Crisis and Discrimination

We had a meeting with our crisis team a couple of weeks ago. There is a general perception that they don’t like taking referrals for over 65s. It has increasingly developed into something of an ‘us and them’ situation so an attempt at some kind of reconciliary face to face meeting was planned.

Personally, I’ve had a few problems in referring. Firstly, they don’t accept any referrals for anyone with any kind of organic mental illness namely dementia. The explanation (although I never actually knew this until last week) is that no-one in the teams have any experience or knowledge of working with ‘these kinds’ of mental disorder.

Even with functional disorders, the input has been more than patchy. Certainly, I’ve had less than helpful responses to requests to refer – even within the ‘just passed 65 with no sign of dementia’ type of situations.

What was actually explained at the meeting (which in some ways helped but in other ways didn’t) is that they receive no funding for catering to the needs of over 65s so any referrals that they do take from us are just as ‘favours’.

I was interested that the explanations were not about ‘providing better services to the population’ or managing more appropriately crisis situations in the community to avoid hospital admissions but rather in terms of ‘doing your team a favour’. I mentioned this in the meeting. One of the psychologists later told me that he thought I might have been a little too ‘emphatic’ in my approach. I love our team psychologists!

Nothing actually irritates me more than this type of attitude though as it seems to have removed the actual purpose of the work that is being done and reduces the entire service the Trust provides  to a professional-led structure rather than a patient-led need.

Of course, this raises so many problems with the an institutional discrimination with the service that it shouldn’t be allowed to pass – but it does and it has.

Why somebody should have greater access to a service before their 65th birthday when the need can be exactly equivalent one day after seems to be a particularly short-sighted way of dealing with issues but it is also one of the reasons I am so eager to remain in this specialist team – so that these discrepancies are consistently challenged at an organisational level.

I know I am being a little one-sided and perhaps unfair but it feels sometimes that we are as much fighting within our trust for services as fighting together for the common good.

Such is the way in specialist services sometimes. And so I am free to argue on as long as I am respectfully argumentative and am able to retain an awareness of how far to push and when to stop.

This report then, published in the last week of the existence of the Healthcare Commission (which is consumed tomorrow, into the Care Quality Commission) which states that older people are often excluded from some of the mental  health services which are available to working age adults hit close to home.

the study showed older people were often unable to access the full range of services, including: out of hours services; crisis services; psychological therapies; drug and alcohol misuse services.

This reflects my own experiences so strongly that I had to check to see which trusts were surveyed for the research. In fact, these points ally closely with our experiences

  • out of hours and crisis services were often not open to older people and only took referrals for people under 65 or for conditions other than dementia. There appeared to be a reluctance to refer and a reluctance to accept referrals, due to workload and the age-appropriateness of the service offered. There was no clear justification for this.
  • Staff at several trusts said some older people had difficulties in gaining access to services for alcohol and substance misuse. Even when services were available they were either not offered in an age-appropriate way or were not available when staff attempted to refer to them. Many were geared towards younger people, usually males, and were felt not to be appropriate for older people who may feel vulnerable in the atmosphere.
  • In general the report makes for interesting reading but interesting reading is only useful if it leads to changes and effecting of change across the board.

    I was glad to see the study published, not least because it expresses similar experiences that hopefully can be challenged even more effectively in the future to provide a more equitable and cohesive service for all the members of the community that we serve.

    6 thoughts on “Crisis and Discrimination

    1. I instilled a new policy in my new community job for “Referral Criteria” – We need a name and contact details and a reason for referral.
      That’s enough to get them in the door.
      We don’t palm anyone off on demographic or on absence of mental illness.
      We accept on ‘needs’ basis.
      If the referral has an identifiable need – no matter what it is (might be employment, housing, disability) it is up to the team to – not just refer on – but make it happen and follow up.
      Then, and only then, will I close the file.
      If they can’t find a service or make it happen – the client remains with us until such time as they do.

      Gosh they love me they do my team…. 🙂

      • That sounds wonderful, Mr Ian! I mean, honestly, that’s how things should be really. We don’t need the crisis team very much to be honest – far less than a similar-sized CMHT – but it’s the fact that we have such difficulty accessing when it is necessary that is the gripe.

    2. It’s so true, our detox unit (wait, did I say “our”, I HAVE A NEW JOB, lol), is totally not set up for seniors. It’s programing and it’s dorms and staff and services just aren’t there. We had someone rather elderly in there the other week (although, being chronically homeless I’m not sure the number 65 was actually there) and the other clients were not impressed. In fact, one of them came to me quite worried stating that he should be in a hospital because he “couldn’t do things for himself…” I gave him a little talk about how we all have different abilities and we all deserve a chance and yada yada, but the truth is, there is no better place for this elderly gentleman. We just don’t have the services that he requires and neither does anywhere else, so we try our best, and make do.

      Interesting, I always worry about phoning the crisis team for my clients because of their substance use. They’re always very adamant that clients be 100% sober. Well, I’ve news for them, some of my clients are never 100% sober, that doesn’t make their crisis any less real, and while I get it, I also know that smelling like mouthwash doesn’t mean you can’t make a plan for your life…

      • I just think it’s more about lack of thought and provision in a sense. I had so many more issues with our drugs and alcohol services that it deserves a separate post but it is basically about that 100% clean thing too..

    3. I went on the internet (scholar) and found this:

      Award Winning Crisis Resolution Service

      Presentation for

      18th Jan 2008

      Intermediate services were developed within Glasgow following the modernising Mental Health Initiative to improve the quality of Psychiatric care in the UK (Dept of Health, 1998).
      Intermediate teams were multi-disciplinary and multi agency in nature, with the main aims of providing an alternative to hospitalisation where possible, to promote early discharge from hospital, and to stabilise mental mental health within the home environment.

      Service Re-Design
      Service Re-design group established in 2005
      Drivers for change are Mental health Care and Treatment Act 2003 and OMIG group.
      Crisis Teams developed and CMHT teams reconfigured as a result.
      Rights Relationship Recovery based nursing review (National Review Of Nursing)

      The Core Concepts of Crisis Work
      To facilitate and promote early discharge from psychiatric in-patient care where appropriate.

      To provide short-term intensive community based care as a viable alternative to hospital admission, where appropriate.

      To engage service users and their families/ carers in tailored programmes of care and promote the stabilisation of an individual’s mental health within their home environment.

      Core Function
      Be available 24 hours a day and over 7 days a week
      Provide alternative to hospital admission and provide an early discharge function
      Provide home assessment and treatment as an alternative to hospital admission for people experiencing an acute mental health crisis
      Provide support to the gate keeping and care coordination function of Community Mental Health Teams to ensure appropriate referral and management of acute relapse in either inpatient settings or through the crisis service

      Core Function
      Provide short term interventions and management of an individuals care during the period of acute relapse
      Remain involved until the crisis has been resolved whilst maintaining robust communication with the integrated care manager within the CMHT who will retain this function.
      The service will also engage with service users who are discharged against medical advice or boarded out from their own Community Health and Care Partnership in-patient area.
      Where inpatient admission is necessary, be actively involved in admission, discharge planning and provide intensive care and support at home to enable early discharge

      Adults over the age of 18 including individuals under 18 who are receiving Adult MH services (e.g. ESTEEM) who are at risk of being admitted to Hospital and who are experiencing acute crisis and/or relapse
      4.1 Eligibility Criteria – Facilitating Early Discharge
      The Crisis Team will play a major role in ensuring an effective interface between in-patient and community services. The Crisis Team will have an active role, providing input to MDT review meetings within the in-patient service
      Adults within acute in-patients services who require immediate intensive follow-up to facilitate early discharge

      In-patients who require home assessment whilst on pass from hospital as part of the discharge planning process
      Patients who are discharged against medical advice
      Patients boarding out of CHCP who can be discharged from the boarding hospital with intensive follow-up

      4.1 Eligibility Criteria – Facilitating Early Discharge
      The Crisis Team will play a major role in ensuring an effective interface between in-patient and community services. The Crisis Team will have an active role, providing input to MDT review meetings within the in-patient service
      Adults within acute in-patients services who require immediate intensive follow-up to facilitate early discharge


      Exclusion Criteria -Crisis
      The team will not engage with service users while their function is so impaired by drugs and alcohol that they cannot participate in therapeutic dialogue
      Service users with a primary diagnosis of Learning Disabilities

      Exclusion Criteria – Facilitating Early discharge
      Patient where another service has been identified as more appropriate to meet their individual needs i.e. D.A.R.T/Addictions
      Delayed discharge patients

      How Crisis team incorporates New MH act
      Non- discrimination
      Respect for diversity
      Informal care

      How Crisis team incorporates new MH act
      Respect for carers
      Least restrictive alternative
      Child welfare

      Team Composition
      1 Team Leader (Band 7)
      2 Senior Crisis Practitioners (Band 6)
      1 Senior 1 Occupational Therapist
      4 Crisis Practitioners (Band 5)
      2 Associate Practitioners (Band 4)
      0.5 Staff Grade Psychiatrist
      0.5 wte Clinical Psychologist ( A grade)
      1 wte Senior Social Work Practitioner
      1 wte Social Work Practitioner
      2 Flexi Support workers

      Innovation award for Specialist Team
      Mental Health Nursing Forum For Scotland
      Judging panel is independent from the Nursing Forum
      Care Commission for Scotland
      NES (NHS Education Scotland)
      SRN (Scottish Recovery Network)

      Comments on Submission
      The service demonstrated excellent understanding of the Milan Principles and how to translate them into practice
      The judges scored the submission 10 out of 10 with regard to its links with national standards
      The service demonstrated effective user and carer involvement at service delivery level
      The submission was clearly evidenced based and well referenced
      The service clearly demonstrated effective use of Staying Well Plans

      Client Comment
      I found the service very inclusive. My thoughts and views regarding my treatment were taken seriously and incorporated into a programme of support. My views were sought at regular intervals, this I found very enabling

      CTT very helpful and understanding without them I have no doubt I would have ended up in hospital

      Performance Indicators Heat Targets
      Reduce the annual rate of increase of defined daily dose per capita of antidepressants to zero by 2009/10
      Reduce Suicides in Scotland by 20% by 2013 (existing target)
      We will reduce the number of readmissions (within one year) for those who have had a hospital admission of over 7 days by 10% by the end of December 2009

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