M ental I llness C oncerns A ll	With this Report ( december 2000 ) there is at last some description of the working practice of a community mental health team; but something of the detail of what goes on in the weekly clinical review meetings, and who attends regularly, is not able to be addressed - by the Inquiry - ( although 1,1/2 administrative secretaries are in attendance at the review meetings ). The team is backed by 13 in-patient admission beds. They serve a population of 46,000 in which there are 28 family doctors, in eight surgeries. There are 300 people 'on the books' from a population of 46,000; eight front line contacts - 5 social workers, and three Community mental health nurses, an odd balance for people who are being re-enabled, sheltered in the community. The first concern is always that the illness will reappear, whilst the social re-integration exerts its pressure on the illness. Each carry a work load of between 20-30 patients . Something like three community patients a week ( out of the total case load for the team of around 300 ) are reviewed at the clinical meetings; as well as discussing patients new to the community team, or those with problems. What is not revealed is who is expected to attend the weekly meetings, who attends regularly, at what level a case care situation is addressed; something of significance when the role of the community mental health nurse is examined. The weekly meetings are one essential element in the supervisory process. The conduct of everybody at the meeting is there for everybody to appraise and offer assistance. Anybody with helpful information can put this in the picture. The Inquiry does not reveal the level of supervision over the community nurses by their own line management. Nor is the supervisory practice between social worker and the Social Work line manager examined . Was supervison left to the field worker to ask for it? Did the practice make that an easy option. The Local Authority runs 30 Hostels in the NHS Trust area ( circa 500,000 people), carrying some 2-300 people for patients discharged after a mental illness. The degree of illness in the hostels has shifted to a greater proportion of the severe and enduring mental illness categories, being accepted for re-integration practice with the community. They break their own rules in not always having two staff on duty.(XX) This Report ( Herbert/Joseph ) - published December 2000 - to the dismay of carers of family members who have schizophrenia, recalls many of the same faults found in Davies/Rous/Newby - published July 1995 . ..... [ Do managers - Local Authority Social Services, Health Authorities, Mental Health Trusts, Regional NHS mental health supervisors, Department of Health Mental Health leads; all our agents, our servants - acting on our behalf - do they ever read the Inquiry Reports. They are there for lessons to be learnt. It seems not. This would be clear if the Department was interested enough. They could just telephone round and enquire how many Inquiry reports are in the libraries of Trusts and Authorities. And if interested again, whose name showed who had taken them out. Everybody has more money than me, and certainly more clout. Maybe the Zito Trust, or the new Commission for health improvement. Ah, better - Professor Appleby and his staff. I can't see the difficulty for them. Nobody would tell me the truth. Not lies , but the other thing , no answers at all. But surely the facts would be delivered to them? Go on. Try. Its 300 e-mails to Authorities and Trusts if the e-mail addresses are listed, are known. I'll have a go, though . In the New year. At least to the Health Authorities - all 99 of them And I'll e-mail this Review - as an attachment - to the mental health lead - and to Professor Louis Appleby - at the Department of Health, to prepare them. well .... half knew how many they had, about three had a system for making sure they were read; the other half could not be bothered ..... ] ... The hostel workers are not given direct mental health support. (NEWBY) Each resident has their own CPN or other keyworker, maybe coming from different community mental health teams. The Inquiry recommends there should be one overseeing mental health contact in overall regular support. His final hospital in-patient stay is as an informal patient and who is in charge is not always clear. Are the multi-disciplinary forces in hospital reflecting upon his support system , and his future potential, whilst he is in hospital? Strangely the working routine in hospital is not described - usually a weekly ward meeting assessment of progress, attended by a regular social worker and ward nurses - important where the lead clinician is temporary - and it is the other members of the multi-disciplinary people who will know discharge needs, know what will be available, and who know and follow the habitual routine working arrangements within the hospital mores. There is a clinical lead vacancy which is filled with locum posts with their own idiosyncracies, not a good basis on which to evaluate and understand the accustomed mores in the local mental health system. The ultimate locum lead was insufficiently trained, experienced or qualified. That responsible appointment should be the personal business of management. If there was no one else available, or the post was unfillable because potential psychiatrists of quality did not see the job there as substantial - then this also is a management failure; local and national. If the Health and Trust Authority Boards, appointed by the Health Ministers, were dissatisfied with the poor level of practice that was all they could arrange within the resources allowed - then, on behalf of patients who cannot fly their own protest, they should resign their posts. No protest of this kind has ever been made. At the time of this discharge there is no standardised system in play for applying the Care programme approach ( CPA ) to this patient, whose care they had taken in hand. So that when the second locum lead clinician is in charge the pre-discharge assessment and care plan is not made; nor is there a record of risk assessment attempt. This - seven years after that system should be in place. The final outcome is absolutely connected to this. There is no fallback position which the team has rehearsed, to retrieve a subsequent breaking down in the aftercare. This system failure is a management responsibility which they did not meet. They seem to have felt that even when what they have set in place has become inadequate, the responsibility and accountability can still stop with the clinical people. They themselves will feel no retribution. Some one should be seen to be in charge - in touch with any development and able to see a route into an adequate response. This applies all round. Either the patient is placed in charge of themselves, and responsible, or the lay carer upon whom they depend has that place, or the professional team carer - key worker - is in charge, wherever the situation is that there can be a flare in a 'Blom-Cooper illness' - an illness known to relapse when medication has not been taken.(*) AJ is wrongly given the lowest category by his social worker. The review does not say if this came from a team approved grading. The last key worker to be assigned is a Social worker for the community team who has never met AJ in person, nor was this key worker at the discharge meeting when the key worker was named. She has a supervisor who does not know what is going on. There is a handover of key working from a mental health nurse to this social worker, without this being decided with a clinical lead. There had been a false assumption, unchecked by the nurse, that medication was continuing. It is not clearly laid out that these two team members, nurse and social worker, attended together at the community team meetings in a regular practice. A regular team meeting would make it readily available for any one in the community team with uncertainty, or who has information, to up-date what the whole team should know. The new key worker , the eventual victim, is the key because it is thought AJ will eventually need his own flat. AJ has been left to self -medicate and nobody has checked to see whether this is happening nor whether his family doctor is prescribing. He is not. The principal family carer contact, who sees him regularly, has no familiar way into this team, has no current contact with the key worker. AJ relapses and it takes too long time ( . 159 ) for a decision to come to admit him. This is crucial decision. It is likely to be unwelcome and to be resisted by AJ. This has to be instigated by a key worker, who has not met him , and has no personal standing with him. Final arrangements for seeing him to consider hospital admission, go astray when the social worker has to re-arrange her programme as her own car breaks down. In that situation she should not have been left to resolve her difficulty by herself. More continuous line management might have led her to be easy in her mind, in calling up 'emergency' back-up from her line manager. It seems she was considered too experienced and may have accepted she should have gone ahead on her own. The Inquiry has some consideration of the position of the line manager in this respect - returning to a subject seen (1)earlier (Blom-Cooper ;Robinson - and(X)as a weakness - how to get experienced and confident post holders, following their own succesful routines , to disclose uncertainties, dilemmas, and find help, without feeling they have lost the respect due to their position of lead or seniority. (cp Newby) It can only be done on the basis of familiarity in openness at meetings with the prospective line supervisor. (xxx) An assignment with backup is changed by her, unilaterally, and she arrives to see AJ on her own, with only one other staff member in the hostel. AJ is able to gain a kitchen knife from the hostel kitchen to stab the Social worker, and when that knife breaks to return to the kitchen, find a fresh knife, and continue stabbing. The Inquiry Report points up a difference between the habit of working of a social worker, and that of a Community Mental health nurse. If a CPN had been made the keyworker, then AJ would have been visited more often, more personally, and the question of his medication, and his continued health, may have become a major matter for confirmation, when deterioration was noticed. But when the CPN was the key worker , there had been no check that the medication was prescribed, obtained, and being taken, and there was no process in the hostel for confirming this. Where the major issue is one of a severe and enduring mental illness which has previously broken down because medication was not sustained by the ill person, then it is the monitoring of the signs of mental illness which is the front priority for concern. The Inquiry Report enters the same reservations about hostel supervision, as in the Rous/Newby Inquiry. Who carries the resposibility of acting when things are not as they should be. It revisits the difficult ambivalent position of the social worker , who is made a keyworker because there are benefits, social day activities, and accomodation problems, but where the serious consequence to be watched for is a likely fall into florid illness. The immediate observation of an ill person falls to inexperienced people, who are governed by their own estimate of some capacity. So long as this allows even a very basic kind of individual survival, there is a reluctance to intervene. The policy of a keyworker being left to coordinate and represent a team approach does not work, unless there is regular meeting to which they can go - - not one left to the discretion of the key coordinator, but the availability of comtinual review with the colleagues of that keyworker, attending at working meetings. When the whole team has a habit of weekly catchment area review and this is in place as a custom, is recorded, then such a review is natural, automatic, and allows regular and mutual supervision. Here, it seems individual workers are not supervised, neither in line management nor at the weekly team review. It may be this was a lapse of habit because of the locum clinical lead appointments.You call for help from someone you know. In a working team, you do know each other, you care for each other, you are ready to back up each other - you develop a commonality, a loyalty to the standards within the team and to the team purpose towards the common good. This working community team seems to have fallen apart, during a period of shifting lead.The ultimate key was left, or chose, to work on her own. Without an insistence on regular weekly team meetings, attended by senior core service leads, individuals are more often, left more to their own devising. That is a lapse in management. The publication is timely as it occurs in the week when a proposed new Mental Health Act is set out. The issue of compulsory medication in a community setting is still resisted, but public outcry is now certain to prevail, and rightly so. A society is entitled to expect a certain standard of civic obligation from its members. Reducing the level of dependency on help from society, is an important concern. Retrieving a position useful to society, is an asset both to the community and to the person concerned. In return those who, because of serious mental illness, cannot claim their own needs, and those, who have to do the actual caring in this setting of poor provison, are entitled to better behaviour from managers - the agents of government, and the servants of the public - and a greater outcry and sense of outrage from the public themselves, when the services, as here, are inadequate to the needs, or are not put in place. It is not possible to wait for health service residential conditions to return to welcoming standards, which a patient will turn to because they know they will receive temporary asylum. Those expectations have gone and must be met in some other way. At present some patients who approach are are turned away, or are turned off by atrocious conditions, by much moving about in posts or by agency staffing, with no continuity of care or interest. Their 'protest' is to lose faith, trust, and to stop medication. Even with the appalling conditions, for some, to become better by compulsory medication and therby regain personal autonomy from illness, justifies the compulsory commitment. For a ...'Blom-Cooper illness' ... a mental illness, which is there, suppressed by medication, but is known from a previous phase to flare up and lead to aggression or self harm, when that medication is forgotten, overlooked, or set aside.'' back to Herbert; A.Joseph	E-mail reaction is welcome mica@didgy.freeserve.co.uk