Looking for beds

The new president of the Royal College of Psychiatrists, Professor Dinesh Bhugra, will according to the Guardian use his inaugural speech to lament the problems caused by the shortage of acute psychiatric beds in the system.

This is something we hear a lot about, and indeed, something described on There and Back Again’s blog about waiting for a hospital bed as an inpatient on leave when the ward is running a 150% occupancy rate recently.

Hospital beds in the hospital empty chamber. Kharkov, Ukraine.

 

 

Image via Wikipedia

Bhugra suggests that

No ward should ever be more than 80 per cent full if patients are to be safe, properly treated and cared for.

and while the sense of this can be obvious, it is rarely, if ever, the case in practice – or certainly isn’t in my own, admittedly limited, experience.

So something has to be done and Bhugra has a suggestion

‘ (Bhugra)..  is calling on the government to introduce a compulsory kitemark system of accreditation for all acute, inpatient psychiatric wards: ‘Until there is a compulsory kitemarking scheme, my prediction is that, as overcrowding increases, funding becomes more stretched and morale of patients and staff fall, overall conditions are likely to continue to deteriorate.’

Interesting. I know I rant against target-based practice but in can work in some areas. Perhaps if Trusts are told that funding will be cut or increased on the basis of their ability to find these beds – or that the levels of occupancy will be monitored by the Mental Health Act Commission and there will be financial penalties for applying poor standards – there will be more incentives to hospital managers to actually work on a solution – which doesn’t seem to be being done at the moment.

This Kitemark would measure against other standards such as staffing ratios as well and, indeed, in another article in the Guardian which focuses on current inpatient care, a spokesman for MIND says

‘A compulsory kitemark is a fantastic idea; these wards slip under people’s radar and that’s dangerous,’ she added. ‘When patients are sectioned, they literally have no choice at all about where they go. This makes it vitally important for society to be 100 per cent aware if these vulnerable people are ending up in wards where conditions don’t meet the minimum acceptable standards.’

Beds have been reduced as the focus has been on community care but the fact remains that some people need inpatient care and there isn’t always a reasonable substitute.

And with the incoming President of the Royal College of Psychiatrists in stating that

‘Acute psychiatric wards are now so poor, he (Bhugra) has admitted in an exclusive interview on the eve of his appointment, that he would not use them himself – nor allow a member of his family to do so.’

That is, perhaps, the saddest indictment of all.

Its pleasing that at least the situation is getting some more attention and will get even more when Bhugra actually makes his speech on Wednesday but one of the criteria that I have consistently tried to work on when considering placements for residential care is ‘would I be prepared for a close family member of mine to go to that home?’ and if the answer is no, I at least look for alternatives as I won’t use a home that I wouldn’t be prepared for a family member of mine to go to – or at least without offering the families and prospective residents an alternative option (which isn’t always taken or perfect for other reasons, like location but that’s another discussion for another day)

However as far as psychiatric wards go, that’s another matter.

Running acute wards at a 100% + occupancy doesn’t do anyone any favours in the long run and can lead to possibly longer or more frequent inpatient stays.

Where I work, I am fortunate in that I have a lot of faith in the psychiatric wards I normally use when people I work with are admitted.

Certainly on the over 65s wards where I know the staff much better, I can confidently say, I would be happy to spend time on those wards and would, without doubt, be happy for my father (only close family member I have that is over 65!) to go there. Because I know the wards are well-managed by an excellent nursing and medical team.

The other wards in the hospital, that I’ve had a bit less interaction with, have given me at least some faith in my interaction and observations of the interactions between patients and nursing and medical staff. I do know that this hospital is perhaps ‘one of the better’ ones.

Until I was on my placement in a different borough in my ASW course, my current hospital was the only psychiatric hospital I’d been to – I know that people had said it was a pleasant enough hospital but I didn’t know what to compare it to.

On placement I assessed and organised  an admission for a patient to a hospital I had heard about but never been to. We arrived. I was genuinely shocked myself about the look and feel of the ward. She was taken to her room and I honestly didn’t realise that there were wards like that around still. I think and have thought about it a lot. It has to change.

And the more publicity and public attention that is focused on the quality and care that is provided on some (but by no means all) of the psychiatric wards, the more hope that there will be for some change.

As for the running at over-capacity – the only solution in my own, simplistic mind, is more beds which means more money. Not very popular, I fear.

Legislating for Equality

Details regarding the new Equality Bill were announced last Thursday. The Bill seems to be an attempt to consolidate existing legislation related to discrimination – a seemingly uncontentious issue – however combined with this are some new proposals which seem to be garnering attention in different ways.

Community Care unsurprisingly, considering the target audience (social care workers, predominantly) , highlights the inclusion of outlawing age discrimination and the implications that that could have on the provision of social and health care for the elderly population.

EVERYLIFEMODERN EVERYDAYLIFEMODERN @ Flickr

It has long been the case that less money has been assigned to older people’s care services when compared to that of younger adults. The same levels of funding and flexibility are not allowed in the provisions of care for the elderly and it has long been an area that I, personally, have had issue with. Conversely, an equality of service can lead to a massive increase in budgets for the elderly – or a massive drop in budgets for younger adults – which, in my own cynical way, I see as being more likely.

As the article points out

‘While age discrimination is outlawed in employment, it is currently the only equality dimension – the others are belief and religion, disability, gender, race and sexual orientation – where discrimination is legal in the provision of goods and services.

The duty on the public sector will put age on a par with race, disability and gender.’

So this has the potential to be ground-breaking legislation – but I have to retain a healthy dose of scepticism because some of the financial considerations about providing an equality of service could be massive. Still, I shouldn’t be too churlish – this is exactly what I’d been waiting for in the services for many years. Hopefully, it will mean that assessments can be truly needs-based rather than having to be divided and considered on the basis of the age of the person concerned.

Ironically, at the moment, I am working with a woman with early onset dementia (because our team, although basically working with over 65s, does work with people diagnosed with early onset dementia due to the expertise in dementia that is held) – she is in her 50s and because the structure of some of the budgets that are held by the department and the provision of services are geared around over 65s, it seems to be an abnormal challenge to the system to coordinate the funding for her care.

Adult CMHTs push it back to the Older Persons’ CMHT  – who push it back to the younger adults services. And so on (the pushing, by the way, is being done by the financial managers rather than the practitioners!).

The lack of flexibility when it comes to budget-holding is thunderous – to the detriment of the provision of service – well, actually it is to the detriment of the provider of the service as we went ahead and arranged a service for her according to her need – it is just now that the different financial departments are actually refusing to pay the bills that the problem  has arisen. She, herself, is fortunately oblivious to the pushing and shoving behind the scenes.

Multi-disciplinary working.. or not.

I read in on the Times website that a letter has been written to the British Journal of Psychiatry,  in which 36 signatories complain that

‘patients with serious problems are often referred to psychologists and social workers rather than clinicians and do not receive the medical therapies they need.’

Now, I don’t have access to the British Journal of Psychiatry so have to rely on the Times reporting.

Apparently, this is a great disservice to the patients who are in need of medical treatment (a position that I can understand as far as it is the case) I’m a little baffled though, as all the referrals we take into our service are referrals to our team which includes a consultant psychiatrist, a  Specialist Registrar (I know, they’ve changed the names – but I can’t remember what grade they equate to now!), a clinical psychologist, some CPNs, Social Workers and an Occupational Therapist. None of us accept direct referrals to individual professionals without the team being involved first.

– and, according to the Times article

The changes came about under a scheme, New Ways of Working, established in 2005. GPs now refer patients with symptoms of mental illness to a team of up to eight people, which will include psychologists, nurses, social workers and a psychiatrist

Now, I reserve the write to be completely wrong here – it wouldn’t be an unusual position for me to take, but my understanding of New Ways of Working initiative is that although a report was published back in 2005, it is still in the consultative phase and was being discussed in 2005 then rather than being ‘established’. Some tentative steps might be being taken in that direction in some trusts but it by no means ‘up and running’

Multi-disciplinary Teams – these ‘teams of up to eight people which  include psychologists, nurses, social workers and a psychiatrist’ have been in play for many years – certainly prior to 2005.

So I’m a little confused by the issues and the facts – although not being able to read the original letter of course, means that I’m relying on the second-hand reporting of the Times.

It seems that the main area of concern is that people with severe and enduring mental illnesses will see one of the team that provides ‘psycho-social’ support rather than ‘medical’ support.

So

‘“If a GP suspected a patient had cancer, he wouldn’t dream of referring him to anybody other than a cancer specialist. A cancer patient might need jollying along, but what he really needs is the correct diagnosis and treatment. That’s what he gets from a specialist. But patients with mental illness are not automatically referred to psychiatrists. If they only see a social worker, there’s every chance that mental illness, or underlying physical illness, will be missed. Patients are getting a bum deal.”

winnie the pooh mbbp winnie the pooh mbbp at flickr

Of course, I am not a doctor and nor do I want to take the role of a doctor. I don’t want to diagnose or prescribe – but I’d also take issue that people that I work with ‘get a bum deal’ when I am involved in their care – not least because there is not a single person that I see that I don’t discuss in a team setting with our consultant psychiatrist on a regular basis. As I said earlier, all allocations come through a team discussion which includes the presence of doctors initially.

And as I work with someone, when there is any change or concern, he is the first person I would contact to discuss these concerns with.

I can’t say I speak for all multi-disciplinary teams in the country but although I’m not a medic or medically trained, I’d like to think I can recognise areas of concern and bring a psychiatrist in very quickly when required (and sometimes when not required – I tend to play safe) . I don’t need to diagnose in order to recognise.

A part of the multi-disciplinary team structure is to work towards strengths. I would also hope that I provide a little more input than ‘jollying along’ but sometimes you just take what you can get and what you can work with.

The New Ways of Working, is, as far as I understand it, is a way of delivering a wider range of services by a broad group of professionals – but not about training others to do the job of doctors or about deskilling specialists. It is, as far as I could understand, about providing a higher skilled professional with more training , into the picture.

Noone wants to see a poor service being delivered or any kind of practice that would detract from medical treatment being provided when necessary. I would never consider myself a replacement for a medical professional but as a different branch of the same tree – because that’s where my expertise lies. I don’t want to be a ‘poor man’s doctor’. I want to be a social worker and not a doctor and to do the job that I am trained and expected to do and I want to do it well.

If that includes ‘jollying along’ so be it but not at the expense of clinical need. Social circumstances and considerations do have a very important role to play within Mental Health services though and to ignore those needs too can be an issue for concern for the patient.

Direct Payments – Chapter One

Direct Payments is the system of, basically, rather than giving a direct service, providing money to the user of the service to ‘buy’ the care that they need directly.

‘Direct Payments were introduced in the UK

– for adults with a disability in 1997

– for older people in 2000

– for carers, parents of disabled children and for 16 and 17 year olds in 2001

Since 2003, councils have been required to make Direct Payments available to those who are able to choose to have them and who wish to have them’

(Source : Direct Payments for people with mental health problems: A guide to action)

I have worked with Direct Payments a few times although it isn’t something that comes up with any great regularity in the field that I am currently working in – mostly because, I imagine, my work is focused on a combination for the two groups of service users who have found the system of direct payments least accessible – older people and people with mental illnesses.

So working in a team for older people with mental health problems seems to be possibly the least likely place for direct payments to be accessed.

I have instigated a few direct payments packages but not a many. One of the things that I have found the most frustrating is the time-lag between going in to someone and identifying a support need – offering and explaining direct payments alongside an explanation of the direct provision of services.

On meeting potential interest, the boxes get ticked but in the meantime the service is needed immediately – it can and  has taken months to get a direct payment service up and running but in the meantime a direct service is needed to meet the need that still exists – sometimes a carer is employed in the meantime with whom the patient gets on very well – seeing no need to change to direct payments after a few months of building up a relationship.

Sometimes the  delay between setting up a ‘new’ system leads to a complacency to fall back to the ‘default’ system.

But sometimes, occasionally, it has followed through.

I have two reasons for bringing this up at the moment

Firstly, I am starting the process of referring someone for direct payments and her daughter for carers direct payments.

I thought it would be a useful illustration of the time it between someone deciding they need a service to its eventual ‘fruition’ if I can follow it here by indicating the different points in the process as they arise.

I hope I will be proved wrong and that we can get things up and running quickly. I really do.

Bit of brief background, service user and potential user of direct payments has an Alzheimer’s type dementia. She has had this diagnosis for a couple of years and can function fairly well. On meeting her, you probably wouldn’t realise she has dementia until you’ve been talking to her for at least about half an hour when some of the conversation begins to repeat itself. She would certainly have the capacity at present to make decisions about her own care and support packages.

She has been receiving a directly provided care package for a while but some of the elements have proved to be less than satisfactory. She doesn’t enjoy the day services on offer and would probably get more from community activities such as tai chi classes at the local leisure centre. One of the ideas of the direct payments is to look at someone to take her to these kinds of activities rather than her going to the local community day centre.

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Outdoor practice in Beijing's Temple of Heaven.

Her daughter is her main carer and lives locally but not walking distance. Her daughter has a young family and provides a substantial amount of emotional support to her mother, visiting most days and taking her mother to stay with her family many weekends.

I’m hoping that Carers Direct Payments will be able to address some of her needs regarding travel costs between the two houses and possibly some of the domestic care.

It’s been a while since I referred a Direct Payment care package so I called the Direct Payment lead (who I get on well with anyway and always find it easy to talk to) to confirm the procedure to refer.

I sent her an initial care schedule with costings and times attached.

Meanwhile, on the ‘Carer’s’ front, I need still (and hope to today) update the most recent Carers Assessment and Carers Care Plan to include the conversation I had with daughter to include Direct Payments for Carers as an outcome.

Anyway, lets see together how long it takes to get these things up and running..