Mental Health and Tentacled Snowballs
There are issues in health and social care at both a macro and micro level at the moment. It does not feel as though any of these problems will be going away anytime soon, in fact the proverbial snowball just keeps on rolling.
I've been reading an awful lot lately about the ‘macro’ problems –by which I mean (rightly or wrongly) those at a national rather than local level – funding the NHS of course, privatisation of the NHS, privatisation of social care (Accountable Care Organisations, anyone?), proliferation and increasing normalisation of food banks, and so on. Celebrities are now donating to food banks and patting themselves on the back over this – well, thank you to them - but how have we got to this point?
Then, in my day-to-day work as a social worker, I came across something of a ‘micro’ issue, which I felt served as an example of how the snowball appears rather ominously to have tentacles as well. This conjures up a fairly mad image, of course, which is an appropriate introduction to the labrynthian workings of mental health services in my home county.
What hope is there that people struggling with their mental health could possibly receive the right support, when the system itself is entirely maddening? The example I am about to give may well seem trivial, but to me it highlights so much of what is wrong with mental health services at the moment. Complicated, system-orientated rather than person-centred, and hierarchical rather than accessible. It also evidences how the various problems in health and social care we are faced with today, are increasingly stretching into every aspect of our lives. It is toxic, and there are tentacles everywhere.
I worked in a Community Mental Health team, for a very short time. This was a service that was exceptionally risk-averse, had an alarmingly limited understanding of social care (social workers were nervous and/or puzzled about the idea of completing Care Act assessments – on the occasions when they'd cottoned onto the fact that they were supposed to), and the team was so entrenched in the medical model I began wondering where my stethoscope was. I was expected to use words like ‘patient’ and ‘euthymic’. I noticed severely paternalistic tendencies, an inaccessible hierarchy, a feeling of mutual disdain between different teams, and a “we know best, the ‘patient’ is wrong” attitude which I thought didn't exist anymore.
So, after 4 months I joined a generic adults social work team where, happily, words like ‘social justice’, ‘person-centred’ and ‘empowerment’ were more relevant. The medical model has taken over mental health services in my home county. This does not make me feel very well.
Then, in my new non-mental health role, I butted heads with mental health services again. It is a very simple example, but I was shocked that the old "Doctor knows best" mantra appears to have persisted in my locality, digging in to the mindset of senior managers. I guess it's an old snowball, and the tentacles have claws as well. For context, whilst in the mental health team I was able to refer an individual to other secondary or primary mental health services (providing they were prepared to wait 8-12 months for it in some cases, of course…this, I think, is one of those ongoing macro problems).
In my new role, I sent out a cheery e-mail letting my good team know that, should they feel someone might need to see a psychiatrist, or be assessed by the community mental health team, or receive some CBT, or therapy to work through their anxiety, they could use the attached form to refer that person to mental health services. My team was grateful for this. Until one of them had a referral rejected because:
“only GPs can refer to secondary mental health services.”
Sigh. I will summarise this briefly. The referral form stated that the form was “for all general mental health referrals”. I think a reasonable person would assume that this means primary or secondary mental health services, but maybe I'm not a reasonable person, perhaps I'm going mad. The form had a section which stated “if this referral has not been made by the GP, is the GP aware of the referral?”
Now, I really do think that a person of sound mind would assume that professionals other than a GP were therefore able to use this referral form. Perhaps I'm not mad. Maybe mental health services are mad.
I thought this wasn't really making mental health services all that accessible for people who might need them, and so I felt that this should be challenged. In all fairness I must mention that people can contact limited primary services via another means, but not secondary services.
In challenging the notion that only GPs can make such referrals, I was told by senior managers that GPs are:
“gatekeepers of referrals into primary and secondary mental health services and able to assess the current mental state of patients to determine the most appropriate pathway and therefore there is an expectation that in order to come to SPA (the referral screening team) the GP has 'assessed' the patient.”
I didn't realise that only GPs could assess the current mental state of 'patients' (people?); I was evidently acting above my pay scale when doing exactly that when working in the mental health team. I really must be going mad.
But wait! There's more! I was also told that:
“In order for the referral to be processed they require a list of current medication, and GP history.”
This is interesting. Let's imagine a scenario. A person meets with a social worker and presents with severe anxiety – shaking, sweating, no eye contact, evidence of self-harm and discloses that they have recently started hallucinating, perhaps even having suicidal thoughts as well. They may be having nightmares about snowballs with tentacles and claws after thinking too much about bureaucracy in the NHS. Their mood is definitely not euthymic (or ‘fine’, to you and me). In such a scenario, my priority is to help them to access mental health services as soon as possible (assuming they consent to this) – ideally, one would think, by making some sort of referral. Their GP history is important – but not the priority here. Access to services is the priority here.
What I can say is that in challenging this I did succeed in effecting change. Yes folks, off the back of my challenge…the referral form will be changed so that:
“where it states ‘Professionals’ this should be and will be amended to ‘healthcare professional within integrated teams.’”
So I guess that clears up who can refer to mental health services now, right?
Contrary to previous advice, not just GPs, but healthcare professionals (somebody somewhere has decided that social care professionals can't be trusted) in integrated teams (because integration is good and right and anything else can't be trusted). I was sure that I was a social care professional when making referrals to mental health services whilst working in the integrated mental health team…but I suppose I must really have been a healthcare professional. Or was I just acting above my pay scale again?
Have I achieved anything here? Are citizens getting improved access to mental health services, or have I accidentally run into a brick wall? Is this madness?
I think I'll just go and change my name to Lunar, and let you judge for yourselves.
The publisher is the Centre for Welfare Reform.
Mental Health and Tentacled Snowballs © Anon 2018.
All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.