That’s fraud, isn’t it?

In our community mental health service we are trying to respond to increasing referrals. This prompts a lot of talk and I often get bored in business meetings. My mind wandered when we were told about the correct way to record a service intervention; “Tick that box for motivational interviewing and that one for graded exposure therapy” and so on. Then a reminder to bring proof that we have fully comprehensive motor insurance, which covers us for business use, and on to the need to find service users we can discharge.

We all take out insurance policies; purchasing a service while hoping that we will never have cause to use it. The adverts persuade us that we are buying peace of mind. The policy is there in the background and most of the time nothing goes wrong, but it is there, just in case. So I wonder; is that want it is like for someone who is recovering their mental health. They hope that they will not get ill again. They don’t really need to see a mental health worker, but it is reassuring to know that they have one there in the background, just in case.

I remember when psychodynamic theory was more often expressed in our talk. There was the idea of ‘attachment’ and that of ‘therapeutic containment.’ A person might grow in their confidence and ability while they are ‘held,’ while they feel secure in the knowledge that a professional worker is on hand, ready to step in if needed. As my mind wandered I thought about a team away day I organised a while ago. We had a mock awards ceremony. I adapted and printed some fancy certificates which I found online. We had to nominate each other and one award was for; ‘achieving the most by doing the least.’ The agenda behind this was to promote the idea of recovery from mental illness as a personal journey. It is the person who has been unwell who must do most of the work to recover their wellness. Workers are doing a good job if they stand back and let the person take faltering steps. Watching someone struggle is not easy and we experience an urge to rush in, to take over, to do the task ourselves and make sure it is done properly.

Suddenly my attention was brought back to the business meeting and I sat up to listen. Making an entry in our electronic clinical record is a contractual requirement. The commissioners will get a report showing how many of which kinds of clinical intervention we have made. So if someone is assessed as falling within a particular cluster, under the Payment by Results structure, we are paid a given amount of money for each six month period of treatment. If we have not delivered and recorded the agreed amount of ‘evidence based interventions’ in that period, then the commissioner will not pay. I am thinking now, is there any evidence that achieving more by doing less is effective? This is not just about the risks involved in having infrequent contact with someone while they recover their mental health, we are told; “If we are not actively delivering treatment then we must discharge!”

When delivering an Assertive Outreach intervention, I have always valued the daily handovers. In a flexible approach we agree, day by day, which service users need to be seen and supported. For periods some will be seen daily, others might just need a weekly phone call and a visit every few weeks, while their mental health is stable. But, if we are taking the money, we should be seeing them and doing some active form of therapeutic intervention. If we don’t see them, that is like committing fraud, isn’t it? We can’t take the money for doing nothing! “But what about the people who disengage?” I asked. “Should we continue in our attempts to maintain contact with them, to monitor and to offer treatment, trying to avoid a relapse, trying to prevent a further admission?”

What is the evidence base for looking through their letterbox, driving through town while keeping an eye out for them, waiting by the bus stop they use, phoning their family and friends? The whole day can go by without a ‘face to face’ contact. Then there is all the liaison, with; Probation, the Police, the ward, the Benefit Agency, the landlord, the Vocational Specialist, the carer’s assessment we do, the Safe Guarding meeting, the Social Circumstances Report and the complex case review. The whole week has gone by and we have not actually seen the service user themselves. Where is the evidence base which proves that those interventions are effective?

Year on year our funding has been cut but we have continued to deliver Assertive Outreach style interventions. This Payment by Results structure is another challenge; “Right,” I said, “So starting next week we are discharging anyone who does not turn up and engage with evidence based interventions; start building some more inpatient wards.” But I will of course continue to work at reaching out.

Ode to Joy

June saw the European assertive outreach community (and a few Americans and Hong Kong colleagues) descend upon Oslo for the 3rd European Congress. I guess I mistakenly thought that a congress in Oslo would be quite austere and business- like. Well it started with and singer, we had a boat trip up the Fjord, a reception at the Town Hall and generally a fantastic mix of social, academic, and practical networking and sharing best practice. A big thank you to the Dutch EAOF ‘fixers’ (Niels, Margaret, Fred), and the Norwegian committee for a great success. There was a bewildering array of sessions, and a keynotes from Mike Slade (UK), Bob Drake (US) and others to slake the thirst of 5 or 600 delegates. You can view the pictures from the congress here http://www.xsonline.nl/oslo2015/ and the slides will be on the EAOF site in due course. Here are a few tasters. Dutch EAOF

Remmers and Rosen Oslo 2015

Remmers and Rosen Oslo 2015

Oslo EAOF conference 2015 UK contingent

Oslo EAOF conference 2015 UK contingent

California Dreaming-personal memories of ACTA

We have just heard that our big sister, the American ACT Association is calling it a day after 25 years or more of supporting US best practice and providing training to ACT teams throughout the US and beyond. We have collaborated together over 15 years and can recall conferences and meetings between NFAO and ACTA over the pond in San Antonio 2003,  Philadelphia 2004, Chigago 2006, Washington 2009, California 2011, and Exeter and Rotterdam over here. Of course the US context for providing healthcare was a great eye opener for us. Cheri SIxbey of ACTA and her colleagues were incredibly generous to us and threw great parties at the conferences. For those of you who have not been to an ACTA conference then prepare yourself for 600 delegates, all in the same huge hotel, Cheri’s hustling and negotiating skills extracting every possible concession from the Hotel including most years the presidential suite for her (site of the legendary parties). It is at some of these events that lasting links were made with Dutch and Spanish colleagues that continue today.

So it is with great sadness, professionally and personally that NFAO says a fond farewell to ACTA. Thanks for the role model and for sharing so much with us, but above all for making sevices that much more special in your home nation and beyond.
Here is their release in full:

The ACT Association is very sorry to announce that as of September 30, 2014 the organization is closing. We struggled for many years with diminishing resources and capacity and could no longer sustain even the nominal staff (Cheri M. Sixbey and Alexandra Sixbey-Spring) and office required to carry out a large annual conference and numerous trainings. Our last annual conference was in Boston in 2012 and we completed our final ACT training in May of this year.

It has been a great pleasure and gratifying work providing the annual conferences and the ACT trainings for over 25 years in support of the mission of the organization – “to promote, develop, and support high quality assertive community treatment services that help improve the lives of people diagnosed with serious and persistent mental illness.”
We feel privileged to have trained, networked, and worked with thousands of ACT services providers throughout the United States and the world, through our annual conferences and other trainings and consultations.

We wish everyone in the international ACT community all the best and trust that this important service model will remain viable and continue to enhance the quality of life of everyone involved with it. Those of us here at the ACT Association certainly know that our lives have been forever changed by this rewarding work.

Many, many thanks to all of you – founders, Board members, individual and organizational members, who believed in and supported the ACT Association throughout its existence – we could not have succeeded without you and will remember you all warmly.

You can reach us at our ACT Association email addresses through September 15, 2014 when the ACT Association website will close down. For those of you who may wish to contact us after that time you can reach us at
actafollowup@gmail.com.

art museum & colleagues

Philadelphia with John Freeman (Sheffield) and the Texas ACT people

Washington DC NFAO

NFAO delegation, Washington 2009 L-R Caroline Williams, Kevin Brenton, Sue Jugon and Mike Firn

Mike and Judy Times Sq NYC

NFAO delegation to Philadelphia, Mike Firn and Judith Fairweather on detour to NYC (pic John Freeman)

hyatt

Conference venue 2010, Hyatt Regency Huntington Beach Resort and Spa, 21500 Pacific Coast Hwy, Huntington Beach, CA 92648, United States

 

Our mystery mental health worker has written about taking a referral from the Early Intervention Team

We welcomed the Early Intervention in Psychosis (EIP) service when it was set up and some of our workers moved on to take posts in the team. It was uncomfortable however when they became the new exiting team with lots of attention from management while we got our budget cut. So more recently, I was not very supportive when they started referring their service users to our team. Why, I asked, would we offer more of the same, when this had not worked? Three years of intensive outreach interventions had not delivered outcomes and now they were asking for more of this!

I am not just being awkward, this is a reasonable question. With cuts to our resources what should we do when people do not turn up to appointments? A young man, Ashleigh, had engaged well with EIP, at times. But then he failed to take treatment and he was difficult to trace in the community. The EIP workers managed to get him to the local Housing Department a couple of times but he did not stay in the temporary bed and breakfast accommodation he was offered. Ashleigh is a ‘sofa surfer,’ staying with various friends for a few days then moving on. He also stays with his mother, but when he comes back late after drinking alcohol or smoking cannabis with his friends she does not let him in. He explains that he often sleeps in the garden shed. When you can find him, Ashleigh presents as friendly and motivated. He promises to settle down and to find work, but when arrangements are made to attend appointments or organise activities, he cannot be found.

Ashleigh’s friends are aware that he has mental health problems, but they do not treat this with any seriousness. It seems that it is great fun to wind Ashleigh up and get him into trouble. He now has a criminal record for minor offences, criminal damage, affray, breach of the peace etc. Across his time with EIP, he was often admitted to our acute psychiatric hospital, responding to voices, feeling paranoid and entertaining ideas about persecution. Last year he absconded on a number of occasions and was then discharged in his absence. He recently appealed against his detention under Section 2 and I travelled to the local PICU to present the Social Circumstances Report. Ashleigh had the support of a solicitor and a mental health advocate. He successfully minimised all concerns about his non-engagement and non-compliance with treatment. He said he would take treatment this time and explained that he just wanted to get a job and get on with his life.

The hearing was going well for Ashleigh. He was again presenting as capable and able to take control of his life. However the doctor stuck with the evidence and described symptoms such as a fear of being watched or followed. Ashleigh was described as making threats against someone he met in the street. He thought this man was recording his actions and when this was mentioned at the hearing Ashleigh started to show signs of anxiety. He challenged the doctor repeatedly; asking why was he so unsupportive? The panel agreed to take a break and I listened to the mental health advocate talk with Ashleigh about the need to emphasis recovery philosophy, rather then pushing the ‘medical model.’ Then, back in the hearing Ashleigh lost his self composure. He told the doctor he would get him struck off, accusing him of being involved in a vendetta against him. Ashleigh was sent back to the ward and the Section was upheld. However, a week later Ashleigh was made informal and transferred back to our local acute ward. The next day he climbed over the roof and has not been seen since.

Our team has taken the referral but Ashleigh’s new care co-ordinator has not met him, despite every effort to make contact. I we spoke with colleagues in EIP who believe Ashleigh is developing an entrenched mental health problem, causing problems with his concentration and his ability to remember things or organise his affairs. In contrast, it seems that he thinks there is nothing wrong with him. If he does feel anxious he believes that a can of beer or some cannabis are better solutions than taking anti-psychotic medication. But our colleagues in the Recovery Team would have to discharge Ashleigh due to his failure to attend appointments. In Assertive Outreach we are concerned by his ‘life-style choices.’ We do not see these as separate from an underlying psychotic illness. We will keep trying to engage him in the hope that we can prevent further admissions, manage risks to the public and avoid a more damaging breakdown in Ashleigh’s mental health.

Our mystery mental health worker writes about time management and complex team processes.

In community mental healthcare we have a lot of visits and meetings to fit into each day and it does not help that there is nowhere to park. We did have several small community bases with convenient parking, but these old Victorian properties cost too much to maintain. The new hospital sites all charge for parking, if you can find a space. Getting about is now more difficult and to ease the pain I listen to podcasts; while stuck in traffic or waiting for the train. I recommend Claudia Hammond’s All in the Mind: I always seemed to catch this programme half way through on the way to my last call of the day, but with the podcast I can listen any time.

I learnt about Complexity Theory this week, in another Radio 4 podcast. A complex system was described as something that has different outcomes, depending on the point at which the system starts to run. Apparently, if someone gets out of bed just five minutes late a chain of events can cause problems; missing the bus, getting to work late, not getting on top of tasks, and so on. Perhaps that’s why am getting to work earlier and earlier. But I was delayed one morning this week. I had not checked my emails and did not pick up messages before driving to a discharge planning meeting; only to find that is was postponed.

I had also missed the morning handover meeting and that is never a good idea. Sometime later that day I called on a service user to make a routine visit. His mother was surprised to see me as he had been admitted the day before. So I was not looking or feeling very professional; I could have spoken to him at the hospital if I had known.

Community mental health teams are a complex system in which there are many conflicting agendas and targets. Our handover meetings are crammed with information sharing as everyone is trying to work with each other to achieve multiple outcomes. I struggle to hold all this information in mind as I try to set priorities. Surely if I start each day with a rational plan I would be able to meet the targets I am set, but somehow it never works out that way.

Maybe I am just trying to be positive about my disorganisation but having time to waste on the ward is helpful. Falling into conversations in an unstructured manner is of benefit. Review meetings often run behind schedule and while waiting I chat with ward staff, building relationships which help ease the tensions. We are caught in conflicting agendas, often they want to free up a bed and I want to take time to get the discharge arrangements right.

On the day that the meeting was postponed I fell into conversation with a patient, Robert. He is referred to our team and admissions are a good time to engage, as symptoms become more stable and needs are met. I was filling time with nothing to do so my conversation with Robert was quite slow and unpressured. I believe that I learnt more about him in that twenty minutes than in all the time I spent reading his files, or assessing him by asking formal and structured questions.

Assertive Outreach is supposed to be targeted at people who have not engaged with standard community services. We were told that Robert had not engaged, but from his perspective, no one had made much effort to get to know him or help him meet his needs. Several of his appointment letters had gone to the wrong address. He had contact from a series of duty workers who all repeated the same questions. Perhaps people like Robert are failing to engage because our community teams are so stretched that an adequate service has not been provided.

Failing to engage with community mental health services is not only an outcome of a ‘lack of insight,’ or ‘non-compliance with treatment.’ People might sometimes disengage because these services do not appear to them to be of any value. So should I refuse to accept Robert as a referral and insist that the Recovery Service try harder? Well we have been working very closely with colleagues in this Recovery Service. Many of them had been off with stress related illness. Managers are talking again about integrating the Assertive Outreach Team with the Recovery Service but I hope that we can find more creative solutions.

 

Our mystery mental health worker writes about difficulties in engaging people while meeting service targets.

We heard last week that a former service user, Joe, is back in town. He has been seen wandering in and out of the local shops. Most people will view Joe as a typical homeless beggar, with his wild long hair, his beard and his multiple layers of clothing. But some members of our team nursed him years ago in our psychiatric hospital, when his appearance was very different. Back in the day Joe was successful, running a local business, with a ‘work hard – play hard’ attitude. It was the excessive use of alcohol and substances which led to increased admissions.

This week Joe called to me as I walked through town, he seemed pleased to see me. We spoke about the different towns he visits and he wanted news of fellow patients he knew from his time on our wards. Now and then when his attention wandered he made an odd twitching movement with his head, he seemed to be spitting out half articulated swear words. I asked him if he needed anything; should I arrange for him to see a doctor? Joe said he was fine, no problems at all, and he certainly did not want any of our medication.

Back at the office I wondered how to record this contact. Joe is closed on our electronic records and opening his case would trigger a possible breach in the Trust’s contract with commissioners. We would need to have an assessment recorded by a certain date and a care package agreed. Joe would come under Cluster 16, Dual Diagnosis. He should be offered interventions such as motivational interviewing, physical healthcare checks and treatment for psychosis. I had noticed, however, that his most pressing need was treatment for his feet. He was clearly in pain when he walked. One of our nurses mentioned a Podiatrist who sometimes treats patients in a room at a local drop-in. A referral would be needed via a G.P., but Joe had been taken off his last G.P.’s list when he caused ructions at the surgery; he is hard to manage when he is intoxicated.

In handover we recalled that in the past Joe was popular with his outgoing personality and his tall stories. However, friends and family fell away as his drug and alcohol binges grew longer and his business suffered. But he had always played the fool and he treated detention under mental health law as just one big joke. In their talk team members were almost collusive, celebrating Joe’s skills in subverting the system, beating the tax man, making money for nothing and scamming his way out of trouble. For example, when he was told that he suffers from psychosis he used this to avoid prosecution for benefit fraud. He explained that his claims for multiple benefits, under different names, were a consequence of his delusional belief that he was several different people.

When he was last in town Joe was denied support from mental health services. It was thought that he was inducing psychosis through this use of substances, or faking symptoms to gain advantage. He is not an easy man to help and if you do not give him space when he shouts he will hit you. But during a brief stretch in prison, his failure to manage led to him being treated and he accepted help. He was placed on discharge in Supported Accommodation. This time Joe was grateful, emotional even, and he cried when we put him back in contact with members of his family. Things went well until we helped him reinstate his benefit claim. A large back payment arrived and Joe could not resist returning to his party lifestyle.

We have some targets to meet around physical health. If we take Joe onto our caseload we must record that he smokes and that we have offered him support in smoking cessation. We need to record his BMI and, while he is clearly stick-thin, if he were overweight we would need to record our efforts to promote healthy eating and regular exercise. These targets make sense somewhere in our management structures but they are not going to enable us to help Joe.

Our mystery mental health worker writes about the difficulty of imposing treatment on people who do not want it

Working in community mental healthcare keeps your feet on the ground and with low staffing I was at work on Saturday, helping to provide a duty service. We were expecting some abusive phone calls from Pat, one of our service users. My colleagues had administered Pat’s depot injection in the week and this is always a difficult experience. She respects the conditions of the Community Treatment Order under which she accepted discharge from hospital. However she does not respect us and she makes her feelings known. She accuses us of raping her. She makes personal and cruel comments about our nurses. In her view we are subjecting her to a humiliating, abusive and unnecessary treatment; we are poisoning her.

We offer a ‘gender sensitive’ approach to depot administration but getting Pat to the clinic requires two members of staff. She shouts at us when we pick her up, she is sullen and prickly when we try to make conversation. She quivers and screams when she see the needle. Our nurses are very professional in taking on this difficult work, but they do use some dark humour. We wonder if we should ask Pat to complete our patient feedback survey: ‘Is she satisfied with our service?’ ‘Would she recommend us to her family or friends?’

Making clinical decisions is difficult and imposing unwanted treatment is not comfortable for us. However, imposing treatment on Pat is justified by medical understandings. We can, for example, understand Pat to be unwell and we imagine a ‘well Pat,’ who thanks us for treating her and enabling her to have a better quality of life in the community. We don’t actually meet the Pat who is well and we cannot see how she could ever be content or happy with her life. But we talk about ‘treatment resistant psychosis,’ we observe a ‘lack of insight.’ These understandings will be useful when Pat talks to her solicitor and we need to write a Social Circumstances Report for a hearing or a tribunal.

In our handover meetings we agree that progress is being made. Pat’s anger is now directed at us, rather than at her neighbours, or random people in the street. The police have stopped phoning us, now that incidents of criminal damage or breach of the peace are no longer reported. We agree that the treatment we force on Pat is damping down her emotional distress. She still believes she is subject to abuse and that people are plotting against her, but she does not act on these beliefs. It occurs to me that we could justify enforced treatment on moral or practical grounds. We could accept that it is Pat who is angry, not her psychosis. She has endured distressing life experiences and has every reason to be mistrustful, to reject authority and to question our medical understandings.

We did not hear from Pat that Saturday, we had no calls, the phones did not ring. We sat in the bleak office which is now filled with hot-desk computer stations. There was a time when we could personalise our working environment but the office offered no comfort in the dismal rainy day. We found out the following week that there were problems with the phone lines again. Cost savings mean that we have to creatively manage this infrequent problem and the lines were open again on Sunday. Conversations turned to the waste of resources in covering weekends. We usually conclude that the occasional crisis we manage across seven days, along with the daily delivery of medication, make the seven day service worth the investment.

We anticipate better engagement this week when Pat gets her benefits payment. Although we are ‘agents of the state,’ who ‘oppress and abuse her,’ she now accepts our support in shopping and organising her bills.