Big Friendly Village

Another active weekend in the teeth of wet weather, the highlight being a walk on the coast path near Llanelli. The tide is in and occasional sunlight breaks through to create a silvery shimmer which needless to say my photos fail to capture.

The centre of Llanelli is mainly covered in scaffolding as an EU-funded facelift gets underway. I'll reserve judgement until I see the result. I have wondered whether the vast expense of renovating Llanelly House, former home of local crachach the Vaughans and latterly Stepneys, is worthwhile - the building was abandoned as a town house for the gentry in about 1800 and used for business and suchlike since - but the die is cast and we should find out next year.

This unique Welsh community, where the same industrial and non-conformist character which once made it modern and progressive now makes it appear very old-fashioned, does not conform to the characterless and impersonal uniformity of modern urban environments (well, outside the central pedestrian shopping area anyway) either in appearance or, more importantly, in its social atmosphere which remains like that of a big friendly village.

Meanwhile the Coast Path Visitor Centre stands out improbably as a bold bit of modernism...

Inexplicable

Swansea City Premiership celebs Gerhard Tremell and Vangellis Moras visited Hafal’s Ammanford Resource Centre this week and had an in-depth discussion with service users which touched on the parallels between recovering from a serious physical injury and a serious mental illness .

The event was a great success: Huw Lake (Player Liaison Officer), players and service users also discussed issues including social isolation, positive mental attitudes in competitive sport and recovery from serious mental illness.

One other topic was the stress of working in a competitive environment, something a professional footballer isn't really going to be able to avoid but it will get a lot worse later in the season as the titanic struggle to escape demotion comes to a head. Jack Army stalwart and Hafal Deputy Chief Exec Alun Thomas thinks they stand some chance as their home goal remains watertight...so far.

I'm strictly neutral as there are a number of Cardiff supporters among us - both clients and staff - who inexplicably failed to join in the celebrations when their neighbours down west went up.

Keith Wins Oscar

Keith Jones (centre) with fellow award winners and BBC Wales Today presenter Lucy Owen (far left) and Health and Social Services Minister Lesley Griffiths AM (second left)

Congratulations to Hafal's Keith Jones who has won a Gold award at the prestigious Wales Care Awards 2011 - the "Oscars" of the caring world.

Keith, a widely-respected Practice Leader based in Bridgend, was presented with the "Promoting Fulfilled Lives" Award at a ceremony attended by Health and Social Services Minister Lesley Griffiths AM at City Hall, Cardiff on October 21st.

Keith was nominated for the award by a service user who has since moved from Hafal's halfway house in Bridgend to his own accommodation and said: "Everybody who has worked here and has lived here has enjoyed his company. He is fun to be with and is friendly and understanding." And Keith's colleagues, who are delighted at this richly-deserved recognition, all echo that view.

Keith, a native of Pyle, Bridgend, worked as a taxi driver for six years but an interest in the caring profession saw him switch to work with adults with learning disabilities and latterly with people recovering from serious mental illness. Keith says he derives great satisfaction from seeing service users achieve their goals.

Cool threads too, Keith...

Blitz

Trying to catch up with a minimum level of fitness I do a gruelling gym yesterday and a couple of long walks today. The autumn has set in properly - the devil has p*ssed on the blackberries (as country folk charmingly put it) so Mrs Blog has moved on to collecting chestnuts, her only serious competitors being the local Chinese community (well, one family actually) so there is plenty to go around.

Of course there's nothing better than just roasting them on the fire but if you want to keep them pop them in boiling water for five minutes and the skin can then be cut away easily and you can freeze the edible insides - quite a valuable crop. Ours is being saved to stuff the Christmas bird and some other delicacies.

This is also the time for pumpkins which are fun for Halloween but should also be used to make this fabulously creamy and yet not at all unhealthy soup...

Toss 2 lbs pumpkin flesh (cut into chunks)and 6 whole unpeeled garlic cloves in some olive oil then roast at 400F for half an hour. Meanwhile finely chop two onions and 2 celery sticks and fry in the bottom of a large saucepan in some more oil. Add 2 1/2 pints of good chicken stock (best you can manage - the quality will depend on this), 2 oz rice, plus the pumpkin and garlic (remove the skin first); simmer for 15 minutes then blitz in a processor (or whatever you use) until creamy. Season well and reheat to serve with some parsley on top.

You can add a bit of cream when you serve to fancy it up but there's really no need. If you don't like garlic or you are vegetarian best find another recipe - you'll need some other flavours and there are plenty of variants on-line although they won't be as good as this one.



Postscript:

So the French put up a good fight but went down to the favourites. What might have been if we had made the final as justice demanded! Ho hum.

Allez Les Blancs?

So Wales came fourth let down again by their kicking. Attention turns to the final and I'm coming out for France which I know is not the done thing around here. But they have sportingly agreed to wear white whereas they could have made the All Blacks change. Julien Bonnaire says they should have stuck to their rights especially since the NZ media is full of stuff about Gallic naughtiness like eye-gouging. As if his consummately sporting nation would ever stoop so low.

In the end you've got to support this mutinous, shabby and chaotic outfit because it would be so remarkable for them to whip their confident hosts. But I'm not holding my breath.

And Another Thing

Since my last post Hafal's policy expert Peter Martin (pictured above with Darren Millar AM last week) has read the draft Code of Practice more carefully than me and points to the absence of clear timescales for the critical periods (i) between referral and assessment and (ii) between assessment and completion of a Care and Treatment Plan.

Of course we all recognise that there needs to be some flexibility for different circumstances but words like "timely" and "appropriate" aren't good enough: we need a specified range of times including a maximum time only to be exceeded in the most exceptional circumstances.

A particular concern, especially of some carers for obvious reasons, is the problem of creating Care Plans for people who refuse to engage with services - often because they do not accept that they have an illness. These patients can be floridly psychotic and very vulnerable but Hafal staff have lost count of the number of times we have been told that "he/she obviously can't have a care plan because they won't cooperate".

This is entirely wrong. It is difficult to develop a plan in these circumstances but much can be put in place through engaging with carers and others in touch with the patient including their GP. At the very least the Plan needs to include contact with the family to help them support the patient and scheduled checks on the patient's health and safety and attempts to encourage the patient to engage; and some imaginative ways of getting help to patients should be considered, for example through oblique offers of help concerning physical health, housing, etc which the patient may accept (and of course holistic care planning particularly supports this approach).

The Code does address this issue but it also needs to give specific guidance on timescales in relation to these patients, in particular prescribing the necessity to develop a Plan more urgently for them. Otherwise, believe me, development of Care Plans will be delayed on the excuse that the patient would not cooperate.

This is a delicate area but there is no room for political correctness here. It is folly to delay formal care planning because you are waiting for the patient to "come around to it" - the Plan must be created quickly even if the patient isn't cooperating and it can subsequently be reviewed and improved cooperatively just as soon as the patient chooses to engage - which the Code does point out.

Talk of the Devil

As fast as I pressed the button to publish yesterday's blog we received the draft Code of Practice that I was talking about (follow this link). A quick read suggests that the Government has done a good job on most of this, including welcome detail on the 8 "life areas" and clarity about these being systematically considered in assessments of need. Two bits in particular need improvement I think...

(1) The guidance as drafted on completing a client's Care and Treatment Plan would lead some practitioners to believe that in many cases it would be sufficient to address just two or three of the "life areas" in the Plan. In fact clients need a plan for all the life areas (except, in some cases, clients' parenting or caring responsibilities). That is not to say that mental health services have to take action in all the areas - in many cases other agencies will be involved or indeed the clients may address areas of their Plan by themselves.

One example: if a client is comfortable that they can manage their own housing needs that does not mean the "Accommodation" life area should be left out of the Plan - because the client definitely needs a plan for where they are going to live in the coming months! Rather there should be a simple statement such as "x lives in a Housing Association flat and is confident that he/she can manage rent and services payments, general maintenance of the flat, and relationships with their landlord without support but will contact the Care Coordinator if problems arise". Job done.

A statement of this sort ensures that the "life area" is covered, recognises the responsibility of the client (which is appropriate and in itself therapeutic), and incidentally covers the practitioner very effectively if problems should arise.

By contrast if there is no mention of accommodation in the Plan it will be unclear whether this means (i) there is in fact no action required by mental health services or (ii) another agency's help is needed or (iii) indeed the client can manage for them self or (iv) the matter has just been overlooked or gone unrecorded. This is deeply unsatisfactory and unsafe considering a few words could have transparently cleared the matter up for everybody's benefit.

(2) The advice on the treatments for mental illness "life area" does not specify that both medical and other treatments (including psychological treatments) should be covered in the Plan. Otherwise, frankly, the common practice of not even considering non-medical treatments will persist for many or most clients.

If indeed either medical or non-medical treatments are not appropriate it would be good to read in the Plan words such as "It is agreed that psychological therapies are not appropriate at present". I know it can be argued that this will have been covered at the assessment stage but in practice it is vital to have this clarified in black and white in the ongoing Plan, not least so that at review the matter will be reconsidered.

Hafal's view originally was that there should be quite separate consideration of the two sorts of treatment in Plans rather than dealing with them together. Apparently the amalgamation came as a result of well-meaning people not wanting to dignify medical treatment too much as a distinct area. Understandable perhaps but in practice we risk losing due cosideration of non-medical treatments unless this matter is very clearly addressed in the Code.



I hope the Government, which should take great credit for painstakingly bringing forward this radical and ground-breaking legislation, will go the extra mile and improve the Code in order to prescribe without ambiguity a truly holistic approach to mental health which embraces the responsibilities of patients as well as of professionals and modern talking therapies as well as medicine.

Anyway, enough from me. I'm delighted to report that Lee McCabe, veteran campaigner for the Measure (indeed he's actually the person who instigated it as acknowledged by Jonathan Morgan, the former AM who got the ball rolling with the LCO) has agreed to dust off his armour like Cincinnatus and take the lead in a public campaign on the Code - watch this space...

Here's Lee chatting to the Minister last week: apparently she suggested he puts his role in initiating the Measure in his CV - good advice!

Another Day Another Dollar

Well, I'm back from my holiday and attuning myself again to the world of work. It feels a long time until next summer as I'm swimming outside in the dark each morning (in the heated pool at my gym I hasten to say) until the hour change at the end of the month - but there's no escape as that will herald travelling home in the dark for the next few months.

It's not really natural to spend all the daylight hours indoors but (on the bright side) working outside isn't much fun in the winter and I suppose it's better than working down a mine where, if you had a day shift, you might not even see daylight for days at a time.

This seems like a good moment for taking stock of what we've achieved this summer. The "Taking the Wheel" campaign has really caught everybody's imagination. In particular our messages about putting patients at the heart of services - for real I mean, not just as a stale old mantra - have really landed and I have some optimism that the Government's new Mental Health Strategy will be built on the individual Care and Treatment Plans at the core of the Measure which Hafal Members instigated several years ago. Those Plans will need to focus systematically on the eight holistic "life areas" which Hafal pioneered and which are included within the law itself.

Of course there is more to do. the Regulations for the Measure will be published shortly as will the draft Code of Practice - we need to ensure that the Code is at least as clear and prescriptive as the Government's Interim Guidance on CPA currently in force - so make sure you get to one of the consultation events (details available from Hafal if you haven't got them).

See our report from "Taking the Wheel" here.

An Echo of 1980

Oh dear, oh dear, oh dear what a travesty! And am I alone in detecting an echo of 1980 in today's game? Back then England beat Wales 9 - 8 against the tide of history following the controversial sending off early in the game of my hero and fellow-flanker Paul Ringer, one of the seriously hard men of Welsh rugby - that's putting it politely and I don't suppose Sam Warburton would take too kindly to being compared with this legendary tough.

Like today on that occasion Wales won on tries (2 - 0 in fact - only four for a try in those days) in a game that was dubbed the "Battle of Twickenham" because of the brutal aggression shown by the Welsh from the start. Indeed the sending off was a case of making an example following a lot of fierce play, something which today's ref could not point to.

I was at university (in England) at the time and watched the game at a friend's house with a crowd of England supporters who became prissy and self-righteous about the uncompromising Welsh tactics and I took a lot of stick naturally when England kicked their winning penalty in the closing seconds.

I've still got my "Paul Ringer is innocent" T-shirt somewhere.

Savages

I lived in Haverfordwest for a few months many years ago but until today I had never visited St Mary’s Church. It’s not much to look at having lost its steeple 200 years ago and it’s boxed in by 18C development - though that is not so objectionable compared with the criminal damage committed by 20C planners on the lower end of the town (it was here that I first observed the phenomenon of local government colluding with greedy local businesses to suppress the flexible, transitory and seasonal local economy which market towns had previously offered, not least through low-rent market stalls).

Inside the church looks a mess too, littered with memorials of the Philipps family, the local big-wigs from Picton Castle. But if you squint and abandon close focus you can see a nice 13C church combining solid local craftsmanship with some French frills, notably the finely carved arches in the nave. The roof is Tudor – spot the giveaway roses.

Dominant minorities often mock the majority which surrounds them out of nervousness of dissent and rebellion. The English-Flemish colony here was no exception and used the opportunity of building the church to take a pop at the savages eyeing them
resentfully from north of the Landsker. There are amusing satirical carvings of their neighbours in the form of a monkey playing the Welsh harp, a pig playing a Welsh fiddle, and a carousing Welsh hooligan brandishing a very modern-looking pint tankard.

I should also mention the memorial to Sir John Pryce who kept the embalmed bodies of his first two wives in his bed, unable to sleep without their comforting presence. His third wife most unreasonably put her foot down and made him shift them out.

An Excellent Metaphor

I'm on holiday so catching up with events in the world of Hafal. Delighted to see the pictures from the Senedd yesterday where our report from the "Taking the Wheel" campaign was launched in the Oriel Gallery by Health and Social Services Minister Lesley Griffiths AM.

The What Users Want! report provides feedback on the popular, client-led campaign which Hafal has been supporting in partnership with MDF the Bipolar Organisation Cymru and the Mental Health Foundation. The campaign empowered mental health service users to take control of their lives and the services they receive.

Backing the campaign's objectives the Minister said: "Taking the Wheel acts as an excellent metaphor for the recovery approach in mental health - something which I strongly support - where people, working with professionals, can take control and drive improvements to benefit their mental health, and be directly involved in their care and treatment.

"This is in line with our commitment to use the legislative powers of the Mental Health Measure. From next year, this will mean mental health support services will be available within primary care in all local authority areas, and service users will benefit from integrated and individual care and treatment plans."

The campaign encouraged people receiving secondary mental health services (or those who have serious mental illnesses such as schizophrenia, bipolar disorder and other diagnoses which typically require high levels of care) to take the driving seat in managing their own recovery from serious mental illness.

The clear message emerging from the campaign is that service users want help across a wide range of Care Planning areas. Significantly, service users view the Care and Treatment Plan as the means of ensuring that mental health services are shaped by patients' needs.

Hafal Expert Patient Trainer Dave Smith explained: "I've spoken to a lot of fellow service users during the campaign and the consensus is that we don't expect vast new resources for mental health services. We know that this isn't going to happen anyway. But we do want client-centred services. And we're agreed that this can be can be done concretely by using Part 2 of the Measure which concerns care planning.

"Service users want individual Care and Treatment Plans but it's not good enough to make these Plans fit the services available. Services should be based on what's in the Plans, not the other way round. And there should be enough flexibility in the provision of services so that they can meet every individual's needs."

Quite so, Dave, and roll on 2012 when the Measure comes into force and we can help all users of secondary mental health services and their families to take control.

To read "What Users Want!" go here; to listen to the Minister's speech go here.

Episcopal Purple

Hafal's employment lead in South Wales Andrew Mulholland's 80 to 1 bet on Wales to win the Rugby World Cup looked even less unwise at the crack of dawn on Saturday as we saw off the rampant Irish and proceed to the semis next week against an inconsistent French side. Maybe it's evens to win that one and 5 to 1 to win the final against New Zealand (or conceivably Australia) which means 10 to 1 are the current odds - so Andrew should only contemplate selling his slip today for 8 times what he paid for it but I'm sure he won't.

After the match I set off to fish but the met office "computer says no" and my only catch is a set of autumnal pictures. See above what is usually a good mark for pollack and wrasse but today would be a death-trap for shore anglers as 20 foot waves crash over the rocks, though I notice that the shags, which on a calm day dry themselves on the island opposite, calmly continue to fish in the boiling seas.

The picture below shows the amazing coloured rocks in a beach cave at low tide. If you are familiar with St David's Cathedral you will recognise the two shades of episcopal purple sandstone which was quarried here and dragged a mile north to the building site nearly 900 years ago.

Quadrille

Interesting report here on the Hafal young people's web-site about a discussion between our Young People's Information Hub lead John Gilheany and the Health Minister. I won't repeat the whole thing (go look!) but I admire her straightforward honesty about how young people can behave. And I mean as we behaved as young people too - this is not one of those fogyish "These young people today!" remarks. She said "If we can educate our young people who tend to be a bit crueller when they're faced with someone a little bit different, that will really help".

Of course young people can be as compassionate as anybody else but I think the Minister is alluding to that phenomenon of children following the herd. Even the nice kids get caught up in the cruelty. Unless you were very brave I suspect that like me you will remember joining in a group to tease a victim towards whom you would have been sympathetic one-to-one.

Adults too can be hostile to difference even when it is completely harmless. I'm reminded of Edward Lear's curious limerick...

There was an Old Man of Whitehaven,
Who danced a quadrille with a raven;
But they said, 'It's absurd
To encourage this bird!'
So they smashed that Old Man of Whitehaven.

The last line is startling as it seems such an over-reaction. But Lear was a thoughtful man and this poem illustrates the deep-seated resentment people have towards eccentric behaviour - it's almost as though they feel they are being made a fool of and this is subtly, I think, at the root of some of the hostility towards people with a mental illness: at some subconscious level people think that the person behaving oddly because of their mental illness is actually mocking them.

Not So Boring

Stifling a yawn or two I've been dutifully reading the Welsh Government's "Programme for Government 2011 - 2016" which includes some useful and some more woolly commitments about mental health - a useful commitment to individual care planning but a woolly promise to "review" access to talking treatments. See the details here.

You can detect the First Minister's own hand on the approach they are taking which is to emphasise delivery rather than reform in public services and specifically to concentrate on things which citizens actually notice as changing for the better in their individual lives. All Carwyn's recent rhetoric has been about this.

You could be cynical and wonder if this is a sign of an administration bereft of big ideas or the "vision thing" - or else you might wonder what previous governments were doing if it wasn't improving individual lives! But Carwyn is a canny fellow and probably realises that the public are a bit fed up with big ideas and looking for a spell of boring but functional government while we creep along in these dire economic times. Anyway they just can't afford to do much new and interesting.

Looking at this positively I think we should work on (and with) the Government's instincts about the way ahead and show them simple, cost-effective things they could do to improve the lives of people with a mental illness and their families.

Here's one example which a patient who was concerned about losing contact with families gave us: "In-patients should have video contact with their homes – available via IT systems such as Skype". Good plan - it would cost peanuts compared with the eyewatering cost of in-patient care and surely save money (even short-term) by promoting recovery (and earlier discharge) for people in hospital through the comfort of sustained contact with loved ones.

Lots of practical ideas like that could add up to making a really big difference in mental health services - not so boring after all?

Baroque

Back for a moment to my piece on Don Giovanni (see here).

My nephew Richard who lives in Spain writes that the fate of Don Juan in literature ("Don Giovanni" is the Italian for this originally Spanish character) has varied according to the state of play in religion and politics...

"El Burlador de Sevilla y el Convidado de Piedra" (the Trickster of Seville and the Stone Guest) was written in 1616 during the Spanish Baroque period by Tirso de Molina, a Roman Catholic monk and the founder of this literary device. In his story Don Juan doesn't change, is unrepentant and bound to his worldly desires and so is punished with damnation. The ideas of the Renaissance have failed and people look for escape in the heavens. It is a time of great stoicism. The play is an inspiration to aim for the higher spheres.

By contrast in "Don Juan Tenorio" written by José Zorrilla in 1844 during the Romantic period the story is the same but with the twist that Don Juan is repentant and in the nick of time he is saved by the love of Inés the nun. This is a post-Enlightenment play: man is inherently good; the religious themes are from Zorrilla’s upbringing as a modern Catholic.

Incidentally Richard tells me that the latter play is performed all over Spain every year on All Saints Day because of its ghostly theme.

Perhaps all this adds credence to the view that it was odd for Mozart to go for the damnation option but of course he did predate Zorrilla so it may simply not have occurred to him to look for a happy ending. And as an Enlightenment man he just wouldn't have taken hell-fire seriously (so he isn't really in the Tirso camp even though he's faithful to that plot) whereas the Romantics might have found it disturbing?

Glad we've cleared that up.

Excellent

Good to see that the BBC has published John Williams' excellent photo of the Towy Valley taken from Dryslwyn Castle (see above and online here). John has only recently taken up this hobby attending digital photography sessions at Hafal's Ammanford Resource Centre on Saturdays. The sessions are ably managed by Rosemary Andrews who has a background in professional photography though her present "day job" is the very important one of paying expenses to Hafal's clients and staff among other vital tasks.

I know exactly where John's picture was taken - you can see me standing a few yards away here!

Never Say Never Again

A surreal weekend which seemed to last a long time in spite of being good fun - a rare combination. The record-breaking weather inspires a final flurry of summer (summer?) activity. On Saturday I ascend into the foothills of the Black Mountain, that bleak and unnoticed western portion of the Brecon Beacons National Park, to swim in the upper reaches of the Usk - about a mile below the source and 55 miles above its muddy end in Newport.

Thirty years ago I camped illicitly with college friends at this pool and in the morning was confronted by an irate official in a silly uniform reminiscent of the Park Warden whom Yogi Bear routinely outsmarts in Jellystone National Park. But this jobsworth was not outsmarted because he asked who was in charge and an idiot friend gave him my real name (instead of "Ludwig Wittgenstein" as we usually said when cornered by the authorities - I recall on another reprehensible occasion finding it difficult to keep a straight face when asked to spell it by a different kind of uniformed official with notebook in hand - and now you know why I'm against bringing in national identity cards) so I spent a nervous few days awaiting some kind of oppressive contact from the law - none came of course. I think today I would be more resilient and defensive: I'm not sure I could anyway take seriously anybody telling me I couldn't camp out in the wilds (quite the rebel, eh?).

On Sunday I'm swimming again, this time in the sea next to County Hall in Swansea. High tide is at 10.20 am and the water is already comfortably warm. You really have to take every chance you get - we didn't get much luck in August so swimming in October is an unexpected gift. I guess this will be the last opportunity this year but you never know...