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.