M ental I llness C oncerns A ll	There seems no reason why the second Secure Unit preparing its report for the Court could disregard the conclusion of the first one - that here was someone suffering from schizophrenia, and change it to 'drug induced psychosis. The first Unit would have had that in mind but came to a different diagnosis after sufficient detention 'off street drugs ', and then they treated what thye saw with medication for schizophrenia which was effective. Schizophrenia can remain subdued for a time after medication has stopped.The second Unit may not have observed active schizophrenia, but nor would it have 'seen' any street drug reaction. The second Unit was mistaken. Prison detention confirmed that. And broke up a coherent aftercare situation. Different Court psychiatric advice would have led eventually to a form of mandatory aftercare, better supervised.   Everything in the NHS provision has become fragmented and unconnected. No pride or satisfaction from being in a teamwork position with a common and realisable working practice. Nobody carrying a purposeful authority - much like the feeling - that 'matron should come back '. How have things come to this? NHS management changes have sapped authority and self respect. Career structures and their implementation - the 'naming of parts' - and posts ! - have taken over the lead thinking from actually achieving the purpose of it all - to deliver service to the patient. Business management - targets and 'efficiency'savings - 1% a year expected by government from managers, have taken 'beds' and staff out of the system, so that frantic pressure and rapid turn-over, has got into the system. The professional view - that 85% occupancy in an admission Unit service, is the maximum that is compatible with good patient attention and effective care planning - was destroyed by management requiring bed reduction , 100% 'efficiency' usage and rapid turn -over; buying in extra from private sources - to top up any overflow. Agency staff , hot-bedding, farming out to private Units well away from the natural catchment; all reduce loyalty , and tire out morale. Line management, which separated nurse from doctor, social work from the hospital, and made re-integration difficult, has nearly destroyed the NHS mental health services . Lack of communication, lack of continuity, lack of authority; all can be laid at the door of central NHS management and the political direction which underpinned it . Central management put out guidelines and boundaries, but left it to local management to implement the desired change... 'because they know the local situation'... and then forgot about seeing what happens in practice at the workface. Here is an example of what follows. A local Health Authority set out a strategy and took it to the general public . Interpreting the mantra - 'to deliver services as near to the locality as possible' , they proposed replacing updating bad old but current admission services with six new Units in local areas. We will ask the local user forums what they want. They like the idea of six local admission units. That will be the plan . They were advised by their local consultant psychiatrists this was not possible. It could not be run . It was criticised by a local carer representative who said it could neither be staffed to deliver all the functions of an admission - separation of different stages and nature of illnesses , nor could it be staffed to be safe at night and weekends or on holidays. Two years later, sorry, six units cannot be achieved. Would you like four or two units. The 'user' forums ; yes, four please . A year later, the Health Authority - four units cannot be serviced safely or properly , maybe three. Finally after five years what is achieved by this? After putting out our consultative process to the public and local users - we have decided upon two Units. We would now like to consult you as to where they should be placed. We have decided the size. But we still want to be seen as concerned to get user opinion for the content of the new Units - and where to put them. These are now the only sites left. The local split, between the funding supply , coming from the commissioning 'purchasing' Health Authorities, and the 'delivering' Health Care Trusts, bidding to deliver services described by Authorities, allowed both to leave checking it out, and to blaming the other. Management experience in mental health practice was not a priority. Mental health funding is only 10 % of an overall health Authority budget . The quality of health authority management is proportional. It is the lion that gets the largest share. Central NHS management failed to monitor what had in fact put in place , and gave no guidance about how to bring about inegrated team working at the patient work-face. Although calling for multi-disciplinary assessments and reviews, they left hospital , community , and Local Authority social service mental health services separated. Just has assessment also been split : carers to the social services : 'users' to health . And added yet another split - family doctors to have a purchasing budget - to commission what they saw as their priority in mental health. Local Authority Social Services remained resolutely separate from NHS Authorities. They had become generic and outside the hospital base. They had lost confident experience in actual illness. Both gave lip service to the importance of 'lay'carers - family carers - without linking them into audit or examination of fault lines - serious incidents, and bringing in to that their long experience . They are the only people likely to able to challenge a care plan because their experience - greater then anyone else - tells them it is wrong . Mental Illness Specific Grant , intended to assist care in the community for those individuals with severe and enduring mental illness, went to those less ill, on asking agencies to manage traditional services - day centres , befriending , rather than responding to individual aims and needs . The individual had to fit in with whatever was there. Or if suffering from residual schizophrenia - drifted away. Ironically - in the light of what happened to JM - a clear statement of good intent comes in the policy document issued for the rehabilitation Unit holding Jason Mitchell . .) "Discharge planning should commence on or before the day of admission and should involve the individual , relatives and carers, and other agencies and services that may be required ."   Inquiry links Inquiry Mishcom; Grey E-mail reaction is welcome mica@didgy.freeserve.co.uk