Local Mental Health Services in Crisis…some thoughts

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Emma Corlett and Daniel Taggart speak at the NSFT anniversary meeting

This week I attended a public meeting marking the first anniversary of the setting up of the Campaign to Defend Local Mental Health Services in Norfolk and Suffolk (NSFT Crisis) with Jane Basham, the Labour prospective parliamentary candidate for South Suffolk. We listened to a powerful blend of platformed speakers from the service, pressure groups and personal testimonies from experts by experience and carers. We got angry, we felt inspired and we wept.

Among the speakers were

  • The Lifeworks Campaign in Cambridge ( a twice-weekly drop-in session for those with personality disorders offering social activities emphasising reintegration into society and social functioning), where service-users occupied their own mental health day centre to prevent the local NHS Trust from closing it
  • Peter Beresford, Professor of Social Policy, Brunel University, London, mental health academic and service-user
  • Emma Corlett, Community Mental Health Nurse, Norfolk County Council Mental Health Champion and Unison media spokesperson
  • Daniel Taggart, University of Essex, on the impact of austerity on mental health
  • Irene Lampert, Consultant Child & Adolescent Psychiatrist, on the impact of the radical redesign on services for children
  • Mark Harrison from Equal Lives, a service-user led advocacy organisation, on the problems his family have had accessing services

The campaign has made some huge and important gains:

  • They forced theTrust finally to admit that there was a crisis of funding and that the Radical Redesign has been a failure;
  • The Trust made several important changes at senior management level, including the Chief Executive, the Director of Operations (Norfolk) and the Medical Director. NSFT began to talk to our Campaign directly instead of dismissing our proposals in the media;
  • NSFT has finally begun to make some positive changes such as announcing the reopening Thurne Ward at Hellesdon Hospital, recruit staff and review the Access and Assessment teams;
  • NSFT has begun to acknowledge the need for a service for those previously under the care of the abolished Assertive Outreach teams, again with a view to improving provision for those patients. The CCGs also gave an undertaking to eliminate the use of out of area beds. These are all positive, though limited, changes for which our Campaign can justifiably claim some credit;

But there remain huge challenges and hurdles to overcome:

  • At the time of writing (28 Nov 2014), 48 people remain in out of area beds at an unsustainable cost of around £25,000 per night not to mention heartbreak, inhumane delay and distress incurred for patients, their family and friends;
  • The NSFT is trapped in an ever diminishing circle with poor community resources upstream which traditionally worked to prevent the relapse of service users that put them in need of an acute bed- a bed that is not in existence when they do:
  • Acute beds at Carlton Court are being closed;
  • The statistics cited above do not include the young people sent out of Norfolk and Suffolk, with CAMHS services at NSFT having suffered the deepest cuts in England. “If psychiatry is the Cinderella service of the NHS then CAMHS are the Cinderellas of psychiatry being awarded less that 19$% of the whole mental health budget” Irene Lampert, Consultant Child & Adolescent Psychiatrist, on the impact of the radical redesign on services for children;
  • Out of area transfers were once emergency practice and are now becoming standard practice, a way of managing everyday working need;
  • The loss of experienced staff, mass recruitment of newly qualified staff and over reliance upon agency staff has resulted in demoralised teams, lacking in the clinical confidence that is born of experience hard won over time, and hence a risk to accurate and measured risk assessment;
  • “The Department of Work & Pensions (DWP) has carried out 60 secret reviews into deaths of people whilst they are claiming benefits and they will not publish the outcomes of these reviews.” Mark Harrison from Equal Lives, a service-user led advocacy organisation;
  • “At the start of our campaign, bed occupancy in the trust was already running at 115% and then they continued to cut beds, despite the run down in community services.” Emma Corlett,Community Mental Health Nurse, Norfolk County Council Mental Health Champion and Unison media spokesperson;
  • THe 2013 report of the Confidential Enquiry into suicides and homicide in mental health states that the suicide rate has gone up in Trusts where Assertive Outreach Teams have been abolished and merged with generic community mental health teams. The suicide rate for people known to the service regionally has risen.
  • The King’s Fund reports the truth that under Norman Lamb’s stewardship, funding for mental health has been cut in real terms.

As the Campaign points out on its website-Norman Lamb is a false mental health ‘prophet who:

We as a campaign must ensure that the Trust is properly funded and not allow local mental health services to pay the price for the hubris of the NSFT when it fails, which it will inevitably do.

The lived experience of several people in the audience, from service users and carers to bereaved parents made powerful testimony that was frequently hard to listen to. From the carer who spoke of the pressures of caring: “I need the mental health services now because of the inadequacies of the service my son receives and the toll it has taken upon me” to the former clinicians who spoke of their own mental ill health and desire to see all staff stand up and be counted, it was clear that the strengths of this campaign emanate from the grass roots up. The anger about the decimation of mental health services is justified and has triggered other service user led initiatives in the region too. The Cambridge based Lifeworks campaign told the meeting how their service users had to occupy their own buildings in order to protest against, and ultimately prevent, the closure of their service, and received no formal help from statutory services to achieve this. They told of the Facilities Department who sent in a pest control service when “In fact the only ‘pests’ in the building were us” and of the need for Lifeworks and the important work that it does in mitigating the lack of a safety net between the inpatient milieu and the community that the person is discharged back into. The planning of measures to help mitigate the ‘cliff edge’ of the discharge-home-GP pathway will hopefully soon extend from Cambridge out to the rest of the county and onto Peterborough.

Peter Beresford told of a relationship between service provider and user that has parallels with an abusive relationship when you factor in the need for staff who support the campaign to keep this secret for fear of the consequences, let alone the impact that speaking out has on service users. “Workers have to be subtle, skilled, nifty on their feet to give support as opposed to being seen to be doing something by the trust” with their ‘opposition (to the Radical Redesign) being managed and known.” In our opinion, staff , trust and service users exist in an unhealthy triangulation whereby they do not feel like a functioning and equal part of a system in which they all pull together; rather they are forced into an adversarial relationship where each has to defend their point of view although it needs to be said that the service user and carer is least likely to be heard or listened to in all this. In addition, service users face having their criticisms dismissed as being product of diminished insight, a failure to engage, lack of compliance or ‘personality issues.’ They have legitimate concerns about the withdrawal of a service from them or their relative unless they remain uncomplainingly grateful for what they do receive.

I find this especially ironic considering that as a student I was taught that “pain was whatever the patient says it is” yet in the mental health services, patients find their psychic pain rationalised within a context that bears little relation to their experience, minimises it or plain denies it as the product of an unquiet mind. Cuts predicated on short to medium term financial gains mean they are shoehorned into ‘sexier’ treatment programmes like CBT (that are NOT one size fits all) because longer term treatments cost more in the short term and take longer to deliver results. However these results, when they happen, tend to save money across more than one sphere of social and health care AND they are better responsive to the person and not just their symptoms. Treatments should be flexible, prioritising the patients move beyond the bottom tier of Maslows Hierarchy of Needs as they move forwards (and sometimes backwards) from needing support in eating, sleeping and ensuring that they are safe to the deeper aspects- the relationship they have with themselves, others and the world.

Worse, the lack of trained professionals means that the Trust risks abusing the very valid Peer Support Recovery Workers (PSRW) that at their best, offer sensitive and insightful support to so many people. The NSFT has lost so many older professionals with eons of experience; many of whom were paid at higher bands. Replacing them (after the shortsighted redundancy and retirement of nearly 500 staff) with newly qualified, agency and unqualified volunteers or PSRW’s has destabilised the service. There seems to be little evidence of coproduction, (a service developed jointly by service users and staff with all its obvious benefits) which would offer protection against the claim that an existing service or staff number is being replaced with something that costs a lot less. On their website, the NSFT quotes PSRW’s who have been through their own in-house training course: “It is very relevant, not condescending, everyone on the course found their own level to self-manage.” and the course itself sounds all very laudable. However my concern is that the ability to self manage will not be continued through onto the wards and community teams once they are in employment and past the preceptorship stage (if this even exists). Wards and teams in crisis do not afford their staff anything past a basic survival level of emotional regard.

To be a PSRW requires well motivated, well staffed, supportive teams because the job can be tough: it needs regular peer and management supervision, contact with the team and the PSRW needs to manage their own mental health to ensure it is not sacrificed in the task of helping others. There is not enough staff to do this and additionally, these staff are increasingly developing their own mental health issues- depression, anxiety, stress because of the rigors of working for the NSFT. They dare not go public with this whilst remaining in post. But it is happening.

Peter spoke of the cruel joke of people in psychological distress having to turn in crisis, to a service in crisis and of a welfare benefits system subject to caps that were not even a feature of the Poor Law. Those unable to work through illness and stigma are, by fiscal definition, subject to modern day Poor Laws and described as living with an enemy that is ruling us all. A government that is forcing the sick, the poor and the disabled to pay the price via welfare cuts for the banking crisis and effects of the American sub prime mortgage scandal that impacted so fundamentally upon the worlds economies. I would go further and say we are sleeping with an enemy that is fucking us over whilst we slumber. Thank goodness that regionally, we appear to have awoken with a start.

An interesting perspective came from Dr Irene Lampert, Consultant Child & Adolescent Psychiatrist who spoke of the impact of working for a service knowing that what you are doing “isn’t the right thing to do, nor is it constructive.” Staff in the eye of the storm can go into survival mode, can even become defensive about the work that they do when in fact their ability to take a step back and question themselves as to what they are engaged in, is limited. From my own perspective in the field and beyond it, I learned that a central part of the role of the mental health worker is self reflection and the old chestnut of ‘know thyself’, which helps to drive forward those skills essential to the development of relationships- and that also involves the intrapersonal relationship, the one we have with ourselves too. Beleaguered staff cannot do this and as a result, they are unable to grow meaningful alliances with service users and that means their roles as advocates, becomes minimised. In order to advocate you have to feel invested and when one feels personally threatened by the job and by your employers it is a normal and natural human behaviour to retreat and protect yourself. Sadly service users may face additional challenges and lack the resources to protect themselves because of the overall impact of welfare cuts and a job market that favours only those with the most resilience. When staff retreat from them they can be left without any resources to fight their corner because not all service users are able to campaign, blog or write emails to service providers. Nor should they have to. They are being attacked from all sides and if I said it feels as if the unspoken government policy is to ‘kill off’ those who need to ask the state for any kind of support ‘they’d’ probably accuse me of having a paranoid delusional framework…But to me, and many others, that is how it presents.

The mental health service we are left with now focuses upon safety outcomes that are strictly to do with preventing death and serious incident as opposed to distressed patients feeling safe and cared for. Having that distress alleviated by the feeling of being cared for in an environment that is both literally and perceptually safe remains, at time of writing, remote. The only statistics available to us with regards to patient safety annually are reports like Professor Louis Appleby’s ‘Annual Safety in Mental Health Care’ which focus entirely upon suicides, homicides and sudden deaths. The report deals only with empirical, quantitative measures of morbidity and entirely neglects the qualitative parts of mental health care- the more metaphorical aspects of the words ‘place of safety’- which are about how services make patients feel. Staff do not feel safe either. They do not feel their job is safe or that their registration is safe because of having to provide ‘care’ that falls well below the standards delineated by their professional codes of conduct. I have said previously in my column for the Bury Free Press that those members of the trust board who retain their own registration as social workers, doctors or nurses should be held directly accountable for their failure to care for patients and reported by those patients and their carers to their professional bodies. Why blame the front line staff who, like their patients, bear the brunt of the consequences on a pay that is a tiny fraction of that earned by those who have caused such damage?

Please do get in touch if you have any comments about this piece.

*Addendum*

Since first publishing this report, mental health charity MIND have finally ended their relatively deafening silence on the national scandal and written to prospective members of parliament to tell them the plain, unadorned truth: that the consequences of the Health & Social Care Act 2012, the introduction of Clinical Commissioning Groups (CCGs) and the tenure of Secretary of State at the Department of Health responsible for mental health, Norman ‘mental health champion’ Lamb, have been disastrous for those who rely on mental health services.

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