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Friday, 21 February 2014

Young people admitted to adult MH wards

Young people admitted to adult MH wards:

This was all over bits of the media (Guardian, Nursing Times, Community Care, BBC that I saw) and the twittersphere yesterday.

It clearly isn't a good thing to happen and around 5 years ago was declared to be a “never event” in the official jargon. So why do I bring it up?

Mostly because of the bee in my capacious bonnet about media coverage of MH issues...

In all the reporting and tweeting did I see any looking behind the headline, anything other than report by press release, any consideration of how such situations arise? Not really, mebbe a tip of the hat but nothing of any depth or substance.

OK, so here are the relevant issues and the questions our esteemed journos never get round to asking...

Why would a young person need admitting to a MH bed? Because their condition is severe enough that community staff can't manage them or because there aren't enough community staff to manage them. My caseload usually had a large chunk of young people who back in the day, before we had more community services, would have been admitted. Or that there aren't such things as day units to fill that gap between community and in-patient work.

Why admit to an adult MH bed? Because there are not enough CAMHS in-patient units and beds.

Why are there not enough CAMHS beds? Because not enough have been commissioned, some of those which were commissioned have been de-commissioned (that is closed in English).

Why are there not enough community staff? Because budgets have been cut and staff lost, assuming that adequate services previously existed in any given area, which wasn't always the case.

How did this happen? Well, one would have to ask senior NHS management, commissioners and their political masters why they took particular decisions, as it is their responsibility.

What about CAMHS clinicians in all this? Let me tell you (as per other posts on this blog) that clinicians have, for 30 years to my certain knowledge, raised issues of staff shortages, inadequate skill mix, lack of beds generally, lack of urgent care or emergency beds in particular, inadequate training, excessively high caseloads and levels of clinical risk, under-funding, poor commissioning, poor decision-making by management and all the rest.

What happened to staff who raised those issues? If you were only ignored you were one of the lucky ones! For others, including me, it was bullying, harassment, victimisation. This gives you a flavour of what can happen, even to consultant psychiatrists (note that in that link 3 of the 12 staff work for a MH trust), so what chance does a nurse stand? Hint – I left one job as a result of trying to get anyone to listen about poor staffing; I had another job “re-structured” away after years of arguing over inadequate staffing levels; I have seen many people moved out of their jobs, sidelined, bullied and the like. Essentially it is pretty much anything goes in order to shut people up and protect those on high, with ranks being closed, wagons circled, if anyone makes a complaint...And I did...

Did anyone in the media ever want to know about those things? No! They most certainly didn't, as per other posts here.

To cut a long story short, this sort of issue is very old. Clinicians have been pointing them out to management (and commissioners when ever we were actually allowed to talk to them) for donkey's years. They didn't want to know, politicians didn't want to know, the media didn't want to know.

I feel somewhat sick...

Tuesday, 18 February 2014

More on health reporting

New tool “predicts” depression in teenagers:

Or so the BBC would have us believe - http://www.bbc.co.uk/news/health-26224812 . The full paper isn't available to the public as I write, so that will have to wait.

Anyway...This is the old “cortisol hypothesis” - http://en.wikipedia.org/wiki/Cortisol – which has been doing the rounds as far back as the late '80s that I know of and still doesn't have completely convincing evidence for it.

But, the report itself...Says “Around one in six boys was in the high-risk category and half of them were diagnosed with clinical depression during the three years of study.” Which is one in twelve...Only half of the supposed high risk group...Errrrrrrr...

How was mood assessed?


A 13 question ticky box tool, which none of us in real clinical practice would use as anything other than a very basic screening device. Yes, it might give a bit of an indication of possible low mood, but there isn't enough there to warrant using it as a hard indication of low mood.

And it is self-report...No external assessment of possible low mood and functioning...Now, call me an old cynic, but I have long taken self-report questionnaires with a bag of salt – they can be useful but must be supported by other information, clinical observation and the rest. I can still remember, as a student on an adult acute ward, asking one person to complete a Beck Depression Inventory (BDI), which is a far more detailed tool. They scored well up into the “ohmigod, why are you still alive?” end of things, smiled at me and cheerily said, “Right, I'm off home on leave now, like Dr So and So agreed”, toddled off and came back as planned, still smiling from ear to ear. I am well familiar with the masks some of us use to hide our depression, but...

Really I am struggling to see what supports the BBC's headline here. This is pretty poor stuff and gives false hope.

May return to this when the actual paper is publicly available and I can see what it really says.

Edit to add: well, the PNAS paper is up, but is mostly behind a paywall - great! However, from the bits I could read it appears I have done the researchers a bit of a disservice, as they used the longer, 33 question, version of the mood questionnaire - oh goody! So boo to the Beeb for suggesting it was the short version!

However, we still have the problems of using self report measures and the cortisol hypothesis...

And the BBC's reporting still is not very good nor accurate.

Monday, 17 February 2014

Anonymity

On Anonymity, Pseudonymity and Related Matters:

Prompted by recent discussion on Orac's blog of a bit of a train wreck elsewhere in the more sciencey parts of the blogosphere and twittersphere - http://scienceblogs.com/insolence/2014/01/23/on-orac-isis-pseudonymity-and-anonymity/ -I felt that some further explanation might be useful.

As made clear –  http://mentalhealthuncovered.blogspot.co.uk/2014/01/about-this.html http://mentalhealthuncovered.blogspot.co.uk/2014/01/about-me.html  – I have taken steps to disguise my identity and the locations of any of the stories I tell, not for the usual superhero reasons of aiding my fight against supervillains, but for rather more prosaic reasons.

Some NHS employers, pacĂ© the whistleblowing post, can be very, very vindictive indeed, and I know senior figures in my last trust most definitely are. OK, I am no longer in any employment through which they can easily get at me, but, with the known history of how dissent is squashed, I'm not taking any chances, so disguised and pseudonymous I remain. Especially when one looks at stories such as this - http://www.independent.co.uk/news/uk/home-news/michael-brown-twitter-account-suspended-mental-health-blogger-and-inspectors-feed-under-investigation-by-west-midlands-police-9133687.html – suggesting that even those who are well-regarded and win awards fro their writing are not immune to sanctions from employers who take against them.

Breaches of patient confidentiality have been a favourite tactic for attacking those who put the whistle to their mouth, so nothing will be revealed which identifies any possible patient – remember my comment about blurring details – not that I would anyway.

I also have friends and ex-colleagues still working in the NHS, many of whom I quite like really, so, as I have no wish to cause any difficulties for them, locations must remain unidentifiable and there can be no suggestion that any of them have breached confidentiality.

Some of the discussion mentioned above revolved around credibility and known identity, with some opining that knowing who someone is confers greater credibility. I'm not so sure, as that seems to be an appeal to authority, and my preference here is to let the stories and words speak for themselves. I mean, even if I used my name there is a limit to what can be checked about me and I would have to be even more vague about any potential patient identifiers, so a good chunk of what I write would still need to be taken on trust. This is especially true, I feel, as my intention is mostly not to discuss individual situations as things in their own right, but to use them as illustrations of broader, more general points. The occasions when specifics are necessary will be quite clear. Thus, who I actually am and where any events actually occurred are irrelevant, and you'll believe me or not according to how what I write chimes with your own experiences and knowledge and whether it has verisimilitude. And if anyone chooses not to accord me any credibility because I am hiding my identity, well, that is just how it is, as I'm not changing my stance.

In the meantime, just keep that green kryptonite well away from me.


Friday, 14 February 2014

M&S and the NHS

M&S and the NHS

So, Stuart Rose, ex of M&S, that well-known healthcare provider, is to “mentor” hospital managers on how to improve relations with staff - http://www.theguardian.com/politics/2014/feb/14/nhs-stuart-rose-mentor-hospitals .

Whaaaaaaaat?

It was dragging retailers into the NHS that helped get us into the current mess – http://mentalhealthuncovered.blogspot.co.uk/2014/02/management-in-nhs.html – so this doesn't fill me with confidence at all.

OK, so my views on NHS management have been made clear already – http://mentalhealthuncovered.blogspot.co.uk/2014/02/management-part-2.html http://mentalhealthuncovered.blogspot.co.uk/2014/02/managers.html – so I do think there is room for improvement.

Let me make some suggestions as to how to improve relations between managers and staff:

Remember that you are there to enable us to work, not the other way round;

Speak to staff like they are real people (they are, y'know);

Please stop all the bullying and threatening;

Actually properly observe the policies and procedures you wrote;

Remember that clinical staff have forgotten more than you'll ever know about their area;

Don't ask people to repeat history, especially when they have already told you why it didn't work before;

Listen properly to staff and stop with the consultations with the obviously pre-decided conclusions;

Stop the nepotism and appointing your mates;

Remember that you are dealing with autonomous professionals, many of whom are more highly qualified than you and can think rings around you;

Actually challenge the obvious idiocies of politicians and higher management, rather than meekly accepting every bit of bullshit from on high;

Cut out all the unnecessary mergers, re-organisations, re-re-organisations;

Stop excluding/alienating/disciplining/sacking those clinicians who have the temerity to challenge you;

Accept that there are other points of view than your own and that some of us do know what we are talking about.

Try that lot for a while and see where it gets you.

And you can have that for around half of what you are paying Stuart Rose!


More on Media and Health

More on Media and Health


It's at best a very simplistic interpretation of data from ESR (the electronic staff records system used by NHS payroll and HR).

Look at his graphs: nursing, but where are HCAs? Do you see that category? Does Mathieson even indicate the existence of HCAs? Same could be said for other clinical disciplines: where are the OT instructors, the psychology assistants and the like?

A quick discussion with someone I know who works with ESR revealed that in most trusts HCAs are coded as “nursing”, and also that many trusts are now employing more HCAs than a few years back.

Now consider how many more senior clinical nurses (like me and one of the other commenters on that Graun piece) who have been “disappeared” one way or another and not replaced – dunno about the other person, but I know my old post wasn't replaced – or replaced with lower band staff. Think about the loss of skills and experience and knowledge and the impact on care delivery: there isn't a Band 5 in existence that could do what I did, as it took me many moons indeed to develop those abilities.

The comments by the psychologist mirror what is happening in nursing, and which I know is also happening in occupational therapy.

This is not reflected in the very superficial “analysis”. OK, the headline makes a reference to changes in skill mix, but the article itself does not in any meaningful way address the implications of that.

In my old area, for example, I did a lot of overdose assessment and self harm assessment. To do this well and sensitively requires experience, skill and knowledge. You can't just parachute in a newly qualified staff nurse to replace me. I developed an interesting sideline in working with gender identity issues, which again not many people can do effectively (though I say so myself).

Take away knowledge, skills and experience and quality of care declines, leadership is diminished, support for junior staff decreases (much of what I did was informal, occasionally formal, support of less-experienced colleagues of several clinical disciplines), training delivered stops or decreases, quality of mentorship of students declines...Do I need to go on?

And yet this is not represented in this “analysis”. The change in skill mix is ignored and its implications may as well not exist as far as the author is concerned. I will leave the cynics amongst you to come up with reasons for that.

Wednesday, 12 February 2014

Recent report on suicides

Recently released suicide statistics and report

Warning – as per title, potential triggers around suicide and self harm.

As one with a long-standing interest in the areas of suicide and self harm I find it useful that such statistics and reports are now becoming more commonplace - https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/278119/Annual_Report_FINAL_revised.pdf https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/278120/Suicide_update_Jan_2014_FINAL_revised.pdf

I have to say I'm not surprised by the slight rise in recent years attributed to financial difficulties, nor in the groups with the highest rates.

I suppose I should issue a disclaimer: I worked for some years in a specific CAMHS overdose assessment team; we developed our own comprehensive psychosocial assessment tool; we assessed young people before discharge from hospital, as per Royal College of Psychiatrists guidance - https://www.rcpsych.ac.uk/files/pdfversion/cr64.pdf ; we trained A&E staff around self harm; subsequently, in a different job, I was co-author of a multi-disciplinary care pathway on self harm (it won awards) and the training related to it, then a related care pathway on bereavement, and continued to work with our more suicidal young people; I have been a member of a Child Death Overview Panel. This is kinda my bit of the forest; it's what I did best, though I say so myself.

The report itself is good, the authors all very sensible people. But (I always have to do this), all these sensible recommendations don't completely tie with what has happened Out In The World.

My old overdose assessment team was shut down for non-clinical reasons (personal vindictiveness on the part of the service manager) and never adequately replaced. A similar team in the last trust I worked for was likewise shut down for non-clinical reasons and not properly replaced. The Royal College guidelines are, in my experience, frequently ignored, with young people not assessed before discharge, especially if there is not a specific team in place to assess, and local CAMHS possibly informed weeks later. For reasons of poor management experienced staff, like me, were excluded from working with self harming young people or from contributing further to the work we had started on multi-agency training and the like.

Like most CAMHS my last couple of teams did what we could to support and work with our local schools, especially secondary schools, with issues such as self harm. However, we have seen pastoral care cut, with either loss of staff or reduction in hours, school nursing services, which play a crucial role around self harm, cut...The voluntary sector, which performs excellent and valuable work, has not been funded to continue brilliant schemes in many parts of the country.

And, as has been pointed out elsewhere - http://www.youngminds.org.uk/news/news/1182_survey_reveals_worrying_state_of_camhs - , CAMHS, often expected to provide the sticking plaster for these other cuts, has also been cut...And if the figure of a 20% cut in service budgets my trust management bandied around is anywhere close to accurate it only gets worse.

I don't intend to disparage such reports, nor their authors, several of whom I hold in the highest regard, but, as with “Closing the Gap”, the good bits are what we have all known for years and, as above, many of us were actually putting all that suggested best practice into, errrrrr, practice when we were allowed to. And does it really take so many people to tell us again what we know already? Then we have to come back to the thorny issue of money, as, in mental health service especially, you need people to do the jobs, there isn't any technology and medication is not always helpful here...Which isn't mentioned. Again.

All the reports, all the statistics, all the discussion does not do the slightest scrap of good unless there are bodies at the sharp end, adequately resourced and trained, in order to put all these good ideas into action. And that is the bit that isn't happening; Norman Lamb can repeat as many times as he likes how much is being put into CAMHS IAPT, but that isn't even covering the cuts already made, let alone the one planned for the next couple of financial years.

I know I've said some of these things in other posts, but there are times the bleedin' obvious needs to be repeated. And this is one of them. Sadly...

The Media and Mental Health

The Media and Mental Health

Strange how one changes one's mind. Yesterday, after reading this - http://www.mirror.co.uk/news/uk-news/child-depression-scandal-ill-kids-3129996 - article and seeing the quote from Alan Johnson MP, which reminded me of what he had been quoted as saying here - www.communitycare.co.uk/2013/10/24/nhs-investigates-camhs-beds-shortfall-as-mps-warn-of-appalling-care/ - some months back, I started a piece about politicians and their part in cutting MH budgets. However, I quickly found that both of those items quoted, without indicating or attributing, a speech Mr Johnson made during a parliamentary debate last October - http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm131023/debtext/131023-0004.htm . So, rather than Alan Johnson repeatedly trotting out the same story to different journos, it was one, pretty sensible, speech, which wasn't mentioned, thus giving a misleading impression of a senior politician saying the same thing over and over.

Now this has become a piece about media coverage of MH issues, which is a shame, as I was looking forward to giving politicians of various parties a good metaphorical kicking, as they get far too easy a ride over their roles in cutting budgets and pissing around with the NHS in general but MH services in particular. Another time, no doubt.

We have come a long way from the appalling state of affairs which did exist, with several TV channels now airing good programmes and series, papers such as The Guardian running regular columns by the likes of Clare Allan (- http://www.theguardian.com/society/2014/feb/04/spending-cuts-hold-back-parity-mental-health ) and that recent interview with Charlotte Walker (aka purplepersuasion - http://purplepersuasion.wordpress.com/ ), but let's not kid ourselves that we now live in The Promised Land of Reasonable Media.

Last October saw the resurrection of old, lazy negative stereotypes with The Sun's “Mental Patients kill 1200” headlines. OK, so they did, eventually and with very bad grace in my opinion, apologise for this inaccuracy, but the damage of reinforcing negative images of those with serious MH conditions had already been done. Those effects are described very well here - http://ceriduck.wordpress.com/2013/10/08/im-the-suns-favourite-mental-patient/ - should anyone be in any doubt. And fair play to them that they did actually interview Ceriduck about her experiences.

Fortunately that “mad axe murderer” or “psychokiller” trope is less frequent than it was a few years back.

However, there is another media tendency which is a lot more insidious and harder to detect, that is “report by press release”, in which press releases, especially from official bodies are regurgitated with no questioning, no challenges, no critical consideration, just presented as factoids.

A recent example (the one that finally pushed me, with some help from a friend, into starting this blog) was the reporting of “Closing the Gap”. If this was reported at all it was essentially the DoH's press office line. I saw no critique or comment at all. Now, as my two very long, item by item, posts about that downblog indicate, it is actually a very flawed, disingenuous, if not outright hypocritical, document, displaying a worrying lack of insight into what is really happening out in MH Land. But you wouldn't know that from any media coverage I have been able to find – and I have looked.

Even more worrying in this regard is that one of my friends wrote to several health and social care journos (as well as a couple of politicians) with a critique of “Closing the Gap”, but she hasn't even had an acknowledgement of receipt of her letter. Which indicates to me that they aren't really interested. This is especially galling as my friend has put herself at personal risk in doing this: she still works for a large MH trust, which has just suspended, on a fairly trumped up charge, a clinician over whistleblowing. (See the post down blog about whistleblowing and how NHS employers view it.) The trust in question does have policies in place forbidding staff from contacting the media about anything which could be construed as being to do with its business without the express permission of corporate affairs. And corporate affairs don't allow anything out which isn't painting the trust in a very rosy glow...

And it happens in clinical areas, with the media reporting drug company press releases or brief to the point of misleading snippets about “research”. The day Straterra (atomoxetine, the non-stimulant medication for ADHD) actually came on the market I was asked about it in my first appointment of the day, as it had been all over Sky News. The official guff telling us that it was now available for use came a couple of days later...

Talking of ADHD: there was a recent report - www.bbc.co.uk/news/health-25946116 – about the possible role of vitamins in treating ADHD, which was discussed further here - http://www.nhs.uk/news/2014/01January/Pages/Can-vitamins-be-used-to-treat-ADHD-in-adults.aspx – making it far clearer than the Beeb's piece that the research was a very small study and hadn't actually compared vitamins to any standard ADHD medication or other forms of treatment. How many clinicians working with those with ADHD and their families have now had to fend off questions about vitamin supplements, based on some optimistic reporting of a very limited and flawed study?

As ever, I could give more examples.

If our supposedly “free” media are not prepared to help hold officialdom to account or report issues in a reasonable manner, what options are open to us?

Blogging and twittering are all well and good, but can become something of an echo chamber as all of us who hold certain views talk to each other and read each other's writings. How many of us have the reach and readership that will actually take any dissenting or critical views to a wider audience, be that within my old line of work or into the mainstream?

I really don't know, but it isn't going to stop me tapping away at the keyboard and sticking this stuff up in an obscure corner of the web, so that at the very least I can scream “I told you that!”

Monday, 10 February 2014

Further thoughts on abuse and prosecution

Further thoughts on abuse and prosecution

Warning: potential triggers around abuse issues and courts.

After my little diatribe on institutional abuse some other thoughts began to run through my head, such as why is prosecution of abusers so difficult? I can't be the only one who's worked in CAMHS, with abused young people and yet seen precious few prosecutions of obvious and well-known perpetrators. Why might this be?

I have encountered very dedicated police officers in Child Protection Units; I know many tenacious social workers; people who will not let something drop. So what happens?

Back to examples from my history to illustrate what I see as the main problems...

To return to the afore-mentioned prosecution of A's Perp, when I was giving evidence as a prosecution witness the defence barrister's main aim was to discredit me. He picked up on a slight discrepancy in the date and time of part of my notes (written in the middle of a hectic weekend, just after A disclosed on a Friday evening, organising social workers, police, being an appropriate adult for all of A's interviews, all while on overtime as I'd done my 37 ½ hours by the time A disclosed). No interest in the content of my notes, just picking away at that apparent discrepancy in timing...

When the judge eventually made him move on, he started on some of the therapeutic activities on the ward, specifically some of the groups we ran, trying to claim that A had picked up ideas about abuse from those, which she hadn't. Which led to a brief exchange about the history of group psychotherapy (barrister was completely wrong!), which was only ended by me asking the judge what the relevance of this was and the judge ticking the barrister off.

Now, I'm an argumentative, middle class, university educated, professionally qualified person, who had been warned what the defence was likely to do in this sort of trial, and was reasonably able to stick up for myself, but I got a very hard time and struggled to stay calm.

A, so I am informed, got an even harder time from the defence but held herself together over around a day and a half in the witness box; I remain incredibly impressed with A as I only had to deal with about 1½ hours...

That is an awful lot of pressure to withstand from someone who is pedantically out to trip you up over every half syllable of what you said and wrote. But this is an inevitable consequence of our adversarial legal system, especially when pretty much all the evidence comes down to “he said”, “she said”.

As a slight aside, that trial resulted in a hung jury. I thought A would be devastated, but she wasn't. She told me that it didn't really matter, as the important thing was that she'd been believed: I believed her when she disclosed (although, to be honest, I had worked out weeks before what was going on, but couldn't do or say anything until she was ready to disclose); the social worker believed her; the police officers believed her; her mother believed her; my colleagues believed her; the CPS believed her. In essence she felt re-validated as a person, to paraphrase what she said.

A was also a well-educated, middle class young lady, so for my next story I shall turn to a very different young lady from another part of the country.

I shall call her B (because I am really imaginative today); she came from a very run down small town, where the local industry had been well-screwed by That Woman, with multiple socio-economic deprivation indices. Her father had left her mother years before; mother subsequently had a string of ne'er-do-well partners.

B was admitted to the CAMHS in-patient unit I was working on with a history of disruptive behaviours, aggression and self-harm. She, unsurprisingly, disclosed abuse by mum's then partner (who I shall call Joker), including that he would in effect pimp her out to his mates.

This was, of course, investigated by social services and the police. But there was a big snag, in that B could never give a coherent, consistent account of what had undoubtedly happened to her, and that she would fly off the handle in the middle of interviews, shouting and swearing and throwing things at whoever was there. She would withdraw statements, then want to re-instate them. All very chaotic. And her self-harm became more extreme and dangerous (I won't go into any details). The chances of getting her to actually go to court, let alone testify against Joker, were vanishingly small, so no prosecution followed.

Again, it gets worse...As Joker had an unusual surname...He cropped up as being at one time or another the partner of the mothers of two other very damaged young ladies seen in the past by our service...His name was known as a possible abuser to both social services and the local police...But there was an utter lack of evidence or other disclosures...So no further investigations and no prosecutions.

And, it gets worse again...Around a year later our consultant psychiatrist saw a young man from the same small town as B, who had buggered a young neighbour...This young man was Joker's nephew...

I have numerous other stories of a similarly horrifying and frustrating nature.

I don't have any easy answers or solutions to offer, however I cannot help but think that the adversarial nature of our legal system, which is not (or so it appears to me) designed to establish truth, but rather who can make the best argument or who can best undermine someone else, neither of which are the same as establishing truth, is far from helpful.

Looking in more depth at these sort of issues would seem to me to be a better thing for politicians and the media to do rather than their usual empty rhetoric and screaming whenever some “scandal” comes to light. And society as a whole could have a long, hard think about what it wants in terms of child protection, so we can move away from the current “damned if you do, damned if you don't” attitude which exists towards, especially, social services.

Thursday, 6 February 2014

Institutional Abuse

The Catholic Church and Other Institutions and Abuse

Trigger alert: generalised discussion of issues related to abuse; also some use of explicit language in relation to this (paragraph 8 below).

Warning: should any of the self-appointed internet “anti-catholicism” police find their way here, this is NOT a Catholic-bashing piece, OK? Other flavours of Christianity and non-religious institutions will also be criticised. This is about institutional abuse, not which institution, and using current news items as a hook. It isn't my fault that there happen to be so many such articles concerning the Catholic Church – think about that one. And, yes, I know about the recorded prevalence of intra-familial abuse, however, for some strange reason, I tend to hold those in positions which have a duty of care, and especially those who espouse an ideology of apparent caring and compassion, to a higher standard than the man and woman in the street.

So, that out of the way, the Catholic Church's shoddy behaviour around widespread and long-standing abuse of, especially, children by priests has been in the news again - http://www.theguardian.com/world/2014/feb/05/un-denounces-vatican-child-abuse – and the Vatican has responded in a not entirely unexpected manner - http://www.theguardian.com/world/2014/feb/05/vatican-un-committee-clerical-sex-abuse-scandal . And in other similar items another, non-religious, institution is also back in the news over historical abuse - http://www.bbc.co.uk/news/uk-england-tyne-26047112 http://themonsterofmedomsley.blogspot.co.uk/ .

Why in a blog mostly around mental health?

At least as far back as my nursing finals in the 1980s the potential importance of sexual and physical abuse in mental health problems was already pretty well established: one of the essay questions in my finals, set by the then English National Board, was about why a woman admitted to an acute psychiatric ward would have waited so long before disclosing childhood sexual abuse. This tied with things I had heard from patients during my training, both on acute ward and community placements.

Now, note that I said I took my finals in the 1980s and that, clearly, the UK nursing establishment, embodied in this instance by the ENB, was well aware of these issues. Scroll forward a couple of years and we have the 1989 Children Act - http://en.wikipedia.org/wiki/Children_Act_1989 – which generated much discussion about child protection matters and further demonstrates that the political establishment was aware of these issues.

I bring this up because it goes some way to giving the lie to the claims made repeatedly by senior clerics of various flavours that they weren't so aware of child protection issues in the 1980s and '90s. To be that unaware must have taken some great effort...

Then there remains the thorny question, which I have yet to hear answered by any of these senior clerics nor their many apologists: at what point did you think fucking children was actually legal? Nor the related question: why do you think you are exempt from the laws which apply to every other person in the country?

Back to mental health...During my CAMHS in-patient days in the '90s a certain young lady, who I will call A, was admitted with a mix of bulimic-type eating disorder and self harming behaviours, a constellation of behaviours we now know to be associated with abuse. I was her key-worker, and we developed a good working relationship, which allowed A to address many things while acknowledging that there was still something very important she was not able to talk about. A went on home leave one weekend, as was standard for most of our young people, and took a massive overdose with clear suicidal intent. Fortunately she was found by someone coming home unexpectedly. When A returned to us from the medical ward I spoke to her about the overdose: she disclosed long-standing sexual abuse. The subsequent investigation led to prosecution of the perpetrator, who I shall call Perp. To spell that out, the local police felt there was convincing evidence and the CPS thought that it met their criteria for prosecuting.

Why mention A in this context? Well, Perp was a senior lay figure in a local church; A's family were members of said church, which is how they knew Perp; not only that but Perp was on the diocesan committee looking at vetting volunteers for working with children and was well known for being especially solicitous of young single mothers in the congregation.

It gets worse...During the trial of Perp (I was a prosecution witness because A had first disclosed to me) the vicar from the church came every day, sat at the front of the public gallery, glaring at every prosecution witness, tutting and harrumphing, to the point that, as I was informed by colleagues, during A's time in the witness box the judge actually warned him about his behaviour and threatened to have him removed.

Now, I will let you draw your own conclusions from the above 2 paragraphs...I drew mine, as did my colleagues and the local social services department...

On a brighter note, A worked through what she needed to work through and last I heard of her was heading off to a Russell Group university with a clear professional pathway in mind.

There's a group of blokes I knew (I say blokes as they are very bloke-y), who all grew up together, have been friends since school, went to the same church, where they were all altar boys...And all bar one were sexually abused by the priest (they do discuss this publicly)...The one who wasn't feels left out, that he wasn't “special” like the others...The priest did, apparently, talk of his “special boys” who got “special treats”...

Amongst this group, 2 display what appear to be OCD behaviours, 2 are heavy drinkers (and I mean HEAVY), one has regular, but not clearly explained, sickness absence from work. None, however, have ever, as far as I know, sought mental health support...

There are many such stories out there, and many different institutions implicated in causing serious, life-limiting and life-threatening damage to young people, especially by people in a position of power and authority (odd how that can aid grooming) who owe a clear legal and moral duty of care to those young people.

This is why I find the attempts by various official and semi-official bodies to squirm out of their clear responsibilities even more reprehensible.


Wednesday, 5 February 2014

Staff engagement or lack of...

Staff engagement


And the report itself, by The Point of Care Foundation, says “NHS chief executives appear confident about their focus on staff engagement. In our survey of chief executives, most (70 per cent) believe that staff engagement is generally improving. One in five rate staff engagement as high and 61 per cent acknowledge it as mixed.
Most claim it is a top priority and say they are investing in improving staff engagement. In a survey carried out by the Foundation Trust Network, nearly all trusts (97 per cent) say they have the infrastructure and systems in place to engage effectively with their staff. Nevertheless, the Chartered Institute of Personnel Development reports that engagement levels in the NHS are relatively low. Fewer than a third are actively engaged, according to its index, and only 27 per cent of nurses (compared with 37 per cent of employed people in the UK).”

Then look at page 9 of the report, covering staff views, especially of appraisals, health and well being, listening and communication...Check the disparity with what CEOs think...

And look at the bottom of page 13, the bit about productivity and staff engagement...Now go and have a look at my post about the NHS failing to look after its staff...

To borrow a phrase, this isn't rocket science, but the different planet the CEOs and the like are on is just...I don't know what...But they certainly aren't in the same world as most clinicians.

Now, let us examine the following: “Clinicians, especially senior ones, sometimes get a bad name for appearing resistant to change. In fact, we know the internal environment and our specialty better than anyone, including what could work better, how best to make change happen and who needs to be involved. We also often know more of the history when there is high turnover at executive level.
My experience is that things work best when managers and clinicians collaborate – and have some freedom – to enable a ward to work both for staff and patients. Creating opportunities for the teams around patients to get together and reflect on how they work, particularly when the trust is facing challenging circumstances, is also really effective in creating a sense of community and shared purpose.”

How many have come across the situations described in the first paragraph? In which the latest fly-by-night manager insists on “change”, but doesn't listen when clinicians point out that we tried that 5 years ago, it didn't work and here's why it didn't work. And still doesn't listen when we say we could try something else instead which stands a better chance of success, because it isn't their idea. And yet we are castigated...And reports like this come out about a lack of staff engagement...Many of us could have told them this donkey's years ago...If anyone had been listening, of course.

The second paragraph is pretty unarguable. But how many have encountered the situation my former service had a couple of years ago, in which the clinicians were instructed by management to cancel all “non-essential” meetings, as defined by management, which included all clinical team, service development and professional meetings, but NOT management meetings, in order to meet the latest arbitrary targets? Were we the only ones?

The “Round Up of Good Advice” on page 17 onwards is again pretty unarguable and most of this is already well known and should be happening already – decent appraisals? Training adequate to the role? Time and space for staff to reflect on their work? Nothing here most of us haven't known for years.

The better questions would be: “Why isn't all this, which is very well known and has been for many, many, many years, STILL not being put into effect?” And why are we still getting reports from lots of high flown people stating the bleedin' obvious? Who holds to account the managers who have not been using this sort of best practice, who have alienated clinicians, who have led to the levels of disengagement described?

But no, those things seem to go unasked; management continues to get away unchallenged.