" Our lives begin to end when we remain silent about things that matter "

... Dr Martin Luther King

M ental I face=Garamond> llness Concerns All carers

a rather repetitive first Draft

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'New Ways of Working' [ NWW ].

There are two systems in the secondary specialist mental health services; there should be three.


admission and holding 'beds'. Facts are assembled at one point by a team working closely together on site. A working diagnosis is declared.
The needs for that care and treatment, are recorded; a plan is made to provide continuing care; which then proceeds in the Community.


a Community team, able to visit and support.


an aftercare provision that sees to it that those leaving first contact or admission, who are better, but not well, remain so
by finding them a weekly programme of activities, giving them something to do, which they are able and want to do.

In Admission units, the process is relatively clear, and historic.
The clinical lead is a psychiatrist and they are visibly in charge, legally so as the Responsible Medical Officer, supervision accessible on the spot
[ where the Responsible Medical Officer is the Consultant] , for detained patients and by being in that potential position, is the accountable clinical lead for any one else admitted from his catchment area.] ,

In the community service, who is 'in charge', accountable at any particular moment, can be unclear: the patient [ and family carer ] to be, does not always see, nor always is seen by, the professional team 'on site'.

A manifest argument has developed over what level of qualification in experience should be there at a first referral to the secondary specialist mental health service.
That person will decide who is not going to be accepted into the service, but is returned to the person referring, giving specialist advice for the future.

Who, in the community team, will be the first point of contact for the first presentation of illness.
It used to be a referral from the GP - the gate keeper - to Out-patient appointment - maybe a waiting period of 2-3 weeks was acceptable.

A new case of schizophrenia would happen something like one in every twelve weeks. [ 12 consultants per half million pop. ] But , of course it would not be a case till it was diagnosed.
Early diagnosis requires thoroughness in collecting information and experience.

[ this was the old system - as commented on in the Sinclair Homicide Inquiry Report. The Consultant was the clinical lead, supervisor and decider.

Otherwise there was a system of advice which could be, by phone call, or by a visit from an approved psychiatrist
to the home or a police station; or an A & E service, or a medical ward where self harm or distrubed mental behaviour was an issue.
Community visit by a psychiatrist, and a GP opinion, checked by an Approved Social Worker, somewhere in the Community
might lead to a Mental health Act admission.; otherwise direct admission as an emergency 'informal patient.
Now it will be a delegate from the team called in by GP or maybe through A & E
or through the police and a place of safety.

The counter argument is that too many people who did not require specialist service would crowd out those that did.
Why not have someone intercept referrals - accepting many more potential cases,
and let a less qualified member of the Team,
backed up by the experience of the rest of the Team, act as the initial gatekeeper.

The representative of the community team, who opens or closes the door to continuing in care with the community team,
decides to 'let them go' or arrange Community team plan of continuing care, or arrange an Admission.

Until the first contact is examined, nobody can know who is best to continue with care co-ordinating.
But who first examines is going to be someone who is a specialist only in their own field.

Will they be qualified to block the entry into the secondary speciaist service team, as an unsuitable referral.

The Inquiries after Homicide Reports are littered with
'not ill enough as I saw them' by people not empowered or qualified themselves to decide admission.
One point interview does not make for a comprehensive assessment.
A patient with schizophrenia is not able to recall or recount illness behaviour.

There is a continuing argument and indecision about who should be the decsion maker
for first referrals to the Secondary specialist mental health services.
Some consultant psychiatrists - not the offical body - say the first stage is the important stage and those people with a first presentation of illness, need to be seen first by psychiatrists referred there by the family doctor.

New Ways of Working [ comments ] has it that things have changed: the establishment of community teams means there are too many referrals of mixed priorities
to the secondary service from the community - GP service and others - for consultant psychiatrist to be able see all new patients. { they would see about 150 new patients per year - x12, would be 1650 patients ; add on say 250 as a follow up second and further appointments , would be 3000 per year; say six patients per OP x 2, weekly; ignoring junior doctor helpers ]

The counter argument is - that if consultant psychiatrists were not having to be available to monitor and supervise the community team members,
and by being out and about in the community, and at their meetings - that the presently much increased numbers of consultant psychiatrists would be enough,
and GP's, who now have counselling backup provision, would sieve out the referrals appropriately.
The response to that arrangement would seem to be family doctors are not up to sieving appropropriately - the team first contact member, buiding from the experience within the team, can do it better. They have quicker access to a consultant opinion. [ see Comment on Inquiry S. para 4 onwards }

In NWW, the first contact will be a member of the team - the one readied to do so at any particular referral moment - who will examine at first interview;
They will decide to accept - or reject - the referral on to the continuing care for the moment, of the secondary team.
Although most admissins will come through the mental health Act these days, they may also be considering and suggesting 'informal admission'

Does the first team contact member have the expereince and qualifictaion to do this ? Perhaps if they have been members of the team for a while, and can be certain to discuss first contact at a team meeting of all the members. [ The secondary mental health community service has 'hospital admission beds'as back up, as with general health secondary hospital services: the Primary service is the GP service ]

A first diagnosis of schizophrenia carries with it a calculation of what the future of the sufferer and family carers will require from the secondary services

The diagnosis must come out of information supplied by the family observer

What if the first contact person from the team doing the initial judgement ... " do we take them on or not " accepts out of the interview situation that they are not to be in touch with other observers, so that enough information for a working diagnosis is not obtained.

Are all patients who are rejected from entry, first described and discussed at a full Team meeting, and if declined,
a full letter sent to the family doctor, with a plan B to ensure future contact for carer and family doctor.

The person assigned to lead care may have been chosen without having yet fully informing themselves of all considerations:
they may not be qualified enough, nor experienced enough, nor involve family carers enough, to acquire all that is relevant.

The people near the bottom of the working care pile do not want to be seen to be 'failing'
and in need of somebody else interfering, intervening,; by people who do not know the 'front-line'. such appeals might smackmof lack of confidence and affect career moves

NWW is seen sceptically as another managerial exercise in reorganisation because resources are not going to improve.
Suspicions arise that it is down to a shortage of psychiatrist with experience and qualification.
The trainee input has dwindled. Many think it is down to the dilution of the consultant authority, arisen in team working as it has been.

The problem addressed is what to do about the 'doctor' - the Consultant Psychiatrist.
They can't see everybody. They have to rely on being informed by someone else in the team.
If they are misinformed or not fully informed because the informant has not asked for all the information, thay refuse responsibility.

If they cannot be certain that they will be adequately informed, then they need to be sure that when they say
they need someone to get the information to them, that the other person will do, will be able to do, as asked.

The words of Shakespeare come to mind

" Owain Glyndwr to Hotspur:-
' I can summon spirits from the vasty deep '

Ay , but will they come when you do send for them "

The situation for some is summed up in the words of one previous leader in a nursing association ...' we are not the handmaidens of the doctors , now.

How do you supervise if you are not fully informed, when the informant is line managed by someone else.
The basic secondary specialist mental health service element is now 'the team',
in which all are equal in their own way, but some are more equal that others.

The idea is that a group of people with different training and experience,
work together to bring their varioius skills and competence to ' the team':
from which can be discovered, the best person from their experience ,
to react to, and maintain contact with, a front-line patient career; the complexity of which takes time to evolve and settle,
Beyond the immediate condition, is a lasting degree of some disability, and of broken support
from people who previously formed the natural network in support.
That support is now gone or uncertain, or radically changed.

Just because the word 'team' is used - it has no meaning until you can 'measure it' - see what it actually does, until you know what is happening to your need, on your ground.

The Latent resistance to NWW is that teams as they are working are not harmonious loyal mambers but that especially nursing staff are resisting medical [psychiatric] authority and supervision.
That means that if the most qualified clinician asks for something to be done by a mental health nurse
that they cannot be sure it will be done as directed.
The nurse takes a view of their own as to what is required.
For an example, some nurses may say something like - 'this is what the patient chose - not to give information, not to let a family member put in their views separately - then we cannot go any further.
At any rate the relationship between nurse and doctor has broken down, and that of the social worker also. Consultant decisions about what a service should deliver are not the pinnacle of advice; the management will now use nursing management as a way to resist it.

First off team 1, is not team 2, is not team 3. All teams are people and all are different.

They have different ways of working locally.

Does the team have a captain ?
This is what you should know or find out about.

The composition and the degree of qualification of those in the team.
How long have they been in permanent post.

There should be a psychiatrist - again - is it the Consultant; a mental health Community nurse - what grade and how long in post; a Social worker - again how experienced ; a.n.other - occupational therapist , psychologist: ?

Team manager. tel no. available Team secretary ? and tel no.

Next their particular way of working .

What area do they cover?
What is their response availability ? What is the out of hours system of contact and continuity?
How often do the team meet together - which days in the week.
Do they all attend? Is who attends registered as attending?
Are their minutes taken and new referraIs and seriouis matters, marked out?
Is there a functional point to the meeting?
One meeting for 'new' referrals and the assignment to a member of the team?
One meeting for general discussion of team behaviour - perhaps once a month ?
Are all first referrals raised at the meeting and discussed.
Do they carry mobile phones ? Can they reach on line case notes?

Is there a first contact procedure that includes direct referral - or is it through the GP

Does the first contact have to take the referral to the first whole team meeting,
or can they and do thay meake decisons to pass on a case directly to someone else - if so beware - the first contact may not know enough to decide that themselves.

Remember if they see sufferer only they will not get the whole picture. Sufferer cannot remember illness behaviour.
You family and lay carers, must document what you have seen and heard which points to illness,
and make sure the first contact reads it - and protects your confidentiality; keeping and filing the document separately from the sufferer.
Your comments are not to be accessible to sufferer without your express permission. And don't give it !

Essentially where the local secondary mental health team team is long established together , has a regular reviewing meeting to review new case referrals, where the consultant clinical lead is always present, and that clinical leadership is respected, NWW is supporting good practice

Regular team meetings of this kind are valuable in that they are educational for all involved, and mutual supervision comes out of the regular nature of the team practice

The local Mental Health Trust Management responsibility is to examine for themselves that the working practice in the team is maintained,
and a documentation service is available to it, and it is used as a matter of record.

The way to do this is for manager to arrive unannounced at the beginning of such a meeting and observe who is there.

That is especially important when the team is disrupted by accumulated changes in its membership.

A Team only works well when its members know each other .