Why Public Services are Like a Fat Lady in a Corset

I think there may be a General Election coming up soon.

This has got me thinking even more than usual about political parties’ manifestos and the policies that they all feel sure will make the country a better place.

The trouble is, that all these policies are based on ideologies that do not reflect the reality of life in this country, and take no account of the long term consequences of those policies.

To be blunt, governments and political parties continually fail to grasp the basics of joined up planning for managing Society as a whole.

You’d have thought that setting a fixed five year term of office would have obviated the political need for short term policy, and facilitated longer term rational planning. But not being a politician, I suppose I’m hopelessly naïve to think this.

One thing all the major parties seem to have in common is the belief that it is necessary to make cutbacks in public spending. But none of them stand back and take a long, hard look at what would actually happen if and when these cutbacks are implemented.

Because Big Society is like a fat lady in a corset: you can try squeezing in one place, but all that will happen is that there will be a bulge in another place. The whole remains the same. In fact, squeezing too much might simply end up in asphyxiating the body you’re trying to manage.

I’m not going to make an ideological argument based on airy fairy social work concepts of social equity and fairness. I’m simply going to try and show that cutting certain services, or throwing money at the political ideology of the day, may not actually result in an overall reduction in the costs of all services in general, and can even result in greater expenditure for less social benefit.

Let’s take housing policy as an example. The Government appears to regard home ownership as an innately good and desirable thing. To this end, the current Conservative Party Manifesto says that it will extend the “right to buy” to people living in housing association homes.

Here’s another way of looking at this policy.

·       The Government gives money, either directly or via local authorities, to housing associations in order to build houses for people who do not have the income or ability to buy their own houses.

·       The Government then sells these houses at a large discount to people who are probably able to afford to buy a home of their own in any case.

·       The Government makes an immediate loss on its investment.

·       The people who buy these houses may then quite possibly decide to sell them in order to realise a considerable profit, only some of which will return to the Government in Stamp Duty.

·       The people who buy these houses then let them privately at larger rents than the housing associations were charging when they owned them.

·       Because this social housing has been sold off without the necessary investment to replace them, there is then a shortage of rented housing, which pushes up the rents of these now privately owned properties.

·       People renting these properties, whether “hard working families” on low incomes or those unable to work because of age or disability, then claim housing benefit to cover these increases.

·       The Government’s costs for housing benefit then increase.

·       So the policy costs the Government not once but twice – and it still hasn’t solved the underlying problem of the national shortage of housing which continues to drive up the value of houses and makes it even harder for “hard working people” to afford to buy in the first place.

Then there’s that policy of allowing people to withdraw and spend their pension funds.

·       The Government makes an initial killing by taxing the money that is withdrawn.

·       A significant number of those pensioners use that money to buy property in order to let it out.

·       The increased demand in property inflates house prices.

·       This makes housing even less affordable, driving demand in renting.

·       Increased demand for private rented property inflates rents.

·       This leads to an increase in people’s claims for housing benefit.

·       This costs the Government more money.

·       And let’s not forget that years in the future, those people who drew their money out of their pension funds then spent it, will be making claims on the welfare benefits system in the form of housing benefit and pension tax credit.

·       And this costs the Government even more money.

And as for that policy known, to the annoyance of the Coalition Government, as the “bedroom tax”?

·       Well, it will continue to cost housing associations money in lost revenue because people are not able to afford the higher rent.

·       They fall into arrears and the housing associations then incur further expense taking them to court to evict them.

·       Housing associations are generally funded through central or local government grants.

·       Vulnerable homeless people have to be accommodated by the local authorities.

·       These people may then end up in those privately rented houses, which had previously belonged to the housing associations until sold off, with inflated rents, and have to claim higher rates of housing benefit than they would have been claiming before the “bedroom tax” was introduced.

And one final example close to my heart – cuts in funding for mental health services:

·       Despite Coalition claims that funding to the NHS has increased, the reality is that, according to Andy McNicoll’s excellent report in Community Care on 20.03.15., there has been a cut in real terms of over 8% to funding for mental health trusts.

·       Community mental health teams have been cut by 5% despite an increase in referrals of 20%.

·       At the same time as there have been cuts to these community services, psychiatric beds have been reduced by 2,100 since 2011.

·       This is during a period of recession when one of the inevitable consequences of high unemployment and low wages was an increase in mental ill health.

·       Trusts attempted to save money by closing hospital beds, but understaffing of community services meant that people could be less efficiently managed in the community, leading to an increase in demand for the available beds, and an increase in requests for assessments under the Mental Health Act.

·       This led to an increase in the use of leave beds, beds nominally occupied by a patient who was on leave as part of discharge care planning, and by the wards being under increased pressure to discharge too early.

·       The consequence of all this was that people were more likely to relapse, and need an acute bed.

·       This inexorable pressure on beds led to increased use of beds out of trust areas, trusts frequently having to use private hospitals.

·       These beds are far more expensive than “in house” beds.

·       There are also increased costs in transporting these patients long distances, often having to use a private ambulance service, because local ambulance trusts would refuse to provide transport.

·       Holes in service provision for crisis intervention also leads to increased use of police emergency powers under Sec.136, and then associated delays in completing the Sec.136 assessment because of delays in finding a bed. This puts increased pressure on police time and resources.

·       And of course there have been huge cuts in funding for local authorities, who among other things are responsible for providing police services, so policing levels have been cut at the same time.

·       Another consequence of cuts to local authorities is that funding for services that have the effect of providing alternatives to hospital admission, such as respite care, or reducing demand on mental health services, such as support services and personal budgets for vulnerable service users, have also been cut, adding even more pressure on NHS mental health services.

As I said at the beginning, you can squeeze as much as you like in one place, it will simply increase pressure on the system in another place.

Regardless of doctrine or ideology, sometimes you have to spend money in order to save money.

Let’s Play Big Society Jenga!

 

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

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

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

Nothing! No wobbles yet!

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

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

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

Still nothing! This is a great game!

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

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

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

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

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

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

Happy New Year!

Why Social Care is Different from Double Glazing

I'm glad we've got that sorted out

(This is reblogged from the 1st issue of Care to Share Magazine)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"Well, they've finally located a bed. Just need to get an ambulance now."

There has been a gratifying media response to the excellent investigation conducted by Community Care and the BBC into the drastic shortage of acute psychiatric beds across the country. This investigation has confirmed what AMHP’s already know: the cuts in psychiatric beds are leading to unsafe and possibly illegal practices, which are often harming patients.

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

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

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

Examples of poor practice include admitting people to a hospital when there is no bed for them, the use of leave beds, premature discharge which then leads to early readmission, and the use of inappropriate beds, such as placing people under 18 in adult wards.

 

In my own experience, one of my service users, who was a voluntary inpatient in her 40’s, went on home leave. The leave did not go well, and she needed to come back into hospital. However, her bed had been taken by an emergency admission, and she was placed overnight on a dementia ward.

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

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

A report in Community Care in August 2012 (Mental health detention rise amid ‘pressure on hospital beds’) quotes an anonymous AMHP as saying that detention under the MHA is “the only way to get a bed these days.” I have certainly had it said to me on more than one occasion that a bed is only available for patients detained under the MHA. I have had to argue the case forcefully in order to obtain the bed.

 

There is more than anecdotal evidence of this practice. Michael Knight committed suicide on 28^th August 2012, at the age of 20. He was assessed under the MHA, and agreed to be admitted informally. However, there was no bed available anywhere in the county in which he lived. This led to an overnight delay in his admission, during which he killed himself.

 

The Coroner in the case stated: “The tragedy in this case is the fact that, after having gained Michael’s agreement to accept voluntary inpatient care, a bed was not then available. I am of the view that the situation was then exacerbated by the to-ing and fro-ing which then took place with regard to a bed becoming free, but only for a very short period of time before it was then unavailable.”

 

It was reported that “following Mr Knight’s death a serious investigation report was compiled, which found that staff followed the ‘right pathways’. It said an acute bed would have been found for Mr Knight if he had been sectioned.” (my italics)

 

The Mental Health Act is very clear in its views on informal admission. Sec.131 deals specifically with informal admission. Sec.131(1) states categorically:

 

“Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital or registered establishment in pursuance of arrangements made in that behalf and without any application, order or direction rendering him liable to be detained under this Act, or from remaining in any hospital or registered establishment in pursuance of such arrangements after he has ceased to be so liable to be detained.”

 

This essentially means that if a patient needs a bed, and they are agreeing to be admitted, then no requirement can be made that they should only be admitted if detained under a Section of the MHA. Any hospital imposing such a condition is therefore acting expressly in contravention of the MHA.

 

The Reference Guide to the Act devotes a chapter (Chapter 37) to informal admission, and begins by saying (37.2): “Nothing in the Act prevents people being admitted to hospital without being detained, and this is expressly stated in section 131. Compulsory admission under the Act has always been intended to be the exception, not the rule.”

 

The Code of Practice (Para 4.9) reinforces this: “When a patient needs to be in hospital, informal admission is usually appropriate when a patient who has the capacity to do so consents to admission.”

 

AMHP’s are legally required to satisfy themselves that detention in a hospital “is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need”, and informal admission is seen as a valid alternative to compulsory detention. Simply because an AMHP concludes that formal detention is not necessary, this does not necessarily mean that the patient does not need to be in hospital.

 

There is no doubt that hospital beds are expensive. Properly funded community based alternatives, such as Dementia Intensive Support Teams, may not only save money, but also provide patients with appropriate support in their own homes, and minimise disruption to them. Many Mental Health Trusts are relying on allegedly improved and enhanced community based crisis services to obviate the need for more hospital beds, and to justify a reduction in beds.

 

But there is a problem with this. I have been working in the mental health field for long enough to remember the plans in the 1970’s and 1980’s to close the long stay hospitals in which people with mental illness and learning difficulties would spend many years.

 

These plans were admirable. These asylums were mostly daunting and depressing Victorian edifices, deliberately built away from communities, and institutionalised the hapless inmates. Most of the inpatients didn’t need to be there, but there were few alternative community services. I was involved in a small way in moving some of these patients into the community myself when I started out as a social worker in the 1970’s.

 

The problem, however, was that community services were supposed to be funded with the money saved from closing the hospitals, but they had to close the hospitals first in order to get this money. It was like having a plan to buy a cow with the money raised from milking the cow. You had to have the cow first, but you couldn’t get the cow until you had sold the milk the cow would provide. Mental Health Trusts appear to be trying to pull off the same trick.

 

The now long defunct Mental Health Act Commission, in their Biennial Report for 2003/05 (p.204), advised:  “ In our view… the focus on establishing community interventions to keep patients from hospital admission must not blind us to the continuing need for inpatient care that patients will enter and reside in voluntarily”. That statement still holds today

The Sun and Mental Health -- That Front Page

The Sun’s full page headline today (7th October 2013) states baldly “1,200 killed by mental patients”. The number 1,200 is in red letters 2 ½ inches high. In tiny letters to the side of this headline is the admission that this figure was the total over a decade.

It’s hard to know where to start in a dissection of this report.

That huge red number is clearly intended to alarm. One has to conclude that the Sun wishes to suggest that its readers are all at risk of being murdered in their beds by homicidal maniacs.

The Sun’s use of the term “mental patients” is not only deliberate use of a term with pejorative implications, but also implies that there are two sorts of people: “normal” people (Sun readers perhaps?) and “mental” people, people who are unpredictable and potentially dangerous.

Having emblazoned its front page with this frightening statement, the Sun’s “full story” is buried on pages 6 and 7. It begins: “A Sun investigation today reveals disturbing failings in Britain’s mental health system that have allowed high-risk patients to kill 1,200 in a decade.”

The article is fringed by 12 brief accounts of people who have been murdered by “mental patients” over the last few years.

So where did the Sun obtain these figures? It mentions “a Manchester University study”. This can only be the Annual Report The National Confidential Inquiry into Suicideand Homicide by People with Mental Illness, published by the University of  Manchester in July 2013.

The Sun’s “probe” (their word), must have taken all of 30 seconds before finding this study, which was published 3 months previously in July. Community Care published a thoughtful article back on 5thJuly 2013, headlining their article with a quote from the Report saying: “The number of homicides committed by mental health patients has fallen ‘to its lowest level for a decade’.” The writer of this report, Julian Hendy, goes on to express skepticism of some of the figures.

The Sun reports that 122 people a year on average were killed by “mental patients”. This would appear to have been lifted from Community Care’s article.

The Sun goes on to lay the blame for these figures on “the slashing of budgets for mental health care”. They quote Marjorie Wallace of SANE as saying that “homicide figures may not have increased in decades – but significantly they have not declined either.”

So what does the University of Manchester report actually say?

Right at the beginning of the report, it is stated: “Homicide by mental health patients has fallen substantially since a peak in 2006, and the figures for the most recent confirmed years, 2009-2010, are the lowest since we began data collection in 1997”.

Although the report acknowledges that some of its statistics may be incomplete, it does say “it is likely that this is a true fall in patient homicide”.

Already, this seems to be factually at odds with the Sun’s report. While I do not wish to minimise the potential effects of recent cutbacks to spending on mental health, in this case, recent changes in mental health legislation and delivery are given as a possible explanation for this reduction, citing the use of CTO’s as a potential factor.

Another failing of the Sun’s “probe” is to place these figures in any sort of context. The Office of National Statistics provides illuminating statistics for overall numbers of homicides.

It gives statistics going back to 1960 for homicides initially recorded by the police. The long term graph shows a gradual increase in homicides from 282 in 1960 to a peak of 1047 in 2002-3. Since then, there has been a steep fall to around half of that peak.

Taking the ONS statistics, it can be seen that during the 10 year period from 2001-2011 on which the Sun bases its figures, there were a total of 7926 homicides. This compares with the figure of 1220 homicides committed by mental health patients quoted by the Sun and Julian Hendy. In other words, a little over 15% of homicides were committed by people who were known patients of mental health services. To put it another way, 85% of murders were committed by people who weren’t “mental patients”.

But I suppose the headline: “You’re 6 times more likely to be killed by a “normal” person than someone with mental health problems” doesn’t have quite the same ring to it.

Trying to work but living below subsistence level

I’m currently working with a couple who typify the unintended consequences of recent changes to welfare benefits arising from the recession. Despite their best efforts, the recession has made it impossible to earn a living wage, and they have then been further victimised by the current system, that should be designed to protect the most vulnerable.

Mr and Mrs Jones live in a Housing Association 3 bedroom house. They have lived there for over 30 years, raising 5 children, and maintaining the property immaculately.

Mr Jones works as a self employed landscape gardener. While not making a huge amount from this work, he has nevertheless managed to support himself and his family for many years without recourse to public funds, but when the recession started to bite in 2008, gardening work became scarcer as people tried to find ways of cutting back, and he began to fall into debt.

He started to get depressed. However, he tried to fight this, and in an attempt to meet his ongoing commitments and to service his debts, he took a part time job delivering parcels for a national company. But, already depressed, he found the struggle to keep up with the schedule impossible to manage. He ended up working hours longer than he was paid to in order to meet the delivery targets.

After a few months of this, and still unable to meet his financial commitments, one morning he woke up and was simply unable to get out of bed. He felt terrified to even leave the house, and would have panic attacks at the very thought of going shopping.

He went off sick, and started to receive statutory sick pay. He also made a claim for housing benefit and council tax benefit. But this is where it became even more complicated.

Mrs Jones has a zero hours contract with a local commercial cleaning company. This means that she fills in for the sickness or absence of cleaning staff. Sometimes she works 6 hours a week, sometimes she works 20 hours a week. Some weeks she is not called on at all.

The consequence of her erratic income is to make claiming means tested benefits very haphazard. Each week Mr Jones has  to notify the local authority how much she has earned, and benefits are then paid accordingly. Of course, there is always a delay in calculating and paying these benefits, which means that there is little guaranteed money coming into the house to pay essential bills. Mr Jones is having difficulty trying to pay the prescription charges for the antidepressant and other medication he has been prescribed to try to help him recover.

To add to Mr & Mrs Jones’ woes, because their children are all adult and have left home, they have two unused bedrooms, so are penalised further by the “bedroom tax”. For the first time in their lives, they are falling into arrears with their rent.

Their current predicament is unsustainable. But what should they do?

 Mr Jones has lost 3 stone in weight because of his depression and anxiety. He considers that leaving the house to walk to the post box on the corner on his own without having a panic attack at the moment is a major achievement. If he went back to work, the stress of his delivery job would precipitate a major relapse. In his current state of mind, there is no way he should return to that job, but his job as a gardener is also unsustainable.

Should Mrs Jones continue doing her job? Her irregular income creates havoc with their finances, and it would surely be better for them as a couple if she stopped work altogether, so that they would at least be able to count on a regular income from benefits, inadequate though it is, especially with the additional penalty of the bedroom tax.

Should they attempt to move to smaller accommodation to reduce their rent and stop being penalised? The problem with that is that hundreds of others in social housing in the area are also trying to do the same thing, and as a consequence, one bedroom properties are in very short supply. And is it really just that a couple who have been exemplary tenants, and who have put their lives into maintaining their house as a much loved home, should have to leave it?

As a mental health worker, whose job it is to aid recovery from mental illness, I would have to advise Mr & Mrs Jones to stop working completely, and be reliant on benefits. That way, their income would be regular and stable, they would be entitled to help with prescription and dental treatment, and they might be able to at least pay essential bills, even if they would not be able to service their debts.

What a shame it is that the welfare system is not designed to facilitate those people who want to work, even if only part time, but instead makes it impossible for them to work. And of course, if Mr Jones remained without work, he would start to be subject to capability for work assessments, whether there was work for him or not. Would that harassment hasten his recovery? I think not.

What Do You Call a Person Who Receives Mental Health Services?

A description or a label?

There are people who have had bad experiences of mental health services – you only have to look in the comments sections of my posts on this blog to find people who have nothing good to say about mental health services  -- who would answer “victim”. (I just thought I’d get that in first).

But this is actually a serious question. When I started out as a social worker in the late 1970’s, social workers, and probation officers come to that, had “clients”. I didn’t then, and still don’t, think there is anything innately wrong with this term. After all, solicitors have clients. Architects have clients. Advertising companies have clients.

There is nothing pejorative or demeaning about the word “client”. It simply indicates that there is some form of consultative partnership going on. There is no hint there of any sort of power differential.

But “client” no longer appears to be a satisfactory term. Nurses and doctors have “patients”, but social workers clearly cannot have patients. The Oxford Dictionary definition of the word “patient” is: “a person receiving or registered to receive medical treatment”. Since social workers (or occupational therapists or clinical psychologists) do not actually give medical treatment, the term “patient” does not really apply.

However, I must say that, working in a multidisciplinary team with doctors and nurses, it is easy to refer to “patients”. I try to resist this, not always successfully. This is made a little more difficult by the Mental Health Act referring to people subject to the Act as being “patients”. So there are times when I have to use that term in a professional context when acting as an AMHP.

There has recently been what in my view is a wholly deplorable move, to use the term “customer”. “Customer” does not describe the relationship between a mental health service and someone who receives that service.

The Oxford Dictionary defines “customer” as: “a person who buys goods or services from a shop or business” while the Merriam-Webster Dictionary gives the definition: “one that purchases a commodity or service”. Since someone who sees a mental health professional, either voluntarily or because they have been detained in hospital or are subject to a Community Treatment Order is in no way “buying” or “purchasing” that service.

This is the problem I have with attempts to apply a business model to a public service. Under the new GP led NHS system, the “customer” is not the person in receipt of the service, the customers are actually the Clinical Commissioning Groups (CCG’s) who are in reality purchasing services from the Mental Health Trusts. It is therefore the CCG’s that the Trusts have to satisfy, not the people who actually receive their services.

If shops treated their customers in the way that mental health services treated the recipients of their services, it might go something like this.

Customer: Have you got this blouse in stripes and size 14, please?

Shop Assistant: We’ve got that in stock, but I’m not going to give it to you. You need a pair of leggings in size 16. Here they are. No need to try them on.

So, I think we’re all clear now that “customer” should never be used when referring to people who use mental health, or indeed and public service.

So what have we got left? The popular term currently appears to be “service user”. Even service users refer to themselves as “service users”.

It’s possibly the least worst, but I’m still not convinced that it accurately reflects the role. It still implies that the “service user” has a choice over whether or not to use the service. This is not always the case, especially where the Mental Health Act comes in. Is someone detained against their will under the Mental Health Act “using” that service? Is it indeed a “service” at all?

Is a prisoner serving a sentence in a prison a “service user”? Not if they have no choice over whether or not they want to receive that particular “service”.

The other problem is whether what a social worker, or a nurse, or a psychiatrist, or a psychiatric hospital can be described as a “service”.

A waiter is providing a service. They are quite literally your servant. The customer is always right. It is the job of the waiter to give you what you want, not what the waiter wants to give you. Contrast that with a psychiatrist, for example.

Patient: I’d like 10mg Olanzapine, as well 20mg Citalopram. Oh, and I think I’ll have some 5mg Diazepam prn, just in case I get a bit anxious.

Psychiatrist: No.

So do I have any alternative suggestion? My only alternative is “service recipient”. That is, someone who is in receipt of a service. Or  at a pinch, “client”.

They Don’t Give ATOS: Public Accounts Committee Criticises Work Capability Assessments

It was reported yesterday (8^th February 2013) that the Parliamentary Public Affairs Committee has severely criticised the Department of Work & Pensions for their handling of assessments of the sick and disabled claimants for their capability to work. Responsibility for conducting these assessments has been delegated to ATOS, which was paid £112.4m to carry out 738,000 assessments in 2011/12.

In a report published yesterday, it was stated:

The Work Capability Assessment process is designed to support a fair and objective decision by the department about whether a claimant is fit for work, but in far too many cases the department is getting these decisions wrong at considerable cost to both the taxpayer and the claimant.

The department's decisions were overturned in 38% of appeals, casting doubt on the accuracy of its decision-making.

Poor decision-making causes claimants considerable distress, and the position appears to be getting worse, with Citizens Advice reporting an 83% increase in the number of people asking for support on appeals in the last year alone.

We found the department to be unduly complacent about the number of decisions upheld by the tribunal and believe that the department should ensure that its processes are delivering accurate decision-making and minimising distress to claimants,

The report also stated: "The one-size-fits-all approach fails to account adequately for mental health conditions or those which are rare or fluctuating."

This is something I have written about on more than one occasion (two actually, and now three) in relation to those with mental health disabilities.

Increasing amounts of my time as a worker in a community mental health team are spent attending work capability assessments with mentally ill service users at the local ATOS centre (“local” is a relative term, as the centre is actually 30 miles away from my CMHT). I feel it is incumbent on me to attend these assessments as I know from bitter experience that if I do not, service users will frequently be taken off Employment Support Allowance and placed on Jobseeker’s Allowance, even though they also been assessed, separately, and by the DWP, as being entitled to high levels of Disability Living Allowance.

I have never understood why a service user who has already been through an assessment of their disability, then has to go through a further assessment of their capability to work. Actually, I’m being disingenuous here: I think it is very likely that the reason for being put through these continuous assessment processes (they often seem to occur on an annual basis) is in order to remove them from ESA and hence to reduce their benefits.

The statement in the report that the assessments fail to account adequately for people with mental health conditions certainly chimes with my own experience of these assessments.

If you had a problem with your kidneys, for example, you might expect to see a specialist urologist. But when you go as someone with a mental illness to an ATOS assessment, it has been my experience that the assessors, who usually appear to be general nurses, have woefully little knowledge of the nature of the person’s psychiatric diagnosis, or how that disorder might affect their ability to work.

Their assessments are entirely geared up to assessing physical mobility, or the ability to bend or lift or stand for periods of time. They do not know how to assess the capacity for someone with chronic paranoid schizophrenia to hold down a job, or how to assess someone with agoraphobia, or depression, or even chronic fatigue syndrome.

Unless such people have a representative, who can describe in more detail how their condition affects them on a day to day basis, they inevitably find themselves on Jobseeker’s Allowance, having to attend work focused interviews – and also inevitably failing at these, and therefore risking being removed from benefits entirely.

It is therefore no surprise that the report finds that CAB’s have encountered an 83% increase in assisting with appeals, nor that over a third of those appeals are found in favour of the service user.

I am glad that that the committee have highlighted these scandalous issues. I hope that the Government will take heed.