To The Barricades?

In the last few posts I've used information from a CQC publication to show a few, widely acknowledged problems with the mental health system in England. The first showed that over 12,000 people are being denied their legal rights. The second showed that poor commissioning has led to people being denied their rights, and gave some suggestions for changing this. The most recent post pointed to wider problems of illegal detention and treatment of people in psychiatric hospitals, of an attempt by some staff to outsource their legal responsibilities for providing people information.

This collection of statements should shock us. The fact that most people who have had dealings with the mental health system will not be shocked by them troubles me deeply.There seems to be a widespread resignation  that things are like that, that change is unlikely, that we should settle for small victories. I no longer want to settle.

I've had a lot of discussions with people as a result of those blogs. Most agree that the situations is appalling. However, when asked how things should be changed the answers dry up somewhat.

Take the example of underfunding of IMHA services. IMHA is accepted as having a key role in supporting people to have more control over their care in very distressing situations.  Yet despite proof that IMHA is generally underfunded, that this has been known since at least 2009, that people have a legal right of access to this service and that this is being denied to thousands, nothing happens. People point out that if we were to fund the IMHA service properly it would lead to reductions in funding for other kinds of advocacy, that maybe we shouldn't be rocking the boat. I don't believe we should be picking and choosing which legal rights we are willing to fight for.

Given the importance that CQC rightly places on people having a voice in their own care, and the fact that CQC reports have repeatedly observed a systematic breaching of people's rights to an IMHA, I might naively expect them to take some action. I have been told that the noting of these breaches leads to a pressure, a knowledge that services should improve their practice, the weight of expectations. Unfortunately, I still believe the title of this blog is relevant - that the distance from "should" to "is" is immense. If CQC does not have some means of implementing the service improvement aspect of its role, of compelling  change in a system which it has identified is malfunctioning, it creates a vacuum that leads either to anger or despair.

So what happens next? How are professionals, services and commissioners meant to be held to account? Unless there is some concerted action by CQC in this regard, it appears that the responsibility lies ultimately on people who are being mistreated and denied their rights. I have heard many people say that things won't change until someone takes a professional or authority to court . Not so much "to the barricades!" as "To the barristers!"

I feel that this is highly unfair. It should not be up to the people who use a hospital to make the system work. Nevertheless, as things currently stand we are placing responsibility for maintaining dignity and rights upon the very people who are having these things denied them.

Personally I do not want to see the money that is so badly needed to support good care being diverted into legal battles, costs and damages. I don't want people to have to fight for good care. I don't want to see hard worked doctors or nurses sued for treating someone without obtaining their consent as a result of inappropriate threats of detention. These do not seem like good uses of energy, but in the absence of other moves towards addressing the situation they seem increasingly likely.

Of course, one barrier to legal challenges being raised is that often people aren't aware of their rights or of their ways of accessing justice. That doesn't have to be the case. There are ways in which people could be supported to raise legal challenges more easily; ways that a link could be forged between individuals, service user groups and the legal profession.

I'm reminded of the yellow card scheme for reporting undocumented side effects of medication. Any time someone talked about a doctor disbelieving them when they described unwanted side effects of the medication they were taking, you could pull out a card on which to record this and send it to a central point for collation. The view of one person might be discounted. The accumulated experience of hundreds or thousands are harder to ignore.

Think of how many service user groups there are out there. Think how many advocacy providers. Think how many local services or support systems for people facing mental health issues. These are all points of potential access, information and support.  Imagine how easy it would be connect these experiences now in this age of social media. Imagine how many legal challenges could arise - my quick calculation in my first blog puts the potential number above ten thousand. That's starting to sound quite expensive to me.

So should we spend public money ensuring people have dignified, appropriate and legal treatment that supports people towards recovery or should spend it instead fighting legal battles to defend a system that isn't working properly? I believe that positive change is the better route but I'm willing explore alternatives.

I'm in the process of developing an organisation called True Voice. I'm going to use it for various things, one of which is to do some campaigning.  If you're interested in continuing this conversation, either comment below or email me 

12,000 people - is that much of a problem?

This is the first in a series linked posts about thousands of people being denied their rights to an Independent Mental Health Advocate (IMHA). This isn’t merely some technicality in the implementation of a health system. 

Ask yourself this question, if you were detained against your will, or treated without your consent, would you want to know what was going on? As you try to find out why you're there - scared and confused, would you want to know what your rights were? Would you want to have someone there that to make sure you were treated with respect; that you were listened to? That is what an IMHA is there for. That's what thousands of people are being denied.

The lack of access to IMHA is a matter of systemic and ongoing breaches of mental health law relating to Independent Mental Health Advocacy.  Upcoming posts will address how the problem could be resolved and some wider underlying issues. This post looks at how big the problem is and why it matters.

Around this time last year I wrote a piece for the Guardian Social Care Network about thousands of people being deniedtheir rights. People subject to compulsory powers of the Mental Health Act, whether in hospital or on a community treatment order, have a right to an independent mental health advocate (IMHA) to help them know their rights and to ensure they have a voice in decisions about their care and treatment.  The Care Quality Commission’s report on the MentalHealth Act (2010/11)   showed that for many people this was not the case.

In January this year, the CQC released their report on theMental Health Act 2011/12. I was hoping to see some changes as a result of the previous report, and indeed there were some. For example, the report showed that people were more likely to be informed of their legal right to see an IMHA.  There was also a rise in the number of wards on which an available IMHA service was found and the attendance of an IMHA when one was requested.

Mental Health Act Report Area	2010/11	2011/12
Is there evidence of an IMHA service?	85%	89%
Do patients have regular access to an IMHA?	65%	74%
Does the IMHA come when requested?	86%	88%

(Taken from figure 11 of CQC report)

However, as these areas are meant to be guaranteed by the Mental Health Act, these figures should be close to 100% . The CQC report shows that their reality is still far from guaranteed. That means that the table could be presented like this:

	2010/11	2011/12
No evidence of an IMHA service	15%	11%
No regular access to an IMHA	35%	26%
People who requested an IMHA who didn’t get one	14%	12%

Percentages can be a bit dry, so let’s put some real numbers to that. The CQC report states that there are approximately 61,000 people detained in a hospital setting at any one time. This means that last year 6,710 people were detained somewhere that there was no evidence of a safeguard to which they are legally entitled. Last year 15,860 people were detained but had no regular access to someone who could help them know their rights and speak up alongside them. And even where people requested an IMHA, 7, 320 didn’t get to see someone. One in eight people that had requested access to a service to which they are legally entitled never received it. One in eight.

Whatever way you slice it, somewhere between 7,000 and 15,000 people in hospital last year were denied something promised to them in law. Given that the report also showed minimal awareness of IMHA amongst the 5,000 people Community Treatment Orders, the figure would rise above 12,000.

12,000 people can be a bit hard to visualise, so here’s some ways to think about it.

• It’s more than the entire English based staff of the Care Quality Commission, Department of Health, Department of Communities and Local Government, Crown Prosecution Service and the UK Space Agency (although, to be honest, there are only 40 of the latter.)

Prefer a sporting example?

• When Andy Murray walks onto Number One Court at Wimbledon today he will be playing in front of a capacity crowd of 11,430. Or put another way, it’s more than the entire crowd that watched Burnely vs Crystal Palace in January 2013 (11,564).

If you prefer culture to sport...

• Get the massed audiences of packed houses at Royal Albert Hall, Hammersmith Apollo and Royal Opera House combined – that’s about it.

Now imagine the news report that says that an entire football stadium is denied its rights, that all those at Number One court today will be failed by a system, that the staff of those government departments will be failed by service commissioning, delivery and regulation. That this state of affairs will be known but not acted on. That this will go on for years.

I dare you to walk onto the pitch at Turf Moor and tell the crowd that you're going to do that to them. I wonder if the staff of those government departments and agencies would feel it a mere problem of implementation if it were happening to them. Well, it is happening right now to people who have been diagnosed with mental health problems. It's been set out in black and white in numerous reports, yet it doesn't seem to create much alarm. Is it the stigma of mental health that prevents us from being up in arms about it?  I don't know, but it needs to change.

Next time, I'll give some practical examples of what I think what needs to change and how we can make them  happen. For now I ask that you accept that this is a major problem.

Getting From A to B

The Distance From Should To is…. It’s an idea that fascinated me for a long time. Usually it's a way of comparing policy, theory and announcements to reality. This time it’s about me.

It’s been a while since my last post, and some might think that this gap is a little curious given the recent select committee report on the Draft Social Care Bill. I’ll write about the draft bill shortly but first I’ll talk about the gap.

I’ve just returned  to work following sick leave. Late last year I reluctantly accepted that:

a)   I was suffering from depression

b)   It was stopping me working properly

It took me a long time to get from a to b.

I don’t intend to speculate on the reasons for depression or to spell out the effects. There are other bloggers out there that can do that far better than I. But other people’s openness about their own mental health issues is something I’ve always admired. It was really useful to me when I was finding my own way through. It seems only fair to add my own small contribution.

I also want to publicly acknowledge that there was a problem, particularly for anyone who may have been wondering why I’ve been so bad at communicating with them recently. It wasn’t you, it was me….

...so, back to me.

I should have taken time off earlier. One of the things that stopped me was the belief that I would be able to turn things round. Even when I accepted that I had depression I didn’t accept that it meant that I would be affected by it. Other people? Yes. Me? No.  

I should have been able to sort things out. I was able to seem ok to most people, surely that meant I was almost ok. I was convinced of this, so I piled more and more pressure on myself.

I always felt that I just needed to sort out one more thing. I’d take some time off in a bit, but not just now. The problem was that I was dealing with what should be, not with what was really happening. As a result I worked longer hours, achieved less, and got worse.

If I had broken my leg I wouldn’t have expected myself to keep running. However, despite a lifetime working in and around mental health, I couldn’t accept that depression would reduce my ability to get things done, so I kept going. In retrospect, this was a special kind of idiocy.  It was harder to sort things out, many things didn’t get sorted. I got worse.

Recently I’ve been asking myself why I was so reluctant to accept the impact of my depression. I've came to the uncomfortable realisation that despite many years trying to reduce the stigma and prejudice that people with mental health problems face, despite being a fan of the Time To Change campaign and the Black Dog Tribe, when it came to me I was somehow ashamed. Other people would be affected by mental health problems. Somehow I thought that shouldn’t apply to me.

Well, it did apply to me.

Taking time off was one of the scariest things I’ve ever done. It was probably one of the best things I’ve ever done. As the eagle eyed amongst you may have noticed from my profile, although I’ve returned to Action for Advocacy, I’m not coming back as Chief Executive. I need to make sure I’m able to put some things into that wonderful pile marked “someone else’s problem”, but believe me, I have enough to get my teeth into.  So let me finish by saying a few things both you and I should already know.

Depression is as real as physical illnesses. It has as great an impact as physical illnesses or injuries. I expect that our society should treat mental and physical health problems with a parity of respect and understanding. Mental health problems no more define a person than does a fractured rib. I have spent years of my life challenging fears, assumptions and prejudice about mental health. It’s strange to realise that one of the most ingrained problems was sitting in my own head.