Continued.....
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?"
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.
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