling. It was almost impossible to tell what the subjects of these paintings were, as they were covered in a film of soot from the oil lamps which were Aggie’s only source of light.

There was what Aggie called a parlour, but which she mainly used as a store room, and there were two bedrooms. Aggie slept in one, and her mother slept in another.

Aggie always took pride in introducing me to “Mother” during my visits. This meant a visit to the bedroom, where Mother appeared to spend her entire life.

Mother had had a number of strokes. This had left her almost completely immobile, and apparently incapable of speech. I certainly never heard her say a coherent word. She probably had dementia as well, but it was hard to tell.

It is very difficult to adequately describe Mother’s appearance. She was very obese, and very pale. Folds of flesh covered her face. Her eyes rarely opened. Her body was covered in tattered and ragged, mainly white layers of old fashioned nightdresses, which put one in mind of Miss Havisham in Great Expectations. In fact, the entire experience of visiting Aggie and her mother was exactly like stepping into a Dickens novel.

Mother was incontinent, and Aggie’s solution to this was to cover the mattress with roofing felt. As well as protecting the mattress, this also served the function, she would tell me, of preventing Mother from slipping too far down in the bed.

During these visits, Aggie would introduce me to Mother, and then prop her up in a sitting position. Mother very occasionally would open one eye to examine me, and even more rarely would make some sort of noise in response. I was never sure she had any idea what was going on, but Aggie would delightedly interpret these possibly random utterances as insightful comments about the weather or current events.

Aggie tried to keep alive the dream her father had of living the good life off the land, but to be honest, she was not very good at this.  She kept chickens, and tried to grow vegetables. She had a grape vine and would attempt to make wine out of the juice come the Autumn. She once offered me a bottle of this concoction, but I could not bring myself to try it.

She also used to make jam, with a minimum of sugar, as it was expensive, which meant that a layer of mould would soon appear on the top. I know this, because she once kindly gave me a jar. She also made various medicinal preparations using traditional recipes. One of my predecessors had once been reckless enough to try one of Aggie’s special complexion ointments, and had come out in a rash.

She and her mother lived a life of most extreme poverty. Their main source of income was their pensions, and although periodically Aggie would arrange for one or two of the cows or calves to go off to market, I suspected that the herd cost her more to maintain than the income she obtained from it.

Because of their isolation, several miles from the nearest shop, Aggie relied on a local grocer who would deliver in his van to obtain her weekly groceries. She had a standing order which would be delivered every week. She was fearful of changing this order for fear of upsetting the grocer and losing their lifeline.

One of the consequences of this was that she would have a carton of salt delivered every week without fail. She once showed me her stockpile of salt that she kept in the parlour. It occupied nearly half of the room. Even though she now had enough salt to last her the rest of her life, she would not entertain cancelling this part of the order “just in case”.

Aggie was very frugal and economical. If she wore out the cuffs of a shirt or blouse, she would simply cut off the sleeves up to the elbow and then attach some other sleeves using large stitches of wool. It didn’t matter whether or not the fabric matched in any way.

Despite apparently living life in the past, Aggie had a portable radio and would listen to Radio 4 all day long, so she was always up to date on national and world events, and actually had a keen and intelligent mind.

Although she had never seen a psychiatrist, Aggie probably had schizophrenia. She would often suddenly start whispering in the middle of a conversation, pointing to the ceiling and muttering under her breath about how the neighbouring farmer had fitted listening devices and was spying on her.

At this point, you may be wondering exactly what good a social worker was doing for Aggie and Mother. What I was endeavouring to do was to preserve the lifestyle they had chosen, and at times to deflect demands for “something to be done”. I would make sure that they had the benefits to which they were entitled, and my regular visits also monitored Aggie’s needs as a carer and provided Aggie with an outlet in which she could engage in an adult conversation.

One day, I had a phone call from Aggie. This took quite an effort for her. It meant she had to cycle the mile to the nearest public phone box.

She was beside herself. Mother had had another stroke. She needed a doctor.

I phoned Mother’s GP. I arranged to do a home visit with him.

I met him at the “farmhouse” and he examined Mother.

He agreed that she had had a stroke and that she needed to be in hospital.

This horrified Aggie.

“Mother won’t like it in hospital!” she wailed. “She won’t be able to hear the lowing of the cows, and the dawn chorus! She’ll pine away! She needs to stay here!”

But the doctor was clear. She was ill and needed to be in hospital. He was off to the nearest phone box to call them.

But I was thinking. What was in Mother’s best interests?

I knew for a fact that, once she was in hospital, she would never be allowed to return to the Victorian hovel that Aggie regarded as home. A district nurse would take one look at their living conditions and would refuse to allow it.

I was convinced that Mother would die in hospital if she were to be admitted.

Aggie offered Mother love and uncomplaining round the clock care in the environment that Mother had always known. So far, she had managed to keep her alive despite her poor health and extreme age. It wasn’t all about the physical environment.

I argued this case to the GP. Although he was clearly looking at the situation from the point of view of a medic who sees a medical condition and has a set of routines for dealing with it, he did nevertheless listen to me. He could see my point.

In the end, it was agreed that he would drop in on Mother over the next few days to observe her progress. She would not be admitted to hospital after all.

I felt pleased. I told Aggie the good news. But she was so distressed by the threat that she felt she needed to focus her distress on someone.

“It’s your fault!” she said. “You’ve come here wearing grey. Grey is an unlucky colour! You’ve put a jinx on Mother! This would never have happened if it wasn’t for you!”

And despite my successful efforts to produce an outcome that would be best for Mother and for Aggie, Aggie refused to see me again.

You don’t often get thanks as a social worker. But that’s all part of the job.

Saturday, 15 June 2013

How to survive in social work: The Masked AMHP's latest Guardian piece

When dealing with hostile and aggressive people you should not take it personally, advises the blogger Masked AMHP.

You can read the Masked AMHP's latest piece in the Guardian Social Care Network here.

Wednesday, 5 June 2013

Delays and More Delays: The College of Social Work AMHP Practice Survey 2013

Two AMHP's waiting for an ambulance
It’s official: Mental Health Act Assessments are beset with unacceptable delays all over the country (or at least England). That’s the message from The College of Social Work’s recent AMHP Practice Survey, the results of which were released at the end of May. And it’s the AMHP’s (and of course the patients) who are suffering the most.

101 of the 152 local social services authorities responded.

There were three main areas leading to delays in admission: lack of suitable hospital beds, problems with ambulances, and lack of police availability.

Lack of beds
The report found that two thirds of local authorities had encountered delays in assessment due to lack of a hospital bed. This figure went up to 80% when reporting delays to compulsory admission. The longest delay to admission was apparently 21 days. (Is this a record, or do you know better? I recall once being involved in an assessment of a man in a care home with learning difficulties where the medical recommendations, which are valid for 14 days, expired not once but twice, before a suitable bed could be found.)

The shortage of a hospital bed in the patient’s locality was also highlighted. This had at times led to either the patient or the nearest relative objecting to an admission to an out of area hospital. This has then led to otherwise avoidable compulsory detentions, and in two cases the nearest relative was displaced because of objections about the distance to the admitting hospital.

I have certainly been forced on a number of occasions to admit a patient to a hospital over 70 miles from the patient’s home. The worst case I have come across locally was a patient detained under Sec.2 to a hospital 150 miles away.

The shortage of beds has also led to undesirable alternatives, and to the bending, if not outright breaking, of the law. Nearly 80% of respondents had experienced patients being kept in police cells or A&E departments for far longer than should have been necessary for this reason.

Lack of hospital beds has also led to delays in the ability of an AMHP to make an application. 42.9% of respondents identified that there had been delays due to Sec.12 doctors being unable to write the name of a hospital on their recommendation. The same would apply to AMHP’s who cannot formalise a detention until they can write the name and address of the admitting hospital on the form.

Another disturbing finding was the use of formal detention rather than informal admission. 16.5% of respondents reported occasions when a patient had been detained because an informal admission was not available. This flies in the face of the requirements of Sec.131(1) MHA. Sec.131(1) states, in rather convoluted language:

Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital … without any application, order or direction rendering him liable to be detained under this Act.”

This means, essentially, that a hospital should not refuse to admit a patient unless they are detained. Insistence on only accepting detained patients directly contravenes this section of the Act.

Ambulance delays
Anecdotally, wherever in the country I have been, AMHP’s I have spoken to have complained about delays in admission due to the unavailability of ambulances. Certainly, in my local authority, the issue of ambulance delays has been such a problem that private ambulance services are often used, and there was even put in place an arrangement for transport to be available via the Crisis Team if all else failed.

The College of Social Work survey bears this out. Over half of respondents reported that local arrangements with ambulance services were either not working very well, or were not working at all.

Police delays
The survey reports that two thirds of respondents reported that MHA assessments had had to be postponed because the police were unavailable to provide support at the assessment.

What is causing these reported problems? I am afraid I would have to lay the blame for this at a cumulative and multifaceted collapse of some of the essential functions of the NHS due to service cutbacks.

One such example was a staffing crisis at the A&E Dept at the Norfolk and Norwich Hospital. The Eastern Daily Press reported in April 2013 that at one point there were 12 ambulances queuing up outside the hospital for up to 3 hours because of delays in processing admissions. At one point it was reported that an inflatable tent was erected outside the A&E Dept. to try to cope with the workload. There was then a knock on effect on the availability of ambulances for other tasks, such as transporting mental health patients to hospital. It has been reported to me that one AMHP had to wait 17 hours for an ambulance to arrive because for these delays.

At the same time, the East of England Ambulance Service, which covers this area, was in crisis. Again the Eastern Daily Press reported high levels of low morale among staff. Tony Hughes, GMB organiser, reported that the Ambulance Trust needed to boost ambulance numbers and recruit more paramedics to relieve stress amongst staff. He stated: “The ambulance service is in total disarray. Lots of investment needs being put in to get it right and policies and procedures are not fit for purpose. Staff morale is almost zero. All efforts should be put in to look after patients rather than wasting time on foundation trust status.”

Then there are the closures of psychiatric hospital beds which has been accelerating at the same time as massive cutbacks in community mental health staff who could reduce the pressure on admission are being initiated. In 2012 the CQC reported that 2000 psychiatric beds, or 12% of the total, were lost over the previous year. In November 2012 the Sunday Express reported that “Six per cent of psychiatric wards have more patients than beds and a further 10 per cent are at full capacity”. It also reported that “in south Hampshire, 30 per cent of psychiatric beds, 58 in total, were axed last year. Six patients had to be sent to the private Priory clinic in London for a total of 127 days at a cost of £66,500."

Unfortunately, Hampshire is not the only place where this is happening. This pattern of bed closures, and the resulting need to use distant and expensive private beds, is being repeated all over the country.

I fear that the major reforms to provision of NHS services, involving the creation of community care groups who will commission mental health services, which came into being this April, are likely to make this an even bigger problem.

The College of Social Work survey reported that “in many cases AMHP’s and AMHP leads are… remaining with patients until the situation is resolved.” As a humble AMHP, I can only see myself and my colleagues having to spend even more time trying to get mentally unwell patients into hospital, with no choice but to wait with the patient in their home and try to manage their distress, and the distress of their relatives and carers. And wait. And wait. Until the job is done.