Mental Health Care in 1888

In a contrast to a few days ago when I was snowed up in Carmarthenshire I find myself strolling east along London's South Bank to meet my friends Frank and Melior who are taking me to see Gauguin Maker of Myth at the Tate Modern (they are Members of the Tate so I evade the eye-watering £13 entrance charge).

My first earnest discussions about Gauguin at university were not with art students but rather with moral philosophers who held him up as a classic case for posing the question about whether great art could somehow cancel out unethical behaviour. This has always seemed to me to be a pointless debate (see this post) and anyway my philosophical studies started and finished - at my choice - with the Presocratics who were more interested in cosmology and the nature of existence (ethics are a secondary consideration I reasoned publicly and, I reasoned privately, harder work).

However, that doesn't mean it isn't interesting to consider the behaviour of famous artists and the charge sheet against Paul Gauguin is a serious one to which I will offer up some defence...

(1) He deserted his wife and children to pursue his art. Well, actually his Danish in-laws chucked him out because he was making a complete dog's breakfast as a tarpaulin-salesman having lost his job as a stock-broker in a familiar-looking banking melt-down.

(2) He seduced native girls in the South Seas and infected them with disease. By modern standards his defence on this one is going to get a frosty hearing but the youth of his girl-friends was unremarkable in those days. The charge of infection is not fair as his syphilis was at a late stage and therefore (an oddity of that illness) almost certainly not infectious.

(3) He drove his friend Vincent Van Gogh to madness and then deserted him in his hour of need. This is arguably not the most serious charge but it's an interesting one for this Blog and there are some lessons for us which I would like to look at. But before that two long but important asides...

First, Vincent's mental illness is legendary and therefore still influential in public attitudes to mental illness. That influence is ambiguous: on the one hand the story is positive because he was a great artist and many people would associate that with his illness (actually a doubtful association - he himself described how his illness got in the way of his painting rather than inspired it); on the other hand there is more cruel humour about the artist's crisis, especially the mutilation of his ear, than almost any other individual case. In fact Vincent's anguish was appalling and his decline towards suicide makes unbearable reading.

Second, what was Vincent Van Gogh's illness? To reassure you I don't make a habit of throwing around diagnoses but at this distance it feels okay to speculate. The majority view is that he might have been bipolar - and there were certainly violent swings in his mood - but I wonder, especially from reading about the last few weeks of his life, if he was actually experiencing schizophrenia. He described hearing vivid, woundingly critical voices and he displayed extreme paranoia on occasions. Some of his delusions could have been caused by alcohol too. Perhaps the important point here was that he was clearly experiencing classic, mainstream, serious mental illness of a kind totally familiar to Hafal's staff and Members both in its symptoms and in the effects on his behaviour.

So back to the charge against Gauguin. It is undoubtedly true that the two artists wound each other up hugely during their stay together in a cramped studio in Arles. But if anything Gauguin was a steadying influence in organising the cooking and sorting out the finances, albeit unconventionally (they had a box with money for rent and food and a separate one for visits to the bars and the state-approved brothel round the corner).

As for the final hours of their fateful cohabitation the police seem to agree with Gauguin that he had escorted an out-of-control Vincent back from the brothel and put him to bed. Gauguin then went for a walk in the square but became aware of Vincent following him and turned to find him brandishing a razor menacingly. Gauguin got away, slept in a hotel, and legged it the next day taking care to tell Theo Van Gogh that his brother needed help.

Meanwhile Vincent had during the night sliced off a part of his ear and presented it to his favourite girl back at the brothel. Following Gauguin's departure Vincent got into a classic "revolving door" situation being taken into hospital, discharged after calming down, and then being readmitted as he went to pieces without support in the community. This stopped when a petition was signed by local people saying he needed to be kept in hospital for his own and everybody else's sake, something which Vincent himself began to realise was fair. Later of course Vincent shot himself and died in considerable pain.

On this account there isn't much to blame Gauguin for. The big story in Vincent's illness was always the role of his brother Theo whose love and care for his sibling, both emotional and practical, was exemplary over many years and caused him terrible distress as a carer with little respite. Theo went way beyond the call of duty in many respects but also grasped intelligently how he could support his brother sensitively and encourage him towards recovery and self-esteem. Arguably Theo did everything and much more than the advice set out in Hafal's Ten Point Plan for carers except to look after himself sufficiently.

For a brilliant account of the two artists' sojourn in Arles - required reading for people trying to understand how serious mental illness affects people's lives - read The Yellow House - Van Gogh, Gauguin and Nine Turbulent Weeks in Arles.

And what of the exhibition? Irritatingly the pictures are "curated" (dread word presaging unhelpful mucking around with the materials) according to dubious themes instead of chronologically - all very clever but confusing and self-defeating because G's work is multi-layered and doesn't fit categories in this way. In spite of this there are some great pictures. I like the ones from Brittany best - he captures some of the spookiness of a place I like to think of as a parallel universe in which Wales experienced no Reformation,still less a Revival, and is still primitively Roman Catholic. On that theme see "The Vision After the Sermon" above showing Breton peasant women having a strange spiritual experience but also note the "priest" to the right - clearly Gauguin himself - and the pert and oddly cosmopolitan "peasant" to the left with nice make-up - actually his then object of interest, a fellow artist's sister.

For a flavour of the Arles experience see this atmospheric piece including the absinthe glass and the sugar lumps through which it was necessary to pour the bitter intoxicant...



And, a taste of the exotic, this very late picture after Gauguin's own attempted suicide (arising from the pain of physical rather than mental illness)...




I won't post here anything by Vincent to compete with Gauguin but note that he worked briefly when in London for Welsh Congregationalist Minister Thomas Slade Jones (the Dutchman was a Protestant by upbringing unlike Gauguin) and sketched Rev Jones' tin church in Turnham Green...

Deep and Crisp and Even

Well, Happy Christmas one and all and I hope your heating is working. A specially warm greeting to Hafal staff working today and to anybody who finds themselves lonely or troubled for any reason over this holiday.

For the first time ever the bath water wouldn't flow away this morning because the waste pipe had frozen somewhere in the wall. It was bitterly cold last night but the sun came up and I did my usual short walk. You can see the tracks of foxes, badgers and rabbits in the snow which have accumulated over several days giving a storyline of great activity. I am no naturalist but presumably they are getting pretty desperate as are the birds which are furiously investigating the outside of our window panes for any spiders and suchlike.

I believe the advice is to give whatever you can to birds during these harsh conditions so out goes the skin and fat off the bacon joint (I hope they don't mind the flavour of cloves and caramelised honey). I would have enjoyed it myself but their need is greater than mine and I suspect my doctor would also approve.

Year Zero

Early this morning I have been revisiting a guide to relationships whose moral compass seems to place it around 1975 - after the sexual revolution but before the "New Morality". Among a mixture of commonsense and mildly reprehensible advice for men and women I read...

• Ensure scrupulous personal hygiene (daily bathing, clipped nails, etc) but (men) stop short of bouffant hair or visible cosmetics.

• Keep your clothing simple, well-cut, and in good taste - stripes okay but avoid spots.

• Brush your teeth regularly.

• Use alcohol as an effective remover of inhibitions but drink moderately if you have love in mind and beware potential disappointment when you see your conquest in the cold light of day.

• (for men) Be nice to your girl-friends' husbands (!)

• Sending a short text stating your interest politely but unambiguously is a good opening gambit.

• Be on time for assignations.

• Don't use the same meeting place for different boy/girl friends

• (for women) Always apply make-up in private but doing your hair sensuously in your boy-friend's presence may work for you...

"Enough!" I hear you say, "It's Christmas and you should be contemplating the birth of Our Saviour 2010 years ago!"

Well, I am (sort of) because in fact this guide was the publishing sensation of the year in which Jesus was born (1 BC - there wasn't a "Year Zero" but don't ask me to explain why), namely Ovid's Ars Amatoria. This is actually much better than my free translation above might suggest being beautifully written in elegiac verse and largely tongue-in-cheek unlike the leaden and unselfcritical guides on this kind of thing which are published today. And, contrary to popular belief and the disappointment of many schoolboys reaching eagerly for the Loeb translation, it's not pornographic or smutty (try Catullus for that) though it is certainly candid when the advice moves beyond the chat-up stage.

Of course I've been selective. There are bits which have little application today including a long discourse on the dual challenge of pursuing both a lady and her slave-girl (in case any gentleman reader thinks he might encounter this situation the poet's advice is to go after the mistress first and pick up the maid later - and don't expect to get away with it for very long).

Some might argue that Christ was born not least to clean up the easy morality of Ovid and his friends. But there was no need to wait for that kind of Christianity because poor old Ovid fell victim to the Mary Whitehouse of those times - that equally puritanical scourge the Emperor Augustus who was very hot on sexual morality and so exiled the poet to a distant gulag for the rest of his days where he hankered for the Roman party scene and wrote a lot of glum stuff accurately called the Tristia.

I was led back to Ovid by a passing reference to him in cerebral stand-up comedienne, Footlights veteran, and classicist Natalie Haynes' The Ancient Guide to Modern Life, a welcome present from Mrs B which I recommend.

In case you were wondering the "text" referred to above was best written, says Ovid, on an apple (he must mean the fruit, not the trendy PC beloved of public relations spivs).

Hot Rats

The death of Captain Beefheart has been widely reported even though he hadn't produced any music for years and didn't sell much when he did. I contributed to his modest sales by buying Frank Zappa's weird 1969 LP "Hot Rats" on which the Captain sings (grunts?) on the "Willie the Pimp" track which you can listen to here (I hadn't listened since I jettisoned my vinyl in 1990 - it isn't very good but I used to take it seriously).

Beefheart belongs to that interesting group of artists in all fields where you can't quite decide whether their work is just an elaborate joke at the expense of the punters or if he really took himself seriously. My friend Frank (no, not Zappa, who died in 1993) found this interesting piece on him here - we are intrigued by the idea that Beefheart might have died from trying to read his drummer's 880 page critique of his work.

Having relistened to several Beefheart classics today I reckon his music is truly great (Zappa by contrast a bit boring) but the theory and production methodology was surely so much hocus. My favourites are Sure 'nuff 'n Yes I do (listen here - not the best recording but irresistible footage of the Magic Band on the beach in Cannes in 1968) and I'm Gonna Boogiarize You Baby (watch the amazing antics of the band here - you kind of know they couldn't have played it properly if they'd kept still).

Beefheart (real name Don Van Vliet) tells the story of how as a vacuum-cleaner salesman in early life he came upon the house of Aldous Huxley, then living in California. His sales pitch to the author of Brave New World was "Well I assure you, sir, this thing sucks". R.I.P.

Champion

I was determined not to write about mental health during my two week break (if you only read this for the professional aperçus please see earlier posts or come back in January) but I should give you a link to our doughty patients' champion Sue Barnes' excellent piece in the Western Mail here.

How glad I am to leave it to Sue and others with the real expertise to tell it how it is - leaving me with my bit of therapy which is this Blog.

Design Special

A trip to the South of England 10 days ago (I've been struggling with a new camera hence the delay) took me to two design classics a mile apart on the sea-front of Littlehampton, namely the award-winning East Beach Café (2007) and the Lighthouse (1948).

The café was designed by Heatherwick Studio (follow the link for their surprising web-site) and has gained international recognition. Inside I had mussels and razor-shells à la portugaise which was similarly classy.



The Lighthouse is not so well-known but it is surely a great example of design of its time - modernist lines and functionality during austerity which could only come from those years. It is a precursor of the Festival of Britain but it's more elegant (and useful) than the Skylon. It was designed and built by my grandfather Arthur Floyd FICE. Much later he conducted the public enquiry which sanctioned the Port Talbot flyover (now part of the M4) which dominates the local community rather oppressively. But where else could it go? Anyway, it's no use complaining to me.

Once more unto the breach...

I'm taking a lot of holidays as you may have noticed from the lack of serious posts and indeed today is my last day in work this year - we've had such an exciting year that I forgot to take my holidays earlier.

However, here's one to ponder. On Tuesday I attended a meeting of the Mental Health Alliance in London. The Alliance had a very high profile when the doomed draft Mental Health Bill and then the (enacted) Bill amending the '83 Act were under discussion. Arguably the Alliance won the argument but not the war, though mental health legislation would have been more repressive if the Alliance had not been there. Hafal played an honourable and distinguished part in the campaign both as part of the Alliance and in our own right: our leading campaigner Jo Roberts' evidence to the Parliamentary Scrutiny Committee looking at the first Bill was widely ackowledged as pivotal in the Committee's adverse report and so in getting the Bill scrapped.

To a significant extent the Mental Health Measure, though substantially a result of consumer pressure brought by Hafal members such as Jo, Lee McCabe, and other campaigners, put in place in Wales the reciprocal rights which the Alliance campaigned unsuccessfully to be included in the England and Wales legislation. But that still leaves unsatisfactory legislation relating to the use of compulsion in the form of the Mental Health Act itself.

Meanwhile it is interesting to note that the Northern Irish government is planning to enact a new mental health law integrating mental capacity considerations - sounds good. Wales of course cannot do this as the piecemeal powers transferred were effectively confined to the according of rights to patients (or, strictly speaking, imposing duties on services) not to amendment of the Mental Health Act except in a very limited, technical way.

The Mental Health Alliance has in recent times confined its activities to monitoring the operation of the amended Mental Health Act - and done a useful job - but there must be a question as to whether it is time to raise the banner again for reform of the England and Wales legislation.

Why? Isn't it too soon? Well, that is a fair point but against that you could argue as follows...

• The amended Act isn't working well. In particular the Alliance's fears about the use of Community Treatment Orders seem to be coming to pass, specifically lazy, long-term use of Orders to exact compliance from patients in place of persuasive therapeutic engagement.

• Many people in the new coalition UK government were, when in opposition, sympathetic to the Alliance's position from both a human rights and a pragmatic perspective.

• The coalition government arguably combines the libertarian instincts of some on the right (people like David Davis - I mean of course the MP for Haltemprice and Howden, not David Davies MP for Monmouth) with those of progressive liberals among the Lib Dems.

• The coalition government is keen to cut bureaucracy and to save money. Reform of mental health legislation could do both as well as serve patients better.

There is an added complication - or opportunity - for Wales inasmuch as the referendum next year could transfer more powers over mental health legislation - but still not powers equivalent to those in Scotland and Northern Ireland because they also have justice matters devolved.

I think we will have to act. The fact is that the Mental Health Act looks more and more out-of-date and anomalous as time goes by.

I wonder if the London-based charities will see it that way too?



Postscript: outing another closet Welsh person...
Why on earth would Henry V, classic English hero of Agincourt etc and enemy of Owain Glyndŵr, say he is Welsh in Shakespeare's play? By chance he was born in Monmouth Castle, hence the unlikely claim. Come to that we should also "out" the "English long-bow" - nothing of the kind, it was a classic Welsh weapon and indeed the famous archers at Agincourt were themselves Welsh mercenaries, veterans of Glyndŵr's failed rebellion. And ironically some of the "French" knights whom they shot down in the battle were also Welsh, their former leaders who had fled to the continent. You can't get away from 'em, especially where there's a fight to be had.

Night at the Museum

I've enjoyed a pleasant weekend in Oxford having driven straight from the Hafal Learning Day in Builth Wells in under three hours. As usual we stay at the Travelodge 3 miles north of the centre. This is a best kept secret as it can be booked in advance for peanuts but is very nicely appointed and sits right next to the park-and-ride so you can potter into town whenever you want. However, we get off to a poor start as on the first evening we are too tired to bus it and so try the KFC nearby on our first and certainly last visit. It is telling that they sell their wares by the "bucket" and my advice is don't chuck it away when you have eaten the contents as you may need it later.

Next day we look around the refurbished Ashmolean Museum which has been cleverly restructured by removing much of the rear of the building and letting light in through walls of glass. I experience my usual problem of only honestly being interested in the European stuff. I'm fairly sure I'm not a cultural imperialist nor do I think other cultures inferior (on the contrary many artifacts from distant cultures make a lot of Western stuff look dumpy and primitive). The truth is I don't understand other cultures so I find them hard to grasp however cleverly they are presented. So my favourite bits were some of the Graeco-Roman statuary (a nice bust of "Sappho" - wishful thinking by Victorian romantics because it's obviously Athene; and a theatrical mask which is funny) plus a setting of early 18c. English pudding course tableware which intrigues as I am presently reading Dan Cruickshank's "The Secret History of Georgian London - How the Wages of Sin Shaped the Capital". So I can now imagine Sally Salisbury, Lavinia Fenton and other demimondaines eating their figs and peaches suggestively.

That evening we are back to eat unsuggestively at the positively-reviewed restaurant on top of the Museum. They serve an expertly-shaken Cosmopolitan (required by Mrs Blog as compensation for the KFC insult) and a fine mezze of Mediterranean delicacies including quail's eggs dusted with toasted cumin and salt cod quenelles. Our friendly Polish waitress says it's not doing so well in the evenings as people find it strange to eat above the closed galleries below. Spooky.

Next day we lunch at Manos - Greek deli and café in the trendy Jericho district - then visit Al Mizan - Sciences and Arts in the Islamic World at the Museum of the History of Science. I can just about engage with this interesting stuff helped by recently reading "Byzantium - The Surprising Life of a Mediaeval Empire" which provides a useful bridge into the historical Islamic world for those like me who want context from the perspective of their own culture. In any case Islamic culture is equally an inheritor of the Classical World but whereas we chose the ancients' literature they opted for their science, medicine, mathematics, and the habit of taking a regular bath. Now, I like Horace as much as the next man but I know where I would prefer to have been living in the Middle Ages...

Let Them Eat Cake

When members of two elite and privileged groups in British society meet by chance in the streets of opulent West London you might expect them to nod acquaintance, tacitly acknowledge their shared good fortune, and go about their business. So why the froideur when students in higher education met Prince Charles and Camilla yesterday?

I have taken seriously the Prime Minister’s invitation to ordinary citizens to help identify savings in public expenditure believing that it is no good fighting your own corner if you are not prepared to point out where savings could be made. So far I have pointed to the village fete in Llandeilo, the Olympic Games, the World Cup (the latter now dodged though £15 million lost bidding for it), and the potential for efficiencies in mental health services (though these should be reinvested in those services – see this post). But here is another area where substantial new funding could be realised.

It is an established principle in modern democracies with constitutional monarchies that wealth held by the head of state and family ex officio (ie in their constitutional role rather than privately) should be in the control of - and at the disposal of - the elected government, notwithstanding any ancient historical title. So the Queen obviously doesn’t have personal control over Crown property: nobody would seriously argue with that.

But there is a glaring exception to this sound and surely unassailable principle. The Duchy of Cornwall, a truly enormous collection of land and other profit-making estate, is currently treated as though it was the personal property of the Prince of Wales. But it is in fact “his” only by virtue of his office as heir to the throne (it is not passed down under the normal laws of inheritance) and should therefore be in the control of the state. The Duchy is a very substantial resource which belongs by right to you and me (okay, the government) and yet Prince Charles is free to use it as he pleases. To illustrate this point note that the government pays annually to the Duchy the princely (forgive me) sum of £667,000 for the ground rent of Dartmoor Prison - a lot of money for a patch of barren moorland and odd that the government would pay out rent when the land is rightfully ours already.

As we know Prince Charles uses the huge profits from the Duchy to indulge his personal interests such as building retro rural architecture in “Poundbury” and experimenting in new methods of agriculture producing up-market, expensive food (and joining with other millionaire foodies like Hugh Fearnley Whittingstall and Jamie Oliver to wag their fingers disapprovingly at poor people buying ordinary bread, veg, and chicken in Tesco’s). He also used some of the lolly to buy a holiday cottage in a Welsh-speaking community apparently as a public relations exercise.

There is an echo here from another royal family. Louis XVl and Marie Antoinette similarly were hobby farmers blissfully disengaged from the realities of producing affordable food in quantity, built pastiche pastoral cottages at Versailles, gave thoughtful nutritional advice to the poor (“Let them eat cake”), and bought second homes in remote and impoverished provinces. Perhaps the students who shouted “Off with their heads!” yesterday when they saw the royal Roller in Regent Street were studying 18c. French history?

Don’t get me wrong. I wish no harm to Prince Charles and republicanism is a tedious and unproductive project in the UK but there would surely be substantial financial advantage to the Exchequer in seeking hand-over of the Duchy to its rightful owners. And Prince Charles, with his declared concern for those in greatest need, could do a lot to maintain credibility by not resisting such a reasonable request in these hard times. Better still he could offer it up unbidden.

Strictly Campaigning

Fun and games in the last half hour of Hafal's otherwise serious quarterly Learning Day in Builth Wells as we play "Strictly Campaigning".



My acting skills are not improving from a low base (see this post) and as the immortal Brucie I fail to capture the veteran song-and-dance man's lightly camp elegance and instead contrive to resemble something between a marauding gibbon and a German adult movie performer from the 1970s.

Others do better, not least Regional Manager Sharon Thomas and National Resource Centre stalwart Fred Dymott who exhibit a seemingly effortless terpsichorean fluency in the tightly fought competition.

Meanwhile earlier in the day Hafal Trustees have agreed our campaigning priorities for 2011 which will focus on encouraging people with a serious mental illness and their families to take matters into their own hands rather than wait for the powers that be to improve services from the top down. Watch this space...

Momentum

The Welsh Assembly Government's budget could have been a lot worse for mental health services (see my previous post here) and the position was very honestly set out by the Health Minister Edwina Hart in the recent plenary...

"Mental health remains a key priority, as does the development of mental health facilities. We have a good track record on delivering capital projects in that area...It will be a question of looking at priorities, and seeing whether we can keep the momentum up in this area. However, ring fencing, and the robust approach that we have taken to mental health expenditure, will make a difference. As I indicated when we took the mental health legislation through, it was a joy to take it through, and we had excellent cross-party support for it. That means that the outside world will be watching to ensure that the resource is in place to make the legislation a reality".

Of course there is no room for complacency and in particular we will have to make sure that the NHS and the councils live up to the government's expectations for mental health - they have a pretty decent settlement in the circumstances and should be able to make necessary economies in their back-room bureaucracy.

There are also efficiencies to be made in mental health services but any savings from those will be needed to meet the continuing deficiencies in those services - that is what the ring-fence and the priority for mental health must mean if they are to mean anything. Hafal has already pointed out two major efficiency savings which could be made both of which would also benefit patients -

(1) Plan strategically and accelerate the "repatriation" of patients currently placed in expensive and untherapeutic services away from their community.

(2) Rationalise the proliferation of community-based teams into single, multi-tasking teams. This would have to include a step change in the approach of CMHTs which well-meaning commissioners have bypassed over the years because they don't believe they can deliver progressive services: taking the best practice and ethos from some of the added-on, specialist teams would be best. Incidentally it would be good to find a new name for new, integrated teams, to help leave behind the old CMHT reputation whether it is deserved or not.

Notwithstanding the potential for such efficiencies it is only realistic to recognise that there isn't going to be a lot of new money for mental health services in the next few years. So how can a major improvement be made using not much more than the existing resources? The key to this is to reform the traditional approach of handing down services to patients and start trusting them to choose what they need on an individual basis.

The platform for such an approach is about to be put in place through implementation of the Mental Health Measure which accords a right for every secondary mental health patient to have a care and treatment plan drawn up to a required standard. Let's spell this out - secondary mental health services should only exist to serve these care plans and they should be commissioned either directly by the patient (wherever possible to maximise personalisation and choice) or, where collective commissioning is necessary, by direct reference to a number of care plans which demand a similar service. For clarity, yes, that includes hospitals and secure services, for example, not just community services.

By this means we could ensure in a clear and systematic way that the only services paid for are ones which individual patients need. By contrast if commissioners see the Measure as just another thing to worry about and pay for on a long list they will have completely missed the point and will not make best use of the 80% of mental health resources which is spent on secondary services.

It is good to see that the Mental Health Programme Board is dedicating a meeting to the Measure this week - I strongly urge them to seize the opportunity to use the Measure and individual care planning as the focus of all its work on secondary services. That is what patients want.




Postscript: some advice for the lovelorn...

Looking for an image to illustrate "momentum" took me to this intriguing news.

Extraordinary

When the title of a government or government-commissioned report strongly emphasises how it focuses on “action not words” there is a suspicion that the authors are being defensive because they are wondering whether much will actually come of their work.

So, when we read that the title of the report just published by the Independent Commission on Social Services in Wales is "From Vision to Action”, we are at once on the alert to see whether it says anything interesting or will make any difference.

They certainly talked to a lot of people, including me. I recollect many months ago surreptitiously scavenging the remains of the Commission’s lunch in the waiting area before appearing before them at the Ivy Bush Hotel in Carmarthen (okayish canapés - but perhaps it’s harsh to judge when they’d being sitting around a while and the Commissioners may have discerningly consumed the best ones already).

The Report says a lot of commonsense things about making the existing arrangements for delivering social services in Wales live up to widely-agreed principles. So there is a lot of reasonable stuff about listening to consumers, intelligent commissioning, engagement with private and third sectors, coordination with health services, etc. There is also a useful suggestion about collaboration between local authorities and the interface with health which is worth quoting:-

The establishment of 7 Local Health Boards covering several local authority areas creates a different set of opportunities for collaboration over a wider area than the 22 local authority areas.

At the moment there is a messy series of multiple interfaces between the health service and local government services, which are costly in terms of time and effort. Adopting the LHB ‘footprint’ for collaborative effort would provide a single interface between health and social care and the range of local government services that contribute to the possibility of independent living in the community such as housing, leisure services and transport together with the independent sector. Although not specifically part of our brief it could be argued that other services such as education could easily fit this footprint.

There is a short section on mental health including just one example of good practice:-

Hafal, a national third sector mental health organisation, has adopted the international model of recovery based on a whole-person approach including personal care and well-being, money, accommodation, caring relationships, treatment, work, education and social and cultural needs.

Actually the model adopted by Hafal was created by our 1,200 members, not taken from an external source, though obviously we looked at and learned from other approaches around the world. You can see the model here.

The Report also says:-

We welcome the establishment of the new All Wales Adult Mental Health Programme Board jointly chaired by a Director of Social Services and a Local Health Board Chief Executive. They will have a key role in providing leadership and direction to achieve high quality and best value for money services delivered to promote and protect the mental health and well-being of the people of Wales. This joint approach properly recognises the interdependency of social services and health and the role of the third sector, service users and carers in delivering whole person mental health services.

We have now seen the Board operate for a few months and the jury is still out on whether it can make any difference.

The problem with all this is that the Report does not recognise the revolution that is surely coming to both health and social care services – that is real personalisation, not meaning just listening to consumers but giving them control over the money and their choice of care and care-providers (nor does it mean the current grudging and bureaucratic Direct Payments system which is not fit for purpose and needs to be simplified and go much further).

Consumers know that they will never get a first-class service by waiting for top-down solutions from Programme Boards and similar dominated by producer interest, however well-intentioned and however much they try to listen to the consumer voice. That’s the old way of doing things and it looks increasingly out-of-date compared with much of Europe and, more and more, England. By all means let us find Welsh solutions but that does not mean dragging our heels on personalisation, individual health budgets and so on. The Report also ducks the crying need to join up health and social services rather than continue to wring our hands about how they might better work together - another important, if secondary, part of the revolution which would reflect consumers' massive indifference to the distinction between the two.

That revolution is at an early stage in Wales and this Report does not really support it in spite of a genuine concern to focus services on consumers’ needs.

So why did the Report not look for more progressive and consumer-focused solutions?

All four members of the Commission – eminent and good people whom I respect - were social workers. In what other area of public life today would government set up an “Independent Commission” solely comprising people from the provider profession? Where was the independent professional voice – somebody from the private or voluntary sectors perhaps? And, most of all, where were the consumers?

Extraordinary! The choice of members of the Commission tells us depressingly and starkly far more about what needs to be done than the whole 56 pages of the Report.

Tin-Pot

£15 million seems to me like a generous budget to run an international soccer tournament but actually that was the amount spent just on England's bid for the World Cup which crashed and burned yesterday. I hear this morning on Radio 4 that the England bid team had failed to "do the necessary behind closed doors deals" whereas Russia (which, we learn from Wikileaks the same day, is seen by US diplomats as a "mafia state") evidently had done the necessary (wink wink).

Jim White sums it all up in the Telegraph this morning...

One of the most depressing things about the bid process this week was the way it corroded the moral fabric of those involved. To see our elected prime minister or future king obliged to apologise any more for our nation’s robust tradition of free speech to some unaccountable, self-appointed, tin-pot dictator would be too much to take. But now – breathe a sigh of relief across the nation – that will not happen.

I suppose £15m is small change compared with the £15 billion to be spent at the expense of charitable causes and tax-payers on a one week professional athletics event in 2012. Would it really be unpatriotic to back off from all this corrupt nonsense, leave the likes of FIFA and the International Olympic Committee to strike their shabby deals with their friends in totalitarian dictatorships (Germany 1936, China 2008, etc), and spend the money instead on playing fields - or perhaps on a progressive, client-run Welsh mental health organisation (which could be run for over 3,000 years for the price of the London Games)?

People are also wondering how Qatar, a small desert community mainly interested in camel-racing, managed to bag the subsequent World Cup. That is easily answered - the Emir sent the second of his three wives to speak to FIFA (see picture). With that competition it wouldn't have helped much even if Becks had brought Posh along.

Training Social Workers

In the past the voluntary sector has often been perceived as an amateur if benign resource to which statutory services may throw scraps of funding to undertake peripheral, non-vital work. However, Hafal has made great progress in developing mutually respectful partnerships with statutory health and social care providers and commissioners and in the vanguard of this modern relationship are our Social Work Practice Facilitators providing future social workers with skills, experience and (most important) a work ethos based on equality and respect for clients - nothing really could be more effective in achieving long-term change in mental health services.

Over the last four years and from a very humble operation we now have 17 Facilitators. That alone is a tribute to all involved but in addition there is compelling evidence of the very high quality of the training provided and there are significant waiting lists of students wanting to learn from us. We have excellent feedback from both the students and the staff who place them that the placements are especially successful and more broadly they like how we operate and the methodical, progressive models of work which we employ with both clients and carers.

All this makes a big difference and contributes significantly to Hafal’s mission. The Facilitators are assisting in ensuring that there are well-informed professionals going forward to work in Wales and beyond; they are demonstrating in practice how a relationship of equals between statutory organisations and a user-led organisation can bring benefits to all; and they are ensuring that our local services not only continue to employ best practice but are also beacons of such practice from which others can learn.

Happiness

If the government's new Happiness Inspectors (see the story here) had asked me where I stood on their "well-being" index at 6.00 pm on Friday (as I struggled down the M4 trying to get home) then the result would have set off alarm bells in Whitehall and Cardiff Bay and calls for more nature trails, sensory gardens and soothing paint-work on public buildings - some of the things which the new research might result in we have been told without irony.

By contrast a few hours later the Inspectors would have found me early Saturday morning swimming outside in the (heated) pool of the Esporta Sports Club in crisp sunshine. Only the 3 second dash from the door into the water creates a moment's discomfort (it is still below zero). My cup is full, I would tell them, go find somebody else to cheer up (or, better still, leave us all alone and go and look after the economy, health and education).

Later on spirits remain high walking in the Towy valley (click on the picture for a bigger image). Powdery snow and warm sunshine are making everybody smile and Christmas is around the corner.

Ken Dodd memorably sang:-

I've got no silver and I've got no gold
Just a whole lot of happiness in my soul [a lazy rhyme that one, Doddy!]
I hope when you go to measuring my success
That you don't count my money, count my happiness

Amen to that but I don't think when Ken said "you" he was addressing David Cameron. Mind you, the veteran Scouse funnyman has admitted that he isn't very good at counting his own money - he was found not guilty of tax evasion after his counsel the late great George Carman QC observed "Some accountants are comedians, but comedians are never accountants".

Anyway, if you really want to you can listen to the whole mawkish horror from 1964 here. Tattyfilarious.

I'll Say This Only Once

All the talk among the political chatterati is about the "Squeezed Middle" classes, a meaningless concept as nobody agrees who they are. There just about still exists a (quite different) class of the "Impoverished Genteel", people with very little money trying to keep up appearances and differentiating themselves carefully from people in (horror!) trade even though the tradespeople might be much better off.

This class has a long and frankly ignominious history, one era of which was portrayed in Mrs Gaskell's Cranford (1851). The stage version we saw this week at the Swansea Grand is from 1950 and the date shows because the plot is crassly manipulated to make a humourless democratic point whereas Mrs G (and the recent BBC series) stuck to a more subtle though sentimental line. But in 1950 the public, not just the politicians, still took politics seriously so it was probably expected.

This is slight stuff, made a little more interesting by having Shirley Anne Field in the cast and also Kirsten Cooke who played Michelle of the French Resistance in sophisticated 1980s sitcom 'Allo 'Allo ("Leesten very carefully..." etc). At least 'Allo 'Allo was a bit edgy because it sent up something of deadly importance rather than a reality (19c. provincial life) which was as humdrum as the fiction. I remember reading somewhere that the French warmed to 'Allo 'Allo but it never caught on in Germany.

Wetherspoons' Thursday curry night has a new offering - Piri Piri Chicken - which does the trick on a cold evening (£4.99 including all the trimmings and a pint!).

Guilty As Charged

It is welcome that the UK Government has accepted that the system for assessing people's ability to work (the "Work Capability Assessment") itself doesn't work. In particular, an independent report states, it doesn't work for people with a mental illness.

The problems are set out in a review by Professor Malcolm Harrington, who was asked by Ministers earlier in the year to look at the assessment and recommend improvements. Employment Minister Chris Grayling pledged this week to accept all the recommendations from the review.

The Harrington Review made substantial recommendations including the need to deal with the complexities of cases involving mental health and similar issues by creating a network of "mental health, intellectual and cognitive champions" in each Atos Medical Examination Centre to spread best practice and build understanding of these conditions. In other words the assessors didn't know what they were doing and they need to bring in people with some clue about what mental illness is.

This doesn't surprise Hafal which has encountered a surreal world of total misunderstanding when trying to resolve blatant cases of injustice: some of our experience is so absurd that it would raise a laugh were it not for the fact that getting these matters wrong risks condemning very vulnerable people to months of anxiety, impoverishing them through withdrawal of benefits, and (tough to say but true I am afraid) threatening their lives because many people with a serious mental illness are vulnerable to suicide.

Chris Grayling said:

"It’s in everyone’s interest that we get the WCA right and Professor Harrington’s recommendations will make the assessment fairer and more effective.

"The WCA should be seen as a positive first step towards returning to work. Those who are found fit for work will get the help and support they need to get a job. Those found too sick or disabled to work won’t be expected to and will continue to receive the help and support they need to lead fulfilling lives."

Well, Harrington has brought in a guilty verdict on the operation of the system to date so we will have to see if it can improve itself and do what the Minister promises.

The WCA is already being used to assess new claims for sickness benefits and from early next year will be used to assess all those on incapacity benefits, to see whether they are fit for work, need tailored help to get work ready, or require unconditional support.

Chris Grayling has asked Professor Harrington to continue in his role as Independent Reviewer. Professor Harrington said:

"I have found that the WCA is not working as well as it should. However, this is not about ripping up the current system and starting all over again. So I am proposing a substantial series of recommendations to improve the fairness and effectiveness of the WCA."

I have my doubts.

Meanwhile Hafal's advice to anybody with a serious mental illness who is concerned about their benefits position (or is being assessed) is:

GET ADVICE!

Best approach is to get help both from a benefits specialist like CAB and from an agency like Hafal which understands your illness - and you will need to involve your doctor.

Don't leave it to chance.

Fair Play

No surprise that the UK Government is ruling out revision of the Barnett formula (the means by which Wales' share of UK funding is calculated). Chief Secretary to the Treasury Danny Alexander slammed the door on this yesterday on a visit to the Assembly - see the story here. There is consensus among economists that Wales is losing out from the formula but the UK Government says it doesn't want to tinker with it while they are tackling the deficit, though remarkably the UK Government is prepared in principle (says Mr Alexander on the same visit) to reform the devolution settlement (surely a bigger undertaking?) to allow Wales to raise taxes. But Scotland would be disadvantaged by reform of Barnett (and Mr Alexander is the Lib Dem MP for Inverness). The previous Government also refused to look at Barnett so it is a proper concern (and not a party political one) for Welsh citizens to seek fair play on this, especially in defence of those most reliant on the devolved budget such as people with a serious mental illness.

Meanwhile we are absorbing the Assembly Government's budget plans (see the details here). In fairness the Assembly Government seems to be listening, making the right noises about the NHS and specifically restating the priority for mental health services; they have also stated a priority for secondary and community-based services; and finally they have also given a priority to social care, sending a message to councils to protect the vulnerable. But we will have to make sure that the NHS and councils live up to this rhetoric...

Wheel of Fortune

Lord Young's resignation following his "You've never had it so good" gaffe is followed by some more honest discussion about who in fact are the winners and losers as first recession and now public expenditure cuts wash over us like a double tsunami. Some of the government's embarrassment arising from Lord Young's comments stems from the awkward truth that we are not of course sharing equally in the pain and there are significant beneficiaries as well as real losers. If your job is secure and you have a large, variable-rate mortgage and similar debts then you have had a big bonus in spending power in the last year or two owing to the very low interest rates - but you don't hear people owning up to this, do you?

As I leave the gym on Saturday morning a pundit on Radio 4 specifically names Swansea as a place which will suffer much more than most areas because it has a high proportion both of public sector workers and also of benefits claimants (and not a few of the latter are clients of Hafal). But it too will have beneficiaries, no doubt keeping a low profile.

The city is certainly looking shabby and forlorn in the drizzle with leaves and fast food detritus blowing around Oxford Street. This pall is only a little mitigated by a sarcastic town cryer announcing Santa's arrival ("but you don't deserve it" he bellows, apparently to everybody's amusement) and two moth-eaten reindeer sitting bemused in a pen. Nearby the slightly rusty-looking "Waterfront Wonderland" is getting few punters but no doubt it will become more popular nearer the holiday - I recommend the big wheel as it gives an unusual view of the city centre (as indeed does the one by the Civic Centre in Cardiff); and maybe this year I will dare try the skating (my last attempt at the Queens ice-rink in central London in 1976 formed the central plank of a strategy to impress a girl - terrifying and unsuccessful in all respects).

Over lunch at the Alfresco cafe next to the Waterfront Museum (bacon and egg bap £3.50 - not that cheap but with a nice aspect overlooking the Marina) I ponder that for all Swansea's lack of overt wealth you won't find a friendlier place of this size - that morning I have chatted warmly and at length to strangers in the queue at Sainsbury's, in Lidl contemplating those German chocolate decorations, in the market, and at the new art gallery in the old Exchange. Had I had time to cross the road into the Queen's Hotel I could still be there now.

Taking Over The Asylum

Hafal's large-scale conference last week gave us a chance to step back from the immediate campaigning concerns (about Measure regulations and the like) and consider the wider priorities of our mass membership. 200 attended the conference and we held forums for both clients and carers which, together with much informal networking, will help to guide Hafal’s campaigning up to the Assembly elections in May 2011 and beyond.

Distilling all that we heard I have identified 5 big themes, all overlapping and interconnected...

(1) Let’s call this one the “respect and rights” agenda. Clients are plain angry and fed up with disrespectful services which say “You’ve got such–and–such illness and this is the medicine you need to take. Oh, and here’s some desultory drop-in you can go to if you feel like it". Dress it up how you will this is still a typical experience of many mental health patients. No holistic approach, no mention of recovery, no empowerment offered, no choice. There is growing realisation that, whatever we do to improve the sensitivity of services to the needs of clients, in reality there will never be a first-class service until clients take control over their own recovery - by which we mean not just being consulted but making decisions about the use of funds available for their health and social care. Of course respect also means not facing discrimination and we need to help clients and families to achieve equality and fair play from the community at large.

(2) Protection of resources for mental health services. Until clients do have the control they need over resources they remain beholden to global NHS and social care budgets and we need to understand and influence those. At present a shaky ring-fence is supposed to protect NHS mental health funding but everywhere we go NHS insiders talk of the limitless "discretion" of LHB finance departments to assign costs as they see fit when reporting on expenditure. Further, some LHBs seem to be snaffling savings made from Continuing Health Care funding as if this wasn’t a part of the mental health budget. Ring fences aren't a great way to manage resources but it’s almost all we’ve got for now so Hafal must help clients and families fight back and support mental health managers to get the resources they need.

(3) Though it links to (1) and (2) above you can’t not have a priority theme about people struggling is the murkiest depths of mental health services, in particular in-patients and those enmeshed in the criminal justice system (especially those in prison who should be in hospital). The public would be amazed if they knew more about the experience of people in hospital – not only the lack of care, especially the minimal personal contact with staff let alone access to talking therapies, but the fear and real danger of neglect and abuse. For prisoners with a serious mental illness the position is dire: it beggars belief that the most vulnerable patients with florid psychotic symptoms and in a desperate state can be left to deteriorate and face real danger in an environment which is almost calculated to make people worse not better.

(4) Benefits are high on the list of concerns for both clients and families. The changes made by the last government and those planned now by the new government are both objects of considerable suspicion and fear. In theory those genuinely unable to work should be protected but Hafal knows otherwise - mistakes are being made and vulnerable people exposed to anxieties which can severely damage their health. It is hard to deny that the remarkable increase over a generation in the number of people assessed as unable to work through disability needed to be challenged (as both governments have agreed) but the targeted decrease in that number is so very bold. Can we believe that the right decisions will be made?

(5) Carers and families continue to get a bad deal for themselves and this results in a bad deal for clients and for the rest of us – because supporting and training families to do a good job (where it is fair to ask them to do so ) can help clients get better quicker and conserve precious resources. Some of the right noises are made by the Welsh Assembly Government but we are a long way from integrating families into the care planning process and respecting them properly for their essential input. The Carers Measure shows willing but actually offers little beyond a right to information.

In the next few weeks Hafal will be putting together its campaigning strategy for next year. No doubt we will address the issues set out above but my sense is that to do justice to the mood of our members we should not just be making demands of mental health services but inviting patients and families to take matters into their own more capable hands - not perhaps by storming the hospitals Bastille-style (happy thought!) but, to give some examples, by exploiting new rights under the Measure to take control of their recovery plans, by seeking Direct Payments, by exercising their right to change care providers, by expanding the range of services which can be managed by client-led organisations, by taking up appointments to management groups or indeed LHBs, by taking legal action on inadequate services and discrimination, etc. The old saying about inmates "taking over the asylum" (suggested to us recently as an edgy slogan - I like it) does not describe such a bad policy...

Bubblegum

It's been a long week. From last Sunday night and throughout a busy though successful Monday to Friday (including our best ever AGM/Conference) I had a nasty cough and sinus headache which only lifted yesterday. This morning it took a supreme effort to get up early, go to the gym, and put in a long session to open up the lungs and generally jump-start my creaking mortal carapace.

While puffing along on the running machine I watch Match of the Day with nice Gary Lineker whose good manners make up a bit for the soporific Premier League "highlights" (what an earth can the rest of these matches be like?) followed by Andrew Marr who is usually good value but the report from Burma is spoilt by John Simpson sweatily telling us nothing at all - what is the point of sending "senior reporters" to news hot-spots about which they clearly know nothing? Anyway, I won't comment myself on Aung San Suu Kyi's welcome release beyond saying what everybody else must be thinking but not daring to say for fear of sounding trivial: I want some of whatever she's on, making her serene and perfectly poised as well as looking hardly a day older than when she was banged up 20 years ago, in spite of her husband dying without her and all the other shocking treatment which would have made a lesser mortal bitter and twisted in both mind and body. Notwithstanding the media frenzy she really is inspirational, very like old Nelson M who surprised everybody when he emerged from prison looking like a mature film star and, even more impressively, with a sunny and generous disposition belying his terrible experience of captivity.

Then to Lush in Swansea for two tubs of their "Prince" shaving cream, a hideously expensive luxury which I allow myself. The hovering neo-punk shop assistant volunteers that her boyfriend uses it, and when I go to the counter the girl on the till says she uses it - I give her a look and she adds without blinking "for under me arms". This does not surprise me as it is evidently part of their training to make you think you have made the smart choice and I've heard the same about Sex Bomb "bath ballistics", Iridescent Glitterbug massage bars, and "Honey I've washed the kids" soap, among many joyful purchases. I love Lush with its charming if implausible staff and crazy fruit and veg aromas, unlike Bodyshop with its indifferent service and cheap smell reminiscent of old bubblegum found stuck under the table of a Great Western train.

Hell's Kitchen

Yesterday's AGM, a daunting enough event for any chief officer who recognises the uncompromising authority of the membership thus legally assembled, is a stroll in the park compared with the final "turn" of the day - me and Company Secretary Nicola Thomas preparing a three course meal in 25 minutes from scratch featuring ribald and frankly disruptive commentary from me and infinite patience and studious attention to the task in hand from Nicola. But we did it, and I think the grub looked okay. I promised a couple of people that I'd publish the recipes so here goes...

First Course
Tomato and Mozzarella salad with vinaigrette. I won't insult you with details of how to slice up the ingredients but the vinaigrette (aka French dressing) is important. Contrary to common practice in the UK it is a crime to add more than about 1 part vinegar to 6 parts oil (Hafal Deputy Chief Exec Alun Thomas' half-and-half admission was truly shocking). Greek olive oil is my other tip - bog-standard Kalamata better than most fancy Italian brands. Add seasoning, spot of mustard, and garlic to taste. We plonked a sprig of basil on top of the dressed dish for dinner-party presentation.

Second Course
Prawn stir-fry with noodles. For elf 'n' safety reasons we used an electric wok which worked quite well in spite of my sniffy contempt. The problem arose when trying to get the completed dish out onto the plates - short of tipping up the whole gadget we had to spoon the gloop out messily. We fried chopped spring onions and peppers plus carrot strips, mangetout peas, ginger and garlic in neutral oil with a dash of sesame oil then added prawns, fresh noodles and soy sauce, finishing off with torn coriander. For a veggie version leave out the prawns.

Third Course
Knickerbocker Glory. This was a healthy version (sounds unlikely, doesn't it?) based on a Mrs Blog trick, namely use of a pressurised canister of pure cream (watch out - most have sugar and other muck added but Anchor do a pure one). Basically you put fruit - we used raspberries, bilberries and blackberries - plus some crushed meringue interspersed with squirts of cream and finished off with a big Mr Softee-style squirt on top with a lone raspberry and sprig of mint. Total calories only about 150. How's that? Because the cream is expanded with a vast amount of air. However, do not prepare in advance - within minutes the cream collapses into a microscopic drip at the bottom of the glass.

A Degree of Deception

I am very proud to show you a picture from my graduation with a Hafal degree in "Recovery Studies" from our AGM/Conference yesterday (lots of pics on Hafal's Facebook will follow here). Caroline Jones, Hafal's manager in Denbighshire, was doing a brisk trade in these "fraudulent-but-fun" qualifications among many other activities which informed and entertained 200 delegates in Builth Wells.

Caroline's isn't the only dodgy academic body flogging degrees in return for no work whatsoever. Indeed I confess this is not the first time I have picked up a qualification by doing precisely nothing. Many years ago I struck a shabby deal with a shifty outfit in East Anglia which knocked out an M.A. to me in return for an "administration fee" of £8. No work at all required - just wait 3 years after you've done a normal B.A. degree (not a vast amount of work required for that either if truth be told) then send in your cheque. In fact I didn't even have to pay for it myself because my canny late uncle Gwyn Williams coughed up, figuring it was a good value means of discharging his duty as my godfather to see that I was suitably brought up.

This neat trick, shared I understand with a similarly shameless institution in Oxfordshire, has quietly been pulled for centuries and provides an enhanced CV to its beneficiaries and understandable irritation to everybody else (don't tell those student rioters - I don't want them round my place).

In ongoing discussion with our Learning Centre Principal Irene Hogan about my training needs (see this post) I have adduced my M.A. as evidence that I clearly don't need to learn anything ever again and, when that ploy comprehensively failed to convince, suggested that a course of study be found on a similar basis (i.e. fancy qualification but no work required). I suppose I could try waving my equally valid Caroline degree at Irene but meanwhile negotiations continue.

More on the conference to follow...

Sausages and Laws

I have deliberately paused for a few days following the passing of the Mental Health Measure by the National Assembly last week in order to reflect first on the implications of the late amendments and the important undertakings given by the Minister during the debate.

First let's check what the Minister said in the debate about holistic care plans...

When the amendment that included these eight important areas was tabled during Stage 2 proceedings, I did explain my misgivings about the requirements to include those areas in every care plan in every case. I remain concerned that to do so would risk losing sight of the importance of individualised care and treatment planning, which is outcome based. I am therefore pleased to see that this amendment does not require all care plans to include all these areas, and its effect is therefore quite different.

As currently drafted, the proposed Measure does not set out the kind of outcomes that the provision of mental health services is designed to achieve. The proposed amendment would make provision for that, and would mean that the agreed outcomes must include at least one of the areas listed. I believe that it is appropriate and necessary for full assessments to be undertaken by practitioners and that such assessments should consider at least these eight areas. Assessments may also consider other matters. As such, it is right that care co-ordinators consider these areas when working with the service user and service providers to develop and agree outcomes for the provision of services. These areas are well-enshrined in existing mental health policy guidance. For example, they are set out in the chapter on care and treatment planning in the code of practice introduced under the 1983 Act. They are also referenced in the interim guidance on the care programme approach, which was issued to local health boards and local authorities in July. Given that amendment 4 sets out prescriptively the areas where outcomes may be achieved and does not require each care plan for each service user to list outcomes in all these areas, I am happy to give the amendment the Government’s support.

On timescales, which an opposition amendment would have required to be included in statutory guidance, she resisted the amendment but said...

On the issue of whether the timescale[s] should be included in the guidance, I am happy to take away the views that have been expressed and consider them further.

On balance I think patients are winning but we have much more to do. The successful opposition amendment putting the 8 "life areas" onto the face of the Measure (under Part 2) has useful but mainly symbolic value – it does count for something that the principle that care and treatment plans should be holistic is flagged up even if the amendment alone would not place a duty on practitioners in practice to deliver holistic plans.

The Minister’s remarks about assessment are welcome – even a positive movement from the last debate. We seem to have an undertaking to ensure that assessments of patients will cover the 8 "life areas" and presumably care plans will cover them where a need is identified in those assessments. This is definitely moving in the right direction but we need a bit more! One of the difficulties we have faced is making our argument for holistic care plans has been the counter-argument that there is no point in recording something in a plan for life areas where there are no needs identified and therefore no outcomes to record. That argument sounds plausibly unbureaucratic and reasonable but ignores the fact that the "life areas" are all matters which every person with a serious mental illness needs a plan for (with the exception in some cases of parenting or caring responsibilities). Take the example of housing: who among us does not need a plan for our housing over the next year? It may not be written down but we all have a plan to pay our mortgage or rent, pay bills, deal with problems that arise, etc. Now in many cases patients may be fully competent and content to fulfil their plans for some life areas without help from professionals or family carers but that doesn't mean it is not part of their plan - what indeed could be more patronising! And there is no bureaucracy problem as it is not complex or irrelevant (in fact on the contrary it is therapeutic for the client and very helpful to the Care Coordinator) to write down something to the effect that "the client is confident that they can look after their own housing needs".

We need to ensure that care plans are holistic and, as night follows day, THEY WON'T BE if this is not required in the regulations...


Je weniger die Leute darüber wissen, wie Würste und Gesetze gemacht werden, desto besser schlafen sie nachts (the less the people know about how sausages and laws are made, the better they sleep in the night) - not Edwina this time but Bismarck.

Slightly Unwashed

Exhausted after a long but productive week I have done no walking and little work this weekend aside from installing my new wireless router courtesy of Talktalk. I carefully meditate myself into the necessary Zen frame of mind to undertake such tasks but while meticulously following the instructions I am told on-screen by the installation disk that "We are struggling (sic) to find your wireless card/adapter" - that would be because I don't have one and you didn't tell me I needed one! Techies among you will scoff at my ignorance but I think I was owed the advice in advance. Grim-faced I drive to Carmarthen to source the required device from PC World. Unwisely I patronise the teenager serving me by suggesting we will need advice from the middle-aged professor-type at the "geek" desk but she of course knows it all (it is uniquely true of IT that you know more the younger you are) so I am patronised back, get the tiny but expensive hardware, and finally complete the challenge not exactly calmly but at any rate without hurling anything across the room.

Having my feet up allows me to finish reading Sebastian Faulks' "A Week in December", a satire on modern Britain which offers a surprisingly sympathetic view of Islamic fundamentalism in the person of a prospective suicide bomber. After 380 pages describing the hypocrisy, casual substance-abuse, greedy materialism, and pointless wage-slavery of our society I can see why some young idealists would want to establish a Caliphate on our shores. Of course they aren't going to convince anybody by blowing them up but they do have something to sell against the alternative of what we have now. It may be my classical education - or is it just contrariness? - which draws me to take seriously radically different models of civilisation.

Faulks is interested in serious mental illness (see my previous post here) and in this book portrays a young man - not the bomber - succumbing to schizophrenia as a consequence of living in western society. He apparently gets the illness by using heavy-duty cannabis in the context of disinterested, money-obsessed parents. Disturbingly in this analogy Faulks blurs the distinction between metaphor and real cause, making this difficult reading I suggest for people personally affected. In the end I fear Faulks is not really sympathetic to people with serious mental illness but uses them in his books to explore human nature.

There is a similar challenge to convention in Claude Chabrol's "Le Boucher" (1970) which I watch last night for the first time in many years having saved on the Humax. The butcher in question is a sympathetic character in spite of slaying a number of women in a sleepy Dordogne community; by contrast his teacher girl-friend gets the blame because she won't let him have his wicked way. Very French, as is the smouldering, slightly unwashed charm of Stéphane Audran. Chabrol was certainly charmed because unlike the butcher he got to marry her, lucky man. Most of the film is rather surreal and improbable but I take notes when the butcher gives authoritative advice on cooking a leg of lamb. He says it is a crime to use any garlic and to cook for just 30 minutes(!).

The idyllic scenery filmed around Perigueux is familiar and I recall that I was in fact in the area on a school trip at about that time, visiting the prehistoric Cougnac grotto where Mlle Hélène (Ms Audran) takes her school-children and discovers a body when blood drips from the cliff above onto one poor pupil's sandwiches. Outside the same cave but less dramatically I picked up shards of flint which our ancestors had napped off while making tools. I am glad we didn't discover a corpse although it would have been worth that risk if our teacher had looked anything like Mlle Hélène (which sadly he did not). We also visited an ancient farm-house foie gras factory including a matter-of-fact demonstration of the machine for force-feeding the geese which did not disturb us at all. Somehow you just expect the countryside to be brutal.