Pass the Donkey - Part 3

"46 year old female, suicidal"

Continued.....

Writing this blog has been a very interesting and worthwhile project, and one I thought I had finished! However, the power and interaction that social media (namely Twitter) brings is debate and opinions from many areas. On this particular job I only sourced opinions from the people and services directly involved on the night; ambulance, police, hospital and of course the patient. What was highlighted was that this job was a 'symptom of a fragmented system'; a system we are all aware of and often vent frustrations against. It was suggested by a number of people that it would be interesting to hear from an AMHP, community MH services or someone with experience in the treatment of mental health. So I did!

Jakki Cowley (@jakkicowley) used to be a practicing mental health and mental capacity advocate. She now has a national role promoting and developing best practice guidance on both Acts (the Mental Health Act & Mental Capacity Act) for advocates and other professionals. With experience in the two key aspects of this job, mental health and mental capacity, I asked her what her thoughts on the job were and what solutions or lessons could be learnt in the future:

"My experience comes from many years working as an advocate, in mental health, learning disability, forensic and acute settings and eventually as a mental capacity advocate.  I now lead on mental health and mental capacity advocacy in terms of promoting and developing best practice guidance, so although no longer a practicing advocate my perspective remains the same – the person at the heart of this process.

I’m lucky and in a privileged position that I don’t have other factors at play when carrying out my job.   I’m there only to find out from the person what they want, what’s important to them, what help they feel they need and how that can be communicated and articulated to others so that their views and wishes are heard and their rights upheld.

In this instance the patient is already known to services.   She threatens self-harm and/or suicide and is known to action these threats.  She’s known to take up a great deal of services time and energy which impacts on how she’s dealt with by all involved.  She’s viewed as a difficult client and that view of her has been set in motion - from the professionals that are familiar with her, those who receive a handover about her ‘difficult behaviour/presentation’ to those she’s never met before - and immediately puts a barrier between her and the professionals involved.  It may not be a conscious barrier, but it exists, she’s viewed as a ‘difficult job to do’.  This leads to a spiralling effect from the private ambulance through to the A & E department and the police call handle centre that means she’s treated as a problem that needs to be dealt with and not a person in mental distress.

But what if she wasn’t seen as a problem?  What if she was seen as a person in distress whose coping mechanisms mean she lashes out, threatens harm to herself but who wants to be heard (she rings an ambulance for a reason even if it’s not apparent).  If she were calmer, polite, rationally explaining why she wants to harm herself, how would she be treated then?  I suspect with compassion.  The issue is the same, but instead the emphasis has become about getting a task done, passing the ‘problem on’, fitting her into a piece of legislation or policy. She has become the least important part of the decision making process. 

@Sectioned_ says it best when she explains she’s in a vulnerable place and needs to be recognised, communicated with and listened to.  Simple yet could make a difference to the process as well as the outcome if she wasn’t viewed as the problem but someone in need and distress who is finding any way of reaching out."

An interesting point was that of not having other factors at play when treating a patient. I think it is often something that hospitals and others services don't understand or comprehend. When the police and ambulance service deal with patients they are often in the public domain and this brings with it its own set of challenges. In this case swigging pints, brandy and wine from strangers' glasses in a packed pub was just one of the challenges we faced. The bystander and the crowd have a lot to do with our decision making process. In a hospital, the nurses of whatever speciality have a cubicle or room in which to treat the patient where confidentiality and due process can be maintained. They generally don't have a sweaty 50 year old drunk man grabbing their arse or the remnants of a Jaegerbomb poured down their neck whilst trying to find out exactly why the patient is suicidal and deserting her wheel chair! A chirpy git leaning over your shoulder saying "I want that one" is not helpful in any way. You also have the onlookers who know best, who all have an opinion and are not shy to share! 

Viewing the patient as a problem is in itself, a problem. Yes, I agree tact and differing approaches are needed but again it comes down to luck. There are 1000's of different combinations of ambulance crews and 1000's of police officers. Some will be willing and open to go the extra mile, some won't be. There are times where I have been faced with 'someone in need and distress who is finding any way of reaching out' but if reaching out means I get verbally abused, spat at, punched, kicked or vomited on, then that is where the 'reaching' will stop; I'll be reaching for my radio and requesting police, and so starts the cycle again. As much as we all want to do the right thing, circumstance, guidelines and personal safety all get in the way. That is the flaw with pre-hospital care. We are in unknown, uncontrollable, often volatile environments, with not only the care of our patients to worry about, but the risks they may pose to unaware members of the public.

Jakki continues:

"The Mental Capacity Act in this instance doesn’t apply as she’s assessed to have capacity.  However if she was assessed as lacking capacity and it was deemed in her best interests to take her to hospital, consideration would need to be given to the use of force and/or restraint and whether it was necessary and a proportionate response to protect her from harm.

However section 136 of the MHA was the therefore used and the place of safety in this instance was a hospital. But it doesn’t need to be.  Local policies and procedures should consider a range of options that may be more appropriate and have a less detrimental effect on a patient.  Whatever their presentation, consideration should be given to the impact on the person’s mental health: will the place of safety exacerbate their distress for example; what environment would ensure a mental health assessment runs more smoothly, would a relative's home be a more temporary appropriate option?  

To end, given this is a complex case with a person with a long history of presenting to services, has her mental health AND her capacity been thoroughly assessed and is there a need for a multi-agency safeguarding meeting to progress the case long term so that all agencies are working together?  Also, given the numerous professionals involved, should she be given the option of having an independent advocate?"

The most frustrating observation from doing this project is that all of the services seem to be singing from the same hymn sheet; the ambulance, the police, the hospitals, the mental health services and the patient all want to work together to find the best outcome. It's a shame we are just the people doing the work. It's a shame we are the ones in contact with the patients. It's a shame politics and budgets play such a huge part in patient care. The concept of 'failure demand' is painfully evident in all facets of mental health care. There is a huge failure to do what is needed, and what is done is not being done properly. That is what let this patient down to a point. None of the services she interacted with on this occasion can be free from blame, likewise, neither can she. Her actions, albeit triggered by cause and a lack of appropriate care and management, put us in a no-win situation where the police are our only option, as only they can restrain and section. Not at all ideal for any party involved, but everyone did what they had to do to cover their asses as Laptop Cop eluded to. I have no doubt her behaviour is a symptom of her mental illness but we can only act on what we see in a moment. We knew her on this occasion but another crew may not, and without any prior knowledge of her history, her actions cause a barrier to be put up between her and those who are there to help.

If all services were allowed to work together, like we all clearly want to, then change can and will occur. Maybe if more people could see that through social networking different aspects of the health services are indeed trying to understand each others' roles better and then perhaps that could be transferred into improving patient care. At the end of the day that is what we are all here for; the patient. How can anyone expect a patient to buck a trend, make positive changes and take steps to get better if the very services there to help them won't do the same? Just sayin'!

I'd like to thank Laptop Cop, Mental Health Cop, @jakkicowley and Stewart Thomas for their input on this project and a special thank you to @Sectioned_  for sharing her feelings and experiences from the patient's perspective. EMS and police blogs can be very one sided I feel that, in this post especially, the patient's view was the most crucial. I recommend all their blogs and Twitter accounts for anyone interested in policing, health care and mental health.