UK Mental Health: Lessons from the Third World?

Re: Mental health services in crisis – tell us your stories The Guardian 21.6.11 Amelia Hill


It can’t be a very ‘happening’ news day when the Guardian’s lead story is ‘Mental health services in crisis over staff shortages’. Not that I have a problem with that, it’s just a little like proclaiming ‘Piers Morgan is a Twat’. It’s not really a story, more a statement of the obvious shoved into the media spotlight on one of those rare days when the coalition haven’t done a U-turn and Premiership footballers are shagging each other’s wives in the relative safety of Dubai or LA rather than the VIP areas of Manchester nightclubs. I’m no sub-editor but I might have shortened the headline to just ‘Mental health services in crisis’. Full stop.

But why? The prod for the story comes from the retirement of Professor Dinesh Bhugra as President of the Royal College of Psychiatrists. Dinesh is a man I barely know personally but who has a professional reputation as a doctor who has combined high-flying eminence with the sort of decent, caring persona that now seems as rare in the mental health professions as an NHS Manager who doesn’t punctuate every other sentence with ‘going forward’. His is a voice I will gladly listen to and take note of above and beyond any half-baked politik-speak from the Department of Health civil servant or, God forbid, a politician. Understandably, Bhugra’s concern centres on his own profession’s lack of ability to attract doctors to psychiatry from the sexier reaches of medicine or surgery, swanning around the wards with a stethoscope and a British National Formulary tucked into a white coat pocket.


But he also points toward what I call the ‘Bedlam Factor’. In-patient psychiatry which used to be, in the olden days of my asylum student nurse youth, divided into Acute Admission, Long Stay or Rehabilitation, Elderly Mentally Ill and Locked Intensive Care is now little more than a series of ever decreasing beds for ever increasing levels of nightmarish psychiatric distress housed within the crumbling ruins of our various Something Somewhere NHS Trusts. The comments from Guardian readers, many of whom have experienced the rawest edges of mental illness for themselves, are punctuated by stories of services falling apart at the seams led by a psychiatric ideology of medical model-ness propped up by labelling, diagnostic box-ticking, inappropriate detentions and powerful medications. 


Some of the more extreme anti-psychiatric views are a little hard to take for an experienced mental health professional who has, I hope, helped a considerable number of people over the years using the sort of skill and empathy that has made me proud to be a psychiatric nurse along with the countless numbers of superb professionals with whom I’ve worked over the years. And using the comments section of a left-leaning broadsheet website to blame our sub-standard mental health care on the current government really is a bit rich. Our current problems go back much, much further than any single administration or era can lay claim to.


As a blogger and occasional author of ‘proper’ books I often find myself a thousand words into a blog post or chapter before realising that what I’m writing is complete and utter bollocks. No amount of re-writing, editing, cutting and pasting will rescue the piece. If it’s that bad I simply delete the thousand words and start from scratch. 

The entire mental health system in the UK is more than just bollocks. It’s a bloody great set of diseased, swollen bollocks riddled with tumours and elephantiasis. Can we delete and start again? Do we have models elsewhere to cure the disease? Yes, I believe we do.

Dinesh Bhugra is certainly not alone in citing staff shortages in both medicine and the other disciplines as being at the core of our diseased system, but the story goes deeper and wider than a simple lack of bums in jobs, assuming that the staff vacancies are there in the first place which, as Guardian contributors have made clear, is far from the truth.

As both a former Ward Manager of a Secure Unit and a Community Psychiatric Nurse I long ago swapped the ward keys and the NHS lease car for a yearly self-assessment form and the words ‘Training Consultant’ on my passport. In case you’re wondering, I like to ensure that my status as a ‘trainer’ is not confused with one of those people in a vest and trainers who shouts about ‘feeling the burn’ and talks about ‘reps’.

But through various friends, family and especially training delegates I still see all too clearly how our mental health infrastructure works. Or doesn’t, as is usually the case. I still get to hear on a daily basis how fundamentally poor our mental health services are and how our prisons have become the new default asylums. I hear about people who listen to the voice of Barack Obama bellowing “CIA” in their ear, or whose sole ambition is to swallow dive from the top of a multi-story car park but whose ‘keepers’ I wouldn’t want looking after a pet Gerbil let alone those suffering the deepest moments of delusion, hallucination and utter despair. 

I hear hair-raising stories of mental health professionals who appear to need a small aircraft flying a banner marked ‘potential homicide’ before they can so much as think of the words ‘risk assessment’. Time after time we read inquiry reports following homicides and suicides, and time after time we hear the same old crap spouted by Chief Executives. “Patient care is our paramount concern”. “ We’ve taken on board the Inquiry’s recommendations.. “ etc etc, while the same situations crop up again and again, usually followed by the standard inquiry finding of professional boundaries getting in the way of good old communication, a total misreading of confidentiality and the Data Protection Act, and just sheer incompetence which all too often seems to be swept under the rug marked ‘lack of resources’, ‘staff shortages’ and even ‘the Receptionist being on sick leave’.

We have a mental health system clinging on by its fingernails supported only by a medically-led multi-disciplinary team approach now well past it’s sell-by date.  It takes a brave soul to see the elephant lurking ominously in the corner of the room, but I know a number of senior psychiatrists who will acknowledge at least privately that they their job involves little more than diagnosing,  prescribing and the yeah-ing or nay-ing of Mental Health Act decisions. 

Despite the ridiculously bloated diagnostic manuals which attempt to pathologise every aspect of human behaviour from severe mental illness to a kid who gets stroppy with his Mum (Oppositional Defiance Disorder, in case you ask) the process of diagnosis in psychiatry is not usually very taxing. Thanks to Stephen Fry and various documentaries and media articles, the bloke who works behind the bar at my local has a reasonable idea of what Bipolar Disorder is, and I think quite a few of us now know that if someone spends an hour checking their that their doors and windows are locked before finally getting out of the house, they probably have ‘that Obsessive Compulsive Thingy’.  

And as for therapy, most psychiatrists spend most of their treatment time writing prescriptions for anti-depressants (to treat Depression) or anti-psychotics (to teat Psychosis) or maybe a mood stabiliser (to treat Bipolar Disorder). But Geoff down The White Hart probably knew that as well. I’ve probably been struck off the Royal College of Psychiatrists Christmas card list at least three or four times in the last two sentences, but hopefully you get the point.

Now I’m not saying for a moment that if I were mentally ill I’d want anyone who hasn’t spent many years of hard medical school graft prescribing me medication that has the potential to leave me staring at walls for hours on end or keeling over with a lethal mix of SSRIs and something I picked up from Holland and Barrett, but most competent doctors have the ability to diagnose most non-exotic mental disorders and scribble their signature on a prescription pad. The real graft and skill of mental health care goes into a therapy programme for the patient with the windows and doors issues, or the social and family support of the person hearing the voice of Barack Obama.

Radical thoughts? Not really. A very good friend of a mine is a Professor of Psychiatry called Vikram Patel. His academic affiliation is not to the psychiatric establishment, but to the London School of Hygiene and Tropical Medicine. I was lucky enough to be in London in March for his inaugural professorial lecture along with Dinesh Bhugra and a number of other notable figures from the great and good of psychiatry. Vikram spoke with great passion about the Global Mental Health movement and the World Health Organisation’s  Mental Health Gap Action Programme (mhGAP). Eh?

Okay. It’s not often that my ego will allow even a close friend’s book to be bigger and better than my own literary efforts, but Vikram’s ‘Where there is no Psychiatrist’ is the acknowledged bible of how to do mental health in parts of the world where there is no such thing as a brass nameplate on a door and where MRCPsych might as well be ‘Hello’ in Klingon.

Vikram (who now owes me at least a pint) has researched and set up programmes all over the so-called Third World (or if you prefer, the ‘developing nations’) whereby local people are trained up to assess mental disorder and put in place therapy and support programmes for local people presenting with psychological symptoms. They come from the same cultural and ethnic  backgrounds as their ‘patients’ and are trained to understand the difference between, for example, someone who ‘hears voices’ but is otherwise perfectly happy, and someone suffering a severe psychotic illness and may require further assessment and perhaps anti-psychotic medication prescribed by a visiting doctor. They possess the local, cultural understanding of how mental disorders arise from both factors such as brain pathology AND the social and environmental factors which are so often brushed aside in our traditional Western model of mental health.

To paraphrase Rolf Harris, ‘can you see what it is yet?’ 

Countries as poor and riddled with life threatening diseases such as malaria and HIV are starting to realise that early, local interventions aimed at addressing mental health issues can dramatically reduce the risk of contracting life-threatening illnesses such as HIV. They can reduce suicide. They can reduce crime. They can reduce drug and alcohol abuse and a whole host of very expensive social ills. And they can do all this with a basic, cheap but well designed and targeted training programme with all but a smattering of expensive, highly qualified medics and multi-disciplinary staff to supervise the work on the shop floor.

We have known for many years that brief psychological interventions can be at least, if not more, effective in treating many forms of mental disorder than endless prescriptions for anti-depressants and tranquillisers. Instigated by the previous government, the Improving Access to Psychological Therapies initiative aims to get GPs to refer people with mental health problems to therapists as an alternative to the script pad.  


It means well, but if I were referred to my local IAPT service in Weymouth I would be trotting along to a dilapidated prefab building plonked in the car park of a community hospital. Yes, it’s handy for parking but looks more like a Crack den than a sanctuary for my distressing psychological issues. This is how seriously we take mental health in the UK, even within a relatively prosperous seaside town in Dorset. 


Faced with a choice, would I rather have support from a trained local with a very short waiting list and a clear plan of action supported by a visiting medic who can prescribe any medication I might need. Or would I plump for an appointment with a highly qualified professional for whom I have to wait six months for a fifteen minute appointment  before being given a prescription and a further appointment for a CPN, Occupational Therapist, Social Worker or Clinical Psychologist who will, if I’m lucky, put me on yet another lengthy waiting list?

Well I know where my mental health would rather be trusted, but please feel free to leave your comments and please don’t hesitate to put me on your Christmas card list. I have a feeling I may need the your support.

Challenging Behaviour: How to Avoid Kicking the Cat

I ran a course yesterday for Residential Care Staff. The imaginatively titled Challenging Behaviour and Dementia course is always interesting in that it reminds me of some of the difficulties care staff have to face, even working with elderly clients. As always, the story of the course is that even little old Doris (85) can and does pack quite a punch when she wants to!

Now according to Google there’s an awful lot of people typing ‘challenging behaviour’ and ‘challenging behaviour definition’ into the little white box, which means if you’re here right now you’re a) writing up a college project or b) working with a bunch of service users/patients/clients who are posing difficulties of one form or another.


Now, I know how it works with students. You just want something quick and dirty to cut and paste into your Word Processor. Yep, been there. So if you just want a definition, here it is. In fact, here’s two!

Definition 1: ‘any behaviour which negatively effects both the ’perpetrator’ and those around them to a significant and/or frequent degree’ (Kinsella 2010)

Definition 2: Culturally abnormal behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities (Emerson 1995)

If that’s fulfilled your essay needs, glad to be of service. Bookmark this page and we may see you again ….

Otherwise, hang on in there.  We’re going to outline some of the key skills we need in dealing with the sort of challenging behaviour which can be problematic, highly unpopular, scary and generally pretty awful, often to the point where we really don’t want to go into work and face another shift. But challenging people with challenging behaviours are no less deserving of our efforts than anyone else, so let’s take a brief look at some of the stuff from the JCK Training Managing Challenging Behaviour course which I hope might be helpful and even save you that extra bottle of wine/shouting at the TV/shouting at family and those occasional feelings of wanting to put our heads through a wall. And of course, we want to avoid kicking the cat. Working with Challenging Behaviour is’nt easy.

The nature of challenging behaviours presented by an elderly care home resident may be very different from those presented by, for example, a young person with borderline personality disorder, but the way we are going to approach the behaviours does not change – we are going to try and replace instinctive, reactionary responses with a more systematic, model-based approach. But first we need a few basic assumptions.
  1. Any service user (or human being for that matter) has the potential to behave in ways which are anti-social, aggressive and likely to have a negative impact on themselves and others. In fact, think of the last time you phoned a call centre. After spending five minutes listening to Greensleeves (no, bloody Greensleeves) interspersed with the patronising grind of ‘your call is important to us but please hang another minute while we make another £4 billion out of your sorry arse’ before eventually getting to speak to a human being called Malcolm, you are probably going to feel like telling Malcolm to shove his headset somewhere dark and possibly a bit damp. See? We can all get a bit challenging sometimes.
  2. The service user is at the heart of our discussion, assessment, planning and evaluation. This may appear to be a statement of the obvious but once a challenging individual has become associated with aggression or worrying behaviour (or put less technically, ‘scared the crap out of us’) that person can easily become marginalised and begins to drift further and further from involvement in their own care. We shall try to avoid this as much as possible although it’s fair to say that some service users will never be able to participate in their own care. In which case a family member or nearest relative  will hopefully be only to glad to be involved. 
  3. It may seem at first glance that a person with severe cognitive impairment caused by dementia or a learning disability behaves in unpredictable, random ways, but all human behaviours occur for a reason and attempting to identify why challenging behaviour occurs is a key aspect of our project.
  4. We are not aiming to ‘cure’ the service user of their challenging behaviour. We are simply aiming to reduce the severity and frequency of the target behaviour so that life is better for the service user and people around them.
  5. Our final assumption is that the advice offered here can offer generic principles of good practice and a guide to using a structured approach. However, there are no magic wands. Local conditions, client characteristics, resources and restrictions will all govern how challenging behaviours are defined and recognised locally, and how we go about managing these behaviours.


The CAPEd (sic) Crusader
In our Challenging Behaviour course we introduce a framework for working with challenging behaviour. Like all frameworks or models we tried to come up with a sexy acronym to help you remember the various bits, but all we could come up with was CAPE

Yes, BANG, WHIZZ or KAPOW might have been more appropriate (and sexy) but the letters didn’t fit. So we have CAPE. So what does CAPE stand for?

  • Clarification
  • Assessment
  • Planning
  • Evaluation


Let’s take  look at these stages and what they mean for us.

Clarification
We start by asking the question: What is the behaviour? This may at first sight appear a simple and straightforward task, but there are some common pitfalls especially when writing down or recording an incident in a service user’s notes or in untoward incident documentation.  We need to be careful here to actually describe the behaviour, not the emotion behind it. 

Writing ‘he got very angry’ in your notes is a description of how he feels, not of the behaviour itself. Right now we need to simply record what has actually ‘happened’. For those of a grammatical bent, we need ‘verbs’ not ‘adjectives’.
We also need to be aware of the possibility that an incident we are trying to describe may become the subject of further investigation, for example by the police or by a safeguarding vulnerable adults panel, so detail is good. Very good.

A key determining factor in where we go next is whether a behaviour meets a stated definition of challenging behaviour. We have defined challenging behaviour above but of course I’m here and you’re there. Local circumstances and environment will be key in determining what is significant or frequent enough to warrant further assessment and perhaps an action plan.  A person banging their head against a wall or shouting at a support worker will be seen in quite different ways in different environments, which in itself will demand quite different plans and interventions.

Assessment
The first stage of our framework has asked the ‘What’ question. Our Assessment stage is where we attempt to look at the Who and Why and How questions, so perhaps we are going to get our hands a little ‘dirtier’ in this stage. But the effort expended will be well worth the effort as we attempt to address problem behaviours rather than simply accepting, putting up with or condemning them.

So where do we start? Hopefully with a clear and concise description of an incident or series of events based on our Clarification stage, but remember this is a structured, proactive approach to challenging behaviour and there are some key questions we may wish to ask:
  1. Is there Consensus within a staff team that what has been observed constitutes challenging behaviour according to an agreed definition or baseline?
  2. What is the Frequency of the behaviour? Are we looking at a standalone event or one of a series of incidents?
  3. What is the Impact of the behaviour? Ask the same question of the service user him or herself, and depending on location and circumstances, support staff such as yourselves, family members, neighbours or other.  Or couched in other words, who were the victims of the behaviour and how are they affected?
  4. If a there is a Victim as such including of course, the perpetrator(s), what are their characteristics? This is particularly important if there is a regular pattern to the challenging behaviour.
  5. Is there a Pattern of behaviour? In residential care for example, mealtimes are often a flashpoint for confrontation. Over a longer period of time, seasonal changes may be important or incidents may be seen to occur at a particular time of day.
  6. Is there a Precipitant for a person’s behaviour other than those we have already mentioned? Remember our starting position that behaviour almost never occurs purely at random regardless of the cognitive or functional abilities of the perpetrator. 
  7. Drugs and Alcohol. It may be a question of judgement whether or not we refer to substance use or misuse, but most of us are more than familiar with the association between intoxication and self-destructive or anti-social behaviour.  Our assessment may require more than a simple association between, for example, a client’s habit of drinking a four-pack of nuclear strength lager for brunch and his or her subsequent hostility on home visits, but it is always attempting to assess exactly how and why a substance affects the perpetrators behaviour as opposed to simply stating that ‘they get angry when drunk.’

The above is just a small selection of areas we might want to examine during our assessment, but our most useful tool is our own knowledge and rapport with the people with whom we work, and let us not forget that often the best informant of all is of course the person presenting the challenging behaviour. I often find when running courses that the most obvious question of all hasn’t been asked of the challenging individual: Why do you do it? This isnt always an easy question to ask depending on the individual and the circumstances, but can (if put skilfully and non-judgementally) yield surprising results. 

Planning
This is our ‘doing’ or ‘intervention’ stage. Whether we are referring to ‘Action  Plans’, Care Plans’, Support Plans’ or any other terminology which essentially means the same thing, most health and social care organisations have some form of written plan which clearly states what we are hoping to achieve and do with a service user.

We need clear consensus between ourselves as a staff member, our colleagues and collaborators from other agencies (such as professionals from Primary Care Trusts or Social Services or supported housing) as to how we describe challenging behaviours, our assessment and how we are going to respond. If and when appropriate, our planning should include as an essential of best practice a clear collaboration between ourselves and the service user.
Remember one of our initial assumption s from our very first page: we are not attempting to ’cure’ the perpetrator or change his or her personality, but simply reduce the frequency of challenging behaviours, the impact of those behaviours on others and themselves, or preferably both.
Evaluation
By now we have hopefully concluded that a consensual, structured, proactive approach to challenging behaviour is more likely to achieve our outcomes than staff response which is haphazard, reactive and fuelled by panic, fear or resignation. There is always the potential for staff who work regularly with challenging behaviours to become ‘over sensitised’ to verbal or physical aggression, self harm, destruction of property or any other of the challenging behaviours we have identified and set out to manage. 

Evaluation is a means of at least trying to ensure that we see worrying or dangerous behaviour for what it is, and whether we are are constantly evaluating informally over a cup of coffee with colleagues and service users, or more formally through meetings and reviews, our intention is to review the outcomes of our Plan in terms of impact, frequency and quality of life, add to our assessment and look toward the short and long term future which will hopefully mean a much better quality of life for service users, and a less worrying time for your cat. 
Emerson, E. (1995) Challenging Behaviour. Analysis and Intervention in People with Learning Difficulties Cambridge: Cambridge University Press.

Kinsella, C. (2010) Working with Challenging Behaviour JCK Training



Visit JCK Training for details of health and social care in-house courses, including Working with Challenging Behaviour

Glee for Free No More

Sky One has ruined my life.  No more Glee unless I’m prepared to cough up for a Murdoch subscription. I’m almost desperate enough to dig one of their flyers out of the bin and give them a call, until I remember a previous dalliance with Sky Sports which left me with bugger all but some mediocre football, a large bill and pressure sores on my arse.

So for purely selfish reasons I’d like to suggest a few reasons why E4 should have a shufty down the back of the sofa for a few more shekels to TRUMP Murdoch and bring Glee back to a terrestrial audience. And if you’re wondering why a social care blogger is writing stuff about a slightly daft TV show when there’s plenty of far more worthy topics to munch upon, well it’s not just a TV show. It’s a weekly dose of serotonin-pumping, feel-good musical energy entertainment and source of POSITIVE MENTAL HEALTH FOR APPROXIMATELY 1.6 MILLION PEOPLE. That’s why. 

Glee is cool
I say this to most normal people and they visibly recoil. In fact, if you’ve ever poured salt on a slug the instant ‘melt’ thing is exactly the reaction you tend to get at the mere mention of the show. But Glee is gradually contagious and every fan probably has a ‘conversion’ story to tell.  You have a family member, a partner or friend who starts off being a bit sniffy about Glee. 

You settle back for the first scene. It might be Finn’s gormlessly handsome face registering that “Uh? What happened to my brain?” look, or a full frontal of one of Mr. Schuester’s sweater collection, but the Glee-sceptic huffs, says something under their breath about ‘High School Musical 4: Post-Puberty’ and whips open their laptop with a disdainful flourish. They’re probably reading sites dedicated to celebrity hair transplants and ‘How to lose 10lb by eating grass’ so they’re in no position to take to take the moral high ground, but you just let it pass so as not to miss a millisecond of goings on at William McKinley High. But resistance is futile. Eventually the mask drops, scales fall from eyes and the laptop is abandoned to witness the full glory of daft teenagers singing and dancing their way through high school. And then there are two of you.

The Glory of Sue
Now purely in the interests of research I’ve just taken the E4 Glee Personality Test. Fortunately, weird half-perv/half-nerd student blogger with glasses and crazy hair Jacob Beth Israel wasn’t an option, but apparently I am most like Mr. Schuester. I think for a while there I was veering toward Rachel but managed to avoid ticking the ‘I want to be a showbiz star at any cost’ option and left with dignity intact.

Online opinion seems divided as to who is everyone’s favourite character. Personally I think if there is a ‘star’ of the show it’s surely the slightly androgynous, track suited she-wolf and head of the Cheerios Sue Sylvester. I wonder just how many viewers of various persuasions have fantasised about having Sue as their school PE teacher, chasing them naked and yelping from the shower with the flick of a moist towel, and …. let’s move on. 

Glee gives good ‘issue’
With sexuality, gender, ethnicity, disability and all round ‘otherness’ hogging the plot lines, Glee ticks off more boxes than a London Borough of Lambeth Policy and Procedures Manual, and critics do complain about the almost demographically perfect spread of ‘diversities’ among the Glee club members. 

But the show has to be credited with sweeping aside political correctness and getting well and truly stuck in to some quite awkward stuff that other shows might well consider a bit too ‘gloopy’ for the target demographic.

Kurt’s struggle with his sexuality is as good an example as any. He’s bullied at school, he hangs out with girls, he squeals at the mere mention of Lady GaGa and his mechanic Dad fails to understand why Kurt thinks a carburettor is a designer shoe. The term ‘coming out’ seemed a bit of a misnomer for Kurt as he’d been showing a pretty full deck of cards ever since Episode One, but Dad proves to be a saint and transfers our glamorous heroine to a private boys school with it’s own show choir. 

The Warblers are the all-singing, all-dancing troupe who somehow manage to spend sod all time studying and huge amounts of time wearing silly blazers and flouncing about to Beyonce numbers without ever getting severely beaten up. Ever. And things get even better for Kurt when he meets all round star, man-love idol and wearer of sensible but expensive leisure-wear Blaine who finally enables Kurt to be true to himself.   


The mental illness box is ticked by School Counsellor Emma and her Obsessive Compulsive Disorder, a plot design that started off as caricature and the source of some rather (admittedly good) gags but has evolved into a more serious issue as time has gone on. 

The eventual and obvious consummation of her relationship with Will Schuester is comically ruined by her morbid fear of men’s bits and bodily fluids, not to mention Will’s sensitive yet rampant masculinity. Now correct me if I’m wrong, but I’ve always imagined Mr Schu’s crown jewels as the cleanest this side of the Tower of London and Obsessive-Compulsive Emma really had no need to worry. I do need to worry about the fact that I’m imagining anything to do with Will Schuster’s genitalia. Which rather grimly brings me to my final point.

Sad Epilogue
As a middle-aged bloke who likes football, beer, owns a German Shepherd and has a taste in music which usually involves moody synth people sequencing a chainsaw or smelly blokes with guitars, I’m probably not in Glee’s target demographic. I’m not in the slightest bit ashamed to say that I love the music, the characters, the dialogue and the sheer joie de vivre. But after holding me in it’s warm terrestrial embrace for two whole series Glee has finally cast me aside like a used tutu and moved across to the Murdoch table with all it’s glitter and it’s gold. Sodding hell, I’m starting to sound like Kurt. Time to go.

Winterbourne View: A Tale of Boiling Frogs, Perfect Storms and the David Brent Analogue

Last Tuesday was quite a day. It started at midnight with a growing sense of resentment over a TV programme and the realisation that I wasn’t going to get any sleep. It continued into the dawn with the sound of my hammer-blow two-fingered typing on an already delicate laptop, and finished with the very weird sensation of listening to myself on Radio 4’s The World Tonight.

Thanks mainly to a tweeted recommendation from The Guardian’s Patrick Butler, my very brief attempt to explain the horror of Winterbourne View quickly went viral, carried along on a tide of national revulsion prompted by secretly filmed footage of a ‘hospital’ for learning disabled adults.

An imagination already heavily influenced by Star Trek and further excited by sleep deprivation pictured banks of overstrained iPlayer servers burbling, shaking and belching out smoke before exploding in a shower of tape.  Either Captain Kirk had asked the computer too many illogical questions, or Panorama had just touched a very raw public nerve.  Through a thick media fog of Cowells, Coles and talent show titbits, the British Public were for once actually noticing learning disabled people.

Now that the media hoo-ha has died down, political knees have been jerked in some way or another yet to be fully determined, and we’re all moving on from abuse to hair transplants, I’d like to acknowledge the time and effort spent on the replies to my article.  Many readers must have spent a great deal of time and effort crafting carefully worded, insightful analyses of the problems at Winterbourne View and beyond, and perhaps we can take a closer look at some of these points before last week’s headlines become this week’s cat litter.

Boiling Frogs and Perfect Storms
Taken as a whole readers’ comments seemed to indicate a ‘top to bottom’ failure of care, not only of learning disabled adults but of the elderly and mentally ill, with the failings at local, regional and governmental levels all adding their ingredients to the perfect storm: catastrophic failures of care.

Several readers were highly reluctant to point the finger at individuals, or as one contributor put it, the ‘coal face workers’. They argued that the type of care worker portrayed on the programme were more often than not the product of poor frameworks put in place by their managers, their managers managers, their managers managers managers and so on up the line toward government itself. 

I have some reservations about removing all aspects of individual blame from institutional abuse, but that’s a big subject and deserves an argument of it’s own which I’ll post tomorrow.

In the meantime Phil Wolsey deserves special mention for introducing me to a new terminology: ‘boiling frog culture’. This is a more than capable analogy of how ‘bad culture’ can gradually pollute even the most enthusiastic individuals. Unless you’re squeamish about amphibians it’s well worth looking up, but let’s just say Phil’s analogy describes how Happy Frog becomes Braised Frog very quickly and without the hapless creature ever really noticing.

David Brent et al
Plenty of you talked about governmental failings, budget cuts and their relationship to an ever descending level of care and the lacklustre response of the Care Quality Commission. We’ll get on to this bigger picture shortly, but Dee asked a very pertinent question: Where were the managers at Winterbourne View?

I’ve been around long enough to have been both a manager and one of the managed, so this was a question I never really asked during the programme but inspired more than a few thoughts on front-line care management once I read Dee’s comments.

Contrary to the plot formula of Casualty and Holby City (i.e Managers/Bad Guys vs. Nurses and Doctors/Good Guys) a functioning system needs managers. They’re a soft target. They come into management in a variety of different guises, several of which loom particularly large in my memory.

First up, there’s the Hapless Incompetent.
The HI is prematurely promoted beyond their own ability by high turnover organisations desperate to keep the more capable of their shop floor staff within that organisation, curiously forgetting that a very competent ‘shop floor’ carer isn’t necessarily a skilled manager. Although several of you argued that pay is not a major issue for many care workers, a larger salary may prove a very attractive inducement for staff members who have traditionally been low paid, and who among us would turn down the chance of a few extra quid even if we had the self-awareness to recognise our own limitations?  If we add in a lack of support or training for our new appointed HI, the results are sadly predictable.

There’s also the David Brent Analogue
The DBA is the bright and breezy new member of staff who, barely in possession of an ID badge, commences the grand corporate scheme. The nameplate is on the door, the office décor is beige with a bit of pastel relief, and daydreams are filled with the fond thought of spinning endlessly around in that faux leather reclinable. In my admittedly anecdotal analysis, these are often people who cannot bear to spend any more time than is absolutely necessary with the smells, sights and sounds of the care environment. The DBA hides away behind a desk updating Facebook, laughing at cat videos on YouTube and finding as much opportunity as possible to get invited to meetings, especially when the coffee and biscuit stash is looking a little light in the top drawer.  Knock on the door? No problem. Up pops the Excel spreadsheet, cue furrowed brow and a hard stare at the monitor. “Come in.”

I’m sure you’re thinking of many more caricatures to add to this collection (comments please – that could be fun!) but my third category of manager is the one I like to think I’ve had the pleasure of working with many times over the years. I can’t think of a smart or even stupid moniker to describe them, but if we could come up with a sexy sounding mnemonic that included the words Teacher, Leader, Strategist and Exemplar, we might be getting close.

These are the managers who balance the spreadsheet and working parties with the needs of both their staff and service users. They are not only visible but actively demonstrate the sort of communication skills and leadership which, I believe, form the best possible training for less experienced staff. They answer questions, spend time with people, observe the often subtle dynamics of an environment, mould and rectify where necessary, and are still capable of getting the admin done and the duty rota up on the intranet. They encourage good practice but stamp hard on the sort of culture so obviously in evidence at Winterbourne View. I’m quite sure they are still out there in numbers, but for how much longer?

The care industry is in a state of flux. Not long ago we ‘enjoyed’ a flourishing bureaucracy and seemingly limitless funds for both the public and private sectors to hire yet another Assistant Director of Stationery or a Strategic Bogroll Supplies Officer. But if what I hear on my courses is anything to go by, we now seem to be plummeting quickly from a state of gross over-management to hardly any management at all. Budget cuts are ridding the care sector of many highly capable front-line managers and I’d be grateful for any heads up on whether the Strategic Bogroll Supplies Officer is still in post, but I can hear the ticking of the attention-span clock so let’s move on to the bigger picture of governmental failings that so many readers highlighted in their comments.

Big bins or small homes?
Rob described recent budget cuts at his place of work and the inevitable impact on the quality of care his clients will receive, which he anticipates will lead to growing frustration and greater levels of challenging, disruptive behaviour.  He also raised a question echoed by Alison Giraud-Saunders from the Foundation for People with Learning Disabilities. In the aforementioned Radio 4 interview, Alison pointed out something about Winterbourne View that had brushed my subconscious only to disappear amid the full body blow of the images on display.

Why on earth, in 2011, are learning disabled people being housed in large, secure institutions, and why was there no mention of the role of the commissioners and care managers responsible for sending people to this so-called hospital?

Let’s not kid ourselves that people with autism and learning disabilities cannot (at times) be difficult, aggressive, and very challenging to work with, even within the finest establishments with dedicated, caring support staff. But with very few exceptions this is not a group of people who warrant detention behind electronically controlled doors.

I worked for many years in secure psychiatric units where patients who had usually committed serious offences were assessed, cared for, treated and detained at the same time under the auspices of the Mental Health Act. These were people suffering from personality disorder or severe mental illness.

People with Learning Disabilities, Autistic Spectrum Disorders or Acquired Brain Trauma make a negligible impact on crime statistics, and even those presenting ‘challenging behaviours’ are generally more likely to injure themselves or perhaps those who attempt to prevent them banging their head off a wall or throwing themselves from a window.

There are a number of much smaller units which manage to combine the safety and security of both staff and residents with a pleasant, homely environment. I’ve worked with the staff and visited the homes. They have houseplants, pleasant décor, and even the odd dog. They have well trained staff who understand the bizarre, the obsessive and the repetitive along with the quieter subtleties of predicting and avoiding challenging behaviour. As far as I can see, nobody to date has done a comparative study of the effect of Laura Ashley soft furnishings on challenging behaviour against the Gulag Archipelago-look of  Winterbourne View, but I know where my hypothesis money would be.

‘Economy of scale’ is of course the reason why large units like Winterbourne View have become so popular with care commissioners and those responsible for placing bums in beds. If you’ve been following the Southern Cross debacle or work in the elderly care sector, the bigger v smaller theme will be already familiar.

The Bigger Picture
It would seem from both readers’ comments and my recent experiences in the training room that a laceration of care budgets will not only force the vulnerable into bigger, cheaper but infinitely unsuitable establishments, but will also expose the raw meat of a rapidly diminishing work force. I see up and down the country how both front-line staff and their often very able managers are being faced with redundancy or re-application for jobs. I hear of closures of key services such as day centres, employment schemes and transport services leaving their former patrons festering amid a fog of endless Jeremy Kyle repeats on ITV4.

And then I remember David Cameron on his pre-election televised lectern.  I remember his preaching the importance of looking after “the vulnerable, the poor and the needy” which, on the evidence so far, is a little like General Mladic professing his undying love for Bosnian Muslims.

Perhaps if there’s one message coming from the rainbow of opinions and comment posted on this site and beyond, it’s this. And it’s a very simple message. There are lots of very good care staff out there, but a few very bad ones. There is good management (at both a local and more strategic level) and of course, weak and ineffectual management. Put these together in the wrong combination and what do we get? Not just Winterbourne View, but Sutton and Merton, Cornwall and many other less well known examples. Has the bravery and persistence of whistle blower Terry Bryan and the subsequent Panorama bombshell made any difference to the likelihood of such horrors happening again?

In a week where a news story about cruelty to learning disabled people eclipsed even the mating habits of Premiership footballers, I’d like to think so. Perhaps we’re not all quite as shallow as we think.

Winterbourne View: Why does this happen?

If Twitter has become the new barometer of the public mood, there were an awful lot of furious people watching TV last night. Most were effing and blinding at Britain’s Got Talent, or rather the lack of it, but for quite some time during and after the screening of Panorama on BBC1,  indignance, rage and even tears appeared to be the order of the evening.

It isn’t often I start throwing metaphorical chamber pots at the television but if you haven’t yet seen ‘Undercover Care: The Abuse Exposed’ and don’t have too many throwable items nearby, this is surely a ‘must see’ piece of tele-journalism. It will have you foaming at the mouth.  Here we have documentary evidence of cruel, callous staff supposedly offering care to vulnerable adults while actually doling out little more than institutionalised torture, bullying and assault.

Why does this happen?
It’s heartening to see the collective hive of Twitter so furious at the treatment of people who get precious little attention from anyone apart from those of us actually involved with learning disabled people or, like me, providing the training to help facilitate their care. But is it enough to simply tweat indignance  about what we see on a secretly filmed expose? After all, by the time you’ve read this Panorama won’t be ‘trending’ anymore and we’ll all have gone back to ranting about BGT, Sepp Blatter, or Jeremy Kyle.

We may see some commentary in the left-leaning media as to how savage cuts to health and social care budgets are the inevitable precursor to many more instances of barbaric, privately run institutions like Winterbourne View. Well I can’t disagree with that point of view, and we’ll return to that theme later. But to really understand how ‘care staff’ come to be filmed aiming drop-kicks at learning disabled patients or acting out Nazi Officer fantasises in the faces of frightened young men, we need to dig a little deeper and go back a little further.

‘A Degrading and Odious Employment’     
About seventeen years ago I published a research paper with a nurse colleague of mine called Chris Challoner. We had both worked in secure hospitals for some time, myself in medium secure units and Chris at Broadmoor Hospital. We were fascinated by the schism between two very different ideas of the term ‘nurse’.  

The more public perception of the nurse was (and probably still is) the idea of the ‘angel’. The little girl who’d been given a toy uniform for Christmas with a big red cross on the front and a plastic stethoscope. She (for this remains a largely gendered profession) couldn’t wait to become a nurse. Having got her treasured qualification she guiltily scoffed chocolates on the Medical ward, the box of Quality Street left by just about every grateful patient as they left for home having enjoyed the tender ministrations of those ‘lovely’ nurses.

And then there was us lot. Much more testosterone, no nice uniforms, key-laden lanyards swinging from belts and certainly little in the way of a lifelong yearning to look after dangerous psychopaths behind electronic doors. We’d just sort of drifted into it, and with a bit of overtime it paid the bills. And our patients never left us chocolates.

Myself and Chris wanted to test whether nurses working in secure environments really were the sort of right-wing, Daily Mail reading lock-up merchants of the stereotype that abounded at the time alongside the notion of the ‘sandal wearing tree hugger’ found in more normal, open psychiatric units.

We were testing a stereotype and achieved what research nerds would know as a ‘null hypothesis’ – there was no statistically measurable difference between the secure unit nurses and those who worked in more ‘therapeutically inclined’ environments, at least on measures of responses to our standardised measures of political and therapeutic attitudes. But we did find out a few other things that didn’t show up in our number crunching, and which, I think, have a direct bearing on the horrors seen on last night’s Panorama.

Firstly, while doing a little research on the history of psychiatric nursing, we came across this little gem:

The evils arising from the generally indifferent character of attendants, and from the deficiency as to the resources they ought to possess, are so great that few things would benefit the insane more than devising some remedy for them.

Very topical. But this was written in 1847 by a Dr. John Connolly, Medical Superintendent at one of the Victorian Asylums, pioneering mental health reformer and a chum of Charles Dickens. It has often been said that psychiatry attracts both the best and worst of the medical professions. Mental health has never been a fashionable specialism, but does attract the intellectually curious doctor as well as those who got a medical degree but weren’t quite bright enough for a scalpel. And to some extent, the same could be said of some of those attracted to psychiatric nursing.

But Panorama featured a private hospital catering for a group of people whose care tends not to attract even the academic curiosity inspired by Bipolar Disorder or Anorexia. As a registered hospital, Winterbourne View provides secure care under the Mental Health Act for people with autism and other learning disabilities. Care doesn’t get much less glamorous than this. It’s a neck of the therapeutic woods which doesn’t attract the starry-eyed little girl with a plastic fob watch pinned to her nurses outfit.

Even a few decades before Dr. Connolly’s scathing attack on ‘attendants’, another Medical Superintendent was waxing lyrical on the same subject:

Although an office of some importance and great responsibility, the role of the attendant is held as degrading and odious employment, and seldom accepted but by idle and disorderly persons

John Haslam’s observations probably weren’t featuring in the 1809 equivalent of a Job Centre. The typical interview of the time was a quick twirl in front of the asylum boss to prove you were a) a bloke and b) a big bloke with muscles.

So hospitals dealing with learning disabilities and challenging, aggressive behaviour have hundreds of years of historical form in recruiting nurses/attendants who are more adept at ‘decking’ aggressive patients than providing any semblance of ‘care’.  But two questions remain to be asked. Has anything changed, and what other reasons are there behind such appalling abuse?

A Question of Management
Our research was partly inspired by the ground-breaking 1979 documentary ‘The Secret Hospital’ which investigated the systematic abuse of learning disabled patients at Rampton maximum security hospital. Older readers may remember the horrifying story (among others) of a male patient with a particularly large penis who provided ‘entertainment’ for the nursing staff by way of a snooker table and a cue. If you didn’t see the programme you can guess the rest as I’m already traumatised by last night’s revelations.

As a separate but recent finding on the sometimes appalling state of elderly care in hospitals has shown, the NHS is certainly no grinning standard bearer of quality care. But last night’s damming evidence did make me think of the private sector organisations with whom my company now refuses to work. In these organisations we see ridiculously high staff turnover, with the few minimum wage staff who actually show some signs of competence being quickly  promoted to management as a kind of ‘golden handcuff’. They leave behind a floundering workforce struggling with the demands of what are often difficult and challenging circumstances, often with a limited command of English and barely a passing awareness of the cultural norms and unspoken rules so important to working with vulnerable adults and challenging behaviours.

For our blacklisted companies (several of which were started by entrepreneur property developers suddenly made aware of something called ‘Supporting People’. Kerr-ching!) the level of training required to work with challenging adults is often summed up by the following management-speak: “Oh shit, we’ve got an inspection next month. Somebody book a course for Christ’s sake!” If anyone from CQC happens to be reading this, no. We cannot infer client abuse or malpractice from the comfort of the training room, but on at least one occasion my classroom suspicions have been proved well founded. 
Fortunately, for every vision of Gothic Bedlam I come across in my travels, there are many more examples of very fine care providers who do actually commit to training and prioritise the support of staff who do what is a bloody difficult job. So why the difference?

Let’s return to the research study for a moment.  Our data gathering involved travelling to various different NHS units. Acute psychiatry, drug and alcohol and secure units all came under scrutiny.  We met the managers of each unit to discuss the purpose of the study, meetings which, with hindsight, told us more about the attitudes and therapeutic orientation of our sample than the wads of questionnaires and measuring tools we brought.  The managers ranged from the bright and enthusiastic sorts who exuded a culture of care from every pore, to the sort of indolent, world-weary pen pushers who, then as now, are so sadly common in NHS management.  We were there to measure the effects of therapeutic environment on our nurses, not the impact of management culture. But as we debriefed and analysed our data after each visit (let’s just call it having a pint before anyone asks) the parallels became obvious. The attitudes and therapeutic orientation of the nurses in each unit were far more a reflection of the management of that unit than the environment itself. In research nerd language, positive management correlated positively with positive patient care.

The Outlook?
So we reach a conclusion that those among us requiring the most complex, skilled care are being left to the support of those who, often through no fault of their own, are most poorly equipped to deliver that care. This is not a mitigation for the water torture, assault, bullying and abuse of vulnerable people, but in my mind at least it’s a hell of a lot more satisfying to try and understand why these disasters happen than to simply press the ‘disgusted and appalled’ button on my Twitter account.  

We’ve been left with a legacy  of front-line care donated by a New Labour obsessed with installing layer upon layer of Blackberry wielding apparatchiks constantly on the look-out for the next strategy group or working party to fill that long post-lunch window. We’re left stripped of the coalface people not wearing suits, who are now in turn getting their P45’s leaving an ever dwindling workforce to deal with problems of mental health, autism and learning disability showing no signs of declining in either quantity nor complexity. Companies such as Castlebeck will be invited, along with the property developers and former used car dealers, to pick up the slack. So-called care providers will carry on using celebrity detox as a front to their profit-yielding minimum wage efforts at managing some of the most vulnerable, difficult and disturbed people in the health care system.

Thank you, Panorama. You may just have stopped the rot for a little while. Not for long, just a little while. 




Visit JCK Training for details of health and social care in-house courses.