Tuesday, 31 December 2013

Let’s Play Big Society Jenga!

For those unfamiliar with the game of Jenga, it consists of a tower of wooden blocks. During the game, players take turns to remove a block from this tower and balance it on the top. The structure becomes increasingly unstable as the blocks supporting the structure from lower down are removed.

The Coalition Government are currently playing their very own version of this game, which I call Big Society Jenga. They are seeing how many basic elements of the structure that supports British Society can be removed before the entire edifice collapses.

Let’s take out Disability Living Allowance, which permits disabled people, who are unable to work, to have something approaching a decent quality of life, and see what happens!

Nothing! No wobbles yet!

Let’s penalise poor and disabled people in social housing for having too many bedrooms!

Look! Nothing’s happened. The tower’s still standing!

Let’s impose ridiculous and perverse capability for work tests! Then we can reduce the income to sick people, who can’t actually get into work in any case!

Still nothing! This is a great game!

What’s next? I know, we’ll reorganise the NHS and in the process reduce funding to make it even more difficult for it to function! We’ll make it so that they have to sack doctors and nurses, reduce the pay of NHS staff and at the same time give them higher work loads. That should be a good one!

Hmmm. Extra pressures on A&E. More old and sick people dying. Wobbling a bit. Still, let’s impose a few targets. That should sort it. And the old and sick can always be looked after by the local authorities.

That gives me an idea! Let’s reduce funding to local authorities!

Well, the tower hasn’t fallen down yet! It’s a bit shaky, don’t breathe too closely to it.

We could always divert attention from the instability by demonising those dreadful economic migrants and health tourists. Everyone hates them any way. Easy target.

The object of this game is to undermine Society. You win if the entire structure doesn’t collapse before the General Election in 2015. And even if it does collapse, then you win anyway, because you can blame it on the previous evil Labour Government, and then privatise what’s left.

Happy New Year!

Wednesday, 18 December 2013

Essential Christmas Gifts for Mentalists!

The Masked AMHP™ produced some indispensable products for AMHP’s a couple of years ago. He’s now introducing a range especially for people with mental health issues! He’s called it the Mentalist Collection.

AMHP Detector
Carry this handy device with you at all times, and you need no longer live in fear of that unexpected knock on the door heralding the arrival of an evil AMHP and his or her Sec.12 doctor henchmen. It will detect an AMHP in the vicinity anywhere within 100 metres, and give you those essential extra minutes in order to make your escape through the back door.
Disappearing ink

Left it a bit late to get away from that pesky interfering AMHP? Well, there’s another crafty ruse! When they’re about to fill in those pink forms, show you’re cooperating by giving them this innocent looking pen. What they don’t know is that within 2 hours the ink will evaporate leaving no trace! So by the time you get to the hospital, they’ll be presented with nothing but blank forms!

Escape kit

So, despite your AMHP detector and disappearing ink, they’ve still somehow managed to get you into hospital. Don’t despair! This amazing lightweight rope ladder folds away and can be concealed inside a toothbrush holder! Then, after lights out, it’s a simple matter to make a clean getaway through your bedroom window!

Tin foil hat kit

Everyone knows that the ESA and GCHQ are monitoring the entire nation’s thoughts with undetectable microwaves. A great way to protect yourself from this intrusion is with a tin foil hat! This kit contains everything you need to make your own! Will also prevent aliens from employing their nefarious mind control techniques!

Electromagnetic mind shield

Concerned that even a tin foil hat may not protect you from external thought wave interference? This unobtrusive headgear is guaranteed not only to shield your brain from any remote sensing equipment, but will also stop your thoughts from being broadcast on local TV stations and prevent persons unknown from taking thoughts out of your head! Comes in three colours: Men-in Black, Paranoid Paisley, and Lucy-in-the-Sky Tangerine!

Pull Yourself Together and Snap Out Of It DVD

You know the saying “There’s always someone else worse off than yourself?” Well, the Masked AMHP Blog team have tracked that person down and have interviewed him for a special mood boosting DVD!

Feeling down in the dumps? Watching this DVD is guaranteed to cheer you up! There really is someone worse off than yourself!

Comes with a special bonus DVD consisting of someone who’s never had any mental health problems saying motivational things designed to make you feel better! Examples include such classic lines as:
  • “It’s like you’re not even trying.”
  • “Try having a nice long bath.”
  • “Go for a walk.”
  • “There’s no such thing as mental illness.”
  • “It’s all in the mind.”
  • “You’ve no reason to feel depressed.”
  • “Try thinking positively.”
  • “It’s as if you don’t want to get better.”
  • “Try smiling once in a while.”
  • And of course the classic “Just snap out of it!”
Please note: The Masked AMHP has now gone for a nice long lie down in a darkened room. He might then go for a walk in the countryside, followed a long bath surrounded by scented candles. It is hoped that normal service will be resumed on the Blog after Christmas.

Saturday, 14 December 2013

A Christmas Eve Mental Health Act Assessment

Don’t you just hate it when you’re on AMHP duty on the day before Christmas, and just as you think you can go home, you get a call?

It was an elderly man. The GP had visited Nicholas at home and was very concerned. He said that he was displaying marked delusional thinking and was also hoarding. The GP said that he appeared to have been buying large quantities of children’s toys, which he was storing in his house, and when questioned about this said that he was going to give them all away.

On the face of it, there appeared to be a number of risk factors, including self neglect and spending money he could ill afford on inappropriate goods.

I obtained a medical recommendation for a Sec.2 for assessment from the GP, and arranged to visit with a Sec.12 doctor. I also took my AMHP trainee with me.

Nicholas lived in a remote house on the outskirts of a village outside Charwood. It was a large rambling farmhouse, set in several acres of garden and paddock. As far as we knew, he lived alone.

I knocked on the door, and after a moment, the door creaked open and a large elderly man with a long flowing unkempt white beard answered the door.

“Hello, Nicholas,” I said, “Could we come in and speak to you?”

He looked distracted. “Do you think you could come back after Christmas?” he asked. “Only I’ve got a lot on just at the moment.”

Peering past him, I could see that the hallway and the room beyond were piled high with boxes and objects of all sizes, all wrapped in Christmas paper. It did indeed look as if Nicolas was a hoarder. Diogenes Syndrome? Obsessive Compulsive Disorder? It was too soon to tell.

“I’m an Approved Mental Health Professional. Your doctor is worried about you. We do need to see you today.”

He looked resigned. “Very well,” he sighed. “But not too long. I’ve got a lot to do before the night’s out.”

We entered the large, heavily beamed hallway, festooned with holly, ivy, and other traditional Christmas decorations, and he led us through into a huge farmhouse kitchen. The table and most of the surfaces were all piled high with parcels of all shapes and sizes. An Aga on one wall kept the room cosy and warm.

This was most unusual. I had never come across a case of hoarding quite like this before. Although it appeared chaotic, all the parcels looked new and were all immaculately wrapped and tied with ribbons and bows.

As I looked around, I could hear rustling noises among the parcels, and movement. It must be rats, I thought with a shiver.

“What’s moving about in the room here, among these, er, parcels?”

“They’re my helpers,” the old man replied, with a kindly smile on his face.

Mental alarms started to ring. “Helpers? Can you tell me a little more about these helpers?”

“They’re mainly elves,” he said. “Do you think I could wrap all these presents on my own?”

“Elves?” I said carefully. Just this brief conversation was confirming my suspicion that Nicolas had dementia and was hallucinating.

“Oh yes,” he said happily. “They’re always so helpful. They help me get everything ready.”

“And what are you planning to do?” I asked.

“Why, I’ve got to deliver all these parcels tonight.”

I looked around. There appeared to be literally thousands of parcels. And this was just what I could see in one room. How could he possibly deliver all of these, even if he did have “elves” to help him?

“So who will you be delivering all these parcels to?” I asked.

“Why, all the children, of course.”

My worst suspicions were confirmed. Nicolas appeared to be planning to give these “presents” to children, children whom he could not possibly know, and to whom he had no legitimate business giving presents. As well as the risks to himself, he was clearly also potentially dangerous to the wider community.

“And how will you be distributing these presents?” I asked.

“I’ve got a sleigh round the back. Do you want to see it?”

“We’d love to,” I said.

He led us out of the kitchen back door into a yard. In the middle of the yard was a large wooden sleigh, complete with runners.

“But there’s no snow,” I said gently. “This sleigh wouldn’t work, would it?” I was trying to see if he still had even the slightest grasp on reality.

Oh, that’s not a problem,” he announced proudly. “My sleigh doesn’t need snow, because it will fly through the air!”

“Fly through the air?” I repeated.

“Why yes! You see, it’s a magic sleigh! Magic will allow me to fly all around the world, giving out presents to every child!”

I had heard enough. We made our excuses and retired to my car, where the doctor completed his recommendation and I filled in my application.

When I told them about his plans to visit children in their homes, the police were very obliging and turned out to ensure that Nicolas went into the ambulance without a fuss.

“But what about all the children?” Nicolas cried mournfully as he was assisted into the back of the ambulance.

“What about all the children indeed,” I thought to myself. While the distraught look on his face made me feel a little sad, I knew that I had done the right thing.

I made sure the house was secure, and looked around outside. I saw a large stable on the other side of the yard, and peeped inside. “Uh oh,” I thought, my heart sinking. Then I had an idea.

“Here’s a job for you,” I said to my AMHP trainee. “Under the Protection of Property regulations, we’re going to have to accommodate nine reindeer! And judging by the condition of its nose, one of them is going to need checking out by a vet!”

Sunday, 8 December 2013

Why Social Care is Different from Double Glazing

I'm glad we've got that sorted out
(This is reblogged from the 1st issue of Care to Share Magazine)

There is a school of thought, which has its origins in some fuzzy concept of “Victorian values”, that there is something inherently wrong with the State intervening in health and social care. This reaches its apotheosis in the USA, where the Republicans regard Obama’s idea of ensuring that there is some basic form of health care accessible to even the poorest as little less than Satanic in conception.

Real Victorian concepts of philanthropy encompassed the idea that doing good was not only inherently virtuous, but was also a pragmatic and utilitarian solution to the problems that impacted on society. When large numbers of the populace are poor or sick, this affects everyone, even the rich. One of the factors that drove the development of National Insurance and improvements to social housing after the First World War was the discovery that many of the men seeking to enlist in the Armed Services were in very poor physical health. You couldn’t fight a war with unhealthy men.

There have been efforts to introduce market forces into the provision of health and social care for many years. The first Thatcher Government introduced the NHS & Community Care Act in 1990. One of the changes it introduced was the concept of the “purchaser/provider split”: this created an internal market, and essentially meant that those who “purchased” social care services should not be the same people that provided them. Until then, nearly all home care services were provided by the local authority. After that, at least 80% of services had to be purchased from private of voluntary providers

I was working in a local authority social services department when these changes came into effect in the early 1990’s.

This is how it worked before the Act. As a generic social worker, I would receive a referral for an elderly person living alone who wasn’t managing very well. I would go out and assess them and establish whether or not they needed a service: a home help to assist with cleaning or preparing meals; aids and adaptations to their home; or residential care.

I would then consult with our Occupational Therapist, who would assess for aids and adaptations, or the Home Help Organiser, who could assess precisely the level of home care services required, and then arrange for one of her Home Helps, who was employed by the local authority, to deliver that service. Some of these home helps could even be neighbours, who might be employed specifically to provide a service for that individual.

This is how it worked after the Act. The social worker would assess the person. They would then have to decide themselves exactly how much time in a week that person required a cleaning service, or preparation of meals, or someone to shop for them, or someone to help them get up in the morning or go to bed at night. The social worker would then go to the Home Care Manager, as they were suddenly called, and tell them what was required, and the Home Care Manager would then have to work out how to provide that service, using a combination of “in house” staff and external agencies.

Since then, this process has accelerated, to the point that more and more local authorities have sold off or out sourced all of their care services, and many are actively looking at how they might out source social workers, too.

The recent reforms in the NHS, centring on the GP led Clinical Commissioning Groups, are creating a culture in which it becomes imperative to provide health services via private service providers. The premise, behind the smokescreen of the mantra of “customer led” service, is that private providers can deliver cheaper and more efficient services.

There is a basic fallacy in all this: health and social services are inherently and fundamentally different from the manufacturing or service industries. You cannot apply models of the private market to the public sector.

This is what might happen if it really were the case that the health or social care service user was the “customer”.

Jeremy’s windows are draughty and let in water. He decides he needs double-glazing. He gets several companies to give him quotations for replacement windows, then makes a decision based on price and quality.

A few months after his new windows have been installed, Jeremy starts to worry about pains in his lower back. He looks these up on the Internet and decides that he must have problems with his kidneys. So he contacts the Renal Department of the local hospital, sees the consultant, and insists that he needs a kidney transplant.

The second scenario is clearly absurd. It is necessarily the role of specialist doctors to assess a patient’s health problems, and it is ultimately their decision as to what treatment the patient requires. Equally absurdly, if we were to apply this to the first scenario, then Jeremy would simply be told what sort of double glazing he needed by the expert double-glazing salesman.

Because in reality users of public services are not “customers”: it is the GP’s, via their CCG’s, who are the real customers. They are the ones who want specific services for their patients, and they choose what service they will go with.

The concept of “Payment by Results” and “clustering” currently being implemented as a means of service delivery in national mental health services is, in the words of the Department of Health, “a major change in the way that mental health care is currently funded, a shift from block grants to Payment by Results currencies which are associated with individual service users and their interactions with mental health services.”

And there is revealed the true state of affairs: in this brave new world, users of public services are not “customers”, they are “currency”.

Tuesday, 3 December 2013

Case Study 1: Greg and The Wicker Man

(Greg has given me permission to tell his story on my blog.)

Greg is one of the people on my case list. I’ve been seeing him for about two years.

Greg is in his 50’s. For the last 40 years, he has been experiencing vivid and terrifying visual and auditory hallucinations. However, he has been under the radar of secondary mental health services for most of that time. That is, until 2 years ago, when he stabbed himself and was admitted to a medical ward.

Why did he stab himself? Because he could no longer tolerate his hallucinations. He would have spells, sometimes lasting days, sometimes just a few hours, of exceptionally vivid hallucinations, when he could both hear and see a number of menacing men, who would threaten to kill him in horrible ways. Most of the time, these figures would stand outside his window, looking in at him. Sometimes, they insinuate themselves into his house.

So one day, after a number of hours of enduring the threats and taunts of these figures, who were telling him they were going to burn him alive like The Wicker Man, he decided that the only way of escaping this awful fate was by killing himself. So he went into the kitchen, inserted a knife into his ribcage, and leaned against the wall, using his weight to push the knife deep inside.

Fortunately, his wife found him in time, called an ambulance, and was able to get him to hospital.

But although they were able to patched Greg up and saved his life, he was still experiencing the hallucinations, and the ward appropriately asked for a psychiatric assessment.

It nearly unravelled at that point. This is because Greg had been self medicating with alcohol for many years. The psychiatrist who assessed him noted his history, diagnosed alcoholic hallucinosis, and decided that no further involvement was necessary from mental health services.

When he was discharged, however, his supportive GP made a referral to the Community Mental Health Team. I started to look through his records, such as they were. This is when I found that he had had a brief psychiatric admission 15 years previously. And unfortunately his history of alcohol use was held against him, and he was discharged with no follow up.

I discovered that Greg had actually stopped drinking completely a few months before he stabbed himself. But there had been no reduction in his experience of hallucinations. So alcohol abuse could not have been the cause. Speaking to Greg, it became clear that he had been using alcohol in an attempt to manage the hallucinations, rather than the hallucinations being a consequence of his alcohol use.

I was allocated as his care coordinator, and the team psychiatrist prescribed him an antipsychotic.

I began to visit Greg regularly, and got to know him well.

Greg is a fiercely intelligent man, who despite suffering from these tormenting hallucinations, succeeded in a variety of jobs, ranging from car salesman, to wine merchant, to a care worker rehabilitating offenders. He is very creative, and had at one point won £5000 in a national poetry competition. But since the breakdown that precipitated his hospital admission 15 years previously, he had not worked.

It was hard to know what to make of his hallucinations. They were exceptionally vivid, but Greg did not present with other symptoms of psychosis. He also had full insight – he knew that the voices and images weren’t real, although that did not reduce the horror for him. Neither did the hallucinations appear to be depressive in origin.

So it was difficult to make a formal diagnosis of schizophrenia, and it was also difficult to diagnose psychotic depression.

Greg revealed that he had been sexually abused by a teacher when he was a child. Did this give a clue? Hallucinations, often very vivid, can certainly be a feature of Borderline Personality Disorder. But these hallucinations usually centre around hearing or seeing the abuser, and again the nature of Greg’s hallucinations did not fit this formulation.

Whatever the origin, the antipsychotic he was taking, while taking the edge off these experiences, did not stop them occurring.

One day, Greg described having a sense of when the hallucinations were going to begin. The quality of the light changed, and he always smelled coffee.

Could this be a clue? Could Greg be describing the aura some people experience immediately prior to having a seizure? Could Greg have a neurological disorder, such as temporal lobe epilepsy?

There were other clues. One day, I took a detailed life history from him. Greg described a life of transience, moving frequently, and never staying in the same job for more than a year or so. He also said that he always threw himself completely into any job he took, aiming to be the best he could, but getting bored quickly. He also described long periods when he would be intensely active and creative. I had also become aware of occasions when I visited when he would be calm, polite and friendly, while at other times he would be agitated and extremely irritable.

Could Greg have a mood disorder, such as bipolar affective disorder?

Greg had an EEG, but this was inconclusive. Nevertheless, the psychiatrist decided to prescribe carbamazepine, which is both a mood stabiliser and anticonvulsant.

Although here was no immediate change, over a period of months, the intensity and duration of Greg’s hallucinations reduced markedly. At the same time, his mood became much more stable, and he was always cheerful and affable during my visits.

I discussed with him ways in which he might manage the hallucinatory episodes. The commonest hallucination was seeing people peering in through his living room window. He did not have any curtains on this window. I asked him if it might help if he put a blind on the window, so that he could shut the images out.

He tried this simple expedient, and reported delightedly the next time I saw him that it had worked! If he begins to see anything outside, he closes the blind, and although he can then still hear voices, the intensity is much more manageable.

With these improvements, his creativity returned. He began to write poetry again. This poetry was accepted and published in a range of poetry magazines. He began to write a children’s book. When he finished it and sent it to a publisher, it was accepted and published.

Writing serves two purposes for him. He found that the act of writing could distract him sufficiently from the hallucinations that he could exclude them entirely from his awareness. He therefore took to writing if he was ever troubled by the voices or images. The success he achieved in writing also improved his self esteem, and provided a shape to his day. He began to look forward to getting up in the morning, so that he could get on with his writing.

In order to prepare himself for his writing day, he spontaneously began jogging first thing in the morning. This improved his fitness, and set him up for the rest of the day.

From being adrift in a sea of hopelessness, with no motivation to do anything, and dreading the day ahead, Greg now has days full of anticipation and achievement.

I do not know to what extent Greg’s improvement is due to the change in his medication, and what is due to my regular visits and support. I suspect it is a combination of the two. I also still do not know what diagnostic label to give Greg.

Which is probably just as well. Greg after all is a person first. The important thing is that, with some assistance from mental health services, who are at last supporting him rather than ignoring him, Greg is leading a life full of meaning and enjoyment. He no longer thinks about killing himself. His “symptoms” have not gone away completely, but Greg now knows how to accommodate them within his life rather than them being his life.

Sunday, 24 November 2013

Possibly the best Social Care Conference in the UK? Review of Mersey Care Trust Annual Social Care Conference 22nd November 2013

I was fortunate enough to be ambushed by Emad Lilo, the conference organiser, back in March of this year, when I was appearing at a North Wales and North West AMHP Association Conference in Manchester. He booked me for the Mersey Care Trust annual conference, and I’m very glad he did, because what a memorable day it turned out to be!
The theme of this year’s conference was “Service Users’ Experience – Social and Medical Models: Exploring What Service Users Say”. Over two hundred social workers and social work students, as well as a scattering of other mental health professionals, attended. The programme was crammed with speakers of the highest calibre, including Professor Peter Beresford, Annie Hudson, the Chief Executive of The College of Social Work, and Professor Sue Bailey, Chair of the Royal College of Psychiatrists. There was even an unexpected, but very welcome, appearance at the conference of Lyn Romeo, the Chief Social Worker for adults.
So far, it might look as if I have been hired by the Mersey Care Trust to promote them, but my enthusiasm is entirely genuine, as this was certainly the most stimulating and inspiring conference I have attended. The commitment and concern to promote the needs of mental health service users was palpable from the speakers and the conference delegates.
The programme was crammed, with over a dozen speakers, not to mention an eminent panel that included Professor Michael Lavallette (oh, and The Masked AMHP, but I didn’t get to say much: there were too many others with important things to say.)
Joe Rafferty, the Chief Executive of the Trust, began by stressing that service user involvement is integral to the way the Trust works – and I believe him. He posed the question: if perfect care isn’t the right goal, then what is? He meant that “good enough” was not actually good enough, that mental health services should aim to eliminate suicide, not just to set goals for a reduction in numbers. He pointed out that a 95% perfect safety record for the Mersey ferry would mean that 4 ferries would sink each year.
He was followed by the double act of Jenny Robb, the director of social care and safeguarding in the Trust, and Iris Benson, a service user. Jenny continued the theme of the importance of service user involvement at all levels, while Iris gave the conference an articulate and truly inspirational personal story of recovery, outlining her severely abusive past and her efforts to overcome the mental health problems she experienced as a result.
Iris gave an enthralling account of her journey to recovery, and the many and varied psychiatric diagnoses, ranging from paranoid schizophrenia to depression to dissociative identity disorder, that she had received over the years. It is encouraging to hear from someone who has had positive experiences of mental health services, and is prepared to share that experience, as well as to challenge poor practice.
Neil Allen is a barrister at the legendary Thirty Nine Essex Street Chambers and a lecturer at the University of Manchester. He discussed the implications of living with mental health, including the fact that people with mental disorder have a responsibility to manage their disorder as best they can, including using any support and treatment available, not just for their own wellbeing, but for carers and others as well. He suggested that, while a social model can be usefully applied to improving attitudes to people with physical disabilities, mental disorder does not fit so well into the social model.
Peter Beresford is both Professor of Social Policy at Brunel University and a mental health service user. He continued and extended Neil’s theme of service users’ experience of mental illness, stressing the value of lived experience, and pointing out that the medical model still dominates mental health services. He was wary about the “new idea” of the Recovery Model, suggesting that this could be as potentially limiting and oppressive, and could disable rather than enable. He outlined the movement of “Mad Studies”, and promoted what sounds like a fascinating book called “Mad Matters”, a book published in Canada consisting of writing that “presents diverse critical voices that convey the lived experiences of the psychiatrized and challenges dominant understandings of mental illness."
And then it was lunchtime.
Annie Hudson, Chief Executive of The College of Social Work, started off the afternoon session, touched on the knotty problem of whether or not social workers should be integrated into Mental Health Trusts, or separate from them. My own view is that this is a Good Thing, as long as a social worker’s core role and identity is protected and maintained. She stressed that mental health should be an integral part of all social work training, as it was equally important for social workers in children’s services to have a knowledge of mental health issues. She also considered that good practice arises from a combination of knowledge, skills and research.
She was followed by the Chair of the Royal College of Psychiatrists, Professor Sue Bailey, whose presentation was both entertaining and humorous. She talked about parity of esteem between different professions working in mental health, noting a marked variability of service between different Trusts. She talked about the recovery model needing to address the quality of life for someone with mental illness within the society in which they live.
Sue raised the interesting point that clinicians and cancer pressure groups stimulated intensive research into the causes and treatment of cancer, with the result that there are now many effective treatments for cancer, and a diagnosis of cancer no longer has the stigma attached to it that it did 20 or 30 years ago. Compare that with treatments for mental illness and disorder – there has been comparatively little research into developing more effective drugs for what can be equally debilitating and life threatening illnesses.
Malcolm Jones and Roger Lewis then addressed the question: what can we do about austerity? Both Malcolm and Roger are major advocates for the rights of disabled people. Malcolm is a social worker and AMHP, as well as being a political activist and a member of the Social Work Action Network (SWAN), while Roger, who is visually impaired, is on the steering committee of DisabledPeople Against Cuts (DPAC). Between the two of them, they gave an electrifying performance, cutting through the cant and ideology of the current Coalition Government to expose the hypocrisy and double standards that is currently driving social policy and seeking to marginalise and disempower disabled people.
The afternoon concluded with presentations from two psychiatrists, Sam Vovnik, who gave a presentation on spirituality in psychiatric care, and Manoj Agarwal, who discussed ways of adopting a more holistic approach to psychiatric care. Rather than following reductive psychiatric diagnosis in the manner of the American Diagnostic Statistical Manual, Manoj preferred to use a grid, which was better able to reflect an individual’s mental health problems. I liked this so much, I will reproduce it here:
Predisposing factors
Precipitating Factors
Perpetuating factors
Biological factors
Psychological factors
Social factors

Catherine Mills, a mental health service user and one of Dr Agarwal’s patients, then gave a moving and illuminating account of her own journey through treatment and recovery.
Delegates left the conference invigorated and encouraged, while recognising that the struggle to maintain and improve services for mental health service users was going to be long and strenuous. We were also under no illusion that the professional status of social work itself is potentially under threat, and the maintenance of social work as a profession has to be fought for.
I hope I am invited to next year’s conference!

Sunday, 17 November 2013

Review of Bedlam, Episode 3, Channel 4 14th November 2013

Jim Thurkle, the social worker featured in the programme
You can read The Masked AMHP's review of this programme, featuring a social worker from a community mental health team in South London, in Community Care.

Saturday, 9 November 2013

What’s the Point of Guardianship?

I’ve been writing this blog for 4½ years, and have written nearly 150 posts, but this is the first post I have devoted to Guardianship under the Mental Health Act (Sec.7).

There is a reason for this: I have a basic aversion to Guardianship. This is because my mother was once frightened by a Guardianship Order while she was carrying me.

Actually, that last bit isn’t true, but the fact is that in my 30 years practising under the MHA, I have only once made an application under Sec.7, and that was in 1985.

It was a fairly traumatic experience at the time. Back then, although I could make an application for Guardianship, in order for it to have effect, it had to be received and formally accepted by the Director of Social Services. I forwarded the paperwork and a report to the Director, and waited. And waited.

The patient was in hospital under Sec.3, and the Consultant was very keen for her to be discharged from hospital. He started to put pressure on me to get it approved. I then started to leave messages with the Director’s personal assistant. Quite a few messages.

Then one day, after yet another message left with his PA, I received a phone call. It was the Director himself. He made it clear that he was annoyed at this campaign of harassment from one of his junior minions. But having never been involved in a Guardianship application before, he did not know what the procedure was, and gruffly asked me what it was all about. I told him what he needed to do, and he finally did it.

In the event, it was not a success for this patient, and the patient was readmitted to hospital under Sec.3 within a few weeks, and the Guardianship Order was discharged.

So what is a Guardianship Order all about?

Sec.7(2) of the MHA states:
“A guardianship application may be made in respect of a patient on the grounds that
(a) he is suffering from mental disorder of a nature or degree which warrants his reception into guardianship under this section; and
(b) it is necessary in the interests of the welfare of the patient or for the protection of other persons that the patient should be so received.”

A Guardianship Order confers on the guardian three powers:
“(a) the power to require the patient to reside at a place specified by the authority or person named as guardian;
(b) the power to require the patient to attend at places and times so specified for the purpose of medical treatment, occupation, education or training;
(c) the power to require access to the patient to be given, at any place where the patient is residing, to any registered medical practitioner, approved mental health professional or other person so specified.”

A guardian may be the local social services authority, or an individual, such as a relative.

The Reference Guide, however, advises (para 19.8): “Although guardians have powers to require patients to attend for medical treatment, they do not have any power to make them accept the treatment.”

It goes on to say (para 19.11): “Guardianship may be used to restrict patients’ liberty (eg by determining where they are to live) but it may not be used to deprive them of their liberty (ie to detain them).” The Guide advises that if the patient lacks capacity, and they are likely to be deprived of their liberty, then a Deprivation of Liberty Authorisation under the Mental Capacity Act should be obtained.

The Reference Guide states (para 19.3):
“In most cases it should be possible for patients who need care, but do not need to be in hospital, to receive that care without being subject to the control of guardianship. However, in a minority of cases, the powers which may be exercised by the guardian, and the structure imposed by guardianship, may assist relatives, friends and professionals to help a mentally disordered person manage in the community.”

The Code of Practice advises (para 26.8) that Guardianship is most likely to be appropriate where: “the patient is thought to be likely to respond well to the authority and attention of a guardian and so be more willing to comply with necessary treatment and care for their mental disorder”. The clear implication of this is that the patient should essentially be in agreement with the proposed Order.

All of the above leads to a number of conclusions in respect of the use of Guardianship. One is that the powers of a Guardian are not enforceable. For example, although there might be the power to require a patient to attend for medical treatment, this does not mean that the Guardian can forcibly bundle the patient into a car and take them to have a depot injection. And even if the Guardian successfully got the patient to the place where the injection was to be given, there is no actual power to force the patient to have the injection.

Another is that Guardianship should not really be used at all where the patient objects. Guidance also suggests that if a patient, once they are on Guardianship, refuses to comply with the directions, then the Order should be rescinded.

These are all reasons why I find it difficult to justify the use of Guardianship in any but the rarest of circumstances. One might think that the power to make the patient reside in a certain place could be a good reason to use Guardianship to admit someone to residential care. However The CoP (para 26.11) suggests that the Mental Capacity Act might be more appropriate in these circumstances, when the patient lacks capacity.

So how is Guardianship actually being used? At the end of September, the Health & Social Care Information Centre (HSCIC) issued its annual report on the use of Guardianship in England for theyear 2012-2013.

One of the key statistics from this report is that, nationally, Guardianship is not widely used at all. In fact, there were only 271 new cases in the year, and as at 31st March 2013 there were only 619 people in England subject to Guardianship. When this figure is compared to the number of people detained to hospital under the MHA in the same period, just over 50,000, it can be seen that Guardianship is extremely rarely used.

Not only that, but there was a fall of 20% in new cases over the year. The study suggests that the year on year fall in use of Guardianship could be due to “alternative legislation which promotes the welfare of people who have a mental disorder which presents a risk to themselves or others”, in particular, CTO’s and the MCA Deprivation of Liberty Safeguards.

The study points out that “11,887 DoLS applications were made in 2012/13 which represents a 4 per cent increase over the previous year.” Over the same period there were 4,647 uses of  CTO’s.

Jones, in the Mental Health Act Manual, notes that the White Paper that preceded the MHA stated that Guardianship would be needed for “a very small number of mentally disordered people”. It appears that most local authorities are taking heed of this, as the detailed statistics appear to show a huge variation between local authorities.

In parts of the North West of England, Guardianship appears to be relatively popular, as the Wirral had 23 cases and Lancashire had 27. Only Hertfordshire, with 21 cases, had more than 20. The majority of LA’s had less than 10; 43 authorities had none. London had a particular aversion to Guardianship: out of 33 boroughs, 60% had no-one at all subject to Guardianship.

The use of Guardianship in Wales is equally miniscule. There were a total of only 74 people subject to Guardianship, and 43% of these cases came from just two authorities: Swansea and Cardiff.

With the MCA and Supervised Community Treatment available, and both Parliament and the guidance to the Act suggesting that there are few people for whom Guardianship would be useful, it is perhaps no surprise that Guardianship is so rare.

Thursday, 31 October 2013

Detentions under the Mental Health Act 1983: The Latest Statistics 2012-13

The latest statistics on inpatientsformally detained in hospitals under the Mental Health Act 1983, and patientssubject to supervised community treatment was published on 30th October 2013. This is an interesting and easy to understand report, and I would urge everyone with an interest in mental health and the use of the Mental Health Act to read it.

This is the third time I have reviewed these annual reports from the Health and Social Care Information Centre, which is part of the Government Statistical Service. The authors clearly love statistics as much as I do (my previous reviews are here and here).

Two years ago I wrote: “What is clear is that, after only two full years of its use, CTO’s are beginning to seriously impact on the overall use of the MHA. There appears to be an inexorable rise in the number of people in the community subject to CTO’s, as once made, CTO’s can be extended indefinitely.”

One year ago I wrote I quoted from last year’s report: ““The total number of people subject to detention or CTO restrictions under The Act has continued to rise. On the 31st March 2012, this figure stood at 22,267 people, representing a 6 per cent increase since the previous year… There were 4,220 CTOs made during 2011/12, an increase of 386 (10 per cent) since last year.”

So what do the statistics show this year?

The report notes that “there were 4,647 CTOs made during 2012/13, an increase of 427 (10 per cent) since last year”. The report also notes that “in spite of larger numbers of CTOs being ended each year, the number issued continually outweigh this, resulting in an increasing number in place at the end of each reporting period.”

Despite some (potentially flawed) evidence that CTO’s are ineffective in keeping people out of hospital, it appears that this is not deterring clinicians from using these orders.

Last year, I observed that, as an AMHP, I was “finding increasing amounts of my work relate to CTO’s. In the last 12 months, I have been involved in 4 new CTO’s (Sec.17A). But I have also been involved in the extension of CTO’s on 6 occasions (Sec.20A).”

And what of my own personal statistics for the last 12 months? Well, a significant amount of my time as an AMHP continues to be occupied in work relating to Supervised Community Treatment. I was involved in 3 new CTO’s, I extended 4 CTO’s, and was involved in revoking 3 CTO’s. These tasks involve an interview and assessment of the patient each time, involvement in S.117 planning meetings, written reports each time I am involved in a new CTO, or an extension, or a revocation, and frequently the necessity to prepare Managers and Tribunal reports and attend Tribunal hearings.

I’ve just calculated that I have spent 85 hours in the last year on work relating to CTO’s. That’s more than two working weeks. It amounts to a significant proportion of the overall time I spend discharging my statutory functions under the MHA.
Two years ago I posed the question: Are Community Treatment Orders taking over the Mental Health Act? The evidence is increasingly pointing in that direction.

Although of course I am ignoring the increasing time that formal assessments under the MHA are taking in general. What with problems in finding a bed, coupled with increasingly long delays in getting an ambulance, assessments can often take 6 hours or more, especially when you are covering a large, mainly rural area, with hospitals few and far between. However, these latest official statistics cannot cover this area.

The Report makes another, rather telling, statement:
“Detentions on admission to hospital increased in both independent and NHS services during 2012/13. For NHS hospitals there was an increase of 3 per cent since 2011/12 but for independent hospitals the increase was much larger at 13 per cent, although the numbers involved were smaller. A large proportion of this increase was attributable to a 31 per cent (313) increase in uses of Section 2 in independent hospitals.”

This is a continuing trend. The Report for 2011-12 noted: “Total detentions in independent sector hospitals increased by 21 per cent; a large proportion of this increase was attributable to a 45 per cent increase in uses of Section 2.”

Last year, I said that “over the last year it has become not unusual in my fairly rural area to have to travel 50 miles or more to admit a patient to hospital. There have been times when there have been no psychiatric beds at all in the entire region. When this happens, the only alternative is to use an independent hospital, at huge expense, of course. This has in any case tended to be the default for young people under the age of 18, and also for people with eating disorders, for whom there are no specialist Trust beds in the region at all.”

The continuing closures of NHS psychiatric beds nationwide is not surprisingly continuing to increase pressure on Mental Health Trusts to use private hospital beds.

I am finding it difficult to understand how the extensive and prolonged use of extremely expensive private beds does not outweigh the savings supposedly gained by the closure of NHS beds, and the reduction in the numbers of frontline clinical staff who might be able to provide alternatives to hospital admission.

Emergency detentions under Sec.4 (where it is not possible to obtain two medical recommendations) continue to reduce year on year. In 2008-9, over 727 people were detained under this section; last year the figure was less than 400, representing almost a 50% reduction overall.

And what about use of Sec.136 (police detentions for people in “a place to which the public have access”)? Well, there appears to have been a slight reduction in overall use of this power. However, outcomes have not changed: in 2012-13, 82% of the use of Sec.136 did not result in detention under Sec.2 or Sec.3.
Although there are no figures for the numbers of people detained under Sec.136 who are subsequently admitted informally, the overwhelming conclusion to be drawn from these figures is still that the police, who to be fair do not have the training in the identification of mental disorder that mental health professionals have, are still using Sec.136 inappropriately.

Saturday, 19 October 2013

Is the Concept of Informal Psychiatric Admission in Jeopardy? A Commentary on the Current Crisis in Mental Health Beds

"Well, they've finally located a bed. Just need to get an ambulance now."
There has been a gratifying media response to the excellent investigation conducted by Community Care and the BBC into the drastic shortage of acute psychiatric beds across the country. This investigation has confirmed what AMHP’s already know: the cuts in psychiatric beds are leading to unsafe and possibly illegal practices, which are often harming patients.

Around 1,700 mental health beds have been closed since April 2011, which amounts to an overall reduction of 9%. However, the changes to community mental health services which are occurring all over the country, which are often driven by the need to make drastic cuts in budgets, do not lend themselves to a reduction in demand for beds, but rather an increase in the demand for acute admissions.

It was reported that “three-quarters of the 1,711 bed closures were in acute adult wards, older people’s wards and psychiatric intensive care units. Average occupancy levels in acute adult and psychiatric beds are running at 100%, while half are over that and all are above the 85% limit recommended by the Royal College of Psychiatrists.”

Andy McNicoll reports in Community Care about the various ways in which this crisis is affecting service delivery and patient care. These include possibly avoidable patient deaths, the use of expensive private beds, and many examples of inherently poor practice, which can have a seriously adverse effect on patient care and outcomes.

Examples of poor practice include admitting people to a hospital when there is no bed for them, the use of leave beds, premature discharge which then leads to early readmission, and the use of inappropriate beds, such as placing people under 18 in adult wards.
In my own experience, one of my service users, who was a voluntary inpatient in her 40’s, went on home leave. The leave did not go well, and she needed to come back into hospital. However, her bed had been taken by an emergency admission, and she was placed overnight on a dementia ward.

Overcrowded wards lead to stressed staff and poor experiences for patients which in turn leads to slower recovery, and an increase in incidents of violence and exploitation.

It appears that one of the worrying consequences of bed shortages is that preference may be being given to patients detained under the Mental Health Act as opposed to informal admissions, presumably based on the assumption that informal admissions are less urgent.

A report in Community Care in August 2012 (Mental health detention rise amid ‘pressure on hospital beds’) quotes an anonymous AMHP as saying that detention under the MHA is “the only way to get a bed these days.” I have certainly had it said to me on more than one occasion that a bed is only available for patients detained under the MHA. I have had to argue the case forcefully in order to obtain the bed.
There is more than anecdotal evidence of this practice. Michael Knight committed suicide on 28th August 2012, at the age of 20. He was assessed under the MHA, and agreed to be admitted informally. However, there was no bed available anywhere in the county in which he lived. This led to an overnight delay in his admission, during which he killed himself.
The Coroner in the case stated: “The tragedy in this case is the fact that, after having gained Michael’s agreement to accept voluntary inpatient care, a bed was not then available. I am of the view that the situation was then exacerbated by the to-ing and fro-ing which then took place with regard to a bed becoming free, but only for a very short period of time before it was then unavailable.”
It was reported that “following Mr Knight’s death a serious investigation report was compiled, which found that staff followed the ‘right pathways’. It said an acute bed would have been found for Mr Knight if he had been sectioned.” (my italics)
The Mental Health Act is very clear in its views on informal admission. Sec.131 deals specifically with informal admission. Sec.131(1) states categorically:
“Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital or registered establishment in pursuance of arrangements made in that behalf and without any application, order or direction rendering him liable to be detained under this Act, or from remaining in any hospital or registered establishment in pursuance of such arrangements after he has ceased to be so liable to be detained.”
This essentially means that if a patient needs a bed, and they are agreeing to be admitted, then no requirement can be made that they should only be admitted if detained under a Section of the MHA. Any hospital imposing such a condition is therefore acting expressly in contravention of the MHA.
The Reference Guide to the Act devotes a chapter (Chapter 37) to informal admission, and begins by saying (37.2): “Nothing in the Act prevents people being admitted to hospital without being detained, and this is expressly stated in section 131. Compulsory admission under the Act has always been intended to be the exception, not the rule.”
The Code of Practice (Para 4.9) reinforces this: “When a patient needs to be in hospital, informal admission is usually appropriate when a patient who has the capacity to do so consents to admission.”
AMHP’s are legally required to satisfy themselves that detention in a hospital “is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need”, and informal admission is seen as a valid alternative to compulsory detention. Simply because an AMHP concludes that formal detention is not necessary, this does not necessarily mean that the patient does not need to be in hospital.
There is no doubt that hospital beds are expensive. Properly funded community based alternatives, such as Dementia Intensive Support Teams, may not only save money, but also provide patients with appropriate support in their own homes, and minimise disruption to them. Many Mental Health Trusts are relying on allegedly improved and enhanced community based crisis services to obviate the need for more hospital beds, and to justify a reduction in beds.
But there is a problem with this. I have been working in the mental health field for long enough to remember the plans in the 1970’s and 1980’s to close the long stay hospitals in which people with mental illness and learning difficulties would spend many years.
These plans were admirable. These asylums were mostly daunting and depressing Victorian edifices, deliberately built away from communities, and institutionalised the hapless inmates. Most of the inpatients didn’t need to be there, but there were few alternative community services. I was involved in a small way in moving some of these patients into the community myself when I started out as a social worker in the 1970’s.
The problem, however, was that community services were supposed to be funded with the money saved from closing the hospitals, but they had to close the hospitals first in order to get this money. It was like having a plan to buy a cow with the money raised from milking the cow. You had to have the cow first, but you couldn’t get the cow until you had sold the milk the cow would provide. Mental Health Trusts appear to be trying to pull off the same trick.
The now long defunct Mental Health Act Commission, in their Biennial Report for 2003/05 (p.204), advised:  “ In our view… the focus on establishing community interventions to keep patients from hospital admission must not blind us to the continuing need for inpatient care that patients will enter and reside in voluntarily”. That statement still holds today