Thursday, 27 December 2012

When Service Users Seek to Deceive, Part I

Reconstruction by actors. The Masked AMHP is being played by the woman at the back

(Before reading this cautionary tale, I want to make clear to readers that this post is in no way intended to imply that people on benefits are scroungers. Quite the contrary – most mental health service users that I know who are reliant on benefits would dearly love to be able to do a meaningful and adequately paid job, but are prevented from doing so by their mental health problems. Many feel deeply ashamed that they are no longer able to work and are forced to rely on benefits. Cutting the benefits of people with disabilities will not spur them on to work; it will only serve to exacerbate their problems.)

As a social worker, it has always been my basic approach with service users to believe what they tell me, unless and until I have evidence to the contrary. Having worked with many people over the years with a history of childhood sexual abuse, many of whom were doubted when they disclosed as children, I know that it is of vital importance to them to be believed.

That does not mean I am gullible, but I am prepared to keep an open mind and apply the Evidence Test. The Evidence Test is simple and straightforward – is there any evidence which contradicts what a person is telling you?

I remember visiting an old lady who told me that her living room had been full of girls singing and dancing the previous evening. She said that they had then all disappeared into a hole in the wall – directly behind her TV. Before coming to the conclusion that the lady was suffering from dementia, and was no longer able to differentiate reality from television, I had a look behind the TV just in case there was, indeed, however unlikely it may seem, a hole. There wasn’t.

There was another unfortunate old lady who lived in Charwood, who was detained under the MHA and admitted to hospital after repeatedly reporting the existence of strange noises in her old terraced cottage. Following her admission, her community nurse arranged to collect some personal effects from her home. She entered the cottage and was disconcerted to hear loud noises emanating from somewhere within the building. It was eventually traced to her next door neighbour, who had decided to convert his cellar into accommodation, and in the process had extended his own cellar by knocking into the space beneath the old lady’s home.

So I initially had no reason to disbelieve Brenda.

Brenda was referred to Charwood CMHT by her GP. The letter catalogued the terrible experiences she had had at the hands of her abusive husband who, even after she had left him, had continued to stalk and harass her and had even broken into her house and raped her on one occasion.

The consequence of this was that Brenda was afraid to leave her house. She had difficulty sleeping, and reported frequent flashbacks to her ordeal. She was afraid of being alone, and only slept with the light on. She reported a full house of symptoms of post traumatic stress disorder.

I worked with her for several months. One of the first things I did was to help her make a claim for Disability Living Allowance. I was surprised when she was turned down for this, and helped her to appeal.

I put quite lot of work into this. She had a neighbour, who was often at her house when I visited, who had told me the extent of the help she had had to provide Brenda, as she lived alone, and had no supportive relatives. I typed up a detailed account of the daily assistance she provided Brenda, which included encouraging her to eat properly, taking her to appointments, and even going round to her house in the night when Brenda was too frightened to sleep. I sent this statement off with the appeal documents, and arranged to take Brenda and the neighbour to the appeal and to act as her advocate.

The members of the Appeal Tribunal were sympathetic, and awarded Brenda DLA at the lower rate of care and mobility. It was backdated 9 months. I was as delighted as Brenda, and felt I had done a good job.

A few months later, Brenda had more problems with benefits. This time, she told me, she had had her housing benefit suspended because of an anonymous tip off that she was fraudulently claiming. Someone had told the district council that she was working. She suspected that it was her ex-husband.

I again offered to write a supporting letter for her.

A week or so later, she told me that she had been summoned to an interview, under caution, at the local council offices, in connection with these allegations. I offered to attend with her as an appropriate adult.

We went into the interview room and the investigating council officers began the formal interview.

The basic charge was that she had fraudulently claimed housing benefit for a number of years while working full time, and that she had not disclosed her earnings, or the existence of bank accounts into which these earnings had gone, to the council.

Brenda denied these charges.

The interviewers listened patiently.

Then the main interviewer opened up a large dossier and began to show Brenda some documents. Was this her bank account? Yes. How did she account for regular sums of money going in on a monthly basis, of around £1000 per month? She didn’t know what the money was for.

The interviewer showed Brenda the payrolls of several different employers. Was this her name and address? Yes, it was. Was this her National Insurance number? Yes, it was. Was this her signature on the forms? It looked like her signature. Was the employee therefore Brenda herself? No it wasn’t. It must have been someone who had used her name and address. Was it same person who had then arranged for her monthly pay to be deposited in Brenda’s bank account? It must have been. And this person was not, in fact, Brenda? No, it wasn’t.

It was becoming blindingly clear to me that Brenda had, indeed, been systematically claiming housing benefits and other benefits fraudulently for several years, and that I had been an unwitting accomplice in this.

In the car on the way home, Brenda continued to maintain, in the face of overwhelming evidence to the contrary, that she was entirely innocent. I couldn’t look at her. I dropped her off at home and advised her to consult with a solicitor. I said I would be in touch.

After consultation with my manager, I wrote to Brenda to say that Charwood CMHT would be discharging her from the service, as we could only work with people with mental health problems. I never saw her again.

Wednesday, 12 December 2012

Get the Masked AMHP™ App This Christmas!

Just in time for Christmas, the Masked AMHP™’s extensive team of Tech guys have completed the brand new, shiny and indispensable Masked AMHP™ App!

One of the Masked AMHP's Tech guys

Crammed with useful tools for the busy Approved Mental Health Professional, you won’t know how you ever lived without it!

The Masked AMHP™ App comes preloaded with a fully searchable database consisting of the Mental Health Act 1983, the Code of Practice and the Reference Guide, as well as all the associated Statutory Instruments! Wahey!

The Masked AMHP™ App also has a fully searchable database of ALL the relevant case law associated with the MHA and the Human Rights Act! Woohoo!

But that’s only the beginning!

Once you’ve downloaded The Masked AMHP™ App onto your mobile device it will solve ALL your AMHP problems!

Section 2 or Section 3?
You’ll never be stumped by this conundrum again! Just point your mobile device at the patient, and it’ll automatically identify which section you need to use. The Masked AMHP™ App will then autocomplete the Section forms and wirelessly transfer them to the nearest printer!

Never fear making an error in discerning whether or not the Mental Capacity Act might be preferable! The Masked AMHP™ App will make the decision for you!

Is the patient Mad or not?
Simply point your mobile device at the patient, and The Masked AMHP™ App will automatically identify whether or not the patient is mentally disordered! (Warning: Still in Beta stage)



Who is the Nearest Relative?
Simply input a list of suspects into your mobile device, and The Masked AMHP™ App will instantly identify who the nearest relative is, and will then autocomplete the section form with a cast iron reason why it was impracticable to consult them! Guaranteed to stand up in Court!

Where’s the nearest hospital bed?
Using advanced GPS technology, The Masked AMHP™ App can instantly locate a vacant bed anywhere in England or Wales! Even the ones the bed managers are hiding!

Problems getting a Section 12 Approved Doctor?
The Masked AMHP™ App can not only identify which local Sec.12 doctors are available, but will also text them with an irresistible reason why they need to attend! Even when they’re on holiday, or simply can’t be arsed!

Tormented by ambulance delays?
The Masked AMHP™ App can hack into your local Ambulance Trust’s system and place your request at the top of their priority list! Simply input an address and postcode and an ambulance is guaranteed to turn up within 15 minutes!

All this and even more!
  • Nurse AMHP’s, OT AMHP’s, Social Worker AMHP’s – who’s the best?
  • X Factor or Strictly Come Dancing?
You won’t know how you ever lived without The Masked AMHP™ App!

 What people have said about The Masked AMHP™ App:

“Now why didn’t I think of that?” Mark Zuckerberg

“Now why didn’t I think of that?” Bill Gates

“Now why didn’t I think of that?” Richard Jones

Tuesday, 4 December 2012

On Being Observed While Doing Your Job

The Masked AMHP (in a suit) attempting to interview in a suitable manner -- with hilarious results. Publicity shot from the stage production of "Ooer, Missus, It Shouldn't Happen to an AMHP!" 

Every five years, AMHP’s have to provide evidence to their local authority of their competence to continuing practicing. One of my local authority’s recent mandatory requirements for being reapproved in the role of Approved Mental Health Professional is to be critically observed and assessed while actually undertaking a live Mental Health Act assessment. Scary or what?

Although there are many professions who are often in the public eye while doing their jobs (teachers,  police officers and nurses to name just three), AMHP’s are possibly more closely scrutinised while performing their duties than most.

A typical MHA assessment in someone’s home, as well as the patient, of course, can easily include two doctors, two or more police officers, a couple of ambulance crew, the nearest relative, and the patient’s care coordinator. There can also be an AMHP trainee shadowing the AMHP, and possibly even students from other professions. That’s a possible total of 11 or even more. And some of them may be fairly hostile to the AMHP’s role, especially if they’ve formed their own lay assessment of the situation.

While Mental Health Cop on his blog is valiantly attempting to educate his colleagues on the law relating to people with mental disorders, police officers nevertheless often find it difficult to understand the factors that AMHP’s legally have to take into account when assessing a patient for possible compulsory hospital admission. And ambulance drivers and paramedics often have alarmingly little knowledge which they are then very keen to exercise.

The nearest relative or other carers will frequently be experiencing a range of distressing emotions, and whatever decision you make may be a source of additional distress to them. They may be reluctant to recognise that their relative needs to be admitted to hospital. They may be upset by a decision to admit, as it means acknowledging that they can’t cope with the behaviour of their loved one any more any longer. Equally, they may be upset by a decision not to admit.

All of this means that AMHP’s often have to explicitly articulate the process of assessment to others, almost in the way that a surgeon may narrate a procedure to medical students and other junior staff in the operating theatre.

This is, of course, no bad thing. A vital part of the AMHP role is to know at all times what one’s legal powers and responsibilities are, and to be able to explain this to all others involved in the assessment in such a way that it can be clearly understood.

The patient needs to know why you are there and what you are doing; the nearest relative needs to understand their specific role as the NR within the meaning of the MHA; and you may need explain to ambulance crews and police officers what their legal powers and obligations are in assisting the AMHP to manage the overall process.

And when the assessment has been completed, the AMHP has to write a formal report on the assessment in which they will need to justify their actions and decisions in case of future challenge.

After a while, stage fright can be overcome, and the AMHP can perform their functions with quiet competence. Being a still point of confidence and calm in the midst of chaos and fear can be of enormous importance.

Nevertheless, there are few professions who are subject to a formal assessment of their competence in such a live situation. Teachers are one such profession, as they have to teach a class in front of OFSTED inspectors when required, with hardly any notice.

Being shadowed by a student or trainee AMHP is something I actually rather enjoy. It keeps me on my toes, it makes me think very carefully and explicitly about why I do what I do and why I make the decisions I do. Trainee AMHP’s in particular are good at asking awkward questions during the subsequent debriefing (Why did you do that? Why did you say that? Wouldn’t it have been better if you’d done so and so?)

So the day came when it was planned that one of my AMHP colleagues would shadow me while doing a MHA assessment. We sat together in the AMHP office, where the day’s duty AMHP’s sit and wait for referrals to come through. And a referral did indeed come.

Aaron was a 19 year old young man who lived with his parents. He was a patient of the Early Intervention in Psychosis Team, as he had presented a few months ago with the first symptoms of psychosis. But he also had marked autistic spectrum traits. He had been fairly well controlled with an oral antipsychotic, but because of side effects, the dose had been reduced, and his behaviour had become more disruptive and difficult for his parents to manage.

His mother had taken him to see his GP, but he had become anxious and agitated and had run out into the street, ignoring traffic and potentially putting himself at risk. The police had been called, who quickly apprehended him, and because of his continuing behaviour in the police car, during which he almost succeeded in climbing out of the window and onto the roof of the moving vehicle, he was taken to the S.136 suite.

And that was where he was on referral.

From the moment of taking the call, I was being observed and assessed. My actions and decisions were being constantly monitored – arranging for a Sec.12 doctor to attend, speaking to the patient’s mother and establishing which of the parents was the NR for the purposes of the MHA, consulting with the Early Intervention Team to get background information, and scanning the patient’s electronic notes.

My AMHP observer, the Sec.12 psychiatrist and I went together to the S.136 suite, where two police officers and his mother were with the patient.

I explained to Aaron what my role was and what tasks I had to undertake. He stared at me fixedly, then as soon as I had finished said, “Can I go home now?”

This was a frequent response to questions I asked him throughout the assessment. He appeared to have only limited understanding of the reasons for his detention and the purpose of the assessment, despite my attempts to explain this to him. Throughout the assessment he maintained fixed eye contact and displayed no facial expression or emotion, although there was implicit evidence of agitation and anxiety. However, he was unable to verbally acknowledge or express this.

He was very guarded during the assessment and was reluctant to discuss any possible psychotic phenomena. He often only answered questions with yes or no answers, and had difficulties with open questions. He eventually said that he had left the doctor’s surgery because he had been disturbed by the doctor’s use of the computer, but refused to enlarge on this. He said that he was willing to take medication and willing to engage with the EIT or the CRHTT if considered necessary. His preference was to return home.

So what would my decision be? I needed to use the information I had obtained, combined with the consultation with the patient, and with his mother.

The Early Intervention Team told me that Aaron had been considered a few weeks ago for compulsory detention, but they had concluded that he could be managed by them in the community. They had also concluded that in view of his autistic spectrum traits, admission to an acute psychiatric ward would be likely to make him worse, and increase his anxiety and agitation. They told me that they would be happy to continue with this plan.

His mother, on the other hand, was concerned about her ability to stand up to Aaron’s demands on her, and worried about how to respond if for example he went off on his bike. However, she did concede that he was capable of cycling from their village into Charwood, where he would go into shops or go to the library. Although she was not prepared to say it openly, I could tell that she would rather he was admitted to hospital.

The psychiatrist was doubtful that compulsory admission was indicated. The discussion with him was helpful. In conjunction with the psychiatrist, the Early Intervention Team, and Aaron and his mother, a short term plan was constructed.

Aaron would not be admitted to hospital. The psychiatrist recommended a change to his medication, and he was also given some diazepam that his GP had prescribed. The Early Intervention Team would increase their input in the short term. The psychiatrist spoke to the GP on the phone in the S.136 suite and faxed his assessment and recommendations to the surgery.

This plan would be open to constant review, and it was made clear to Aaron that if his mother felt unable to manage his behaviour, then a further assessment would become necessary.

Aaron and his mother went home. The police officers vacated the S.136 suite. My observer and I returned to the AMHP office for an in depth debrief. And of course, I had my assessment report to write.
At the end of it all, it felt quite satisfying. I had quite enjoyed the experience of being formally assessed. It was all part of the job.

Tuesday, 27 November 2012

On Inappropriate Mental Health Act Requests

All AMHP’s will be familiar with being asked to do assessments under the Mental Health Act when it is not appropriate, but is motivated by the desire on the part of the caller to pass the buck. They might, for example, receive a request to assess an elderly person who actually just needs residential care, not a hospital admission, or to assess someone who is in emotional distress, where the professional involved with them is uneasy about leaving them over the weekend and just wants to relieve themselves of the responsibility.

Sometimes, it is possible to avoid a formal assessment. But at other times, you soon realise that, whatever the likely outcome, you’re going to have to go out and do a face to face assessment.

Back in the days when I did out of hours social work sessions, I was on duty one Saturday evening when I received a rather agitated call from the police.

They had a “situation”. They were asking for a MHA assessment to deal with it. They had earlier taken a call from Mike, the partner of Bella, because Bella had threatened to cut her wrists if he left the house. Mike was on police bail having assaulted Bella, but had been to see their six week old baby. The problem was that he would be in breach of his bail conditions if he did not leave, and stayed overnight.

When the police attended, they became embroiled in a domestic situation which did not seem to have an immediate solution. Mike wanted to leave, but Bella wouldn’t let him.

The police could not arrest Mike, as he had so far done nothing warranting arrest, and neither could they arrest Bella.

Bella had a considerable history of involvement with mental health services with depression, having had a couple of inpatient spells following suicide attempts, and had been receiving considerable support from mental health services, which in the past had included periods of 24 hour domiciliary care. She currently had regular visits from a domiciliary support worker in connection with the baby.

However, they could not detain Bella under Sec.136, as she was not in a public place. So they requested a formal assessment under the MHA.

It was further complicated by the presence in the house of a three year old child as well as the six week old baby. Removing the mother would raise considerable difficulties about who was to care for the children, especially the baby. In the circumstances, Mike was not an appropriate person to care for the baby, and the three year old was not in any case his child.

It became apparent that the only appropriate response as an on call social worker was to attend to make my own assessment.

The police were relieved to see me. So relieved, that they left almost immediately, despite me asking them to stay while I attempted to find a solution to the problem.

I decided to try to interview the two of them separately, but Bella was very reluctant to do this.

“He’ll leave the house if I let him out of my sight,” she said. “And then I’ll kill myself.”

“But I’ve got to go, or I’ll get arrested,” Mike pleaded.

“But you can’t leave me. I can’t live without you.”

Bella threw herself at Mike, who pushed her away and raised his fist. Bella seemed to be provoking him to hit her, but to his credit, he turned away, obviously distressed.

“I have to make a proper assessment,” I said. “I need to speak to both of you, but not together. Otherwise, we’ll just go round and round in circles and get nowhere. I have to be sure that both you and the children are going to be safe.”

“Leave the children out of this!” she screamed. “You’ll take them over my dead body!”

“I’m not proposing to take your children away, that’s the last thing I want to do, but I do need to make a proper assessment.”

I did eventually get them to agree to go into different rooms, and Mike promised he wouldn’t leave until I had completed my assessment.

With Mike out of the room, Bella slowly began to calmed down. She told me something of her mental health history, and talked about her fears that she would lose Mike because she had not been feeling like sex since her depression. I saw that she had cut her forearm, although it was only superficial.

She spoke to me of her feelings of inadequacy with looking after her new baby, feeling that she wasn’t a good enough mother. It became clear that this was at the root of her unwillingness to let Mike go, despite his violence towards her. I tried to reassure her, and gradually she relaxed and became less anxious.

I then talked to Mike on his own. He was in turmoil. He wanted to leave, but feared that Bella would harm herself. She had cut herself in front of him, and he had never encountered anyone deliberately self harming before. He couldn’t understand it, and that made him afraid – both for Bella and for his baby.

“Look, Mike,” I said. “Bella’s much calmer now, I suggest you leave now, while you’ve got the chance. I’ll see to Bella.”

I saw him out of the house, and heard him drive away.

Bella also heard him, but by the time she came out of the room she was in, he had gone. I persuaded her to make a cup of tea, and as we talked together, her anxiety subsided again. It became clear that she had a good relationship with her baby and older child, who were both blissfully asleep upstairs, and oblivious to the drama going on downstairs.

As we talked, Bella recovered some of her own confidence in herself, and began to make plans for both the immediate and the longer term future. I encouraged her to do this, and her mood began to brighten. She even managed a couple of smiles when talking about her children.

I was feeling increasingly confident that not only did Bella not require hospital admission, but that she was capable of caring for her children. Additionally, I was aware she was having a visit from a domiciliary care worker the following day, which would provide monitoring until normal office hours on the Monday.

I began to inwardly congratulate myself on having averted not only a detention to hospital under the MHA, but also the prospect of having to find a foster placement for a three year old toddler and a six week old baby late on a Saturday evening.

Then I heard a car pull up outside. Was it the police, coming back to check how things were going?

I went outside to investigate, and to my horror saw that Mike had returned. As he got out of the car, I asked him incredulously, “Why have you come back?”

“I wanted to make sure Bella and the kids were OK,” he said.

I found this hard to believe. I could only think he was somehow trying to stir things up some more. Perhaps he did not like feeling that Bella wasn’t, after all, entirely reliant on him.

At this point, Bella came out of the house. All her insecurities became reactivated.

“Don’t go, Mike, stay with me. I need you,” she pleaded.

“No, I can’t stay, I’ve got to go,” Mike replied, making a move to get back into the car.

Bella flung herself onto the bonnet of the car as he revved the engine.

“Don’t go, don’t go,” she repeated.

“I’ve got to go, I’ve got to go,” he yelled out of his window.

This was rapidly turning from pathos to bathos. I had to take control of the situation. Desperate measures were required

“Right,” I said, “It’s becoming apparent to me that you’re both clearly unable to look after your children. I’m going to have to get the police back, and they can make a Police Protection Order and take them to a place of safety.”

Bella was horror struck. She removed herself from the car bonnet and came towards me, pleading with me not to get the police. This gave Mike an opportunity to leave again, which thankfully he did.

 “Come on, Bella,” I said firmly but gently, “Let’s get back inside and check that the children are OK.”

 I stayed another half hour or so, mainly to make sure Mike did not decide to “check up” on Bella again, and when I was convinced that Bella was again calm and composed, I left.

Neither Bella nor the children came to any harm.

Thursday, 15 November 2012

The Abandoned Illness – the Schizophrenia Commission’s Report

The Schizophrenia Commission published their report on Schizophrenia and psychosis yesterday (14th November 2012). You can find the full report here.
It's a pretty scathing report. It lays bare the devastating effects on individuals experiencing this illness in the social, health and economic spheres. It finds that “people with severe mental illness such as schizophrenia still die 15-20 years earlier than other citizens”. It notes that “only 8% of people with schizophrenia are in employment”. Despite schizophrenia and psychosis costing society £11.8 billion a year the commission found “a broken and demoralised system that does not deliver the quality of treatment that is needed for people to recover.”  The report notes that “mental illness accounts for 23% of the disease burden in England, but gets only 13% of NHS resources.”
None of this comes as a surprise to professionals working in the mental health field. The report comes at a time when many mental health trusts are having to “reconfigure” services (a euphemism for devastating cuts in staff and resources, which have been necessary because of the year on year reductions in the budgets being doled out by central government.). One of the innovations the report praises are the creation of early intervention teams, specialist teams who focus on treating emerging psychosis at the earliest signs – but at the same time it observes that these same teams are being cut back in these trust “reconfigurations”.
The report also expresses concern about the increasing numbers of people treated under section, “partly because they delay seeking help until they are at crisis point. Levels of coercion are on the increase too, with a 5% increase in detentions under the Mental Health Act in 2010/2011 over the previous year.” (And it’s not getting better -- for the year 2011-12 there was a 6% increase.)
It notes too that “too much is spent on secure care – £1.2 billion or 19% of the mental health budget last year – with many people staying too long in expensive units when they are well enough to start back on the route to the community”. These people will be of course inevitably be detained under various sections of the MHA.
The commission unfortunately sees current and future changes in legislation continuing to adversely affect the prospects of people with serious mental illness. I have written here and elsewhere about my concerns about the suitability of the Work Capability Assessment when applied to people with mental illness. The commission makes it very clear that it is “not fit for purpose for people affected by mental illness and is in need of reform. The design of the assessment does not accurately identify the barriers they face in a working environment. There is also a low level of mental health expertise amongst assessors. Schizophrenia and psychosis can make it more difficult to complete the application and assessment process. Sadly, therefore, some of the most vulnerable claimants are potentially being excluded from the support they are entitled to.”
I wrote in the Guardian some months ago about my own experiences of accompanying people to these assessments, where it was quite apparent that the assessors often had no knowledge or understanding of mental illness. I found myself having to explain that paroxetine was an antidepressant, and the assessor only showed any interest in the assessment when the service user mentioned that he had a bad back – within seconds they had him on an examination table, manipulating his spine to see if he was experiencing any pain. But this was not the disabling condition.
The commission recommends “that the Work Capability Assessment process is amended for people with schizophrenia and psychosis to require the Department for Work and Pensions to seek information from health professionals to guide decisions rather than requiring potentially vulnerable people to navigate complex systems in order to provide it. The same principle should be built into plans relating to any qualifying assessment for the new Personal Independence Payment.”
Other changes affecting people with schizophrenia include the changes to eligibility criteria for personal budgets (the system whereby local authorities provide people with disabilities with money to help them with the problems they encounter in their lives in relation to their disability). To counter inconsistencies in the way this is administered, the Government is currently setting a national eligibility threshold through the Care and Support Bill regulations. The report expresses concern “that the social care eligibility threshold will be increased so that people with schizophrenia who are deemed to have ‘moderate’ needs (often due to their condition fluctuating) will lose support. Without this, a person’s mental health condition may deteriorate, resulting in a crisis and requiring access to more costly health or social care interventions, and possibly use of compulsory powers of the Mental Health Act.
The report makes many recommendations, designed to counter and resolve the indentified problems. The report is hopeful “that outcomes can be improved for everyone affected by severe mental illness. But it will require a radical overhaul of the system including an integrated approach with health and social services working together, a greater emphasis on patient preferences and a widespread application of flexible and innovative solutions. We do know what works – let’s apply it.”
I’d like to feel as optimistic as the Schizophrenia Commission appears to be, but I fear that “knowing what works” is not sufficient, when evidence based policy seems to be being replaced by political dogma.

Friday, 2 November 2012

Detentions under the Mental Health Act 1983: The Latest Statistics

What a tasty graph!
The latest statistics for people detained in hospital or on Community Treatment Orders has just come out. These cover the period from 1st April 2011 – 31st March 2012.

I always get a little moist looking at these statistics. I guess some people might think that’s just wrong, but what these statistics do is to lay bare some curious and perhaps unexpected consequences of law and policy, and they can provide insights into how the trends and changes in the real world impact on the use of the MHA with people with mental disorders.

So what do these latest statistics reveal? Well, last year, when the statistics for 2010-2011 came out, I wrote a post about what these statistics revealed about Community Treatment Orders (AreCommunity Treatment Orders Taking Over the Mental Health Act?).

I noted back then: “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.”

So what do the latest statistics show about CTO’s? Guess what, the report finds:

“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.”

Hand in hand with this is a reduction in the overall numbers of people admitted under Section 3. The report notes:

“In the 2011 publication of these statistics, we suggested that the decrease in the number of admissions via Part II Section 3 may be linked to the rise in the number of people on CTOs... Before the advent of CTOs, patients with a particular type of case would have been repeatedly admitted to hospital for treatment under this Section. What we may now be seeing is these patients are instead placed on CTOs and are seen in hospitals under recall instead. The underlying Section will only be reinstated if the CTO is revoked.”

As an AMHP, I am certainly 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). These CTO’s and CTO extensions also result in the necessity to write Tribunal and Managers Reports, and to attend Tribunals and Managers Hearings.

And what else do these statistics reveal?

“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.”

What exactly does this mean? Although the total numbers of people detained in independent hospitals is small compared to detentions in NHS hospitals (3,045 compared to 27,855) there is a very strange discrepancy between Sec.2 admissions to independent hospitals in 2010-11 (696) and in 2011-12 (1,011) – an increase of 45% year on year.

I have a theory about this, based on my and my local AMHP colleagues’ experience. While I cannot comment on AMHP’s experiences in other parts of the country (although I would welcome feedback from other AMHP’s) what I do know is that my colleagues have been finding it increasingly difficult to find beds in local NHS hospitals.

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.

And how has this shortage arisen in the first place? Could it be anything to do with the year on year cutbacks to NHS and mental health funding, which has resulted in reductions in beds, and in the numbers of community staff, who might be able to avoid admissions in the first place (and with more to come as the cuts continue to bite)? I couldn’t possibly comment.

I have noticed some other intriguing trends in these figures. One relates to the use of Sec.4. The report says:

“Section 4 is used to detain a person when emergency assessment is required and compliance with the usual Section 2 requirements would involve an ‘undesirable delay’. Uses of this power have decreased by 14 per cent since 2010/11 (from 535 to 458), continuing a downward trend in its use over the last five years (in the 2007/08 reporting year, there were 851 uses of Section 4).”

Although the use of Sec.4 is comparatively rare, it is good to see that its use is declining year on year, as it is frequently only used when it has been impossible to obtain a Sec.12 approved doctor, who has particular experience and knowledge of mental disorder. I would like to think that this is because it is becoming easier to obtain Sec.12 doctors for assessments.

Then there are the statistics for the use of Sec.136. Sec.136 is used by the police when they find someone in a public place who appears to be mentally disordered and in need of care or control. This seems to have increased year on year at the same rate that Sec.4 detentions have decreased over the same time (not that I can see a connection, mind). Also the numbers are hugely different: in 2011-12 a total of 23,569 people were detained by police under Sec.136.

The report comments:

“During 2011/12 the majority (11,567 out of 14,149) of Section 136 uses in a hospital setting did not result in formal detention (under Section 2 or 3). Following use of Section 136, a patient who is not detained is either discharged or remains in hospital voluntarily, but data on these outcomes is not collected separately. The proportion of Section 136 uses not resulting in detention has increased from 71 per cent in 2007/08 to 82 per cent in the most recent reporting year.”

I think these figures are troubling. Since the latest figures show that 82% of people on Sec.136 are not then formally detained (there are unfortunately no statistics to differentiate between people who then remained in hospital informally and those who were not subsequently admitted to hospital at all), it seems to be intimating that the police are frequently using their powers under Sec.136 inappropriately.

Some of these detentions might be due to intoxication by drugs or alcohol, which would not tend to result in eventual hospital admission, but which could provide a police officer with sufficient grounds to use Sec.136. However, it may also indicate a need for more training for police officers in identifying mental disorder in the first place.

There’s a lot more to be gleaned from this report. Those sufficiently interested can study them in full here. 

Sunday, 28 October 2012

Social Work with the Dead

Perhaps it’s the dismal weather we’ve had recently, perhaps it’s the shortening days. Whatever the reason, I’ve been thinking quite a bit about the dead. In particular, my first hand encounters with death.
Thankfully, I’ve seldom come face to face with a dead body during my career as a social worker. However, on four occasions I have been in the unfortunate position of being directly involved in the discovery of a recently deceased person.
I have already written about two of these on this blog. One was many years ago, but still sticks vividly in my mind. I wrote recently about this sorry tale only last month in Origins 5: Death in Charwood. The other was the case of Lenny, who I wrote about back in July 2011 (Lenny: A Life and Death in the Mental Health System; you can read it here and here).
Because encountering a corpse in social work is so rare, when it does happen, it’s not something you tend to forget. So here, then, are accounts of the other two.
George was in his 50’s and was a  longstanding patient of the Community Mental Health Team. He had a very long history of chronic paranoid schizophrenia, and was on a range of antipsychotic medication, including a fortnightly depot injection. Although I was not his care coordinator, I had had to detain him under the Mental Health Act on a couple of occasions.
One day, Jim, his community nurse, went round to his house, where he lived alone, to give him his fortnightly injection. He had been unable to get a reply. Jim returned to the CMHT and discussed this with me.
It was not like George to be out on the day his injection was due, or not to answer the door. We decided to go out together to investigate further.
We rang the bell and knocked on the door, but there was no reply. The curtains were drawn, but we could hear the television. Jim knelt down and peered though his letter box.
“Oh, God,” I heard him say, as he backed away.
“What is it?”
“I can see him. He’s sitting in his chair in the living room at the end of the corridor. He’s not moving. I think he’s dead.”
I had a look myself. His profile could be seen clearly through the open door of his living room. His head lolled to one side, supported by the wings of the armchair. I called, but there was no movement. I feared the worst.

We decided to call the police.
When they arrived, we explained the situation to them. They too had a look through the letterbox, then tried to find an open window or unlocked door, without success.
One of the police then revealed an arcane piece of knowledge. The windows on this estate all slid within a groove in order to open them. There was a way to jiggle the window so that it could be slid back a little way, even though there was a window lock, and then it was possible to reach through and release the lock so that the window could be opened enough for a person to climb through. He didn’t tell me how he knew about this.
The police officer climbed into George’s house and opened the front door. We all entered and went into the living room. His eyes gazed sightlessly at the morning TV programme. He appeared to have been dead for at least a day or so.
Once we had formally identified the body, we returned to the CMHT.
Jim was pale. He was badly shaken. He was looking at something far away.
“So lonely,” he said. “So alone. Looking down that long corridor through the letter box, there he was. He died on his own. He was so alone.” He began to cry quietly. There was nothing I could do for him.
One morning I had a call from one of my service users. Beth was a middle aged woman with whom I had been working for several years.
Not long before I first started to see her, she had finally escaped a long, abusive marriage to Gordon. Gordon was an alcoholic. Throughout the marriage he had terrorised her, undermined her, hit her, and sponged off her.
I had helped her through the aftermath of this, including aiding her resolve not to return to him, affirming her decision, and assisting her to go ahead with a divorce. Over time, she had adjusted to being a single parent, and her confidence in her own ability to be a parent for her children slowly increased.
In recent months, after a long time with no contact, she had started to see him again – not because there was any prospect she would return to him but through pity. Because of his drinking, he was in very poor physical shape. For the sake of the children, who still had contact with him, she wanted him to get help for his drinking and also tried to persuade him to see his doctor, as he had lost weight and was physically quite frail, even though he was only in his early 50’s.
“Masked AMHP,” she said, “I’ve been round to Gordon’s flat, but I can’t get any reply. I was going to do his shopping for him. I’m sure he’s dead. I’m convinced of it.” She began to cry.
I arranged to pick her up and go round to the flat again. Sure enough, there was no reply. She has last seen him a couple of days previously, when she had done some shopping for him. He never left the flat. So I called the police.
The police managed to get a key from the housing association, and I arranged to meet them at the flat. I persuaded Beth not to come. I didn’t want her to be in the position of having to identify the body, if our worst suspicions were realised. She didn’t want to, anyway.
I went into the flat with the police officer. We found Gordon huddled on a sofa. He was dead. He looked tiny, emaciated, desiccated, almost mummified; there was hardly any weight to him. He didn’t look as if he could ever have been alive, somehow. Although I had never met Gordon in life, I had no doubt it was him. His skin was a deep yellow, almost mahogany. I had never seen anything quite like it.  He had clearly been in the last stages of liver failure.
Beside him on the floor, still in a carrier bag, was the last shopping that Beth had done for him. Still in the bag was a 3 litre bottle of white cider.
I went to see Beth at her home. She was crying profusely. I told her roughly what had happened. I didn’t give her the details of his appearance.
“I killed him, you know,” she said in between gulps of air.
“What do you mean, Beth?” I asked her.
“I didn’t want to. He made me.”
“What do you mean?” I asked again.
“He made me buy him some alcohol, that last time,” she wailed. “I knew I shouldn’t have. I killed him.”
“Beth, he never opened the bottle. He didn’t have a drink before he died. It was drink that killed him. But not that particular drink.”
Over the months following this incident, I had to spend many sessions helping her to work through her bereavement and guilt issues. But the fact that I had gone in that day, and had found that bottle, and had seen that it hadn’t been touched, and could tell her this, certainly helped to absolve her of at least some of her guilt.

Friday, 19 October 2012

The Masked AMHP Profiled in Guardian Select

You can read the fascinating things The Masked AMHP has to say to the Guardian about himself and his blog here.

Monday, 15 October 2012

On Assessing People Who Conceal Their Symptoms

Over the years, I have frequently found myself in a position where I have had to assess someone under the Mental Health Act where their presentation on assessment is directly at odds with the reports from relatives and other professionals of their behaviour and symptoms.

What is the AMHP supposed to do in these situations? While it is important for the AMHP to “interview in a suitable manner” and reach their own conclusions about the need or otherwise for admission to hospital, it is not sufficient to take the patient’s reports at face value; the AMHP also has to be satisfied “in all the circumstances of the case” that the patient needs to be admitted, whether formally or informally. It is therefore essential for the AMHP to obtain information from relatives and carers, as well as other professionals who have had involvement with the person.

One has to be very careful in weighing up this evidence. On the one hand, people who may be depressed and suicidal, or seriously and dangerously psychotic, may be fully aware that if they are truthful about their symptoms, they are likely to be admitted to hospital against their will. After all, if your intent is to take your own life, you won’t want an AMHP interfering with your plans by detaining you in hospital.

Equally, if you know beyond doubt that there is a global conspiracy initiated by alien invaders from the Dog Star designed to prevent you from achieving your potential as the saviour of the world, you are likely to believe that the nosy AMHP asking you probing questions is simply part of the nefarious plot.

On the other hand, someone may have unusual but not necessarily psychotic beliefs; while you personally may have difficulty in believing that Jesus visited the American continent and left the evidence on gold plaques which later mysteriously disappeared, many people do believe this, and most are probably not thought disordered.

It is also not unknown for people to make malicious and false allegations about the mental health of their relative. I have had a number of demands from estranged husbands to assess their partner under the MHA because they are clearly unreasonable and deluded in objecting to their applications for custody of the children.

A good illustration of these difficulties is the case of Siobhan. Siobhan was a single woman with a school age daughter who lived in a local authority house in Charwood. Her mother, who was originally from the Republic of Ireland, also lived in Charwood. Over a period of more than 10 years, I received a number of requests from her mother to assess Siobhan under the MHA.

On the first occasion, Siobhan’s mother reported a range of behaviours and incidents that anecdotally seemed to indicate that she may be psychotic. However, when I formally assessed her, Siobhan presented at entirely free of any symptoms of mental illness, presenting as warm and appropriate. We took no further action.

A few months later, however, we received a letter from the GP saying that Siobhan had been taken by her mother to the Republic of Ireland and had been admitted to a psychiatric hospital there. She had been diagnosed with paranoid schizophrenia and started on depot injections of antipsychotic medication. She was now back in Charwood and needed the CMHT to give her injections.

I was bemused. Did she or did she not have a psychotic illness? The nurse who gave her her injections found Siobhan to be much as I had, warm, appropriate and without symptoms. But then that could be due to the medication. After a year, Siobhan decided she did not want her depot any more. She disengaged from mental health services. We were not unduly concerned, as we only had anecdotal evidence that she had a mental illness.

A year later, Siobhan’s mother again contacted the CMHT. Siobhan had a partner, and was pregnant. She and the partner were both concerned about Siobhan’s mental health. Both her mother and her partner came to the CMHT to see me. They reported that Siobhan believed that she was not giving birth to a human baby, but to an alien. She had told her partner that she was preparing to be transported to another planet when her alien baby was born. She was neglecting herself and her daughter, and keeping her daughter off school for no good reason.

These were very disturbing reports. I arranged to assess her at home with the CMHT psychiatrist and her GP.

We arrived late afternoon. She answered the door and welcomed us warmly in, even though she was not expecting us. Her daughter and a friend from school were there, playing a game in the living room. Siobhan was preparing a meal for them in the kitchen.

Throughout the assessment, Siobhan again presented as rational, calm, warm and cooperative. The house was in good order, and her daughter appeared well and relaxed. Siobhan denied having said any of the things reported, but said that she and her partner had been having problems and she was unsure if she wanted the relationship to continue.

The psychiatrist, the GP and I retreated to my car to have a discussion. The contrast between Siobhan’s presentation and the reports of the relatives simply did not fit together. I was inclined to go with my impression of Siobhan as she was today, except – this time it was not only her mother reporting psychotic symptoms, but her partner as well. She was pregnant – what if she really did think her unborn child was an alien? What risks to the child might arise from that?

We all felt deeply uncomfortable with the decision, but eventually we decided to believe the mother and partner, and with heavy heart I made an application for Siobhan to be detained under Sec.2 for assessment.

Siobhan took it all with calm resignation. We made arrangements for her mother to look after Siobhan’s daughter and take the friend home, and Siobhan packed a bag and came with me to hospital.

For a fortnight, Siobhan was observed and assessed on Bluebell Ward. During that time she was not given any medication. Also during that time, she did not display any symptoms of mental illness. After 14 days, the section was discharged and she went home.

Despite having displayed no symptoms of mental illness, she did agree to seeing a nurse from the CMHT. She gave birth uneventfully to another daughter, and there appeared to be no problems.

Four years later, Siobhan’s mother again came to the CMHT in a state of agitation. She told us that Siobhan had assaulted a number of people and had also broken her own window. She was insisting that she was mentally ill and needed to be in hospital. While she was telling us this, the police arrived. They had gone out to see Siobhan at mother’s request, and she was not prepared to let the police into the house. The police were expressing concern, as Siobhan’s two children were also in the house.

I decided to go out with her nurse and the police. When we arrived at the house, the police had gained entry. We found Siobhan in the sitting room.

Throughout the interview Siobhan presented as understandably stressed, but nevertheless calm and collected. Her manner and affect were entirely appropriate for the situation, and she did not reveal any symptoms of thought disorder. She said that she had been pressured by her mother and had broken the window as a response to this. She readily admitted that there had been times in the past when she had been unwell, and was aware of her early warning signs. She also said that she wished to continue taking her present medication.

I saw both of Siobhan’s daughters. They both appeared unperturbed by the situation. They were clean, well dressed, and well nourished. They happily reported to me what they had had for breakfast and lunch (cereals, and meatballs with rice respectively). There was no evidence that the children were neglected or in danger. The house was untidy but not dirty, and appeared to be in good decorative order. Again, there was no evidence of significant neglect in the house. I concluded that there were no grounds to consider admission to hospital either formally or informally.

I suggested to Siobhan that we could arrange a meeting with herself, her mother, her nurse, her psychiatrist, and me, to try to reach some agreement about a course of action. Siobhan readily agreed to this idea. I arranged to call in to see her the next morning.

We returned to the CMHT and saw Siobhan’s mother in the presence of two police officers. She was very agitated, and was reluctant to listen to what we had to say about our assessment. She became quite abusive. The police officers were clearly irritated by her. They told her not to harass her daughter, and they wanted Siobhan to be told to inform the police if her mother harassed her further.

The next morning I visited Siobhan as arranged. There was no reply, but the lights were on upstairs and I saw that a venetian blind was momentarily opened.

I phoned her from my car.

“Hello,” I said. “This is The Masked AMHP. Can I come in and see you?” I knocked again, but again there was no reply. However, I heard noises from inside and heard her tell the children to stay in a room.

I phoned her again.

“Do you know who I am?” she screamed down the phone at me.

“You’re Siobhan,” I replied calmly.

“No I’m not,” she shrieked, “I’m her Royal Highness, the Queen of the World!”

“Siobhan, can you let me in?” I asked her, approaching the door again. I heard her thump the inside of the door and then she turned up the stereo to full volume.

I returned to the car to phone her one more time.

“I’m the fucking princess!” she bawled at me when she answered.

It was clear that she was not going to let me in, so I retreated back to the CMHT.

I called the police and explained what had happened. They agreed to go out straight away, especially as the children were inside the house with her.

I returned rather quickly with Siobhan’s GP. There wasn’t time to get a Sec.12 doctor.

The police had managed to gain entry. I found Siobhan curled up in a foetal ball under the stairs. She looked up at me as I knelt down beside her.

“Are you my daddy?” she asked me.

 I detained her under Sec.4.

Thursday, 27 September 2012

Clustering and Payment by Results: The End of Service User Centred Mental Health Care?

Most mental health service users will be completely unaware that when they are assessed by Community Mental Health Teams or in hospital their mental health problems and symptoms are now subjected to an arcane system known as Clustering.

The Department of Health issued guidelines in October 2011 (a link is here) which proudly announced:

“2012-13 is the introductory year for what is a major change in the way that mental health care is currently funded, a shift from block grants to PbR currencies which are associated with individual service users and their interactions with mental health services.”

(PbR, by the way, stands for Payment by Results. Payment by Results is the new way in which local NHS Trusts will be funded by the GP consortia that are due to replace PCTs in 2013.)

It is the preliminary stage in “introducing the mental health care clusters as the contract currency for 2012-13 with local prices. This means that prices will be agreed between commissioners and providers, and are not set at a national level.”

Mental Health Professionals working within the NHS are now expected to assign everyone they assess to a specific “cluster”, using the Mental Health Clustering Tool. This tool has 18 scales. Examples include “Non-accidental self injury”, “Problems associated with hallucinations and delusions”, and “Depressed mood and ideation”. The assessor has to assign a score between 0 (no problem) and 4 (severe to very severe problem). Depending on these scores, the assessor can then assign each service user to a cluster.

A cluster is not a diagnosis but rather a description of an individual’s mental health problems and its impact on their ability to manage daily living. Someone presenting with moderate depression, for example, might be assigned to Cluster 3, which is defined as “Non Psychotic (Moderate Severity)”. Someone with chronic schizophrenia might be assigned to Cluster 7, “Enduring Non-psychotic Disorders (High Disability)”. Someone with a borderline or emotionally unstable personality disorder might be assigned to Cluster 8: “Non-Psychotic Chaotic and Challenging Behaviours”. 

I wrote about Clustering in the Guardian back in January of this year (link here). At the time of writing that article I was still quite new to clustering. Now, I have over a year’s experience of clustering service users in Charwood Community Mental Health Team where I am based. I have also been on further training.

So far, it has become clear that it is very difficult to use this assessment tool in any sort of meaningful way. The point of clustering is apparently to assign service users to the care or treatment package that best meets their identified needs. However, unless these care packages are known, it is almost impossible to know which cluster to assign to a specific individual. And these care packages themselves have not yet been defined, which the training course admitted.

It’s a bit like being on one of those TV cookery competitions, and being given a pile of ingredients but without being told what dish you’re supposed to be preparing.

I apologise if this post has appeared a little dry and boring so far. Imagine what it’s like for mental health professionals trying to apply clustering to their assessments. Unfortunately, even though inserting sharp objects into one’s own rectum might appear a preferable pastime to using the Mental Health Clustering Tool, it is now not only a compulsory requirement, but it will also have a profound effect on the funding of mental health trusts.

And this, of course, is what clustering is really about. It actually has little to do with actually trying to identify the needs of service users, and then providing care and treatment according to those needs. That is the old, unfashionable, “needs led” approach.

Over 20 years ago, when Charwood CMHT was first created, the team spent a considerable time trying to identify what a CMHT was for. It was, of course, to try to meet the needs of people with severe and enduring mental health problems, as well as those in acute distress where there was a severe risk to that person or their ability to function. Our services were therefore developed to try to meet the needs of those individual service users.

One example of this was the identification that many people presenting to the CMHT with depression, self harming and suicidal behaviours had significant histories of childhood abuse. If all we did was give them some antidepressants and some supportive contact until the crisis was over and then discharge them, we realised that these people would keep coming back. So we started to develop specialist counselling within the team that was designed to address their underlying problems. If the reasons for a person’s low mood or urges to self harm were dealt with and resolved, then not only would they feel much better, but they would also be less likely to relapse.

Over the intervening years, there have been many changes to the shape and organisation of community mental health care. 20 years ago, the CMHT was part of Charwood District Health Authority. Then it became Charwood Health Partnerships Trust. Then it became a Mental Health Foundation Trust.

Other teams were created: the Early Intervention in Psychosis Team, the Assertive Outreach Team, the Crisis Resolution and Home Treatment Team. Some of those changes made our job a little easier; some made it more difficult. But despite those difficulties, we always tried to keep the needs of the service user at the centre of what we did. We didn’t always succeed in this, but we always tried.

Clustering and Payment by Results, while giving lip service to the concept of service user led service provision, in fact does nothing of the sort. The “customer” is not the service user. Under this new model, the service user, or rather their cluster, explicitly becomes a unit of currency. So mental health services become a market place in which this currency can be spent.

The real “customers” in all this are the new GP consortia. With their cluster currency, they can shop around, looking for the best deals. The potential implications of all this are that interested businesses can cherry pick certain treatment packages.

Many Tesco stores have pharmacies and even dentists. What’s to stop them offering cut price treatment packages for Cluster 3 (Non-Psychotic, Moderate Severity) or even Cluster 11 (Ongoing Recurrent Psychosis, Low Symptoms)?

CMHT’s could simply become places where people are assessed and sorted, a bit like an egg grading production line, before being farmed off to any of a range of private or voluntary organisations offering the cheapest prices.

But how many of these organisations would see the commercial potential in Cluster 14 (Psychotic Crisis)? And what about Cluster 8, Non-Psychotic Chaotic and Challenging Disorders – after all, people with personality disorders aren’t very rewarding to work with are they? They’re difficult and challenging, take a long time to treat, and above all can be very expensive in terms of services. They’ll probably be left for what’s left of NHS mental health services to pick up.

Is this really what the changes in the NHS are all about: a means of privatising the NHS by stealth, using the GP’s as unwitting stooges, and at the same time cutting back on funds? Ultimately, these “currencies” are nothing more than Monopoly money; the Government can and will control their actual value.

And despite the Government maintaining that NHS spending is increasing, in spite of the evidence of cutbacks that people working in the NHS are faced with every day, the actual evidence is that, certainly in mental health, funding has decreased. The Observer on Sunday 27.09.12. stated: “After inflation, expenditure fell by 1% in 2011-12, dropping by £65m to £6.63bn, according to reports published by the department of health. Older people's mental health was hit hardest, seeing a real-terms spending decrease of 3.1% to £2.83bn in 2011-12.”

Phew! Perhaps a bit radical for the Masked AMHP! The trouble is, I’ve endured and survived so many changes to service provision over the 35+ years I’ve worked in social care. I fear that this is one change too many.