Of Mouse and Man

I probably picked the wrong clothes to go to work yesterday. I knew I was going to visit a house that had been kept in what might be called ‘less than sanitary conditions’. Although that is a fairly gross understatement. As a student accompanying me remarked as we approached the property  – ‘There’s a mouse on the windowsill.. or is it a rat?’ (I’m pretty sure, for the record, it was a mouse).

The smell wasn’t so overwhelming until we got to the front door and then, it was a battle between the odours of urine and faeces to see which could outwit the other. There was probably less obvious ‘rotten’ smells as well but it was the toilet-related ones that, quite literally, jumped out at us.

The referral had come via housing. We had no history and there had been a number of previous attempts to see the occupant of the house. It was one of those matters of proactive engagement. I banged at the door enough for my hand to start hurting. I looked around through the windows for any sign of life. There were rodent droppings piled up on the insides of the windows. There was rubbish piled from floor to ceiling.

The occupant had been deregistered from his GP as he had not returned the slip of paper which ensures continued registration. That pulls up a few older patients. I wish the surgeries wouldn’t do that or at least would take account of the types of people they deregister from time to time.

Sensing little luck, I turned to my detective skills, knocking on a few neighbours’ doors. I am very vague when I do this but we needed to know when the occupant had last been seen or if there was a possibility he was trapped or worse, inside the property.

A neighbour came out to talk to us. She knew a lot about the man. He usually goes out around this time, she said. He goes to have lunch at the luncheon club in a neighbouring borough. He’s used to going there. She had known him since they had both moved into the then, newly built properties, 30 years ago. He had been more reclusive and the house wasn’t always like that – but he always greeted her with a friendly smile.

A few leads at least. We know somewhere we might see him outside the property at least. As good a result as could have been expected, I think.

But we will have to return. I want to see the property from the inside.

Want might be overstating – perhaps ‘need’ is a better call.

Into the Night

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Although the nature of AMHP work is that it will be crisis-orientated, I have found that assessments are usually planned to some extent. Last week, we received a referral to our team at about 3.30pm. For reasons that smack of ageism and that I shouldn’t explore for fear of rising blood pressure, a situation that had been brewing had become much more risky, much more quickly – and the Crisis Team were not able to intervene.

The community consultant knew the patient and family very well and asked if it would be possible to manage an assessment so that he could be a part of it – but we understood it would be necessary for a same-day assessment.

I alerted the local police station and ambulance service and to be fair to the police – and perhaps unsurprisingly as there was a risk of physical violence and aggression (much of the cause for such concern to be honest) , they attended very promptly.

We have a good relationship with a fair few Section 12 registered doctors (independent doctors who have trained specifically in psychiatry in order and whom we may consult for medical recommendations for Mental Health Act Assessments)  and I happen to know one who lives very close-by and fortunately he was able to attend. We didn’t have a bed though.. yet. But had left that in the capable (?) hands of the bed manager.

The assessment was as we had thought it would be. Very fraught and distressing. There was a very obvious risk to maintaining the situation – and I had a lot of concern for the carer who had managed a basically untenable environment and had provided more support than could have been expected for his spouse.

As I sat with Mrs K while we waited for the ambulance, some of the heightened levels of emotions present subsided. We sat together in the living room. She put the television on as we waited. We had packed bags and I thought in a snapshot moment, how much the emotion of the moment had played into her illness and presentation.

While pondering some of her anger subsided and was replaced by distress and fear, which are emotions that are  no less fraught but somehow less confrontational. We talked and we talked. We sat together waiting for the ambulance. Calls to the duty bed manager had established a bed locally. Not as near as to be perfect but not so far as to mean that it would make visiting hard. Fortunately it was in a part of London that was very familiar to Mrs K as it is where she had spent the majority of her working life.

We arrived at the hospital late. I typed up the report on the ward so as not to leave it to the next day but fortunately the consultant had both provided me with very recent up to date information and had also advised the secretary to attach all the notes from the same day visit that had been made, to the database system that ‘follows the patient’ so there was lots of immediate background information for the ward.

I left the hospital late and walked to the bus stop. A colleague in a child protection team later in the week asked me why I hadn’t considered getting a taxi home as she was sure I could claim for it. I have to say, the thought never even crossed my mind but I wish it had as I arrived at the bus stop and saw that it was closed. Fortunately, it was an area I wasn’t completely unfamiliar with and a fine, hearty walk led me to the nearest tube station.

I pondered on the conversation in the ambulance where the patient had asked me (we had been talking for a few hours together at this point – it was quite a wait we had) when I would see  her – and I explained that I probably wouldn’t see her again when we arrived at the hospital. I wondered at how a situation which had been so fraught and painful could be brought down to a human level and sometimes seeing these situations that exist and the very acute suffering that often accompanies quick admissions, how decisions are made about admitting or not.

Although in reflection, and I’ve reflected a lot, I don’t think any decision other than the one we made could have been made, because there were no means of community support with a home treatment team not being able to engage and a carer at the end of their ability to cope, I sometimes think the force of admitting someone to hospital when they do not wish to go, is extraordinarily powerful. Power again. It isn’t something that sits pretty with the ‘social work’ role but we, as public servants and employees are dishing out the practical policy that the governments and local authority deign to be necessary.

And if the distress and illness can be treated – which I have no doubt it can – in this case, and some possibility of hope for recovery and a return to a life at home with spouse as soon as possible, I can justify it as a necessity. However unpalatable it might feel in the moment.

Note to Self

When clearing a day for a Best Interests Assessment under the Mental Capacity Act Deprivation of Liberty Safeguards –  even if you think you have planned and informed the hospital/care home well in advance, probably best to phone just before you head off to ensure that the patient/resident isn’t on leave when you turn up..

On the plus side, it’s probably looking like it might not be an actual deprivation of liberty as patient/resident can come and go apparently quite freely..  and it is in a rather pleasant part of London…

Music

Earlier in the week, I went to see someone who had been newly allocated to me. He had been known to our team for a while and had been previously allocated to a number of other care coordinators, who had found it difficult to establish a rapport with him.

I have no idea if I will be any more successful and although I like to enter and engage with each challenge afresh, sometimes it is hard to maintain in the face of office chat.

He is a man with severe depression. He was a musician. Music was his life. Until he became deaf following an accident. He is profoundly deaf and coming to it later in life, relies on lip-reading rather than sign language. The deafness has removed from him a significant raison d’etre, in a world without many social contacts and friends.

He uses a hearing aid which is of some use. When I approached his home, I could hear the music from many feet away. I wonder what his neighbours’ reactions are. Fortunately, he lives in a discrete house rather than in the middle of a high rise.

The meeting went fine. Although generally first meetings do. There is no cause yet to be a disapppointment and no promises have been made that can be challenged on. My main purpose has been to promote Individual Budgets to him and see how far we can run with it. There is a lot of scope for a very individual care package.

While ensuring I spoke clearly to him, we interspersed the conversation with a few written prompts when my words were not clear enough. A couple of cats joined us during the time I was there which proved to be a great ice-breaker. I saw a desperate social isolation. Groups were a problem because communication was better managed on a one-to-one basis and background noise could hinder due to the nature of the hearing aids.

And there is an understandable bitterness of a world in which someone who valued and relied on his sense of hearing for so long – has been robbed of it.

I don’t have any stories about what we did or how we worked through the issues or even if we did because we have just started working together.

There is something about first visits and meetings that I savour. The freshness and the hope. The plans that are made before they can be remade and remade and reworked.

I have thought a lot about him though – and how much I would miss the music.

The trouble with Aesop

The Aesop ( Aetiology and Ethnicity in Schizophrenia and other Psychoses) study is controversial. Reported last year, the conclusion of this large study completed by the Institute of Psychiatry read that social rather than genetic causes for severe mental illnesses could be related to circumstances that may be more prevalent in the lifes of (particularly) African Caribbean community for example issues of family breakdowns, unemployment and I’d suggest poverty, all of which are more prevalent in minority ethnic communities.

This study creates all sorts of problems. Even in my own office, I’ve seen the ‘I told you so’ attitude expressed by one practitioner who maintains the differences. I personally, while unable to debunk research carried out without exploring the methodology, have an understanding that poverty has a significant effect on rates of serious mental illness and our ability to cope – regardless of ethnicity.

The Guardian, back on 9 December 2009, quoted Louis Appleby as saying that ‘New Horizons’ took into account this research study and has been written with this in mind, focussing less of different services and streams for people from minority ethnic groups but rather looking at personalising services to individuals across the board and – with the rest of New Horizons – shifting more attention to preventative matters.

“There are genuinely very high rates [of schizophrenia], and the causes are social causes affecting people before they come into contact with mental health services. That’s quite a step, and you won’t find previous documents that have been so clear about these controversial issues. Instead of trying to build separate services for individual groups, it is about a service that is more personal to individuals.”

So where does that leave us?

Today, the Guardian prints an open letter from a number of mental health campaigners and academics challenging the Aesop study, its conclusions and the way it has been reported.

Quite rightly, the letter states that this conclusions tell us nothing new. We have known for a long time that there are higher rates of incidence of schizophrenia among minor ethnic populations however, there are reasons for this that might be related to the way and the stages at which diagnosis is made.

The letter states that

The way in which this ‘finding’ about diagnostic patterns has been reported stigmatises and pathologises African ­Caribbean communities as being inherently flawed in some way that generates ‘mental illness’ – a throwback to the discredited Moynihan report in the US, which stated in 1965 that the African American family was a ‘tangle of pathology’. There is plenty of evidence on the nature and extent of institutional discrimination and racism in the British mental health system. Failing to recognise this and, even more seriously, singling out groups and blaming their lifestyle or culture is the thin end of a socially divisive wedge. If ’social engineering’ is being called for, it may be more effective to apply it to mental health services and service providers, not to communities.

Which (unsurprisingly if you look at the signatories!) makes the point far better than I could.

I feel the loss of community and culturally based resources wouldn’t necessarily help Mental Health services in the long run and if we try to ignore the impact that racism on a personal level as well as on an institutional level has had on creating these societal constructs in the first place – we can absolve ourselves of responsibilities for the cause and blame minority cultures themselves for the situations that oppressions have set them within.

Unsurprisingly the BNP (British National Party) – jumped on the Aesop Study – providing the ‘evidence’ for their beliefs of racial and ethnic superiority. That isn’t to say the research itself is necessarily flawed but research studies can be made to report just about anything we want them to. There is a research study around that can point to just about any issue and provide evidence for it or against it.

The problem with producing evidence such as this is that it can shift responsibility. The responsibility though of creating environments in which the difference thrives, lies with the majority ethnic group as well.

Difference is crucial to accommodate within services and if it is done in a way which acknowledges the significance of decades, nay, centuries of oppressive practices and institutional racism within the ‘system’, it will be far more effective – rather than trying to separate an individual from their cultural heritage or cut services that might be more tailored to different cultural and ethnic groups.

It is most definitely a challenge for the New Horizons ‘era’ that we are moving into but hopefully one that practitioners on the ground, at least, will be able to address to some extent.

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• Poor research or an attack on black people? (guardian.co.uk)

Failing Students

This week, Community Care prints an article about pressures on universities to pass students who might not ‘meet the grade’.

This has always been a concern of mine as there is an incentive on universities to ensure students graduate rather than ensure that high quality social workers are pumped out into the ‘system’. The needs are conflicting as a student can be very able academically (or not.. )  and that does not necessarily imply good practice but for as long as the degree in itself is the gateway to qualified status, the decisions are left in the hands of the universities.

Practice placements exist to ensure that it is not only on academic levels that students are assessed however there are well-documented difficulties with placement and there is not necessarily an equality of experiences between students at the same university and the way they have experiences and assessments on placement.

This is particularly heavy on my mind at the moment as I will imminently be taking a student from one of the local universities into my work place and have turned my thoughts to preparation for this.

I know from a colleague’s experience how difficult it has been to try and ‘fail’ students who have not met the standards expected to practice on a final placement and the practice assessors who have been in my team, have been leaned on heavily to keep giving more and more chances to students they felt were not achieving well enough.

I’m all for second chances  but some people are not cut out for the profession and trying to force too leeway into the framework of assessment does noone any favours.

The article presented in Community Care draws parallels with the Teacher Training programmes where

‘The Training and Development Agency for Schools, which funds teacher training, has chosen to remove any incentives universities might have for retaining students who were not likely to pass the course or become competent teachers … this should be the same for social work.’

Personally, I think the proposed year following qualification in which newly graduated social workers will have to practice will help in this area. I think that the universities have not been able to be trusted with the process of training social workers – especially as concerns about appropriate placements have grown. If social work students cannot spend substantial time with social workers ‘on the job’ during their courses, then they must be compelled to subsequently.

Noone wins with a dilution of the quality of entrance to the profession and as well as rigorous academic standards, a certain amount of confidence, assertiveness and thoughtfulness is required.

If there is anything that will raise the status of the profession – something which the Task Force seems to be particularly focussed on – it is a good quality, effective workforce who are able not only to advocate on behalf of service users but also able to advocate on behalf of themselves and their profession when they see poor systems in place.

ADASS concerns over Free Home Care

Over the weekend, a few news reports emerged regarding a statement from ADASS (Association of Directors of Adult Social Services) which raised questions about the government’s speedily announced plans for ‘free personal care at home’ and particularly about some of the sums involved.

According to the ADASS survey the true cost of the policy could be a minimum of £1 billion, with the overall cost to local authorities rising to more than twice the £250 million originally calculated by Central Government.
Calling for an urgent meeting with the Department of Health to help clarify these issues, ADASS President Jenny Owen said: “Government assumes that personal care needs can be met through an average package of 6.54 hours of care per week at £15.75 per hour amounting to £103 per week.

“However our research shows that local authorities have estimated a much more expensive average care package for a user with high needs. Information we have received from 61 authorities shows that the average cost of care is about £200 per week.

“Also, the number of existing self-funders in any given area is often unknown, as is the number qualifying as eligible under the Fair Access to Care eligibility criteria.”

My first reaction to the statement is that if the government truly believe that most ‘critical’ care needs are met through packages of care of 6.54 hours per week, they have some very dodgy figures that they are going on – in my very humble and perhaps limited personal experience.

‘Free’ also sounds so good. Perfect for building an election campaign on. Everyone likes ‘free’. Free however needs money and funding. Free is likely to create far more problems than it solves if all the money is channelled solely to those who are at the very edges of the ‘critical’ band of need.

I was discussing this with a colleague from a neighbouring borough last week at a forum we attended. She commented that she had always been able to manipulate the FACS (Fair Access to Care Services) criteria according to how she determined need as she assessed them and that it can be as flexible as one wants it to be. I can see her point to an extent in that it is fairly easy to interpret the bandings in different ways and something that might be ‘critical’ in the view of one person – could be ‘substantial’ or even ‘moderate’ in the eyes of another.  This will be of vital importance as if it is to be a method of determining whether care is free or not, it will become more tempting to assess upwards those that might completely refuse care if they have to pay for it (who are frequently not the people with the least amount of money, for the record).

I have no problem with ‘free’ but where I feel uncomfortable is that those who are fully able to pay are going to be the more vocal and assertive in demanding the rights to ‘free’ and those who have fewer means will be excluded from lower level services in order to fund the more critical needs of people who are more wealthy.

A critical need is a more immediate difficulty but a moderate need not attended to or managed can become a critical need fairly rapidly. I also fear a system as complex and controversial as the current continuing care system which is as inaccessible and confusing as it is possible to make any kind of system at present.

Continuing Care is currently ‘free’ as it is care provided by the NHS to those whose primary needs are health-based rather than social care-based which to all intents discriminates against older adults and particularly those with dementia (as it is seen as a social care need rather than a health need). The arguments can and do go on.

How the new proposed system will add more expectations of entitlement, we will just have to wait and see. The ‘free’ care will have to come from somewhere. It is likely to be minimal when it is provided. A  few 30 mins visit here and there isn’t enough to meet social care and health needs appropriately in the community.

I also wonder how it will tie in to the push towards Individual Budgets. Will the free care be provided through Individual Budgets? I think it’s going to have to be  – as, before long – all care will be provided through Individual Budgets,  This may increase the level of human hours needed to support and assist which is no problem as far as I’m concerned. I’d love to spend many more hours supporting people putting together individualised care packages however the time taken by the workforce and the costs of staffing have to be taken into account at some point.

Ideally, I’d love to drop the cynicism and embrace the policy with open arms. I am just so sceptical that the electioneering is taking the place of consultation and common sense and the government have just jumped on this issue without an understanding of the implications.

Social Care is an easy target for swift government promises. Helping Vulnerable People is A Good Thing. No thought of where the additional money will come from and rather about what will be lost from the preventative and early invention work to provide free care to those who are very well able to pay for it – can only lead to poor legislation.

As Service Users

Yesterday, I had a telephone call from one of the board members of our borough’s Foster Carers Association. They call new carers from time to time to find out how things are going and see what support can be offered on a peer basis.

She caught me as I had just finished a visit and was on my way back to the office so it was a particularly good time for a chat and I explained some of the issues that had been placed in front of us – particularly the frustrations with the local authority to be honest.

I ended up though, in the middle of my exasperated discussions of our interactions with social services, explaining that I was a social worker myself. I think she wasn’t expecting that. I do think it gives me some understanding of the pressures involved. I think it might make the social workers I deal with a little wary of me and it certainly has led to some misunderstandings when they have made assumptions that I know and am aware of the minutiae of the details of various Children Acts when actually, the last time I learnt about that legislation was 10 years ago. Boy, I’d like to quiz them on an equal level on the provisions of the Mental Health Act and the Mental Capacity Act but this isn’t a ‘fair’ relationship – I know we talk about power differentials but it has been very apparent in my dealings with Childrens’ services of the massive power issues at play.

All I can do is take those thoughts and feelings with me to try and ensure that I do my best to work with and against them in relation to the work that I do and the interactions I have.

Meanwhile, another colleague was trying to sort out some care arrangements for her own father with a neighbouring social services department. After coming off what sounded like a difficult phone call (it’s an open plan office.. I can’t help overhearing!), we had a chat about the situation and she said she hadn’t told her father’s social workers that she was a social worker. She said it would just have complicated things.

I thought about these issues a lot last night. Is it that social workers find working with other social workers threatening? I am not immune to it. The first person allocated to me in this team had a daughter who was an ASW (as was) and I found it a bit intimidating myself – but actually, it was no different (quite rightly) than dealing with anyone else. We are subject to the same prejudices and judgements that others make and possibly more susceptible – just as sometimes we can be more critical about people of our own ethnicity or background than we might be of others.

The main thing to take away though is that we are not separate from the clients with whom we work. The less there is of the ‘us’ and ‘them’ mentality, the better. I think possibly in older adults’ services, it might be different because often we have older family members ourselves, parents and grandparents. Many people in some capacity, have experience of an adult who has needed assistance or support. My father required support from social services for many many years prior to his death so perhaps for that reason I’ve never felt overly  separated  from the client group I work with and having foster children in the house and living their lives with them while providing as much support as is possible, has emphasised the sameness and the community in which I live.

A job does not define me –but how I do that job and the way that I preserve the characteristics that drove me to seek this profession in the first place – they  might very well define me far more.

Murdered for Medication

I saw this story on the Guardian website and was amazed that it was the first I heard of it.

Rachel Baker, the manager of Parkfields Nursing Home is on trial accused of murdering two women who were in her charge, and stealing their prescription medication that she was addicted to.

Baker, 44, who ran the Parkfields care home in Butleigh near Glastonbury, Somerset, became addicted to drugs, including heroin, after being prescribed painkillers for migraines. She allegedly fed her addiction by “diverting” drugs prescribed for residents at the care home. She either stole the drugs from residents who needed them or exaggerated or made up symptoms so that drugs the elderly people did not really need were prescribed.

Baker has admitted eight charges of possessing controlled drugs and one of intending to pervert the course of justice. She denies the murders.

Just imagine the coverage if the victims had been 5 and 7 years old rather than 85 and 97 years old and that, I think, tells us all we need to know about society’s ageism.

Broken Britain?

I was disheartened at how quickly the appalling story of Edlington – where two young boys, aged 10 and 11, under the care of the local authority attacked two other boys and subjected them to what surmounts as torture almost to the point of murder – turned into a party political debate about ‘Broken Britain’.



Firstly, there is no doubt that the case indicated is sickening. I’m sure that mistakes were made by professionals – as much as been said openly. But for the leader of the Conservative Party to extrapolate, as he did in a speech last week, that it indicates that society in Britain is ‘broken’ and lays the blame on the current government, reeks of mean-minded opportunism and a poor understanding and analysis of the country today.

We shouldn’t forgot what the previous Conservative government did to break society and to break Britain – from the sell-off of social housing which has led to increased overcrowding and a more desperate rush for the homes that are available to the miners strike and breaking of the industrial base of the north of England, leading to greater divides between the North and South and the promotion of the ‘me’ culture.

Cameron says we must as ask ‘deep questions about social breakdown.  A few of the questions I would ask would be about the responsibility of government for every shocking story that emerges ghoulishly onto the front pages of the tabloids to foster the middle-class angst about the state of the country.

I’m not saying there is no effect of social policy on some of the ‘issues’ that are raising themselves but relating them to one particularly shocking story is at best ingenuous and at worst, a use of the victims for the benefit of party political gains.

I wonder how much Cameron, in his very cosy upper middle class ivory tower, has an understanding of poverty and how it affects and drives social mobility. It is hard for him to convince me of his desire to tackle poverty head on while he talks about policies that are based on the benefits to the middle classes that are so essential for the Conservative government – but this is the rhetoric that feeds perfectly to Surrey chattering classes.

‘Oh look at how awful ‘poor people’ are’. ‘The government is responsible’ ‘We should do something’ ‘See, dear, we have to find the money to send little Johnny to private school so he doesn’t meet yobs like this’  – it plays straight into the Mail reading crowd  who can blame ‘other people’ and increasingly detach themselves from the rest of the population who might be less able to speak up or involve themselves in politics.

The Conservatives have accused some on the left of playing up ‘class war’ issues in the run up to the election and emphasising the private school backgrounds of most of the shadow cabinet. I say that Cameron’s rhetoric about ‘broken Britain’ plays this line absolutely.  It doesn’t seem to be ‘his’ Britain that is broken. It is the Britain of the underclasses or ‘other people’.  Surely by having a greater understanding of the societies in which these crimes take place and those many communities where no crimes take place but where poverty is pervasive, he would have a better idea of what the country needs, rather than writing it off as ‘Broken’ which is an easy shot.

I don’t think society is any more damaged than any generation has been. Crimes and awful crimes at that, have always taken place. We have more access to reporting them though. I work through all echelons of society from extreme and almost unbelieveable poverty to some pretty impressive townhouses that woudn’t fall short of a few million. I see pensioners with barely enough to eat and heat and having to make those choices on a real basis as well as retired stockbrokers and UN officials on very comfortable pensions. The pain and distress can be differently focussed  but it exists in both just the same. I see much more that unites than divides – all the same being one community and one society.

Society today has much hope in it – and many good people. I think of the young, unemployed neighbours of a rather grouchy elderly woman I worked with who redecorated her home and visited her daily for a chat just because they didn’t have anything to do – I see some kids who pop into a local residential home to chat to the residents in exchange for a cup of tea and biscuits or the young lad who offers to do bits and pieces of shopping for his gran’s friend who doesn’t have any family of their own.

We don’t see this reported though. There is more good than bad in our society and in our young people. As a foster carer,  I think of the young girl in the care of the local authority who is sitting in front of me as I type this and speaks of how she wants to make the world a better place and ‘help old people’ when she grows up (ahem. .I had no influence during our ‘what you want to be when you grow up?’ discussion.. cough.. cough) – but in her and the other children I have had the pleasure to have as guests in my home, I see a lot of hope for the future and for the society they grow up in and create for us to grow old in.

What is needed by the Conservative and the Labour Party is firm and distinct social policies which will not focus on particular crimes but rather on resources being distributed more towards those who need it and where it is be best used rather than creating a side show of crime for the middle classes to guff at.

There is no doubt that a lot can be done to make this country a better place to grow up and grow old. That doesn’t take as a baseline that all hope is lost at the moment though – but there’s nothing wrong in striving to make things better without writing off the society of today.