M ental I llness C oncerns A ll	Contact with the supporting services is erratic and changeable so that any particular plan cannot be invoked and sustained. His level of compliance shows willingness and personal warmth - he often presents himself for help - but the level of contact available in community service does not allow a day to day routine of occupational activity to develop nor does he achieve a completely satisfactory level of medication which neutralises the illness without too oppressive side-effects. He acknowledges a quite extensive use of alcohol, cannabis, and cocaine which he says raised the activity of his illness. He says he had taken cocaine on the night before the killing. He sees many different medical and nursing staff. The local catchment service provision is undergoing rapid and extensive change during the final year of his care. But the supervision and lead for the new teams was not clear or effective, for some time. One reason was the absence of any consistent psychiatric clinical lead direction in the community teams. The consultant psychiatrist was over worked and overstretched., for a populationof 60,000 in a poor social area. He also handled alcoholism services. His admission ward was at 120% occupancy so that patients on weekend leave could find their 'bed' taken when they returned, and had to go elsewhere. He had only a trainee assistant, which took time. On two occasions there was no bed available when it was requested. The mental health provision - in a difficult social area, is not up to the challenges of the locality problems and the management of this illness in the community. There was no opportunity for a longer stay of supervison which might have given enough time for a full after care support system to be put in place. It can be said that even with that resource opportunity, his own network was too insubstantial to maintain him in appealing occupation and personal aims. Feza M did not attend the official day centres preferring those set up by his own ethnic countrymen.Those centres said they got poor response from the official services when they asked for help. The link support was not there. The day to day activity possibilities afforded in-patient in the pre-community era have not been replaced in the community, nor has the backing of a consistent domicile routine. Patients resettled in the community from the old mental hospitals, are not better, though they declare themselves better pleased.They increase the load on admission services by re-admissions, and the admission ward replacements have neither the staff nor the variety of provision to enable them to cope as they should expect. Remember the Raymond Sinclair Inquiry - before reorganisation consultant, social worker , mental health nurse worked in adjacent rooms in weekly outpatient and had natural and regular meeting to the common good of the patients they serve ... after reorganisation they fell apart - ( ! ) Congratulations to Hackney for remembering the wheel and reinventing care practice. They follow [ * ]Somerset ( Review Laming; Cummings ) in going back to go forward. The Report suggests that the arrangement - then - at that time - whereby social services and health community services were in the same team , did not work effectively, maybe because the two services had different hierarchical feels - and different lead and supervision practices; different disciplinary positions and leadership decision making. There was a Joint Management Board of Social Services and Community Trust but it did not include inpatient/community working supervision of linked passages of people. There was no clear clinical lead figure - certainly no psychiatrist directly in the team. ( o ) After the tragedy, management acted decisively and comprehensibly. In reponse to an immediate local Inquiry -' East London and Hackney community Trust .. agreed to the appointment of one additional consultant to each of the four locality teams in the area. [ This meets the Royal College of Psychiatry recommendation that no consultant psychiatrist with community responsibilities should have more than a twenty-five thousand population to deal with - and in circumstances of social difficulty - as in East London - rather less. ] para. 224 .. " The panel visited Tuke Ward ( an admission ward )... and spoke to the ward manager and the Specialist services manager ....he said there had been a 95% turnover of staff since the ward and community team were linked under the management of the one locality manager. There were now clear strategies in place to strengthen ward and community links. These included : every Monday, locality clinical meetings were held, chaired by the locality manager or ward manager, and attended by team leaders and the Consultant. On Tuesday the ward manager goes to Anita House ( the catchment base ) for a clinical management meeting where patient issues were raised with the team and likely admissions discussed.This was chaired by the Consultant. That is the fundamental change. It brings about a ready forum into which updating considerations can be met. On Wednesdays and Thursdays ward rounds were held and attended by keyworkers. A CPA assessment was carried out on admission of a patient and the ward manager was of the view that no patient would leave ..without being assessed for CPA - though they would not always have a key worker A daily fax, introduced by the ward manager in 1998 between ward and catchment base , gave information on ward activity: discharges, admissions, patients on leave and details of staff on each shift. ...the proposed introduction of the East London Mental Health Joint Care Trust provides a good opportunity for the respective agencies to review the current balance of community and inpatient services , in the light of ... the National Standards framework . It is just a shame that management learns only after events of this kind - many times repeated, elsewhere. ( x ) { The letter in the a January 2000 BMJ medical journal suggests the community teams in the East London Trust are approaching the expectations of a working together community arrangement. } ... " The catchment area of 18,000 in the east end of London [ East London Trust - Hackney - ed. ] that I cover in my general adult psychiatry work has none of these services [ ... cognitive behaviour therapy, assertive out reach, early intervention teams, crisis resolution teams... ] Nor do I have access to a day hospital, 24 hour staffed care, or any of the other fashionable alternatives to admission that are promulgated. Instead, I work closely with a community mental health team focusing on patients with severe mental illness ;none of my patients is currently in hospital. This may not be evidence of anything much; but clinicians should have the right to question whether treatments and service models that are similarly unsupported by evidence should be imposed by central diktat. There are reasoned arguments in favour of the notion that introducing stand-alone teams that deal with only a subset of patients may be unhelpful . When we are told that we need to provide this or that service in such and such a way we are entitled to ask why. I suspect that often the response we receive would prove unsatisfactory when subjected to even the most cursory examination...." Back to List of Inquiries	back to Inquiry Feza.M     <   E-mail reaction is welcome mica@didgy.freeserve.co.uk

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