Model Research

Since December 2008 the name Approved Social Workers has been changed to Approved Mental Health Professionals. These include social workers, nurses and occupations therapists.

Care management cycle and the Fair Access to Care Services (FACS) eligibility criteria apply to all adults with community care needs, and not just those people with mental health needs

Background to this individual not included, but most schizophrenics develop the condition in early adulthood. Research shows that early intervention is effective. Usually referred by a GP. Many, like this individual hear voices, but this is not necessarily a mental health problem. It becomes one if the individual is distressed by it. The local health service in most areas works in partnership with the NHS. Psychiatric services are the only authority (apart from the police authorities) who can deprive people of their liberty but only sectioned for short periods of time (needs the approval of two doctors) as the objective is to enable people to live independently as far as possible. This individual is suffering from command hallucination, so would be sectioned until he could learn to live with these command voices and would not present a danger to himself or others. Once judged to be able to live independently will return home. A needs assessment will then be made, based on problems, strengths, financial issues, daily living situation, social, cultural and spiritual needs and other personal issues. Care will be based on this assessment.

This individual will collect medication either from GP or from local mental health services. Schizophrenics often have medication by injection. An occupational therapist will work with him to try to help him overcome or live with his phobia - ie help take him shopping for frozen food and give him a freezer and a microwave, (through a direct payment) so that gas does not have to be used. Meals on wheels are available, if need is determined, but usually given to older people who cannot go out shopping or are beyond making choices of food etc. Personalisation of care is the keyword - that is not fitting the care into boxes to suit existing structures, but allocating help according to individual need. Could also claim Disabled Facility Grant.

This individual will be on Incapacity Benefit (this is means tested) and Disability Living Allowance (not means tested) which has two components a care and a mobility component. If the individual cannot drive he will be given a Freedom Pass, so that he can travel freely on any public transport. As he is unemployed his rent will also be paid through Housing Benefit. (Most people suffering from schizophrenia in the UK are unemployed, finding it difficult to find jobs).

Other professionals would be involved if, for example, the individual had children. At the moment a new Anti-stigma campaign has been launched. http://www.time-to-change.org.uk/

Case 4 Mental Health Disability

Sex: Male

Age: 40s

Family: Single

Medical History: Schizophrenia

He has experienced pathological perceptions such as auditory hallucinations and delusions, which make his mental conditions unstable. He continues to receive mental therapy and drug treatment by visiting a hospital (once in two weeks). He is at risk for harming himself impulsively, which must be prevented by being watched carefully. He is unlikely to need to go to hospital fortnightly for his medication, unless he is receiving a particular time of depot injection. Most ongoing treatment is delivered in the community, either at a clinic or at the GP surgery. Community Mental Health Teams (CMHTs) are based in premises outside the hospital, with facilities to meet clients, interview them and to provide treatment. The risk of harming himself impulsively is a big one. If the risk continues, then he is likely to need to remain in hospital. Even with ongoing symptoms, the aim of treatment (both drug and psychological) is to reduce the risk to the point where they can live their life fairly independently. Therefore, without wanting to pick holes in the scenario, this is not realistic. No one who is living independently can possibly be "watched carefully" to avoid such dangerous behaviour. This would only happen in hospital. Even if he had major problems living independently, and needed to live in supported accommodation, he would not be supervised to this degree, and would have considerable level of freedom to come and go as he pleased.

ADL: No assistance needed for daily activities such as eating, dressing and toileting. (He uses home help services once a week for 4 hours.)
As I mentioned when we met, home help services are unlikely to be used with this person. A more specialist community support service would be used to maximise his independence, maybe with the help of an occupational therapist for a limited time to help him develop independence skills, or regain lost skills. The stringent criteria for allocating assistance is such that there would need to be a specific need (which is not identified above) before any home help (or community support) services would be provided. I told you yesterday about the national eligibility rules for Community Care services: Fair Access to Care Services (FACS). Everyone with some prima facie evidence of disability has a right to an assessment of their needs (NHS and Community Care Act 1990) but no one has a "right" to services per se. The requirement to provide services is dependent on the assessment of need. Assessment -> identified needs (as opposed to "wants") -> care plan to address those needs -> services. The "care management" cycle is completed by the professional monitoring and reviewing whether the services are working to address the needs, reassessing and amending the care plan as necessary.

IADL: He cannot use gas appliances because of fear (which means he cannot cook or take a bath by himself). He can use a washing machine to wash laundry but cannot hang them on a laundry pole.
Again, sounds rather unusual for someone with this sort of illness. Occupational therapy would be used to try to help him overcome the fear. Crucial to know what he is afraid of. Most people with this sort of condition can't cook (if that is the problem) due to lack of motivation. Similarly for self care. I've never heard of anyone who wants to cook and bathe but can't due to fear (which I am assuming is part of his schizophrenic illness in the scenario). The focus here would be very much on teaching and/or encouraging him to learn these skills himself. If he really couldn't do any of this, I think he would probably need more supported accommodation, such as a hostel for people with mental health needs. There are quite a few around, with a variety of levels of support, depending on the needs of the residents. Some have 24 hour cover, while at the other end of the continuum, others have staff on duty just 9-5 Monday to Friday (usually with a phone number to call in emergencies).

Ability to Travel: Basically he needs assistance when traveling because he sometimes hears voices in his head telling him to jump in front of a train or a car while he is on a platform or on a pedestrian crossing or a pedestrian overpass on streets.
If he hears these voices (these are known as "command hallucinations" and are very serious), and is unable to control them, he will need to be in hospital, as he is an acute risk of killing himself. Combination of mediation and psychological treatment is used to reduce the impact of voices and/or help the person manage them more effectively. Someone with these symptoms would need to be closely monitored to make sure they were able to manage the symptoms, and to minimise the risk of them harming themselves.

Social Activities: He is engaged in the activities of a disability organization in the community but he has no regular income because he works on a voluntary basis.
This contradicts some of the earlier information, as it suggests he is fairly stable in his mental health. We talked about the stigma of mental illness, and the very high proportion of people, particularly with schizophrenia, who are unemployed. If he is getting disability benefits, he will be limited in the amount of hours of voluntary work he will be able to do without jeopardising his benefits. Don't know the details here, it's all very complex. That's why we have CAB and also specialist mental health benefits advisors linked to the service.

I mentioned the current developments in care provision, away from the traditional fixed services like home help, day centre, meals on wheels, to more individualised services which are sensitive to people's individual needs. The policy development is called "personalisation" The actual policy tools are Direct Payments and the next generation is called Individual Budgets, where a person is assessed in the way described above, and their needs identified, and as a result, instead of allocating a limited menu of traditional services, a resource is allocated to the person to do with (within reason) as they wish in order to address their needs. For example, meals on wheel costs ?x per meal and a day centre costs ?y for a day.

They may have been allocated because the person is unable to make their food (meals service) and is isolated (day centre) If you allocate that funding to the individual, and they decide to get a microwave and frozen meals from Sainsbury, or go to the gym, then this may be able to address those needs in a much less institutional way, developing increasing independence and making the person feel much more like a normal member of society, rather than a dependent ill client.