Rising Detentions

Community Care have a short report about figures were published yesterday by the NHS which indicate that there has been an increase in detentions under the Mental Health Act over the last year.

As the article says

The numbers of people being detained under the Mental Health Act rose by 1,692 in the last financial year according to figures published by the NHS information centre.

The 3.5% increase brings the total people detained under the act to just under 50,000 in one year and represents the largest increase in three years.

The total numbers admitted to hospital also increased to 30,774 in 2009-10, a 7.3% increase from 2008-9. The rise was attributed to an increase in admissions to NHS hospitals, while previous increases have been driven by private sector treatment.

I thought it would be an interesting point to consider as, on an incredibly unscientific basis, I can say that I have been personally busier as regards making applications for detentions under the Mental Health Act in the last year than I was in the previous year.

It’s ironic considering we’ve had a number of wards closing in our Trust and the number of beds available has decreased.

The reason? Again, I repeat this is completely based on my own experience but I’d put it down to the impact of the Mental Capacity Act 2005 and particularly the provision of the Deprivation of Liberty Safeguards. This has led to a massive increase in the amounts of assessments I’ve been asked to complete for people who might previously have been informal patients in psychiatric wards who lack capacity to consent to admission or treatment.

Of course, this group of people should probably have been brought under the auspices of the Mental Health Act previously, on the basis of meeting the criteria for detention and despite all the perceptions and stigma associated with ‘being sectioned’, personally, I think the legal processes allow for much better protection of the individual than ‘being an informal patient’. There are various issues about how ‘voluntary’ an admission can be if someone has the threat of a potential compulsory detention hanging over their head but if there is a question of them being stopped from leaving, it has to be a strong consideration.

There is a greater awareness of issues of capacity now and that one doesn’t have to be rattling the door down and repeating ‘I want to go home’ every five minutes to be objecting to ones detention on a psychiatric ward.

There is also the sticky s117 issue which had allowed some consultants and Trusts to ‘dodge the bullet’ on making recommendations for compulsory detentions when really they might have.

s117 of the Mental Health Act ensures that the NHS remains responsible for any aftercare services provided. That may include residential and/or nursing care costs which can rack up to thousands of pounds fairly quickly.

Guidance has changed over the past few years (due to case law clarifications) and we are told that we cannot now discharge the s117 responsibility if someone has dementia as it is not likely to improve and therefore the aftercare is provided free for life.

Now, I’m not saying that these potential high costs might have prevented some informal patients being admitted formally to wards but it is a massive potential cost.

The DoLs (Deprivation of Liberty Safeguards) have led to greater awareness and training on the wards in relation to the interaction of the Mental Health Act and the Mental Capacity Act. I’m not saying that is the sole reason for an increase in compulsory admissions on the wards as I am aware my experience, being particularly in the field of older adults, is an area where this matter is much more relevant to those who might work with adults of working age,  but for me, it has been the key factor in the increase in applications for compulsory detentions that I, personally, have made.

Drowning in Paper

I was on the ward yesterday morning. For a substantial chunk of time. Our borough had a rush of applications for assessments for authorisations of deprivation of liberty in the last few days in April. Just in time to take advantage of the extended April deadlines.  They came from the wards in the psychiatric hospital that cater for over 65s.

Going from training roughly 30 Best Interests Assessors, the actual number able and willing to carry out assessments has fallen to single figures. Some teams are claiming that until there is any acknowledgement and workload relief, they will not accept any assessments, some people didn’t actually pass the training course and need to resubmit and some people are refusing to complete any assessments until that are actually paid the additional money that was promised.

I didn’t know that there was a reason to object so have got on with the assessments I was given. Yesterday was my third. Hardly overwhelming – but it’s all time that could be spent doing ‘other things’. Isn’t that always the case?

So as I wandered onto the ward to meet the Mental Health Assessor at the prearranged time, I saw another social worker in the office locked in conversation with the independent doctor.

She was just completing her second best interests assessment and  the doctor had doubled up  and  very sensibly arranged the two Mental Health parts of the assessment for the same morning.

The amount of paper was unbelievable. These forms while not as scary as they seem at first, they are long and they are wordy.  There are tick boxes that account for all possible outcomes. So there are lots of pieces of paper with lots of choices. We had reams of paper scattered around in an attempt to organise these forms into some kind of order.

image anomalous4 at Flickr

The doctor commented about the sad death of all these trees. It really was, with all the forms scattered and trying to organise them, a veritable paper mountain.

I can’t help but think there must be a better way to have organised this. Electronic forms and tablet PCs, perhaps. I wouldn’t be loved for sugggesting it to a those of my colleagues who suffer from technofear and of course, some kind of electronic signature arrangement needs to be in place but the amount of pieces of paper was just mindboggling.

My colleague had a bit of a crisis when the Mental Health, Mental Capacity and Eligibility Forms all got mixed up into a kind of mass mess of papers. We used my ‘stapled’ blueprints to unravel them.

So anyone who is involved in these assessments, another lesson learnt – always staple your forms together before you go because the pages can look remarkably similar!

As for my assessment – I didn’t actually think there that the situation amounted to a deprivation of liberty for the person in question. Restrictions, yes – but not a deprivation.

That seems to have been the conclusion for a number of these applications which were made en masse.

At some point, I may well return to the distinctions between restrictions and deprivations of liberty –  but my brain needs a bit of recovery time..

Actually later  today someone that I care co-ordinate is being assessed. I spoke to the Best Interests Assessor yesterday. I was amazed that application had been made as I hadn’t considered that she was being deprived of her liberty – again, I’d had definitely said there was a restriction but not a deprivation.

Seeing as these referrals (and there were, I think about six) have all emanated from the same source, I foresee some additional training running from the DoLs office who have been having a little panic.

Bed Blocking

I hate the term ‘bed blocking’ but it’s something that came up a lot when I was working in the Adult Community team. It seems to imply some kind of intent or purposeful wish to disrupt the smooth-running (or not) of hospitals.

The term is used in relation to hospital beds and the need to ‘release’ those beds when the occupant is ‘medically fit’.

Perhaps because we are based at the psychiatric hospital and we (the community mental health team, that is) pop onto the wards with frequency, we are not put under the same amounts of pressure to discharge as happens on in the general hospital but it’s also an issue of ‘demand for beds’.

image oskay at Flickr

As well as that, there is the issue of payment. The Community Care (Delayed Discharges) Act 2003 allowed for local authorities to be charged by hospitals for patients whose discharges were delayed by ‘social care needs’.

Currently, mental health wards are exempt from these charges although there have been rumours and mutterings that this might change at some point.

Why do I mention this now? Because since Christmas, I have been asked to arrange two assessments for two patients in the general hospital who are medically fit to be discharged. In both situations there are reasons that the discharge cannot be a straightforward discharge home. In neither cases did I feel that the risks and the degree of the mental disorder necessitated a compulsory admission into the psychiatric hospital.

Sectioning someone is not an answer to a blocked bed. In both situations, there is no way we would have considered admission to hospital had these people been exhibiting the same symptoms in the community.  Actually, in one of the cases, the patient had been experiencing the same symptoms for a number of years prior to admission to hospital.

It’s not that I can’t understand the pressures that are faced on the wards, especially at this time of year, but I found it vaguely worrying that a psychiatric admission (especially a forced one) seems to have been considered as a first choice rather than a last choice option.

Method in her Madness

Over the weekend, the Guardian printed an excerpt from a book which is about to be published by an author called Nora Vincent titled ‘Voluntary Madness : My Year Lost and Found in the Loony Bin’.

Apart from squirming at the title for a number of reasons, the premise of the book also  makes me uncomfortable. This is a woman who has made a decision to enter a psychiatric hospital.

image tahitianlime at Flickr

It is not a pleasant experience, unsurprisingly. The author had spent time previously as an in-patient and had wanted to come back with a journalist’s eye to present the wrongs that were being practiced in these institutions.  As she says in the extract

In November 2004 I had checked myself into a locked psychiatric ward as a patient. I was in that zombie parlour for four days, and returned home a wreck, swearing that I would never willingly go into such a place again. And yet there was the lure of the spectacle, and what I saw as the outright wrongs of the insanitarium, wrongs I longed to write about and hold up to public scrutiny. Which was how I now came to find myself back in a big city public hospital – this time as a journalist.

It is clear that the hospital in which she was treated was without doubt practising the type of ‘care’ that belies the meaning of the word itself.

She rails against the situation that she is forced into as a patient

There was so much you weren’t allowed to do. There was little exercise – we were taken up to the roof for 15 minutes a day – no smoking and a no-touching rule between patients. A necessary rule, in some ways, in a world where people had few boundaries, but to deprive desperate human beings of the healing comfort of a hand on the shoulder or a kindly hug was, at times, just another reason the place made you feel less than human.

Definitely food for thought but everything has a layered value and risk and hospital is and really should be a place for the people who are most acutely unwell that care cannot possibly be provided by any other means.

I am somewhat sympathetic to Vincent’s view and experiences. It is something I think about a lot when determining the need for someone to be detained on a compulsory section in hospital.

I read a little more about Vincent’s background and the book as I had not come across her.

Her first bestselling book was called The Self-Made Man : My Year Disguised as a Man which pretty much does what it says on the tin, so to speak.

According to US News, the experience of disguising herself as a man for a year, instigated a period of depression and Vincent’s first admission to hospital which she revisited for the purpose of writing this book.

Vincent …  decided to have herself voluntarily committed to three different institutions. (She declined to provide their real names to protect the privacy of doctors and patients she met there.) She first faked her way into a big city public hospital by pretending to have a recurrence of her previous depression. She then intentionally caused a relapse of her depression by going off her antidepressant, which led to her being admitted to a small private hospital. Finally, she tried a recovery facility replete with yoga classes, gym, and facials.

This book hasn’t been published yet so naturally I haven’t read it. I did feel a little uncomfortable about having the luxury of writing about a situation that you have chosen to put yourself in, but on the other hand, I would absolutely not want to condone inhumane treatment on any level and perhaps attention and discomfort are needed to draw attention to poor practice.

Or perhaps it is just the name of the book that makes me feel uncomfortable. I am relatively curious to read it  but probably not curious enough to buy it. I suppose some of my discomfort also comes from the choice to be ill which is not present to the other patients with whom she is living and about whom she is writing.

Meanwhile, Time Magazine print a review of the book (provided by someone who has read it!)

As for a possible alternative, I read Poppy Shakespeare a couple of months ago after missing the TV programme. I was hugely impressed by Clare Allen’s take on the system. I know it’s a difference premise and it’s fiction rather than non-fiction but to  me it had an absolutely genuine ring to it. Unsurprisingly, as Clare Allen is a very engaging writer with personal experiences which include admission to hospital.

I am definitely intrigued as to what the reception will be to Vincent’s book here and will try and chase some more reviews when they emerge.

If the attention does garner an introspective into the running of some hospitals that engage poor practice and care then that will, indeed, be a fine achievement but I am not entirely convinced by the motivation (possibly again relating to the title).