Thursday, 1 December 2016

Ask the AMHP: Problems with Sec.117 and Autistic Spectrum Disorders

Ask The Masked AMHP for the answers to your thorny MHA related problems. He might know the answer. Or not.

The Masked AMHP always tries to assist people, whether professionals or patients, who ask for assistance or advice. However, I cannot guarantee that my advice is definitive.

My postbag continues to contain frequent requests for advice from parents of mentally disordered people who are encountering problems in receiving appropriate aftercare, and are then being charged for it despite being subject to Sec.117 aftercare. They often find themselves caught in funding arguments between the local authority and the Clinical Commissioning Group (CCG).

Here are a couple of cases which also involve issues concerning Autistic Spectrum Disorders and mental illness.

A parent writes:
My daughter has learning disabilities and was admitted to an assessment and treatment unit under Sec. 2, followed by a Sec.3. She was discharged onto a CTO after a long drawn out battle trying to get the CCG and the local authority to agree who was going to pay for her continuing care.

She lived in residential accommodation before the section but it was not appropriate for her to return due to the severity of her needs. She had been diagnosed with Bi-polar disorder, and subsequently whilst in hospital on the Sec.3 she was assessed as being on the Autistic Spectrum and it was agreed she would be best supported by a provider with specialist knowledge around Autism.

She has been settled in her placement, but after a financial assessment by the local authority she has to pay nearly £90 per week towards her care costs. She has Sec.117 aftercare funding and the CCG pay 50% of her fees and the local authority pay 50% of her fees (then bill her for the £90 per week) After a recent DoLS application the BIA has questioned why she is paying for her care at all when she has Sec.117 funding. They are adamant my daughter should not be paying at all. My daughter had to be housed out of area as there was no provision to meet her needs in her home area. They have not argued this.

Can you help?

The Masked AMHP replies:
There can be no doubt. As she is subject to Sec.117 aftercare she should not be paying anything towards her identified mental health needs. She should be entitled to a full rebate of what she has been charged already.

The parent:
Would it make a difference that the CCG argued that her learning  disability is not related to her mental health issues? So they should only pay for half?

The Masked AMHP:
A learning disability is a mental disorder within the meaning of the Mental Health Act. Therefore needs arising from the learning disability are covered under Sec.117.  They're really trying it on!

Another parent writes:
My son is 30 and lives in supported accommodation that is funded by the local authority where he was living when he was sectioned under the 1983 MHA (many times, mostly under Section 3).  He was in and out of hospital for several years before being discharged 3 years ago.

Since he left home to go to college when he was just 19 his mental health was very poor and he was admitted to hospital with psychosis on numerous occasions.  He was put on anti-psychotic medication and eventually, when discharged from hospital, he was on a CTO.  The medication made things worse for him. The CTO is now lifted and he is now off medication.

For many years we thought our son was autistic (Asperger's) and that this was at the heart of his distress.  Eventually he was diagnosed with Autism Level 1. This diagnosis has really helped him turn his life round but we have had to pay for the psychological and day-to-day specialist support for him as the supported accommodation that he has been living in for the last 3 years is for people with mental health problems only and is very inadequate.

We have now found excellent supported housing that is Asperger's specific that will support our son to gain the life skills he lacks.  It will only cost a little bit more than his current care package (24 hours a week) but the CMHT and LA social worker are saying that the Housing Panel is not likely to support the move as the recent Placement Review recommended our son be stepped down to 'independent living'.  We have said we can afford the top-up on the fee difference.

The social worker is now implying that our son no longer has a mental health condition, that he is autistic and therefore should be assessed by the Adult Social Care team and won't be eligible for funding for supported housing.  Our son is very bright and articulate but this masks so much of his vulnerability and fragility.  The social worker is now intimating that he is no longer entitled to Section 117 aftercare funding.  This would mean he would be expected to live alone without support (unless we pay for it) and all that might mean for his safety and fragile mental health.

We see a continuum from our son's autism to his previous poor mental health - the social worker just sees CMHT/LA dividing lines and overstretched budgets.  How can we protect our son's Section 117 funding at least until he is receives the right support to enable him to live independently successfully?
  
The Masked AMHP replies:
It's difficult to give a definitive reply to your question. You say your son has experienced periods of psychosis in the past, but that he is no longer prescribed any medication. However, if he is still seeing a psychiatrist and/or has a care coordinator in a mental health team, then he is still receiving aftercare, and therefore would continue to be entitled to Sec.117 aftercare.

He could only be discharged from Sec.117 aftercare if he was no longer receiving any services for mental disorder, and was no longer considered to be suffering from a mental disorder within the meaning of the Mental Health Act. However, the definition of mental disorder is broad, and would include autism or autistic spectrum disorder.

A difficulty would be the difference between what you would like for your son, and what the local authority and mental health services consider he requires to meet his mental health needs.

If your son is still under a mental health team, it might be worth getting a NHS psychiatrist to review his diagnosis. If he has been discharged from the mental health team, then his GP could refer him for a NHS diagnostic assessment.

But in any case, autism is still a mental disorder.

The parent:
Thank you for your very detailed response.  It is helpful to understand that autism (albeit Aspergers) is considered to be a mental disorder (eating problems, anxiety and OCD are part of my son's life too).  My son hasn't yet been discharged from the mental health team but the pressures on the LA social care budget are such that he would be an easy one to pick off and no longer fund.  You are right it seems that there is now a difference of opinion about what we feel our son needs and what the CMHT and LA feel - painful.

11 comments:

  1. Re your first example wouldn't you have to establish why the patient was placed on the 3. It could plausibly be they were detained for a mental disorder not associated with their L.D. Which they are now cured! Surely the 117 would only apply to this disorder not the L.D.. Of course if they were abnormally agressive or seriously irresponsible and placed on the 3...

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    1. No. Mental disorder is mental disorder. Admission is often used to assess and diagnose, and diagnoses can change over time. How can you differentiate? If someone receiving residential care for schizophrenia develops dementia, does that mean they no longer have schizophrenia? It would be rather convenient to rediagnose and consequently be able to suddenly charge for services, wouldn't it?

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  2. There are "austerity" moves afoot to downgrade S117 provision and to discharge people who have been "stable" for some time back to their GPs. In other words, to remove the props that keep them "stable". Is it not true that S117 was introduced to maintain provision "in the community" for those who were previously maintained in the long-stay hospitals?

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  3. Hi, I was hoping to private message you but wasn't sure how to. My son is on section 37 no restriction, has autism and has been to secure places in the past either on section or DOLS and does really well. However when he is in the community he is very vulnerable to get into trouble or risky situations or does not care for himself. I had a meeting yesterday and was told that they think he is doing so well they need to look at discharge but they all know a move back to the same area is risky for him and nothing has been put in place or any 117 support. Do you know of any services in the UK that support people to make sure the appropriate support and services are put in palce to try and prevent further issues so he end up back in hospital? Also leisure activities, having breaks away on holiday, role-models, psychologist sessions and alternative therapies have always been helpful to keep his mental wellbeing healthy are these things that I could argue for his 117?

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    1. He will certainly be entitled to sec.117 aftercare after being detained under Sec.37. They must set up appropriate services for him before he is discharged, especially as he must have a forensic history. It may be helpful for him to have an Independent Mental Health Advocate (IMHA), who can advocate on his behalf. The hospital should have the details for how to get one. Regardless of Sec.117 aftercare, he would be entitled to an assessment of his care needs from the Local Authority under the Care Act. Voluntary organisations such as MIND or the National Autistic Society may also be able to help.

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    2. Thank you for replying. He had an advocate who attended the last CPA meeting (from the local advocate service) but as the hospital pay privately to there own or a different one (I'm not sure) the advocate can not stay involved but the hospital's advocate has never turned up when asked or to be involved and the Doctor from the hospital said he didn't think one was needed. I'm considering looking into legal advice but that is another long search process. Forensic history is linked with being led by others-professionals report how 'highly vulnerable he is' but as he does well in environments like this the hospital are saying he doesn't need to be there but no one seems to know what assessments he needs to do or who needs to do them. He has had social care involved for a few years now but they just don't seem to offer anything (they left him when he didn't have capacity to get into all sorts of dangerous situations-we went to COP and the judge told them straight they had let him down & he was moved to a specialist provision and did well and again no after care for when he left he had to stay in a hotel and then came back to me). Social care are saying they don't have time to update the assessment until March and hospital are saying they may not be able to keep him due to not needing to be there and human rights?? I'm so confused and know he has been let down with after care support in the past that I just do not know what to do. It is like they hope to play on his black and white thoughts of wanting to get out without processing the consequence of what will happen with no assessment or 117 support. I can't believe that no one seems to know what 117 is-I have done my research and seem to know more than them (which seems to be annoying them. I am a specialist professional who works within education and autism and to be honest they don't like it when I challenge things. NAS did a care plan a few years ago as social care paid for them to do it and then social care didn't follow it. It is so scary how people get so let down.

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  4. Just to also mention they are also now considering a personality disorder although I believe this is due to them not understanding his autism although they say they are an autism specific service. They do not use any autism specific strategies

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  5. How do I ask the masked AMPH a question? I just can't see how to do it. It's regarding Section 117

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    1. You can make a comment on the blog or you can email me. My email is on the right hand side of the blog. Just scroll down and you'll find it eventually.

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  6. My mother has come to stay with us after the care home said they could not cope with her. She was placed there after being detained under section 3 for several months. She has lewy body dementia, high blood pressure, diabetes and was refusing to take medication.

    She lived in extra care sheltered housing before being sectioned, and we have been told she needs constant nursing care and should go into a home. She is receiving CHC funding for carers except at night which the family are currently covering, but who work full time. We want her to be given accommodation again where the carers can go in day and night as the family are not coping and who are exhausted. We get no finance to help with my mother's needs while she is here but we really want to know if we can insist on accommodation with carers in her own home with activities, such as going to daycare both of which are being refused at the moment.

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    1. As she has been detained under Sec.3 she will be entitled to Sec.117 aftercare. That does mean that, regardless of whether the NHS or the LA pays, she herself cannot be charged -- and you should not be incurring any expenses for caring for her either.
      As she has been assessed as qualifying for continuing health care, I am surprised that anyone thinks that you are capable of caring for her. If she needs carers (at present, you) at night, then CHC should be funding that care.
      It is extraordinary that qualifying for CHC, and being too difficult for a care home to manage, it was deemed appropriate for her to go home to live with you.
      You need to make a formal complaint to the NHS Trust and the LA who are responsible for her aftercare. If they do not respond, complain to the Care Quality commission and the local authority ombudsman.

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