Unthinkable

I first went to the National Botanic Garden of Wales shortly after it opened 10 years ago. We had been given free tickets by an American volunteer working there to whom we had given a lift during a summer rainstorm.

At that time there were more staff than plants and more plants than visitors. The whole project had begun disastrously built on hopelessly optimistic expectations that vast crowds would flock enthusiastically to see a limited display of quite boring plants - because instead of an exotic tropical extravaganza the organisers had decided to use the huge glasshouse to exhibit the flora of arid deserts like Australia where the plants are stunted, small-leaved and frankly dusty and uninteresting unless you are one of a dozen people in the world studying that sort of thing.

We visited again today (free entry again, this time for everybody throughout January) to find that the desert plants had struggled over the last decade to create a bit of scant foliage under the glass but otherwise there wasn't much change. They have put up a modest tropical house (perhaps having worked out that's what the punters actually want?) but we were told that a lot of the plants had died of cold last month when a pipe froze in the heating system. You would think somebody would have been checking and, on finding the problem, would have put a couple of 3 watt fan-heaters in until the repair was made?

The main glasshouse itself is quite fun, reminiscent of a Bond villain's lair, but I won't be going again until the next time it's free entry.

There is a good view of Paxton's Tower, erected by the builder of the house on the ruins of which the Garden is now placed. The official line is that he put up the Tower to commemorate Admiral Nelson but everybody locally knows that in fact the folly was erected (instead of a useful bridge across the Towy) to spite the people of Carmarthenshire who had happily accepted Paxton's bribes in the 1802 election (including over 25,000 gallons of beer) but didn't then elect him. Of course this story cannot be true as it is unthinkable that there could ever have been political corruption in West Wales.

Courageous

This morning I am in the BBC's Swansea studio to comment on a report by the Ombudsman for Wales into the suicide of a man in Cardiff. A mother complained about the standard of care afforded to her late son by services before he took his life in October 2008.

The Ombudsman’s investigation (see it in full here) found that:

• The threshold for admission to hospital appeared to be at a high level and there was no clear policy guidance or definition as to what constituted a “severe case” warranting admission.

• The high threshold coloured the way in which the man was dealt with. This was particularly evident immediately following his return from a trip with his mother, when he had self harmed.

• There was no clear guidance in place as to what should happen when patients recently discharged from the Crisis Team’s care "self presented" at a hospital front desk, out of hours, requesting admission.

However, the Ombudsman did not uphold the complaint that shortage of beds had influenced the decision not to admit the man, as he was satisfied that a bed could have been sourced elsewhere. He also asserted that it could not be known whether admission to hospital would have prevented the suicide (this was, I think, a superfluous remark in an otherwise well-judged report because obviously you couldn't know that for sure in any circumstances).

The Ombudsman has to confine what he comments on to fairly specific aspects of the case and I think he’s reached the right conclusions here.

However, there are also wider implications. The mother of this gentleman has courageously posed a question for the wider public: if somebody in your family was in a very bad state mentally and tried to take their own life more than once in recent days and weeks, and if they then tried to get admission into hospital, what would you expect to happen?

I think most reasonable people would say that either the person should be admitted or there should be a flexible service available which ensured that someone is available to stay alongside the person until the crisis is over.

There is a weakness in the suicide strategy in Wales – it concentrates on early stage prevention, which is of course important, but much can and should be done at a later stage when a patient is at high risk.

Cod Psychotherapy

Last night I saw the multi-Oscar-nominated "King's Speech" about George VI (Colin Firth) getting to grips with his stammer with the help of a maverick Australian therapist. This was our default choice as there wasn't anything better to see so we didn't have high expectations and I wasn't at all sure Mrs Blog would engage with it as she has a visceral, "anarchist peasant" (as opposed to metropolitan lefty) distaste for royalty.

In fact the stuff about dealing with the stammer was compelling viewing (and I see that the British Stammering Association approves heartily of the film - see an interesting interview between Firth and their Chief Executive here). The therapeutic technique was multi-layered, ranging from direct speech therapy (practising links, strengthening the diaphragm, etc) through cognitive stuff (association of ideas, release of blocks through colourful swearing) and onto heavy-duty if (for filmic purposes) cod psychotherapy exposing some bitter experiences including a cruel nanny, invidious comparison with siblings, enforced right-handedness, and absence of friendships.

Though I couldn't judge to what extent the film was true to life (or indeed whether such techniques are appropriate to the condition) the film did convey one great truth about therapy, that is that the therapist must warmly, genuinely and demonstratively show their care for their client irrespective of how off-the-wall their methodology may be. And no doubt the film will do a bit of good concerning this very common but little-discussed problem.

But the background history was simplified to the point of being misleading. The abdicating Edward VIII was accurately portrayed as a nasty piece of work with little intelligence but some unpleasant enthusiasms including Nazism and the sinister night-time skills of Mrs Simpson. But the hero "Bertie" (as the king was known to his intimates) was played as a straightforward patriot with the right instincts about Churchill etc. whereas in fact he was a dull booby, had little grasp of the international situation, thought Munich a great triumph, and favoured appointing appeaser Lord Halifax as Prime Minister when Chamberlain resigned.

So, lucky he had no say in the matter or we would all be speaking German - not that he wanted that, of course, whereas his older brother might have been ambivalent.

But the point is that we aren't run by the royals and their personal opinions are no more interesting or important than the next person's. The old Queen Mum (played by Helena Bonham-Carter in the film) knew this and, though apparently she had very unreconstructed, right-wing views, she only shared them with her closest friends and was therefore the darling of the nation ("Gawd bless 'er!") in spite of apparently looking down on us lowly oiks from a great height. Like her husband she was not a very bright person but, also like him, she did at least know as much and therefore kept her mouth shut.

Would that some modern royals would also Socratically recognise their limitations, keep quiet about their daffy plans for the nation's health, architecture and eco-system, and thereby avoid swelling the numbers joining Mrs B in wheeling out the tumbrel.

No Surprise

More confirmation of Hafal Members' dire experience of assessment by the Department of Work and Pensions and their agents in the form of their own report which states that the process of claiming Employment Support Allowance (ESA) is particularly stressful for people with a mental illness. See the full story plus useful commentary from Hafal's employment specialist Short Steps Information Officer Helen Lovitt here.

The report, which focuses on the Work Capability Assessment (WCA) and the Work Focused Health Related Assessment (WFHRA), is based on interviews with claimants, healthcare professionals and Jobcentre Plus advisers.

It was found that the ESA50 medical form, which forms the basis for the discussions at the WCA and WFHRA, was often badly completed and, in some cases, not returned at all. This was a particular issue with people with mental illnesses. The report recommends that assistance to complete the ESA50 form should be offered to all claimants.

Many healthcare professionals also reported that, in direct contrast with people with physical impairments or disabilities, people with mental health issues tended to under-describe their conditions on the ESA50 form. This specific problem of understatement by people with a serious mental illness is one which we have been trying to get across for a long time (see this post from last July).

The report found that several claimants were not clear about the purpose of the WCA, with many believing that it would be a full medical examination. In actual fact the WCA is primarily a discussion based on the ESA50 form, about the physical and mental barriers to work which the claimant experiences.

When it came to informing claimants about the outcome of their claim, decision letters were criticised as being badly worded, with a tendency to suggest that the claimants are not really ill. The report recommended that in future, decision letters should contain details of the evidence which was considered in reaching the decision.

All this follows the previous report which I highlighted last year here.

I seriously doubt whether this giant gap in the understanding of mental illness by DWP can be dealt with by fiddling with the forms and procedures or even by staff training. Long ago Hafal wrote to the DWP Minister in the previous government about this problem suggesting that formal advocates were required to assist people with a serious mental illness in these matters. How right we were.

10,000 Steps

Of all the advice around about keeping fit and healthy I think one of the better ideas is to try to increase the number of steps you take each day with an ideal target of 10,000. I've studied this a bit and can tell you that you can do about 100 steps in a minute if you walk at a reasonable pace so it would take 1 hour and 40 minutes to do the 10,000 in one go, though that's unlikely to be necessary unless you spend all the rest of your time lying on a divan eating peeled grapes.

I do a useful and consistent 2,000 steps 9 to 5 in the office (without going out), where I spend most of my time sitting and only occasionally getting up to fetch something or to go and talk to somebody - so the steps mount up almost imperceptibly. I guess the average person will do quite a bit pottering around at home too (although I confess I'm probably closer to the grape-eater in my domestic setting). Nevertheless I suspect that most people doing sedentary jobs are not going to do more than 5,000 a day without contributing purposefully by going for a walk (although if you use public transport you may well add a lot getting to and fro from bus-stops and so on).

But it's hard in the winter to get out for a walk other than the weekend (my pictures are from a 6,000 step walk late afternoon today - the second picture taken just 14 minutes after the first). I try to compensate by going to the gym and if I was more consistent with that I could hit the target with the added bonus of some affect on cardiovascular fitness and suppleness. Walking out lunch-time is a good idea for office-based staff especially in winter - and surely good for our heads too.

I am wary of giving anybody advice on exercise but will just offer the suggestion of buying and experimenting with a pedometer (that's how I checked my own step-count as described above). Unlike most exercise equipment it costs very little and needn't depress you and sap your will through lack of use; rather it can actually show you the good you are already doing yourself and encourage you to increase activity in your own time by taking the odd walk opportunistically. If you do get one don't set unrealistic targets - just monitor your current steps for a while and try out new habits to increase them. I find the psychology which goes with the pedometer most encouraging, for example turning walking around the shops from a chore into an opportunity to exercise. Try my Saturday shopping habit of parking free outside the town centre and walking in - lots more steps and save yourself a couple of pounds to buy a nice lunch.

Northbound

I'm on my way to Hafal's quarterly North Wales meeting stopping off at our Learning Centre in Aberystwyth to get some work done. I am distracted from humdrum chores by evidence of our local clubs' artistic activities on the wall and I have snapped and posted two examples - a fine mosaic of the iconic Hafal microbus and a neatly-executed collage of the 1970s which captures the eye-popping taste of that decade epitomised for me by the amazing style crimes of Roger Moore as James Bond: he may have had a licence to kill but surely nobody would have given him one to dress like that?

Money, It's a Gas

A lot of things come down to the money in the end so as the Assembly is having its first substantive discussion about the budget today Hafal's Peter Martin and Junaid Iqbal are staking out the Senedd with the objective of holding the Government to its word on protecting both mental health services and, generally, the most vulnerable people in our communities.

Let's remind ourselves what the Government has said about this...

“Health and social services has been protected from any cash reductions in its budget in 2011-12 and 2012-13 and receives a small cash rise in 2013-14. This level of protection reflects our commitment to ensuring the provision of frontline services across Wales.” (Draft Budget p.33)

“Revenue funding for 2011-12 and 2012-13 remains at the same level as the budget for 2010-11.” (Draft Budget p.33)

“We will continue to prioritise spending on mental health services. Approximately 12% of total NHS funding is ring-fenced for mental health services, and we will provide investment to support the implementation of the proposed Mental Health (Wales) Measure.” (Draft Budget 6.para.6.6 p.34)

“The Assembly Government is committed to ensuring the provision of essential social services. Social Services, in the main, are funded from the Local Government Budget and the social care element of the RSG includes the necessary resources to deliver a 1% protection above changes in the Wales DEL. We have also maintained investment in social services funded through the Health and Social Services MEG.” (Draft Budget 6.para.6.7 p.34)

That all looks promising but will actions follow words? Our message to Assembly Members and others keen to protect people with a serious mental illness and their families is to keep a close eye on the money by...

•Seeking a clear undertaking from the Assembly Government that resources for mental health services will be protected and that this is evidenced by transparent reporting

•Asking Vice Chairs of Local Health Boards (LHBs) – who have a specific brief for mental health – to check and confirm that services for people with mental illness are protected in their area

•Asking LHB Chief Executives and Directors of Finance to demonstrate how spending on mental health services is fully protected

•Checking with LHB Directors of Primary, Community and Mental Health Services that their experience matches what their LHB is saying is being spent on mental health

•Requesting from Local Authority leaders information and evidence of how services for people with a mental illness are being protected.

All this and more including a response from patients can be seen in our briefing here.

It can be an invidious thing to seek protection of one area of public spending over another but I think Hafal is also right within the context of mental health to argue the priority of people with a serious mental illness both on moral grounds (they are among the most vulnerable) and also for the simple reason that their dependence on public sector funding is much greater than other people's and in most respects they have little recourse to other ways to get by.



My post title today comes from Pink Floyd's "Dark Side of the Moon" (1973) which I used to listen to on my cheap Russian record-player when I was incarcerated in boarding school during the mid-seventies. There's a lot about mental illness in the album - the title is a reference to "lunacy" - but nothing all that profound. You can hear the relevant "Money" track here (it's musically distinctive in unusual 7/4 time apart from the guitar solo) and note the famous sound effects but (on reflection at an older age) trite lyrics...

Money, it's a gas
Grab that cash with both hands and make a stash
New car, caviar, four star daydream,
Think I'll buy me a football team

Although maybe there is a little satire in the lines

Don't give me that do goody good bullsh*t...
Share it fairly but don't take a slice of my pie

Water Water Everywhere

Dramatic events at Blog Towers yesterday as first our electricity and then our water supply fails, the latter not a cruel coincidence but a consequence of the resolute leccie contractors from Balfour Beatty digging up the street.

After struggling all day at around five their foreman tells me that they have discovered that the main cable right along fifty yards is a write-off so the whole street needs to come up not just a couple of judicious holes. Wistfully I say that they "obviously won't get that done today" but he looks me coolly in the eye and states unequivocally "Well, we will have to" and, sure enough, after desperate pick-axe and shovel work all evening, at midnight they reconnect and likewise the water people. I hope they were on at least "double-bubble" and maybe a bonus for getting it done quickly (because I'm not paying anyway) as this was heroic work in terrible wind and rain.

It was especially uplifting to see the surgeon-like delicacy with which the electrician stood at the bottom of a muddy hole in heavy rain under a feeble light to connect it all up just before it turned Sunday (perhaps they were strict Sabbatarians? Or did Mrs Blog's judicious distribution of tea - from bottled water heated by gas - play a part?). Meanwhile I spent the evening reading a book, pausing after each chapter to recharge my wind-up torch.

My post title from the Ancient Mariner (Water, water, everywhere,/
Nor any drop to drink) is apposite as we had no tap water in spite of the extensive local flooding. I have previously mentioned the author Samuel Taylor Coleridge's likely bipolar disorder in this post.

Treatment

Because Hafal is managed by people with a serious mental illness and their families (rather than by health care ethicists or hand-wringing Guardian-readers) we have never been very interested in the stale old “medical versus social” argument about mental health care. What our Members are interested in is getting the range of care and treatment they require to achieve recovery.

For people with a serious mental illness that often, but not always, includes medical treatment but (equally) it is folly to imagine that medication will go very far without other areas of treatment and care being systematically addressed.

The new Mental Health Measure itemised the 8 key areas which need to be addressed as follows:

(i)finance and money
(ii)accommodation
(iii)personal care and physical well-being
(iv)education and training
(v)work and occupation
(vi)parenting or caring relationships
(vii)social, cultural or spiritual
(viii)medical and other forms of treatment including psychological interventions

The more alert among you may have noticed that this is one less than the 9 areas identified in the Assembly Government’s Interim Guidance on CPA published previously. This is because two areas have effectively been combined, namely medical treatment and other forms of treatment.

This is more interesting than may first appear so bear with me!

Hafal has always been in favour of separating the two in the context of serious mental health illness because a single heading for treatment can allow a “traditional” professional to tick the box about treatment having actually only considered (and probably prescribed or recommended) a medical treatment. Let’s face it, that’s what normally happens at the moment. By contrast if there is a separate box for other treatments then the professional effectively has to propose other forms of treatment or explain a decision not to suggest a psychological or other therapy. That’s a useful pressure, we think.

However, I understand that in consultation events on the Guidance and the Measure some people thought it gave “too much status” to medical treatment to give it its own box. A well-intentioned point but a tactical mistake because in real life medical treatment is always at least considered for a serious mental illness whereas other treatments are scandalously often scarcely thought about.

Why is this important now? Because shortly the Assembly Government will be consulting on the format for Care and Treatment Plans required under the Measure and we need to ensure that:

Either: there are two separate sections for medical and other treatments

Or: if there is just one section (which is fine) then there is a requirement to record explicitly in that section consideration of both medical and other treatments.

A care and treatment plan for somebody with a serious mental illness can’t be called holistic – or even adequate – if it doesn’t include active consideration of both forms of treatment.

For an overview of treatments see Treatment for Severe Mental Illness - A Practical Guide and to get the broader context of an holistic approach to recovery see My Recovery - a Step-by-Step Plan for People with Serious Mental Illness .

Still 2010

Our first big walk of 2011 ends curiously in 2010, that is in the Gwaun Valley where the people hold to the Julian Calendar and so it won't be New Year until what will be 13 January according to the somewhat more widely accepted Gregorian recalculation. The sense of going backwards is reinforced as I find the walk tough being out of condition after the holiday when I didn't do much exercise.

Whatever the date may be the days are lengthening - I took the photo while driving home just before 5pm today (at Bethesda on the B4313 between Maenclochog and the A40) when it would have been dark a couple of weeks ago. Cause for a little bit of optimism though it is a long, long wait until spring.

Boyle Watch

Comedian Frankie Boyle is getting a reputation for offensive jokes, evidently aiming to become the Bernard Manning of our time. He has targeted disability a lot because there is ambiguity about where the broadcasting "line" lies. His latest wheeze was a sketch making fun of anti-stigma messages put out by Time to Change, the English mental health anti-discrimination project which Hafal and others hope to extend to Wales soon.

The sketch depicts an ordinary-looking man conveying an anti-stigma message but as the camera retreats a number of murdered children come into view, apparently his victims. The offending clip has been put on-line (poor quality and don't look if you might be upset) here and you can see what he is sending up here.

Quite rightly our sister charity Rethink has complained about this but, though unwelcome, Boyle's "joke" is a kind of recognition that the discussion about these issues is becoming mainstream; it also has the merit of being so crass and unfunny that, even if you make allowance for the bad taste, you would have to be a complete klutz to laugh at it.

Where Next for Hafal in 2011?

Happy New Year everybody and welcome back to worky blogging after the holiday fripperies of the last couple of weeks.

Yesterday Hafal’s management team met to look at the year ahead and the picture looks reasonably good notwithstanding the current squeeze. We certainly have several new developments confirmed not least from European funding and our substantial new Haverfordwest housing service is coming on-stream right now.

Meanwhile this is a good moment to remind ourselves what the key issues are for 2011 and beyond. I suggest the big five are as follows ...

(1) The Assembly Election

Hafal has an excellent track record of getting mental health onto politicians’ agendas at election time and we need to repeat that as the May election date draws near. The main lever in this game is to get parties and individual candidates to recognise that there are votes in mental health, in other words many voters will be interested in what they have to say about care and treatment for people with a mental illness because they or their family or friends are personally affected.

The problem is often the extent to which voters are prepared to raise the issues in the first place (because of stigma or lack of confidence in articulating their concern) and that’s where Hafal can help. We will publish not just a manifesto but also guidance for voters on how to raise issues not least covering the four matters listed below ...


(2) Public Expenditure

We are already actively engaged in the issues arising from the current squeeze having welcomed the Assembly Government’s declared commitment to protect mental health services and the priority placed on secondary health services and on protecting social care services for vulnerable people.

All good stuff but what guarantee is there that the NHS Local Health Boards and the Councils will put this into action? Our plan is to look for support from key players including Assembly Members, local councillors, and (importantly) the “insiders” who will want to protect services for which they have responsibility. We are particularly keen to encourage the non-executive Deputy Chairs of the LHBs (who have a brief for mental health services) to take care that LHB Chiefs and Directors of Finance don’t raid funding which should go to mental health.

In the same vein we also need to encourage LHB Directors of Primary, Community, and Mental Health Services to fight their corner on the executive side – specifically to take an active interest in comparing the funding which they actually get for mental health services with the reports submitted back by LHBs to Welsh Assembly Government!


(3) The Mental Health Measure

Although Her Majesty signed the Measure into law late last year some of the biggest battles may still be ahead. We need to ensure that the Regulations and Code of Practice for the Measure are sufficiently prescriptive and clear. We expect consultation on the Regulations to start very shortly and Hafal intends to conduct a vigorous campaign to ensure that the prescribed content for Care and Treatment Plans (to which all secondary patients will have a legal right under Part 2 of the Measure) sets out all the “life areas” which must be addressed holistically. A late opposition amendment did set out the key areas on the face of the Measure but it will be important to ensure that these are explicitly included in the format of the plans rather than just “alluded” to in notes or guidance.


(4) Benefits

For all that mental health patients are concerned about health and social care services it is a simple and unsurprising truth that they are most concerned about benefits. Why? Because though many or most have ambitions to achieve employment and financial independence they need the support of benefits while they work towards recovery – and those in work need the reassurance that they will be supported if they relapse.

Hafal is presently working on its response to the (UK) Government’s current review of DLA – if you’ve got any direct experience you want to share (many have already) then do let us know.


(5) The Future of Mental Health Services in Wales

Just because there is a public expenditure squeeze doesn’t mean we should give up on revolutionising mental health services in Wales – though the squeeze should point us towards a cost-efficient approach obviously.

Hafal’s overwhelming sense is that change is most likely to be achieved through the initiative of patients and their families rolling up their sleeves and taking charge both of their own circumstances and, whenever practicable, of wider services. They could wait forever for the top-down approach to work and there aren’t many signs of that, though consumers should of course engage with and try to get a real dialogue going with the Mental Health Programme Board which the Assembly Government has established - even though it has no executive powers.

Shortly Hafal will announce a new campaign to encourage patients and families to empower themselves using their rights under the Measure and bringing their experience to bear on commissioning and running mental health services. Watch this space!


Keep up to date by regularly visiting Mental Health Wales, Hafal and our excellent Facebook page which is alive with breaking news and snappy pictures, plus this Blog of course.



Postscript: I haven't got any personal New Year Resolutions but got off to a good start on New Year's Day by barbecuing sausages on the beach in West Wittering, Sussex, with old friend and educational consultant Nick Jarman who lives up the road. The view behind is over to Hayling Island, on the route of the British Heart Foundation's annual "Round the Harbours" bike ride - very scenic and includes two ferries (useful respite for those of only "average fitness" on the 35 mile route).