Wednesday 30 November 2011

Justice v Fairness

The preliminary psychiatric assessment of Anders Breivik, the Norwegian who has admitted killing 77 people last July, has been published to mixed reactions. As discussed in a previous post (see here) it is important for mental health service users and their families to consider these events carefully because, like it or not, the British public will draw conclusions from the case about the nature of mental illness and what should be done about it.

Some people in Norway are dismayed that he may not stand trial as he was suffering from paranoid schizophrenia. Others, including some relatives of victims, have made measured comments about it not being so important how the illness is seen legally as it is to ensure that the public is protected from him in future.

The case is perhaps most interesting to us in drawing out statements about the system in the UK and I was particularly struck by the comments from Richard Charlton, chairman of the Mental Health Lawyers Association, which relate to the points I made in my previous post on this. He reports that he has represented people who have killed other people believing they are saving them from the devil, but courts have not found them to be insane.

He explains that if the patient knew that killing was wrong, even if God told them to do it, then that's not enough to give them a defence of insanity although it might be sufficient to give them a diminished responsibility defence (which, as the term implies, still means that the person is held significantly responsible). Insanity requires a higher test, and one example he offers is somebody who throws a baby onto a fire in the belief that the baby was a piece of wood and not a baby.

When you consider this it is actually not a fair test because it can convict a person who acts from good (but deluded) intentions and therefore there but for the grace of God go many decent people who might sadly experience a serious mental illness in the future. A police officer who shoots a suspect who points a replica gun at him properly has a defence even though (i) he was deluded because there was in fact no danger and (ii) he knows that killing people is generally wrong: the point is that the police officer acted with good intentions.

The truth is that, as my late father (a lawyer) told me years ago, the justice system is not really fair at all in spite of the rhetoric of some high-minded lawyers and philosophers. In practice justice is a compromise between fairness and expediency - the latter being based on what politicians believe the public will bear. And politicians don't think that the public will tolerate not holding people responsible for their actions even though in practice they had no control or realistic choice over those actions.

The consequence is that patients are blamed for actions over which they had no control whereas they might have been detained for reasons of public protection but at least meanwhile been allowed to establish their innocence by reason of insanity and thereby gained some compassion from society.

This isn't going to change in a hurry but we must be prepared to engage in thoughtful debate. It may be said that following events like those in Norway isn't the best moment to have that debate but I'm afraid the debate is happening as I write, in the British media and in pubs and clubs up and down the country.

Tuesday 29 November 2011

Tricorn Hats and Bodices

Take a look at Hafal's latest briefing for Assembly Members here which gives a good summary of the key current issues for mental health in Wales, namely...

The Mental Health (Care Coordination and Care and
Treatment Planning) (Wales) Regulations 2011
- more or less a done deal but requiring National Assembly sign-off (due today but delayed as business is disrupted by tomorrow's strike)

The Code of Practice for Parts 2 and 3 of the Measure - currently subject to formal consultation.

The new Mental Health Strategy for Wales - currently being drafted by officials.


My brother Skypes to tell me that the Picton trial (see my last post) featured on telly last night in "Garrow's Law" (I've never seen it but apparently it's a sort of low-rent legal version of Tom Jones - all tricorn hats and bodices) but they got the century wrong and, more disturbingly, the result, oddly neglecting to report the retrial where he got off! Artistic licence is one thing but if you are purporting to reflect real events this is rather misleading - and a reminder to trust reliable sources like this Blog rather than the BBC. Anyway here he is dying at Waterloo...

Monday 28 November 2011

Brutish and Uncompromising

A relaxing weekend catching up with the world beyond Hafal. I have previously commented on the phenomenon of people objecting to the celebration of historical characters because they are found to be wanting by modern standards (see here). The latest manifestation of this is a campaign to remove a portrait of Waterloo hero Sir Thomas Picton from the courtroom in Carmarthen on the grounds that he was prosecuted for torture when he was governor of Trinidad.

Actually he was found not guilty (so you'd think that the lawyers objecting to the picture might respect that verdict?) but in truth attempting to defend Picton on any test of modern moral scruples is a completely hopeless proposition. He was a brutish and uncompromising soldier who would have snorted with derision at this spat.

But the most interesting thing about the Picton trial was that it took place at all. Contrary to many modern assumptions the rule of law did matter then (1808) and it could be used to protect the most humble people from oppression by the most powerful. In this case Picton was prosecuted for allowing the torture of a young mulatto girl suspected of theft who was made to stand on one toe for up to an hour on two occasions - certainly a nasty experience but small potatoes compared with practices found to have been used in our name in recent conflicts. He only got off on appeal because he persuaded the court that Spanish law (which permitted all kinds of excesses) applied on the island as British law hadn't yet been formally adopted - a neat lawyerly defence.

It is commonplace to sneer at our predecessors for barbarism and injustice but can you imagine today's senior British military commanders being seriously held to account for mistreatment of suspects abroad which falls short of death or even injury? In fact little has been done about much worse behaviour, a measure of our moral degradation and disrespect for people of other cultures.

Tuesday 22 November 2011

Landmark Moment

Time to reflect on the great news that mental health service users in Wales have won the legal right to holistic care plans. Years of campaigning by service users and carers have resulted in new Regulations which give patients in Wales the right to a Care and Treatment Plan covering all areas of life.

The new rights to holistic care planning have been set out in the Regulations for the Mental Health (Wales) Measure which were laid before the Assembly two weeks ago. The Regulations, which cover Care Coordination and Care and Treatment Planning, set out what professionals must do in order to deliver the new Welsh mental health law which comes into effect in 2012. The Regulations are now subject to the approval of the National Assembly on 29th November.

As Dave Smith, Hafal's Expert Patient Trainer, explains:

"The Regulations prescribe a comprehensive Care and Treatment Plan which covers eight areas of life, and they are accompanied by a template which clearly provides a space to address each of these important aspects of recovery in a holistic way.

"This has the potential to transform the service provided to people with a serious mental illness in Wales. It means that all secondary mental health service users will have a legal right to a Plan with spaces for all areas of life to be addressed ensuring that important issues such as accommodation, employment and physical health are covered in their Plans.

"Hafal Members have campaigned for years for the legal right to a comprehensive Plan so to have such a Plan prescribed in law is a massive victory. It’s truly a landmark moment for service users in Wales."

A reminder of the eight "life areas" to be covered in Care and Treatment Plans...

a) accommodation

b) education and training

c) finance and money

d) medical and other forms of treatment, including psychological interventions

e) parenting or caring relationships

f) personal care and physical well-being

g) social, cultural or spiritual

h) work and occupation.

Hafal’s Members pioneered this methodical, holistic approach to recovery from serious mental illness which was based on the experiences of hundreds of people and we published our methodology six years ago. This holistic approach was then rolled out through Hafal’s projects across Wales, resulting in remarkable recovery successes for Hafal’s clients.

Following the organisation’s adoption of the recovery model Hafal’s Members continued to campaign for the adoption of this model across Wales for all secondary mental health service users, and successfully lobbied for the creation of a mental health law in Wales.

The Assembly Member who initiated the new mental health legislation, Jonathan Morgan, said that the most convincing evidence for reform came from listening to the story of service user and Hafal Recovery Practitioner Lee McCabe. More recently, speaking about the Regulations, Lee commented:

"When the Regulations were published in draft it wasn’t made clear that the Care and Treatment Plan would need to include space to address all the eight life areas. Hafal launched a massive user-led campaign which was supported by hundreds of service users and carers across Wales to ensure that the eight areas are clearly given space in the Plans. We are very pleased the Government has listened to our standpoint and amended the Regulations to give proper prominence to the eight life areas."

It is to the credit of the Welsh Government that they listened to Hafal’s Members when we called for a Welsh law and latterly that they took on board the need to include the eight life areas explicitly in Care and Treatment Plans.

The next step is to achieve a robust Code of Practice which prescribes in more detail how health professionals will deliver the Measure; the first draft was published last month and service users feel that it needs to be improved to ensure that the eight areas of the Care and Treatment Plan are routinely addressed, that psychological therapy options are always covered, and that there are clear timescales for agreeing Care Plans.

Of course when the Measure comes into effect in June 2012 it doesn’t mean that it will solve all problems and guarantee a good service. But for the first time it will provide a solid platform of care planning so that people’s needs will be properly assessed and recorded and the required actions agreed with them. From this basis we can build great mental health services and help more people achieve recovery and become fully engaged in society, be economically active, and lead rewarding lives.

Saturday 19 November 2011


I am enjoying a long weekend looking after my brother's livestock out west and taking the opportunity to check out places of interest which I haven't seen before.

Today we head off to Cilgerran Castle en route to Cardigan market. Best known for its scenic position it's fairly run of the mill as castles go but famous for a notorious Christmas party in 1109 which got seriously out of hand when Nest, daughter of Rhys the last king of Deheubarth and wife of a Norman carpet-bagger called Gerald de Windsor, got carried off by local bad boy Owain ap Cadwgan. Or was she seduced and went willingly? Or was it a secret Welsh plot to get her away from her in-laws and start some trouble?

The arguments still rage in obscure Mediaevalist circles but I would just make the observation that Nest seems to have been the ancestress of a sizeable proportion of both the Welsh and Norman aristocracy having put herself about - or been put about, let's stay neutral on this - with everybody from Henry I downwards (the king's son by Nest was Henry Fitzroy or Fitzhenry). What everybody seems to agree is that she must have been the greatest beauty of her era, a veritable Welsh Helen of Troy - shame there are no pictures.

By way of contrast I take a look at the little-known church of Bayvil just a mile east of Nevern church which is itself famous for its Celtic Cross, bleeding yew, Ogham inscriptions, etc. In fact I suspect that Nevern's fame may account for Bayvil's uniqueness as a perfect example of a late Georgian church unnoticed and so unruffled by Victorian meddlers who probably thought it too new and too boring to spruce up and so concentrated on its glamorous neighbour.

As you can see from my picture it is ultra-simple, in-your-face low-church, and dominated by a pulpit which allows the preacher to lean right over his flock and inculcate the Word without any idolatrous distractions. The only symbol in view (and it isn't really a symbol at all but clearly symbolic) is the vast bier for bearing the coffins of deceased parishioners which is stored in full view below the pulpit - an entirely practical arrangement (where else could it go?) but no fancy icon, painting, or statuary could provide a starker memento mori to any member of the congregation whose thoughts might otherwise wander (Lord preserve us!) into a day-dream about the deeds of Princess Nest...

Tuesday 15 November 2011

Shifty-Looking Rogue

I'm catching up with the pictures from our record-breaking conference last week which saw over 200 eager participants making their way to Builth Wells from all parts of Wales - and they definitely had a good time as we score nine out of ten in the evaluation, also I think a record although we do get consistently good marks for our events thanks to the tireless effort of the organisers and a lot of care taken on the day with our guests who include many very vulnerable people for whom the day is quite a challenge. It was great to see a lot of new faces from new services which we have developed since last year in the teeth of the financial squeeze.

The most popular side-show of the day was the paint job on our life-size model VW camper (the real thing was just outside though represented indoors by our surreal camper tent visible in the picture above).

There is some discussion about the identity of the driver painted in the left-hand seat (correctly - it is left-hand drive), a shifty-looking, crop-haired rogue in a Hafal tee-shirt peering over Tesco Value glasses. Later in the day someone adds a halo which is confusing.

As last year the most stressful part of my day was not Hafal's AGM which passes off in swift good order but the "Camper Cookery Master Class" in which I pretend to prepare a three course meal while our bomb-proof Company Sec Nicola Thomas does the real work, impressively managing not to get food on her posh red sari.

This year we knock out smoked mackerel paté, pitta pockets with griddled beef and mixed vegetables plus couscous, and fresh pineapple with cream and a cherry highlight.

It's all going quite well until I attack the pineapple with a knife and, regretting my failure to practise beforehand, I slash aimlessly at the fruit and in the panic my specs fall off into the sticky juice (luckily they are just Tesco Value ones - a snip at £10 including prescription lenses).

Tuesday 8 November 2011

All Aboard!

I'm looking forward to Hafal's "All Aboard!" Autumn Rally in Builth Wells this Thursday which is set to break all records with a massive attendance. Hafal Events Coordinator Emma Billings tells me:

"Two hundred delegates have already booked to attend the Rally and the aim is both to offer an opportunity to network and also to explore the challenges faced by people recovering from serious mental illness. This will be a lively event, with different areas for those attending to visit and enjoy throughout the day."

Highlights include:

• "Taking the Wheel" - celebrating the success of the 2011 campaign run by service users with support from Hafal, the Mental Health Foundation and MDF the Bipolar Organisation Cymru.

• The Exhibition Station - an interactive exhibition showcasing Hafal's work across the 22 counties of Wales.

• The Learning Centre - opportunities to meet our team of Expert Patient Trainers, talk to colleagues from Wales' new National Centre for Mental Health and Bipolar Disorder Research Network, get advice and guidance about IT, learning, employment, housing issues and criminal justice, and pick up a range of new publications, FREE of charge.

• Art Corner - getting creative and helping us give our giant model VW camper a paint job!

Emma adds:

"We will also hold our annual meeting specifically for users, as well as an important meeting of the All-Wales Mental Health Carers' Forum - which offers visitors a special opportunity to network with families from across Wales."

As usual I have been unnecessarily poking my nose into the preparations but must resolve to back off and leave it to Emma and her many assistants.

Sunday 6 November 2011


A weekend of sunshine lets me get the bike out for a spin around the Swansea corniche followed by lunch al fresco in the marina - it could easily be Biarritz except I make do with a bacon bap instead of a plateau de fruits de mer and a pot of tea rather than a crisp sauvignon blanc. Not that much like Biarritz then.

Later, on a walk back inland, I discover a curious fungus (not edible) on a dead tree which appears to offer stereo sound (picture below).

Meanwhile in the long evenings since the hour change I've been reading Claire Tomalin's Thomas Hardy The Time-Torn Man. I recommend it as she makes the old melancholic come alive and doesn't bore on with too much literary criticism like so many biographies of writers.

I like Hardy's poetry best and struggle with his novels ever since reading the Woodlanders which starts with 40 pages describing how to whittle sticks in order to make hurdles (whatever they may be). I think the idea was to convey the tedious monotony of country life for the poor and in that it certainly succeeded but at some risk to the reader's patience.

I was reading how Hardy twice interviewed veterans of Waterloo in preparation for a project (the unreadable Dynasts epic) when by chance I heard on the radio that an actress called Norrie Woodhall who knew Hardy well has just died aged 104. It is surprising how closely linked we are to events which otherwise seem distantly historical. Sometimes these links matter, for example in the case of Marshal Pétain who infamously persuaded France to surrender and collaborate with Hitler: as a child he had been enthralled by the stories of an ancient uncle who had also fought at Waterloo (in 1815 for heaven's sake!) and taught him to hate the British...

Business Everywhere

Apologies for the the long gap between posts. I was in North Wales for the latter half of last week and the Orange "Business Everywhere" plug-in stick didn't live up to its name meaningfully in room 207 of the Colwyn Bay Travelodge. I did try but felt like the telegraph officer on the Titanic attempting to transmit letter by letter with a desperately slow connection (well I suppose he was more anxious than I was).

Anyway, the important news is that Lee McCabe has now published his campaign on the Code of Practice for Parts 2 & 3 of the Mental Health Measure. This sounds boring and technical but don't stop reading! Honestly, this Code sets out in practical terms how Care and Treatment Plans must be developed for all users of secondary mental health service. It may therefore be even more important than the new Mental Health Strategy currently being written.

One of the three issues that Lee raises is about timescales, both:

● from referral by a GP for assessment for secondary mental health services
to that assessment being carried out; and

● from assessment as a "relevant patient” (needing secondary mental
health services) to the completion of the required Care and Treatment Plan.

There is guidance on assessment timescales under part 8.9 of the draft Code
but this relates to Part 3 (which concerns former users of secondary mental
health services) and it is not mentioned in relation to Part 2 (which concerns
care planning).

The timescale for getting assessments done needs to follow the Welsh Government's own timescales for assessment set out in its interim community mental health team guidance which says that:

- Emergency referrals will be seen within 1-4 hours;
- Urgent referrals will be seen within 48 hours;
- Routine referrals will be seen within a maximum of 4 weeks, but usually much sooner.

And there should be clear deadlines for the creation of Care and Treatment Plans following assessment as a “relevant patient”. Lee suggests:

- Plans must be created a maximum of 6 weeks from assessment under most circumstances
- Plans must be created a maximum of 12 weeks from assessment even in the most exceptional circumstances.

To read all Lee's points, and for links to the draft Code and other key documents, follow this link. You can also find there a link to Hafal's own draft response to the consultation - we are trying something new by showing our work in progress and you are welcome to contribute.

Lee's position already has the support of the Mental Health Foundation and MDF the Bipolar Organisation as well as Hafal so we are confident that this campaign has legs and we can achieve vital improvements to the Code.