Assessing Best Interests – Part 3

After some days back at work, the taught part of the Best Interests Assessor training resumed yesterday  – and almost magically as we were promised, lots and lots of the pieces seem to have fallen into place.

Just as a recap, this is a short university-level course which will enable me to act as a ‘Best Interests Assessor’ under the Mental Capacity Act 2005.  The basic version of it is that UK was found guilty of breaking the European Convention of Human Rights (Human Right Act 1998)  (Article 5 – liberty and security) with respect to people who are detained in residential care or in hospital and who lack capacity to make a decision as to whether they should be there or not.

Some of these people will be being deprived of their liberty and as such, a legal framework needed to have been put into place to ensure that these decisions were not made arbitrarily and that (although this is  probably something I’ll return to) they have some kind of leave to appeal these decisions made through legal processes.

The role of the Best Interests Assessor will be as a part of the process which will be put into place come 1 April to determine whether an order can be granted to deprive an individual of their liberty in this manner – or not.

That is a very brief summary which in fact, needed about a week of training to thrash out – so apologies if it is a bit over-simplistic.


Partly, I think because of how the course has been structured. I have found the content very interesting which surprised me – I didn’t really expect it to be as compelling. 

Although when I was at school, I did want to be a lawyer (as well as the person who quality tests crisps)  so perhaps it is that aspect that is coming to the fore now!

The people attending from a wide variety of boroughs have added enormously to the learning process as there is a massive amount of experience in the room to draw on and with some having been trained through the switch to the 1983 Mental Health Act and through the initial implementation of that legislation with all the attendant procedures.

The training that I am attending is specifically for people who are already working as AMHPs and honestly, I think that having even a little experience of working within the frameworks and procedures  serves as some advantage.

We are also all social workers, although the training allows for nurses, OTs and psychologists to train. I suspect it is because we are doing the training for AMHPs and almost all current AMHPs are social workers. But it will be interesting to see the mix across the board.

My own borough has mostly trained Best Interests Assessors because the issue of payments for people who are not employed by the local authority has not been settled yet.  We, the social workers, are employed directly by the local authority and seconded out to the Mental Health Trust – and the PCT and Local Authority have agreed a joint intake of assessments. The Mental Health Trust has not decided yet how to manage these additional payments to ensure equity.

Although the people involved in the training were very quick to highlight the differences  – they put it in terms that we are more acting like a Section 12 doctor (the independent doctors with additional training in psychiatry that we would be assessing with) where we provide advice and a professional assessment but the responsibility for organising the assessment and making the decisions based on the recommendations we make, remain with the Supervising Authority (which would be either the Local Authority (for registered care homes) or the PCT (for hospitals)).

So yesterday we discussed the detail. What we are actually expected to do as a part of the process of the assessment – from looking through the forms (there are, unsurprisingly, mountains) to the procedures for registering authorisations of deprivations of liberty – and much more discussion about the conditions (or rather the preferred lack of them).

A lot of the questions I had last week have been resolved – at least as best as they can be before the undeniable confusion that will develop in practice.

All this is in the detail and I don’t expect it to interest more than a couple of people but it was probably one of the most useful days that I’ve spent training.

We also had a Q&A session with the person who has been appointed as Best Interest Assessment/Mental Capacity Act lead in our borough (I’m not sure of the exact job title).

So we were told about the processes that have been going on over the last 18 months or so, at least in the London region and how we were actually going to be assigned (and paid for (hurrah!)) assessments. We have been agreed some kind of payment at least – although this might seem a bit mercenary, the work is likely to need a fair amount of time and attention and I didn’t think it was entirely fair (although I had expected it) that we would be expected to carry out an additional role without an additional payment.

The concerns I have now, at least about the process, have diminished considerably and I am starting to see how the pieces will fit together in a much more practical sense.

We have another day of training today though. It includes a legal test among other things.

And then I have some study days scattered over the next couple of weeks to complete the written pieces that we need to submit – just about in time for the 1st April.

Interesting times, indeed.

8 deaths – 10 days

I’m back to one of my least favourite topics today. Southern Cross Healthcare. And yes, the headline just about says it all.

Crown Nursing Home in Harwell, Oxfordshire is a small 16 bedded nursing care home which was run by Trinity Care – bought out by Southern Cross in 2002. It has a good inspection report.

Now, I don’t want to be unreasonable or unrealistic. People who live in nursing homes, by the very nature of the care, have high needs and people die when they become old. It happens. I imagine the death rate in nursing homes is substantially higher than that in the general population and I’d get no statistics or mathematics prizes for making that assumption.

But for half of the homes’ residents, namely, 8 people, to die in a 10 day period between January 9th and January 25th. Well, that is something that I’ve not come across in the years that I have been working with and around care homes.

The BBC report that

Eight pensioners died from “chest-related illnesses”

And a spokesman for Southern Cross says

“These were as a result of individual chest-related illnesses. All regulatory authorities are aware of the deaths and there is no concern over the cause of each death.

“The average age of each resident was 93-years-old and all had been happily living in the home for some years.

“Management at the home have evaluated their infection control procedures, which were of the highest standard, and are reviewing newly issued NHS guidelines.”

And with no knowledge at all of chest-related illnesses except a very cursory one. I think with an average age of 93, cold weather and chest illnesses there is a possible line there for the home to take.

It still seems more than a little uncanny to me.

The Mail offers a little more explanation

Half of the residents at a 16-bed care home died when they contracted ‘chest-related illnesses’ after being left without central heating for up to ten days.

The eight pensioners all died over two weeks shortly after the heating system at their home failed around Christmas.

Last night the son of a woman of 93 who was among the dead, accused the home’s owners, Southern Cross Healthcare, of responsibility for the deaths after it took up to ten days to have the fault fixed.

Now that, at least, offers a bit more plausibility to the story. Especially in conjunction with the story from a couple of weeks back at another Southern Cross Home where the heating allegedly failed with tragic results.

And the Mail have a statement from the Southern Cross spokesman again – he’s quite busy, clearly

A spokesman for Southern Cross Healthcare insisted: ‘The central heating broke down on Boxing Day.

‘Temporary heaters were made available and at no time did temperatures fall below the recommended level.’

The nursing home, which charges fees of £721-£760 per week, was rated ‘good’ by the CSCI at its most recent inspection

So are they honestly claiming that there is no link between broken heating and an uncommon amount of chest infections. I’m no doctor, maybe someone who is can comment with authority, but to me, it just doesn’t sit right.

The home manager, according to the local press, said pneumonia was the cause of death for all the residents, but the Southern Cross spokesman (again) seems to contradict her, as he

said pneumonia was only registered as the cause of death in six cases and instead pointed to “chest-related illnesses”.

The PCT has been very measured in the statement that it has given to a local newspaper

An Oxfordshire Primary Care Trust spokesman said: “The PCT is not aware of an evidenced pneumonia outbreak within Oxfordshire. We cannot speculate as to the cause of the deaths at the Crown Nursing Home, which is a private provider of care services.”

And the local social services have said that

The county council is not aware of any widespread problem with pneumonia in Oxfordshire.”

I am sure that the standard of care by the staff on the ground was good, that’s certainly what the families seem to indicate – but – issues of maintenance of buildings seems to have come up more than once and I admit that this is pure speculation – I wonder if any pressures have been put to save money in areas such as boiler maintenance or emergency central heating repairs.  Surely, this is some kind of corporate responsibility for people who need to be assured of warm, safe buildings and properties particularly throughout the winter.

As a layperson, but knowing that Southern Cross own a considerable amount of real estate, I’d have thought they might see fit to make sure it is at a good state of repair as the opposite can have massive effects.

Again, I had to dig around a bit for the details of this story. I’m amazed it hasn’t been more widely reported. And saddened to be honest. Each time I see one of these stories, I am plain saddened.

Coming Home

One of my colleagues is not well at the moment and is unlikely to be back at work in a rush. So as is the norm, her work needed to be reallocated.

That’s how I found myself with a file for Mrs K. A woman who has a diagnosis of Alzheimer’s type dementia. Through a series of ways and means (she likes going on to the seaside), she found herself in a hospital a few hundred miles out of London.

Much liasing with hospital wards and hospital social workers ensued and although I even suggested going to visit Mrs K the very suggestion was slightly ridiculed. I have to say though, just as I don’t like to place people in residential care homes that I haven’t seen, I also don’t like managing care for someone that I have never met.

Anyhow, when someone is in hospital they are well-placed for lots of reports to be written and for decisions to be made on those accounts.

The decision-making process was befuzzled by a couple of factors. Prior to Mrs K’s admission to hospital, she had not been in receipt of any care services.  She was visited regularly by a care coordinator for the purpose really of trying to coax her into receipt of home care – but she had, to date, refused.

The reports from the hospital indicated, however,  that she required dementia nursing care.

That’s quite a jump in a couple of weeks – by any standards – considering the hospital admission was for a chest infection.

After a period of delayed discharge payments when both boroughs were having some kind of argument about whose responsibility paying for an IMCA would be (personally, I dispute that she is unbefriended in any case – as there is a partner – but that’s a different argument for a different day (and perhaps an indication of institutional homophobia as her partner is female)) , we made a temporary interim care placement to a nursing home in London with a view of planning care from there. At least she is now somewhere that her family find it more easy to visit and, well, yes, I do too.

National Gallery, London

Having now visited her a couple of times and spoken to the residential home as well as her friends and partner, I am assured that we should, at least, try to move her home with a care package. After all, she states explicitly that that is what she wants and there is a good historical knowledge that she has always been incredibly attached to her home. She has a cat and a canary waiting for her too. Moving to residential care from an acute hospital admission is always heart-wrenching although sometimes unavoidable but there is a grief process for a familiar place and setting that is often disregarded when such moves are made.

Now though, I have a race against time though having been allocated what I consider to be not-enough-time to arrange a safe move home. Not least because (as I discovered on visiting yesterday) the home needs a rather thorough deep clean before we’d be able to put a service in.

But as always with these time-limited issues (and this is something I have grown better at with experience), I phrased a humble email to the respective manager explaining risk and safe return home and how much preferable to our ethos (and to the council’s bank balance) a return home would be as opposed to a permanent nursing placement (which I suspect was expected).

I most humbly stated I was doing all that I possibly could to speed up and facilitate a move (which is true – I’m just away on training for three days). I expect to follow up with another humble and apologetic email next week updating what I have achieved in the additional time and why I need an extra extension.

I have to say though, these kinds of situations – moving someone home against the expectations – give me a considerable amount of satisfaction.

Trichotillomania and me.

My usual pattern is to read through various newspapers and articles first thing in the morning and to write either in response to something I read, or something I do at work.

I haven’t got through many intensely personal posts and that is wholly intentional.

I titled my blog on the hoof – initially it was intended to be random mumblings mostly to myself and were I to go back to the start, I would have chosen a much more clear title like ‘The Blog of a Social Worker’ or some such thing. It would certainly have got more ‘hits’ from Google and less people searching for ‘monsters’, ‘fighting women’ or ‘fighting’!  I was though, when I created it, more than a little stressed from work and was acutely aware of the fine line that we place between mental health and ill-health.

A large part of my doubts and worries relate back to a particular point in my childhood when I was hauled in front of a child psychiatrist and asked to tell him about myself. I didn’t. Although I’m going back to about 25 years or so, I remember then at the age of – well, roughly ten or eleven – sitting in the room with the psychiatrist and being appalled that I might be ‘mentally ill’. It is amazing how the stigma permeates through to our consciousness.

I don’t remember seeing him much. I think there were a couple of family sessions but any time he saw me alone or with the family for that matter, I didn’t speak to him. I resolutely and consciously refused to engage.

So look where I am now. Eventually – or as I see it – the ‘services’ either gave up or we ran out of allocated time. I’m not sure how it worked back in the mid-80s.

But flash forward to today and I saw an article in the Times that brought these memories, thoughts and recollections which are, for the most part, dormant.

image Pushek on Flickr

It’s called ‘Beautiful Women who Tear their Hair Out’. While far from beautiful, that’s exactly what I did at that age. That’s why my father sought input from the doctor, the mental health services – that’s why the schoolteachers wavered between chiding me and worrying about me. I pulled all my hair out.  I stopped gradually, and feel wonderfully fortunate to have done so. Especially when I read some of the stories in the Times article. Looking at me now, noone would even have a clue – which is one of the reasons I feel safe writing about it here. But when people praise my long, thick hair – I still feel the pangs of the humiliation that I suffered and the shame of going to the hairdresser to have my hair cut when they would see the swathes of bald patches on my head.

And I still haven’t been to the hairdresser for over a year. I might manage to work myself up for it every couple of years or so.

I’m glad that there are articles to describe this. I know personally, that I never had understood there was an actual name to what I was doing at the time. Later, as I grew through it, I assumed and attested it as some kind of Obsessive Compulsive Disorder with a particularly visible effect.

But to read, as noted in the Times

It is thought to affect as many as one million women in Britain today, or, according to other estimates, between 2 and 4% of the general population.

The figures are on a par with those for much more widely known conditions, such as anorexia, panic attacks and bulimia. But most people have never heard of trichotillomania. Neither have most GPs in this country, even though it’s estimated that every GP is likely to have at least 10 trichotillomania patients in a typical list of 1,000. Nor will most teachers have heard of it, despite the fact that 100% of them will at some point have a child with the condition in their classroom.

All I can say, in retrospect, is that if I had only known that I wasn’t the only person in the world who was experiencing this, I think that would have helped me enormously at the time.

Trichotillomania almost always starts at puberty and predominantly affects women. Classified as an impulse control disorder, it is thought to be triggered by anxiety. Some studies suggest a genetic link, others that it’s a neurobiological disorder. On MRI scans it looks similar to Tourette syndrome, which is usually a motor disorder. Others claim it’s an atavistic grooming instinct gone wrong.

Manjit Ubhi, a glamorous psychotherapist from Birmingham, suffered for 25 years before being treated successfully and now counsels other sufferers. She is convinced there is a link with trauma, in particular bereavement. Pulling, cutting or shaving hair, she notes, was an ancient act of grief and mourning. She started pulling out her hair when she was 10, shortly after her mother died

There are some uncanny links in the article to my own experiences. From the explanation of the rituals that surrounded it to the secrecy and the possible link to parental bereavement but in particular the shame that is engendered by an adolescent with a massively noticeable bald patch.

Of course, I feel enormously fortunate to have been able to ‘get over it’. I’m not sure I could go on to tell others how it happens. Personally, I think it’s when people – friends, teachers, doctors, family – stopped telling me to stop, I did. I relate it as being linked to the anxiety and telling me to stop increased my anxieties so I did it more. I never wanted to though. I hated myself for succumbing to the impulses. Of course, it might be a bit of a chicken and egg situation but somehow the chain was broken and particularly, looking back at the article, I feel incredibly fortunate in that.

But you know, as it says, in the article – it isn’t the same as the mental disorder that I am faced with on a daily level. Although I can’t really pin down how or why I stopped. I did. But those adolescent memories of being different – they do still remain. But it was never life-threatening. Just increasingly shameful experience that I tried to explain that I didn’t have any control over amid lots of disbelieving snorts and sniggers.

I have to say though, I was slightly tickled when I read this

Dr Gray and Lucinda Ellery agree that trichotillomania is most likely to affect women of above-average looks and intelligence. And Philip Kingsley notes: “Oddly, it is often women with naturally luxuriant hair who are more prone.”

– or rather caught between feminist outrages at having to justify conditions by physical beauty and just inward chuckles of the 12 year old girl who who just felt so very odd, awkward, ugly and different.

On Call

As I’ve alluded to and outright said on various occasions, myself and a colleague are running a kind of rota for AMHP work between us. Seeing as the Trust we work in feels that it is more appropriate that those who work in specialist teams (of which the Older Adults Service is one) are best placed to manage there own assessments.

It is difficult running a rota system with two people. We did try initially – we had a week on and a week off. But without being able to clear work for those periods, there can be clashes. We had, we thought, an agreement whereby when neither of us were available, we would pass the assessments to the other CMHTs depending on the local area.

But the one week on, one week off rota kind of melted into a ‘whichever of you is around’ rota. Generally, the consultants like the system as they know us and we are managing and arranging assessments much more quickly than when they had to ask the general CMHTs for ASW support.

Between us though, we try to chivvy up the work as fairly as possible. Fortunately, we get on well and see each other as reasonable people so it  hasn’t been an issue.  Currently, both of us are involved in the training for the Best Interests Assessments – yes, we could have chosen different dates, but of the proffered available dates, the current ones happened to suit both of us best.

We have a  referral on the go at the moment. It is a community assessment for a man about whom we have very little information. But we know he has a violent history and he is thought to have a variety of fairly intimidating offensive weapons in his property.

So we get the warrant (history of refusing access) and request police assistance. Police assistance is needed at a fairly high level due to the history and levels of risk so we have to wait for them to come back to us.

The police come back with an available date which is when we are both attending the aforementioned training.

True to form, I call the local CMHT to ask if they can pick up the assessment for us.

I am told, very bluntly ‘No’.

‘You should be able to organise the rota between the two of you’.

‘Hrm’, I think.’Are you refusing then?’ I ask, just to clarify in my own mind. ‘Yes’ is the response.

‘Rearrange the police – we have to manage our own teams’

‘But you have more than two people’ I respond. And then I stop realising I’m not going to win this particular argument.

I haven’t the authority nor the seniority to argue. I grumble to my manager and send a more terse email to relevant authorities.

Honestly, I’m disappointed that there has been no assistance offered. I am amazed that we are expected to run a 5-day-a-week rota between two people – one of whom manages a team and the other (me) has no caseload relief (as promised, I hasten to add) as a result of the additional work.

So a generalised grumble is in order – or perhaps I am being unfair.

Either way, I am not happy for assessments to be postponed on this basis. The local teams seem to happily accept work freely from each other when they are short-staffed.

Surely a timely assessment in the case of medical need should be act as a guide to providing the best services.

I’m not going to let it lie in any case.

Mental Health and Public Office

While pottering around on the web, I came across this story from the Camden New Journal, about Councillor Chris Basson – an elected official who suffers from bipolar disorder.

He resigned from his post earlier this week, following, according to the article

three years on the council that were wrecked by poor attendance and gossiping.

Poor attendance, fair enough, but I think we can venture a guess or two as to what the nature of the gossiping might have entailed.

His statement of resignation reads as follows

“I was diagnosed with Bipolar Affective Disorder in 1996 – more commonly known as manic depression,” he said.
“With appropriate medication, I was able to manage the condition in the run-up to the 2006 election. However, since then I suffered from a series of relapses including nervous breakdowns – which have involved hospitalisation – and I have struggled to bring the condition under control.”
He added: “I have been unable to carry out my duties in the way I wanted. I regret that I haven’t had the confidence to talk about this publicly before now in the way that others, such as Stephen Fry, have.”

Honestly, I was struck with more than a hint of sadness when I read this. It does make me realise the importance that the removal of stigma has.

How supportive do opposing politicians need to be though?

In a tense week at the Town Hall, the Lib Dems have been accused of picking the wrong candidate in the first place and then allowing Mr Basson to stay in office longer than was appropriate.
Labour councillor Jonathan Simpson: “Of course it is sad whenever somebody experiences difficulties like this but this is why you have to be careful about which candidates you chose. ”

Personally I feel the Lib Dems come out of this with more credit than the Labour councillor quoted above.

It’s interesting that while enforced hospitalisation would disqualify an MP, it would not disqualify a councillor. And the people in that ward would not remain unrepresented by one councillors absence as there are three councillors per ward and it sounds like party members may be willing to provide cover for colleagues.

However there is also a statement explaining that his health has deteriorated since his election. Perhaps the pressures of public office have taken their toll? So, the opposition parties claim, have the Liberal Democrats failed in their duty of care to this councillor by not persuading him to stand down earlier?

It’s hard to know which way to call it. It is a sadness though, for him and those associated with him. We need people who understand and experience services and situations that the people they represent do.

Similarities are drawn with another member of the same council,

It had been an open secret at the Town Hall that Mr Basson was in poor health – his attendance seemed to get worse and worse – but the issue was not pressed. To some extent, this sympathetic convention mirrored the treatment of Camden’s longest-serving Labour councillor Roy Shaw, whose health failed while he was in office.

It’s hard not to determine that the differential consideration is given to a councillor whose physical health fails but when he becomes more unwell mentally, it becomes a game for political football.

I certainly wish Basson a speedy recovery and certainly hope this does not put an end to the impact that he has on public life. Not least because it allows a much deeper exploration of prejudices.

Assessing Best Interests – part 2

The training continues – it’s a fairly robust one as far as it goes and although it might not be apparent, despite the  density of content, I am finding the substance interesting.

As promised on the first day of the training, more of the bits and pieces are fitting together as we progress and a better idea of how exactly the assessments will be conducted is forming somewhere in my head.

Generally, I have found the Mental Capacity Act (2005) very helpful in my work to date. It has codified a lot of ‘common law’ practice and provides a much stronger system of safeguards to both those who are affected by it through the lack of capacity – either temporary or permanently.

It also includes safeguards for those who work with people who lack capacity.

Yesterday among lots of other things a couple of issues jumped out from the course. Firstly that when there is a call to authorise deprivations of liberty there will be two types of orders that can be made.

Standard orders which need to be completed within 21 days and can be completed prior to the deprivation of liberty taking place. These are what we will be concerning ourselves with – there is some leeway just this April to manage backlogs and the timings will be slightly more generous – but these are the assessments which will require the ‘6 tests’ (Age, Mental Health, Mental Capacity, Best Interests, No refusals, Eligibility (phew, I did that all without looking – something must be getting through to the brain!)) by at least two people (the Mental Health part of the test has to be completed by a doctor and the Best Interests part has to be completed by a Best Interests Assessor).

In some ways though, the Urgent orders were more curious. These orders can be made for ‘up to 7 days’ and can be made by the managing authority which would be a hospital or a care home.

On the training with me, were some AMHPs who are based in general hospitals in liaison teams – so this perspective was coloured a little by their experiences – and, to put it lightly, I expect liberal use of urgent orders over the next few year or so.

On the course, the trainer referred to ‘sectioning’ under the Mental Capacity Act – by which these orders were considered. And come to think of it, it is an authorisation of a deprivation of liberty that is not so very different from the sectioning process that is currently undertaken under the Mental Health Act. Of course, there are many substantial differences but it is still a significant action and  power – being able to make judgements and compelling orders requiring someone to be in a particular case. Of course, capacity (or rather the lack of it) might purvey a less draconian impression but ordering people around is not something to be taken lightly.

The other curiosity was the discussions regarding conditions that can be attached to orders regarding the deprivation of liberty. Again, a few eyes (and mine included, I have to say) lit up at the prospect of being able to attach conditions to care homes and hospitals – a way, perhaps, of solidifying rights and promoting better care. I have attached conditions to a Guardianship which has specified that a person has access to local community amenities to ensure she is not ‘held’ in the care home or hauled back every time she tries to leave.  A condition, for example, that Mr T can be deprived of his liberty for up to a year on condition that he has given frequent access to the local community.

We have been forewarned though about attaching conditions to which any cost may be attached. I am assuming this will be something that will be shaped over time and in practice.

So I have a break in the training now – we have some more days to attend next week as well as some written work, a presentation and a legal test (and hopefully – although this is something I am yet to negotiate – some study time from work).

Our ‘homework’ task is to, within our localities, find out exactly what and how our employers are prepared and to come back with a knowledge of the details of how assessments will be managed by the local PCTs and Councils and how they will be distributed amongst BIAs (Best Interests Assessors).

I am quite looking forward to getting my teeth into that one. Not least because I am desperate to know the answers!

And in other, completely non-related news, I completed a job application form for the first time in, well, a few years. Haven’t sent it yet though. I am sure I’ll get around to commenting on it over the next week or so..


Assessing Best Interests – Part 1

So I’m in the middle of a training course at the moment which will enable me to act as a Best Interests Assessor come April. It is fairly intensive training which, quite honestly, left me shattered at the end of the day – although I have to say – it was much more interesting than I was expecting. The post, therefore, might be a bit more haphazard than usual but I wanted to fill in some random thoughts I had yesterday.

Just to clear up though, the Best Interests Assessor role is a new one that is being created in response to a European Court ruling in HL v Bournewood (2004) which, to cut a long story short, found that Bournewood Hospital had acted illegally in detaining a patient who lacked capacity in an informal manner when he had no way of leaving the hospital. He was, as the judgement say, being deprived of his liberty.

The result of the judgement is that if someone lacks capacity and is not being held in hospital under the Mental Health Act (1983) , they may be being deprived of their liberty.

The so-called ‘Bournewood Gap’ is being papered over by adjustments to the Mental Health Act and the Mental Capacity Act which mean that those who are being deprived of their liberty in a hospital or a care home setting will need to be placed, according to Article 5 of the European Convention of Human Rights (incorporated now, into the Human Rights Act 1998) within a legal procedure that enables this deprivation of liberty and – as became a point of much discussion yesterday – under Article 5 (4).

4. Everyone who is deprived of his liberty by arrest or detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful.

So here we are, having a new procedure in place to assess and, if necessary, through legal process – authorise a deprivation of liberty for up to a year, maximum – of someone who lacks capacity.

IMG_1187 (can a cat be deprived of his liberty?)

There seems to be ongoing consternation about how the actual assessments will be undertaken. One of the benefits of doing the training – such as I am doing – is that there are people there present from a wide variety of local authorities. None seem terribly well prepared (including my own).

There were stories of people hearing about other authorities that were much better (and  much worse) prepared. Some of it is quite frightening really.

One person attending the training was the sole person undertaking this course in the borough that she works in. I wouldn’t want to be in her shoes. There were a couple of people who had recently or were about to retire and were looking for an ongoing income stream which seems particularly canny.

The course I’m attending is particularly for people who are already working as AMHPs so we are all social workers – although Best Interests Assessors can equally by nurses, chartered psychologists or occupational therapists. There are different (and longer) training courses for those who are not practising AMHPs – basically to fill in on the Mental Health Act interfacing that we are already up to date on.

The worrying thing is that the assessments look to be fairly time-consuming. Each assessment will need to be carried out by at least two people – a doctor (for the Mental Health part of the assessment)  and  Best Interests Assessor (for the.. er.. best interests part).

I might come down to more of the details in a future post and as the course progresses.

We make ample use of the Mental Capacity Act (2005) in our team already. My impression is that it is most widely used currently in services that relate to Older People. Certainly the people in these teams (I know, it’s not very modest because I’m including myself) have a better working knowledge of the Act to date. We’ve done lots of training around the Mental Capacity Act and are all fairly used to the new forms of Mental Capacity Assessments and the ways and means of the decision-maker through this process – but there really is no room for complacency because, as I am discovering, there is a whole lot more to learn.

I have to say Bournewood Hospital was cursed once or twice throughout the day.

Ultimately though, safeguards are important – it is just a process that I imagine will need a lot of fine-tuning – probably through case-law, before it is perfected – if it ever is.

Admirable Admiral

John Suchet, a newsreader, hit the headlines yesterday by running with a series of interviews about his wife, Bonnie’s diagnosis of Alzheimer’s and the way that he, as her carer, had managed this diagnosis as well as the support that he had received.

He spoke of the help given by Admiral Nurses – a kind of Marie Curie-type set up – with specialist dementia nurses rather than cancer nurses.

image Muffet at Flickr

Anyone watching or reading the interviews given cannot help but be moved by the way that Suchet describes the fading of the memories of the woman he is married to.

Carers do need a lot of support through the process of a diagnosis of dementia.

One area that Suchet spoke about was the need for a wider roll-out of the system of Admiral nurses – although I suspect that is what the Dementia Strategy is envisaging. And in the course of his explanation of the role of the nurse, I recognised a lot of the roles that I undertake myself – or at least endeavour to – from explaining and preparing the changes in relationships and needs as lover becomes carer.

Of course, there is not capacity for the work in CMHTs to be replicated nationwide – nor for everyone who has a diagnosis of dementia to be allocated a care coordinator and the service that Admiral nurses provide is far from national.

In fact, the terms of postcode lottery were mentioned frequently.

I have often thought that if I had a magic wand (or failing that, just more authority and experience) to change the service we provide, I’d like to allocate specific workers to carers. I definitely think a lot more needs to be done, especially with older people where carers are not as able to attend the support groups that exist across the borough.

We don’t have Admiral nurses in our borough but we are blessed by a wonderfully active local branch of the Alzheimer’s Society.  I have no doubt that a roll out of a service which provides support and information could be anything other than beneficial.

Sometimes it is a matter of having a telephone number to call and a familiar voice to answer some of the questions, doubts and worries that come with the onset of dementia.

I was considering with the public campaigns of Terry Prachett and now John Suchet in going public regarding dementia, if we are turning a milestone in terms of publicity.

I also ponder on the fact that the people who become the public spokespeople for dementia and Alzheimer’s are those affected by early onset Alzheimer’s. I wonder if it is part of a marginalisation of older people or just an ability to identify more with people who don’t seem to be ‘so old’.

Not that I’m knocking it – I think identification with public figures does go a long way to societal acceptance. Maybe people who had not thought of discussing their experiences of their or their family’s dementia might be encouraged to do so as a result of these pushes.

In any case I  hope some of the stigma that exists around dementia will drop away and people will feel more able to talk.

It does bring me back to a discussion I had a couple of years ago with the wife of a man who has severe depression to the extent that he pretty much wasn’t getting out of bed. She confided to me that she almost wished she could tell people he had dementia because she thought they would be able to understand it better than telling them that he had depression.

Food for thought.

Guardianship – A Case Study

I have been working on another Guardianship application. It is an interesting scenario. I thought I would present a scenario based on some of the issues in the form of a fictional case study. I have been liberal with the actual details  which have been changed fairly dramatically to protect the privacy of those involved. The following is quite far removed from the actuality.

Mr and Mrs A are a loving couple. They have been married for over 50 years. Mr A  has an unspecified dementia. He is becoming more aggressive, verbally and physically and Mrs A after much heart-wrenching, cannot manage to care for him at home. She doesn’t want to move him into residential care but she can’t cope.

Mr A moves. He is at a local care home. It isn’t as near as it could be.  Mrs A feels guilty but Mr A settles. Mrs A feels so guilty that she takes Mr A back home after about 6 months. Mrs A can’t manage. Of course, this is contrary to all ‘professional’ advice – but honestly, what’s advice against love and years of marriage and togetherness.

But after a few days seeing that it is too much for her to manage, Mrs A wants Mr A to go back to the residential home. Mr A doesn’t want to go. He is at home and his wife is with him. She looks after him well. Why would he want to move back to a residential setting?

Mrs A, meanwhile is almost literally tearing her hair out. She is getting no sleep, no peace. Mr A is verbally abusive and is refusing any outside help. There has been physical abuse in the past and it may be the time we are teetering on the brink.

Mr A can’t be gently persuaded. He can’t be persuaded by any means and his wife is now desperate. She hasn’t slept for days which become weeks.

His mental health has not deteriorated. He has a diagnosis and treatment plan. Hospital admission would simply be a means of displacing him from one setting to another.


So what can we do to ensure Mr A moves?

This is where we considered the Guardianship application. I think we considered all other possibilities.

We needed a means to convey which the law changed recently to allow. Moving via a ward would make the move more disruptive. Mr A did not have capacity.

I wonder this kind of situation does not present itself more frequently. And if there were any other possibilities? And if the best decision was finally made?