Mental health service closures

Whilst working within mental health and mental capacity law, I’ve found that there are many situations which really strike me personally. In particular, I have developed an interest in wrongdoings within mental health services, because I can see the situation from the perspective of the outpatient service user, having been involved with services since 2012.

Access to services is a huge issue at the moment. I was rather lucky in that I was able to gain access to services quite quickly through IAPT, though, once my course of CBT had ended, I was basically left in the dark.

I read something on twitter the other day from a service user, stating that he’d missed an appointment because the letter from the hospital had taken so long to arrive. I mean, in 2016, how is that still happening? It may seem like a small thing to some, most likely to the hospital, but these appointments, in times of both crisis and calm, provide routine and stability for service users.  When I was making regular trips to appointments with mental health services, it gave me a sense of comfort just to know that I was doing something. Had I missed an appointment because of the appointment letter being sent by carrier pigeon, particularly with my anxiety when it was at its worst, that would have been one of the worst things that could happen; from the outside looking in, it seems that mental health services can’t empathise with this or many others’ experiences.

Access to inpatient services is where this real division of interest is shown. We’re all aware of the distinct lack of beds within mental health units, which are needed by those who are usually in crisis and cannot be treated effectively in the community. Yet despite this known issue, more and more mental health units and hospitals are closing every year.

According to The Kings Fund, ‘Mental health under pressure’ (November 2015) 40% of mental health trusts experienced a reduction in income in 2013/14 and 2014/15. The analysis by The Kings Fund confirms what many of us interested in this area already know – there are more and more people being detained under the Mental Health Act (a 9.8% increase in 2014/15 compared to the previous year); a lot of these actually receive poor care, particularly when in crisis (only 14% of patients say that they received appropriate care in a crisis); the number of beds is decreasing, meaning that services cannot meet the demand; and, despite this, mental health units continue to be closed down. So, what is the outcome from that? People are either left without the help that they need, or are detained in a hospital somewhere far from home, far from normality, and far from comfort. According to a Freedom of Information request by the Community Care and BBC News, 4,447 patients were sent out of area by 37 NHS mental health providers in 2014/15. 88% of the 4,447 were sent out of area due to beds being full.

I have been looking in to closures of mental health units and, even if you just give it a quick google, you can see the scale of the problem. By way of example, in October 2015 Bootham Park Hospital, York’s only public adult mental health hospital, was closed following a report by the CQC, with 5 days’ notice being given. How many people did this affect? 30 inpatients and 400 outpatients. When something like this happens, particularly with such short notice, it must be like being abducted, and ripped away from everything you knew. In February 2016, Outpatient services resumed, after a huge amount of local pressure. However, for those patients in crisis, requiring inpatient care, they, and their families, are expected to travel 50 miles.

50 miles isn’t the worst it could be. There are instances of people being placed 300 miles from home. But, when these patients are very unwell, to be placed in hospital in a completely new area, in my opinion, surely can’t help them in the short term. Whilst detained under the Mental Health Act, a patient can be granted section 17 leave from their Responsible Clinician. I can’t imagine how difficult it must be to enjoy leave in an area you have never been before. Leave is a way of readying patients for discharge, but, certainly for those with anxiety, going out in the community in an unknown area would be incredibly daunting, and could even be a bit of a step-back. It’s hard to see how having leave in a town 100, 200, 300 miles from home is going to prepare you for living in your community.

Another example of mental health unit closures, resulting in patients having to travel, and one that is actually happening right now, is The Welland Centre, in Market Harborough. I came across this closure in an article a couple of weeks ago – The Welland Centre, which provides adult community health services, hosts clinics for up to 450 patients. That’s 80 patients each week and approximately 4000 appointments each year, and patients will be expected to travel elsewhere to access the help that they need.

One patient of the service has developed a petition to save the service – https://petition.parliament.uk/petitions/131744 – which currently has 764 signatures, one of those, of course, being my own. Should the Welland Centre close, patients would be expected to travel for one hour and a quarter to reach the service. For those who do not drive, like myself, this is two bus journeys. When I was having regular appointments with mental health services at Warwick Uni, I had to travel by bus from where I lived in Leamington Spa onto campus. Sometimes, when I was feeling particularly low, I simply couldn’t do it. I had so much anxiety around the University campus, the bus, the students, that I physically couldn’t get on the bus to get to the appointment sometimes. I probably never would have attended any appointments if I had to take two buses.

Now, putting my legal hat on, one big issue for me in situations involving closures of services, is that patients, families, and those who simply have an interest, do not know that the law can assist. When people are informed that their service, usually a service they have used for many years, is closing, they can feel alone. People generally don’t know (and, to be honest, why would they) that there are possible ways to legally challenge the decision to close the service – to go back to Bootham Park hospital in York (https://www.theguardian.com/society/2016/mar/14/the-nhs-mental-health-hospital-closed-with-just-five-days-warning), lawyers are representing the families of some former patients of the hospital and are seeking a judicial review of the “forced closure” of the service.

Judicial review is where a case is taken to the High Court, and it is argued that a decision of a public body is unlawful. This could be that the body has acted beyond its powers, or has not taken something into account etc. Obviously, there is no guarantee that any challenge would be successful, but I think that it is vital that there is something that can be done legally, at least to try to stop any decision to close a service.

That is why I really enjoy working within this area of law. Despite all of the issues with mental health services, and despite the general thought that lawyers are cold and can’t help real people, I like to think that in this area we actually could make a difference and, if a difference can’t be made, it is always nice to say we tried.

 

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Oh the places you’ll go…

“You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose. You’re on your own. And you know what you know. And YOU are the one who’ll decide where to go…”
Dr. Seuss, Oh, The Places You’ll Go!

For those who regularly read my bog and twitter feed (@AC_MentalHealth) you will have noticed that there has been a distinct lack of posts recently.

Lying in bed last night, I stumbled across the above quote and felt that it was more than apt to my current situation. Things may not go to plan, but it is me in the driving seat and I have control of which way I steer.

It’s pretty obvious that I absolutely love my job. I started working in a regional office of a London firm in March of this year as an Admin Assistant. The hope was to work my way up with the firm and, in a perfect world, secure the elusive training contract that every law graduate in the country would also be applying for.

Six months on, I have worked my way up to the position of Mental Health Caseworker with Admin responsibilities. When I tell people my role, a lot of people have absolutely no idea what it means. A few of my family, through no fault of their own, simply lack of knowledge, thought that mental health law meant that someone with mental health issues had committed a crime and mental health lawyers try to ‘get them off’.

The role of a mental health lawyer is to ensure that the rights of those with mental health problems are upheld. For me, it’s about protecting the most vulnerable in society. Now, some people with mental health problems are detained under the Mental Health Act if they are really unwell, but that doesn’t at all mean that the person has done something wrong. There is something called a ‘forensic section’ which deals with those who have committed crimes, but, generally, those detained under the MHA are just like you or I and Doctors simply feel that they ought to be in hospital for assessment (section 2) or treatment (section 3). There are other sections but these are the most common.

Now, on Facebook recently, a fellow Warwick University Graduate who works as a mental health paralegal in London, posted a status saying that he was representing someone detained under the MHA at a Hospital Managers’ Hearing the next day. It’s safe to say that I was incredibly jealous! Then, someone who I don’t know, commented on the status saying that he was a junior doctor in psychiatry and asked why the person was detained. My friend said that the gentleman had schizophrenia with paranoid ideations. To this, the JUNIOR DOCTOR IN PSYCHIATRY replied “then why are you contesting it. Dude needs help”. Well, that got me angry, because help isn’t always a hospital.

The role of the mental health solicitor/paralegal is to advance the rights of the client, so if they say that they would like to be discharged from hospital then this is what we tell the Tribunal or Hospital Managers’ when the person appeals their section, with arguments added that discharge would be appropriate. We’re not ‘getting people out’.

For some people, being in hospital can make them worse. Especially if the ward is particularly disruptive, and where drugs are rife that can make things a lot harder. Assessing/treating those with mental disorder should not be about keeping someone in hospital until a doctor decides that they’re better. It’s about the individual, who may find it helps more to be at home with community psychiatric support, than in the often chaotic surroundings of a ward.

Anyway, I digress. What I’m trying to say, and what I could have said in eight words is, I really love working within mental health law.

And that’s when the rug of contentment was pulled right from underneath my feet…

All employees at my Firm were recently given notice of redundancies. Such an unexpected life-changing shock isn’t the best for someone with anxiety disorder. For the past week, I have had the worst headaches, and I never get headaches. Although, interestingly, there was no headache on Wednesday when I had my University day. It’s difficult because I got to the point where the stress of not knowing what was going on was really starting to become an issue, but I felt that I couldn’t say anything because of that fear of mentioning anything related to my own mental health having a detrimental impact on my future, as if it would show that I “can’t hack it”. Of course, that’s me being ridiculous but it is how the vast majority of those with mental health issues feel.

When I told my Grandma that I was potentially losing my job, she said “well you’ll just have to get another one won’t you”. God, if only it was that simple! Basically, there are no mental health paralegal jobs being advertised for in the whole of the North East, so that isn’t looking great.

All I can hope is that I will be able to continue doing the work that I love, wherever that may be. For now, I need to focus on my own mindfulness and wellbeing. One thing is for sure though, I won’t give up because I’ve worked too hard for that.

Dr Seuss is right, and every time I see my #semicolonproject tattoo, I’m reminded that I can conquer anything.

semicolon project

Nicholas Salvador – not guilty by reason of insanity

Today’s news has been filled with the face of Nicholas Salvador, a 25 year old gentleman who, last year, killed two cats before going on to behead an 82 year old grandmother in her own back garden.

Nicholas Salvador is a paranoid schizophrenic. He has today been found not guilty by reason of insanity and will spend an indefinite amount of time in a secure psychiatric hospital. What is not discussed in the news is how such a verdict works in practice. Well, officially, Nicholas Salvador will be detained under section 37/41 Mental Health Act 1983.

Section 37 is a hospital order and it operates as an alternative to a prison sentence. Section 41 is a restriction order and this is something added by the Crown Court if there are concerns regarding public safety and the patient’s own risk. Prior to someone being admitted to hospital in such circumstances, two medical practitioners must carry out assessments of the person. For a judge to give a restriction order, one of these medical practitioners must speak in court.

It is possible that Mr Salvador will have to spend some time in prison whilst waiting for a bed to become available for him – the procedure is that the Hospital Managers should find a patient a bed within 28 days.

The reason that the newspapers are stating that Mr Salvador will be detained indefinitely is because, since 2007, a section 37/41 does not have a time limit, meaning that it can run for as long as necessary with no need for it to be renewed.

Although unlikely to happen, it would be possible for Mr Salvador to appeal against today’s order of the court to the Court of Appeal, but this would need to be done within the next 28 days.

A section 37/41 is naturally strict – a patient detained on this section cannot leave hospital without the agreement of the Secretary of State for Justice. When the person’s Responsible Clinician (the doctor in charge of their care) thinks that the patient is well enough to be discharged from hospital, he will ask for the Secretary of State’s agreement. The reasons for such strict rules are clear – the person, had they not been suffering from a mental disorder, would have been sent to prison. It is section 41 that places these extra restrictions on the detention. Even if the patient wants leave from hospital, and a request for leave is made by the responsible clinician, the Ministry of Justice must agree to grant that leave, and it may simply be leave to go to the local shop.

Once the hospital order has been in place for six months, the person detained may apply for a Tribunal. With a Tribunal, a successful appeal of a section would mean that the patient can be discharged. Such discharge can be either absolute or conditional. With absolute discharge, the person will be released from detention. It is unlikely that someone who has been subject to a forensic section i.e. a section 37/41, will be granted absolute discharge. Conditional discharge is much more likely as it allows the person to remain subject to the Mental Health Act whilst living within the community. Should any of the conditions specified be broken, the patient can be recalled to hospital by the Secretary of State. As soon as a patient on a section 37/41 is recalled to hospital, there is an automatic tribunal within the first month of discharge. Following this, the section must last for six months before the patient is able to apply to the Tribunal himself.

Alternatively, if the conditional discharge goes well and all conditions are complied with, the patient may wish to apply for absolute discharge, although they do have to wait at least one year. If the application for absolute discharge following one year of conditional discharge is not successful, the person is only able to apply two yearly.

Nicholas-Salvador-_3349677b

Ta-dah! Hopefully this explains what all of the newspapers are talking about and the process involved when detaining Nicholas Salvador.

Deprivation of Liberty Safeguards

The number of people living with Alzheimer’s who are subject to deprivation of liberty safeguards (DoLS) is on the increase. DoLS are intended to ensure that residents in care homes and hospitals are protected in a way that does not deprive them of their liberty (if a person lives in supported living or their own home then it is possible to deprive them of their liberty in their best interests, but this must be done by applying directly to the Court of Protection). Effectively, DoLS authorise a deprivation of liberty when it is necessary to do so for a patient or resident who lacks capacity to consent to care or treatment in order to keep them safe from harm.

It has recently been reported that DoLS are linked to delays in families being able to bury their loved ones when they have died in a care home. This is because regulations require state inquests into such deaths, even when the cause of death is fairly clear – the deceased who was subject to the safeguards is considered to have died ‘in state detention’ thus an inquest is needed and the release of the body is delayed.

The Independent on 28th May 2015 interviewed a relative of someone who had been subject to the safeguards and who was forced to wait for 2 months before being able to bury the deceased. That relative stated “who actually benefits from these safeguards? It’s a box ticking exercise and I’m just so glad it’s finally over”.

There has been a dramatic rise in DoLS applications over the past year – The Independent quotes that 113,000 applications were made and that 36% of these were granted. That same article also includes a quote from George McNamara, Alzheimer’s Society, who states “DoLS are important for people with dementia to make sure they are not wrongly deprived of liberty but the current system is complicated and there is lack of awareness about the process”. I agree entirely with this statement and hope that this post will bolster people’s understanding of DoLS and their beneficial uses.

Deprivation of Liberty Safeguards are part of the Mental Capacity Act 2005. A deprivation of liberty is described as occurring when ‘the person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements’.

For a person to have capacity, they must be able to : 1) understand information relevant to the decision they want to make 2) retain that information long enough to allow them to make a decision 3) weigh up that information to come to a decision 4) communicate that decision.

The ECtHR has clarified what may amount to a deprivation of liberty. Examples of such deprivation include: restraint so that someone may be admitted to hospital; medication given against the person’s will; staff making all decisions about a person; and staff restricting a person’s access to family and friends. The point is that, whilst doing these things does deprive someone of their liberty, it is done for the person’s own benefit – therefore a DoLS is something that legally authorises the deprivation of liberty. If the examples above took place without a DoLS in place, then the person’s human rights would have been breached. Thus, under the MCA restraints and restrictions are allowed to be used when in a person’s best interests, but DoLS are needed if this restriction and restraint amounts to a deprivation of liberty.

If a relative were in a care home/hospital, and you felt that they were being deprived of their liberty but there is no authorisation for such deprivation in place, then the first port of call would be the care home manager – always attempt to resolve things from the bottom and an agreement could be reached re more freedom for your relative. If the care home manager does not think that an authorisation is needed, then you would approach the local authority and ask them to investigate whether a deprivation of liberty has taken place.

It is against the law to deprive someone of their liberty without there being an authorisation in place.

The recent case of Re AJ [2015] clarified that a local authority, when it knows that a person will be entering a care facility on a permanent basis, should make an application to the court or carry out a DoLS assessment. Effectively, authorisation should be obtained before any deprivation of liberty occurs. If an authorisation has not been made prior to a person’s move into a care setting, then an urgent authorisation could be made by the care home/hospital manager when the person arrives, although Re AJ [2015] confirmed that such an authorisation should last for no more than seven days, save in exceptional circumstances, and that an application for standard authorisation ought to be made at the same time.

The assessment process for a standard authorisation involves at least two independent trained assessors – one mental health assessor and one best interest’s assessor. If the pair do not think that all of the conditions have been met then the deprivation of liberty will not be authorised. This procedure is intended to protect the patient or resident in question. Part of the assessment process is that family, friends and paid carers who know the person well be consulted so that they may give suggestions as to how the person may be supported without depriving them of their liberty.

Should the care home resident or hospital patient concerned have no family or friends, they can utilise the support of an IMCA (Independent Mental Capacity Advocate) during the assessment process.

Following authorisation, a Relevant Person’s Representative (RPR) should be appointed as soon as possible. It will tend to be a family member or friend who will fulfil this role but if no one will take on the role on an unpaid basis then the supervisory body will have to pay someone to be the person’s RPR. In such a case, it is likely that this will be an advocate. If the RPR is unpaid (which would be the case if it were a friend or family member) then both the person and the RPR are entitled to the support of an IMCA.

An authorisation for a deprivation of liberty is intended to last for the shortest time possible, with the maximum authorisation time being 12 months, during which time regular checks must be carried out to determine whether the authorisation is still needed. If the authorisation is no longer necessary, then it must be removed. The patient/resident and their RPR are able to challenge the deprivation of liberty in the Court of Protection at any time, and can also require the authorisation for the deprivation to be reviewed at any time. The review would determine whether the criteria to deprive the person of their liberty is still met and, if so, whether the conditions need to change.  The home or hospital should do all that it reasonably can to explain to a detained person and their family what their rights of appeal are.

Useful info on DoLS can be found at:

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/deprivationlibertysafeguards.aspx

http://www.scie.org.uk/publications/ataglance/ataglance43.asp