Wednesday, 19 October 2011

Are Community Treatment Orders Taking Over the Mental Health Act?

There have been a couple of interesting publications released in the last month relating to Community Treatment Orders. One was the annual Government statistics for the use of the Mental Health Act, which includes detentions and discharge under Supervised Community Treatment (In-patients formally detained in hospitals under the Mental Health Act, 1983 – and patients subject to supervised community treatment, Annual figures, England 2010/11). This relates to the second full year’s activity for CTO’s.

What a clear and easy to follow publication this is! It even begins with a concise and easy to understand analysis of the figures. And what these figures show is the full impact that the introduction of Supervised Community Treatment (Sec.17A) in 2007 has been having on general uses of the MHA.

I can’t paraphrase the summary any better than the report itself, so I will quote directly:

“Although the total number of formal admissions to hospital and the number of new Community Treatment Orders (CTOs) decreased between the 2010/11 reporting period and the previous one, the overall number of people subject to the Mental Health Act [this includes formal detention in hospital as well as CTO’s] at 31st March increased by 5.0%, from 19,947 in 2009/10 to 20,938 in 2010/11. This increase can be attributed to a rise by nearly a third in the number of people on a CTO at 31st March.”

On the face of it, the figures seem contradictory; for example, the total number of formal admissions decreased by 2.2 per cent, and yet the number of people detained in hospital at 31 March increased by 0.2 per cent. This, however, can be attributable to a rise in the number of CTO recalls, two thirds of which were then revoked. The underlying Sec.3 then comes back into force.

The report also observes that “the number of people on CTOs at the end of the year rose, even though the number of new CTOs made during the year reduced. This was due to the number of new orders made being greater than the number of orders from which people were discharged: 3,834 new CTOs were made in 2010/11 and 2,185 orders were closed.”

The report states that admissions for treatment under Section 3 fell by 14.4 per cent. This can also be attributed to the rise in the use of CTO’s, as they mask the true use of Sec.3, since in essence the detention under Sec.3 is merely suspended by the CTO, and can be reinstated when a CTO is revoked without a fresh formal assessment.

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.

At least part of the reason for this can be found in a study recently published in The Psychiatrist, which looked at the views of psychiatrists relating to CTO’s (Community treatment orders in England and Wales: national survey of clinicians’ views and use, Manning et al, The Psychiatrist (2011), 35, 328-333).

This study found a considerable popularity for the use of CTO’s among psychiatrists, despite an initial reticence before the new powers came in. The research found that “clinical reasons were rated as being more important in decision-making than ethical or bureaucratic concerns. For example, the most important factors in initiating an order were considered to be promoting adherence to medication, protecting individuals from the consequences of relapse, and ensuring contact with health professionals.”

AMHP’s may find this more than a little alarming, as an AMHP must consider the ethical implications, and must also necessarily ensure adherence to due legal procedure. However, the study does conclude that:

“There remains considerable disagreement and uncertainty regarding the clinical usefulness of CTOs. It is important that clinicians are mindful of this. They should seek multidisciplinary input when making such fundamental treatment decisions in the face of enabling legislation, a lack of evidence, and (perhaps more challengingly) a lack of professional consensus or guidance. Multidisciplinary discussion and decision-making should reduce variability in the use of compulsion.”

In my post back in January this year (Community Treatment Orders and the Role of the AMHP) I looked at the previous years’ figures and concluded “since CTO’s are often being kept in place for a year or more, this could mean a growing accumulation of patients in the community on CTO’s.”

Both the new figures, and my own personal experience of CTO’s, bear this out. Back in January, I had only been professionally involved with CTO’s on two occasions. However, in the last 12 months, I have endorsed 5 CTO’s, 3 extensions (Sec.20A) and 2 revocations (Sec.17F(4)). Additionally, I have frequently been involved in multidisciplinary discussions of patients detained under Sec.3 in which discharge under SCT has been mooted, where it seems likely that more people currently detained under Sec.3 will be discharged on Community Treatment Orders in the future.

As I have said before, the AMHP role can be very quick and easy to discharge legally – you do not actually have had to interview the patient or Nearest Relative, and it is not even a formal requirement to provide a report, although at least the CQC are now promoting this as best practice. I would say that that is all the more reason to exercise diligence and best AMHP practice when a request is being made for a CTO, or an extension or revocation.

Of course, a consequence of that is for assessments for CTO’s to become drawn out processes occupying a lot of AMHP time. One recent example of this was when I received a request to endorse a CTO for a patient with learning difficulties who was detained under Sec.37 MHA (by the courts), following the commission of a serious sexual offence. He had been detained in a secure hospital for several years, during which time he had been provided with an extensive sex offenders’ treatment programme. It was now felt that he could be managed out of hospital, and a bed in care home had been identified.

Since I knew nothing about this patient other than the bare bones, and in view of his serious forensic history, I felt that it was necessary to make a thorough examination of his medical and nursing notes. This entailed a visit to the hospital, and an afternoon closeted away in a side room working through his very extensive files. In particular, I wanted to know precisely what the nature and degree of his mental disorder was, as well as the treatment he had received, the progress he had made, and the plans for his aftercare on discharge.

I then attended the hospital again to interview him and for a CPA/Sec.117 review meeting. This was a useful, although gruelling, meeting, as the prospective community Responsible Clinician was present, as well as the clinical psychologist, hospital psychiatrist and nursing staff who had been treating him, and the Nearest Relative of the patient. We concluded that it was appropriate for him to be discharged on a CTO, and the hospital RC and I then completed the paperwork together.

The entire process had taken me around 10 hours, including two visits to the hospital and a written report, but I felt that professionally it was necessary.

Another consequence of the increase in the use of CTO’s is the additional and unavoidable burden of work on the AMHP, or the patient’s care coordinator. Although I have not yet come across a patient who has appealed against their CTO, what I have been discovering is that imposing a CTO (which lasts for 6 months), and extending a CTO (which would initially be for another 6 months), can lead to automatic referrals to the hospital managers, the Tribunal, or both. This of course then entails the necessity to interview the patient, to consult with the Nearest Relative, and to write a report, followed by mandatory attendance at a Managers Hearing or Mental Health Tribunal.

These Hearings and Tribunals themselves can be rather surreal. What I am finding is that patients who are offered the chance to leave hospital and return home, as long as they accept being on a CTO, are unlikely to object to this. Once they are have been discharged home, they are also fairly unlikely to want to return to the hospital in order to attend a hearing.

One patient I was involved with explicitly stated that she wanted nothing to do with the hearings that had been arranged for her, and neither did she want a legal representative. This resulted in attending a Managers Hearing where only the 3 hospital managers, the hospital Psychiatrist and I were present. The hearing lasted all of 15 minutes.

The subsequent Tribunal consisted of the community Responsible Clinician, the three Tribunal members, and I. This lasted for a full 30 minutes, at the end of which the Tribunal members looked at each other, then at us, and gave their decision without an adjournment. Considering that the average length of a Tribunal for an appeal against Sec.2 or Sec.3 is well over 2 hours, the RC and I were somewhat taken aback.

We are now 6 months on from these latest figures, and so far I have not seen enthusiasm in the use of CTO’s waning. I await the figures for 2011/12 with interest.

Friday, 7 October 2011

Origins of the Masked AMHP Ep. 2: Seebohm, London Overspill – and Quaint Country Pubs

Part Two of an occasional series

One Monday morning in the early autumn of 1976 I turned up for work at Charwood Social Services Department, along with 3 other people who had also succeeded in getting jobs as unqualified social workers in Charwood.

This post may turn into something of a history lesson for my younger readers, as social services provision was very different 35 years ago. In 1974, only two years before I started work as a social worker, there had been a huge national reorganisation of social care provision, precipitated by the Local Authority Social Services Act 1970. This in turn had been inspired by the Seebohm Report, published in July 1968, which had proposed the integration of disparate social care services into single, generic departments overseen by local authority social services departments.

Until then, social care had been administered in a range of guises. For example, mental health had Mental Welfare Officers, defined by the Mental Health Act 1959. Services for children and families had Children’s Officers. Hospital social work was done by Hospital Almoners. In 1974, all these people were moved into these generic departments, and all became known as “social workers”.

Most of the people already working in Charwood area office had come from these areas. Most of them either had no formal qualifications, or had qualifications in their specialist areas. When I started there were only one or two staff in the entire team of more than 20 who had actually formally trained and qualified as social workers.

The area office dealt with everybody in the community who had a social care need: children and families, the mentally ill, people with learning difficulties (who were then known as “mentally handicapped”), people with physical disabilities, the elderly, and people with sensory impairment (although they were then formally known as blind, partially sighted or deaf).

As a generic social worker, I was expected to have a caseload with a mixture of all these people.

We had comparatively little to do in the first couple of days: we had a brief induction process, to explain administrative procedures: the filing system, methods of recording, and so on. The expectation was that all contacts with service users would be written by hand and then given to the large team of typists, who would then type it onto contact sheets, which would then be filed.

Within a couple of days, however, I was sitting in with the duty officer, whose job it was to take any calls relating to enquiries or requests for services from any source, and to see and interview anyone who walked into the department requesting help. After a morning of this, during which I sat in on several interviews, ranging from a request to have a home help for an elderly relative, to a young mother saying that she couldn’t cope any more and wanted her children “taken into care”, the social worker decided I had accumulated enough experience to field a call, and the next time the phone rang she told me to answer it.

My bowels immediately turned to water. I broke into a sweat as my shaking hand reached for the ringing phone. Everything suddenly seemed to go into slow motion.

“Hello, can I help you?” I asked with a quavering voice.

Thankfully, it wasn’t a service user. It was a doctor, asking for one of his elderly patients to be assessed for Part III accommodation. I had picked up in the previous couple of days that “Part III accommodation” meant a local authority old people’s home, so that didn’t phase me. I took down the details of the person and told the doctor we would arrange to see her. I had successfully managed my first duty call!

Charwood social services catchment was very varied. It covered a geographical area about 20 miles in diameter, which included Charwood, as well as a couple of small market towns and a lot of villages. About half the population lived in the villages and small towns, and the rest lived in Charwood. The main problems for people outside Charwood related to age and infirmity. Charwood itself, however, was quite different.

In the 1960’s through until the late 1970’s, the Greater London Council embarked on a massive social housing building programme in existing towns outside London, as well as encouraging the creation of new towns such as Milton Keynes. Businesses were encouraged to relocate to these towns, taking their employees with them. Charwood was one of these London Overspill towns.

It meant that Charwood had a very unusual demography for the county in which it lay. Charwood had increased in size from a population of about 4,000 in the 1950’s, to approaching 20,000 by the mid 1970’s. Most of this increase consisted of families with children, who had all moved from the London area, and who all had jobs in the relocated light industries, since the requirements for obtaining one of the new GLC houses was that you had to live in a London borough, and you had to have a job in Charwood.

Since I met these requirements, I was entitled to one of these houses, and for the first year I lived on one of the largest of the new GLC housing estates. As Charwood Social Services Department was in the old site office of that estate, I did not have far to go to get to work.

We four rooky social workers were sent on a three day residential induction course. The course took place in a convent in a very rural area of the county, where the nuns provided home grown and home cooked food, a venue and sleeping quarters. There were around 40 on the course, as the county had been engaging in a massive recruitment programme.

(Back in those days training departments had reasonable budgets, and courses were frequently regarded as a perk of the job. Residential courses, often in very pleasant country hotels, were not unusual. Nowadays, you’re lucky if a course provides free coffee.)

During the course we learned about the organisation in which we were employed, the nature and philosophy relating to generic social work, and the basics of the different client groups we would be serving.

However, the main thing about the course that I remember now was the vast difference between life in the London Borough I had moved from and life in the rural county in which I now lived. This was exemplified by the pub a group of us found in the nearby village one evening.

The village itself was charming, consisting mainly of thatched cottages around a large village green. We had been told there was a pub in the village, but we could not immediately identify where it was. There was no inn sign to be seen anywhere. We trooped past one charming cottage after another, none of which looked remotely like pubs, until we came to a double fronted detached farmhouse. We noticed above its unremarkable 30’s style front door that there was a statement saying that Miss Enid Abbs and Miss Hilda Abbs were licensed to sell alcoholic beverages for consumption on or off the premises.

We tried the door, and it opened onto a narrow corridor, lit by dim ceiling lights covered by ancient lampshades, at the end of which was a half door with a small counter attached to it. There were doors on either side down the corridor. We looked in one, and found an entire extended family, ranging from elderly grandparents to small infants, all sitting round a large table containing several glasses containing alcoholic beverages which took up most of the room, watching a TV perched high up in the corner on top of a cabinet. Another door opened into a room where several men were playing a range of pub games, including dominoes, darts and shove ha'penny. They all stopped what they were doing and stared at us in silence until we closed the door again.

We eventually reached the half door at the end and realised that this was what passed for the bar. Beyond was basically a kitchen, with a stone sink in one corner, a row of beer and cider barrels ranged along the back wall, and a counter in another corner containing a range of bottles of spirits. An elderly lady, who must have been one of the Miss Abbs, smiled at us and asked us what we would like to drink.

Once our orders had been taken, she told us to go through another door, and that she would bring us our drinks. The small room was unoccupied. Ancient bench seats were ranged around the walls, and the middle of the room was again occupied by a large table. A small coal fire burned in a grate. Once we were seated, she brought through our glasses, along with several large jugs of beer freshly drawn from the barrel.

We got a kitty going in the middle of the table, and then set to work on transferring the contents of the jugs into our glasses. The old lady periodically checked the jugs, removed the empty ones and replaced them with brimming ones, taking the appropriate amount of money from our kitty as she did so. What a splendid arrangement.

I decided that I was going to enjoy working at Charwood.

Next time: Learning the ropes as a generic social worker: my first home visit. I get a caseload!

Saturday, 1 October 2011

The Masked AMHP makes it into the Guardian!

The Masked AMHP has had a short piece published on the Guardian website in their new Social Care Network. Based on my recent post about my pre social work career, you can find it here.