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DanBC

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  • First name
    Dan
  • Last name
    Beale-Cocks
  • Country
    United Kingdom

About me

  • About me
    Working to improve safety and patient experience. I have a particular interest in suicide prevention, and also quality improvement. I am a Patient Safety Partner with Gloucestershire Health and Care NHS Foundation Trust.
  • Organisation
    Gloucestershire Health and Care NHS Foundation Trust
  • Role
    Patient Safety Partner

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  1. Article Comment
    Is there anyone in the health and social care system who has been asking for this? Are there any very senior leaders who think it's a good idea?
  2. Content Article Comment
    Also, there's some other things that have an effect here. We know that merely giving people the diagnosis of personality disorder will cause them harm. Under ICD10 you cannot give a dx of personality disorder to someone under the age of 18. But we see CAMHS using phrases like "emerging personality disorder", and we see CAMHS and adult services using phrases like "traits of PD". These pseudo-diagnoses cause some of the harm without bringing much of the benefits that a dx can have. They can also causes diagnostic over-shadowing. Access to autism diagnostic services is dire in many places, and so there are autistic women who don't get an autism dx, but do get a pseudo-dx of "traits of PD", and are then denied access to suitable autism support because 1) that doesn't exist and 2) they've been put on a HIN pathway.
  3. Content Article Comment
    Thank you for this post Steve. To me SIM and HINs raise a couple of important points. 1) Many (but not all) people under the carer of HINs will have been given a diagnosis of personality disorder. I would be interested to know how many of these people previously had access to care recommended by NICE. NICE make two recommendations, and in healthcare we tend to only say the first and forget to say the second. 1) "People tend not to benefit from inpatient admission" 2) "People do benefit from copious amounts of community based psychological therapy". I know that in many areas access to this care is restricted. Often a referral will be made to community based psychological therapies (so, not IAPT, but a much more intense programme) and the referral is rejected because the patient is "too unwell". Clearly, without access to evidence based support the chances of recovery decrease. When we look at this patient group we see a lot of use of S2, S3, S136, the forensic sections, the community treatment orders. We see a lot of use of acute MH hospitals, PICUs, secure units, eating disorder inpatient units. We see a lot of use of community treatment teams - community MH, crisis teams, ED teams. We see a lot of use of emergency departments, and acute physical health hospitals and burns units. We see people have these huge, complicated, packages of care that are mostly reactive to crisis and do not do much to help people get back control over their life. In my opinion this clearly sucks for those patients. We should focus on the collapse of provision of high intensity community based psychological therapy. We should also focus on the collapse of "system wide" working. 2) In Gloucestershire we used to have a thing called "MARMAP" (multi agency risk management and assessment panel (I think it was something like that). Because it was a local authority thing it got a different name in every LA region). This was run by the local adult social services department. It was a big multi agency meeting to discuss how best to provide care. There were problems with it, it was far from perfect. But it had some good points. It recognised the need for excellent care coordination and getting all HCPs to stick to the plan, and to only make changes in agreement with the patient and each other. Often, an HCP will feel frustration at lack of "progress" and will just change the care plan. This can lead to chaos. And blame for that chaos is never placed upon the clinician changing the plan, it's always placed upon the patient for "splitting" the team. LA funding has been decimated. This means they had to stop providing things like this. So, when you have a patient with a system-wide package of care there does need to be excellent care coordination and I don't think we have that. 3) When we talk to staff about this group of people we find that staff feel they do not have the skills and competence to provide support; they do not have the time to provide support; they feel confused by the lack of psychological therapy; they feel unsupported by their organisation. If you know the right questions to ask you can sometimes find shocking examples of stigma and discrimination, a real lack of compassion. Into this vacuum (lack of community based psychological therapy, lack of excellent system wide care coordination, lack of competence within an organisation) we get SIM. To me this is why SIM got rolled out so quickly, with such little scrutiny. Systems need something to happen. Orgs need something to happen. Staff are glad there's now a more specialised service. And patients? Well, often they're pleased to be getting anything at all, even if it's not good. I think we probably need to be careful to be clear whether we're talking about SIM or HINs, because it's possible for a HIN to be a good intervention even if there are problems with SIM. I think we also need to be clear about whether the withdrawal of service is a result of SIM/HIN or because of something else in that local system. Some people who've been prosecute for breaching CBOs were not, I think, under the care of a HIN. When you scrutinise any model of care you can probably find something concerning. That's the point about "always improving". The surprising thing about SIM and some HINs is that you don't have to look far to find problems. SIM frequently talks about interventions "done to" and not "done with" service users. Here's part of an answer from one of their FAQs "If you have been approached by your local mental health provider to talk about being supported by a high intensity team, then it is highly likely that a multi-agency panel called a High Intensity User Group (or similarly named risk panel) will have already met to discuss your care and safety. This panel consists of key decision makers from the NHS, the police, the ambulance service and local A&E; departments. The panel could also include: Social Care, Drug & Alcohol Services and specialist 3rd Sector/Charity providers. " -- this is pretty far from "nothing about me without me". It's not coproduction of care. It's not personalised. There appears to be a very low threshold in some regions before people are put on a HIN pathway. The original IOW documents talk about 8 patients per 140,000 population. But then we see far more people placed on a HIN pathway. In some places the HINs are about providing a clear and easy to understand plan: "When you feel like this, you should do these things in this order", and about making sure care providers respond appropriately. But in other places the HINs do appear to be about withdrawing support. Police describe their presence as coercive. This should be really concerning in the context of MCA and MHA. (See slide 3 here: https://emahsn.org.uk/images/End_of_project_status_report_SIM_implementation_April_2020.pdf The slide that talks about benefits to police forces mentions "reduction in the use of police cells for people in distress (and therefore the reduction of deaths in custody)". To me this isn't talking about a reduction in death. It's talking about where that death happens. That's chilling, isn't it? I saw an anonymised care plan for someone in a HIN. A lot of the care plan was spent detailing how this person was at risk for death by misadventure, but not suicide. I felt that 1) dead is dead and we want to prevent death 2) defensive working to provide evidence to a coroner is a sub-optimal way to work and 3) it's a misunderstanding of coroners conclusions. The language used around severe emotional distress is genuinely awful. "Within my mental health service, I have two groups of service users with Personality Disorder. The first group makes clinical progress. The second is simply uncontrollable". https://www.iow.gov.uk/azservices/documents/2880-04-PJ-PB-SIM-MENTORING.pdf (And, again, this slide pack mentions "accidental suicide" which is incoherent.) And then there are the problems with data. There's a slide somewhere (and I struggle to find it now) where they compare use of emergency service pre- and post- HIN. But they're comparing the full year before HIN, and only 4 months on SIM. And for one of the people they say "Look, use of S136 / PICU / Ambo call / Ambo triage / Ambo attendance dropped to zero, A&E / police / missing person all dropped". They mention, but don't highlight, the fact that for the four months this data covers this person was in hospital. There are *loads* of examples like this. So, I get that everyone is really busy. I get that for meetings there are too many papers; the papers are too long; the papers are too dense. But it means that scrutiny is now based on "they're probably trying to do the right thing, and we'll fix any problems later". We urgently need better regulation and scrutiny and oversight. There were so many people involved in this that could have read the slide deck and said "you need to fix the language" and "you need to fix the data" and "you really can't say it if it's not true". And maybe they did say these things, but because it all happened behind closed doors, away from patients, the already low levels of trust have been destroyed. Finally, I speak to a lot of people in this kind of situation and while I hear talk about the need for clarity and for strong care coordination I've never heard people say "we need more police involvement". They overwhelmingly ask why community based psychological therapy isn't available.
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