In our community mental health service we are trying to respond to increasing referrals. This prompts a lot of talk and I often get bored in business meetings. My mind wandered when we were told about the correct way to record a service intervention; “Tick that box for motivational interviewing and that one for graded exposure therapy” and so on. Then a reminder to bring proof that we have fully comprehensive motor insurance, which covers us for business use, and on to the need to find service users we can discharge.
We all take out insurance policies; purchasing a service while hoping that we will never have cause to use it. The adverts persuade us that we are buying peace of mind. The policy is there in the background and most of the time nothing goes wrong, but it is there, just in case. So I wonder; is that want it is like for someone who is recovering their mental health. They hope that they will not get ill again. They don’t really need to see a mental health worker, but it is reassuring to know that they have one there in the background, just in case.
I remember when psychodynamic theory was more often expressed in our talk. There was the idea of ‘attachment’ and that of ‘therapeutic containment.’ A person might grow in their confidence and ability while they are ‘held,’ while they feel secure in the knowledge that a professional worker is on hand, ready to step in if needed. As my mind wandered I thought about a team away day I organised a while ago. We had a mock awards ceremony. I adapted and printed some fancy certificates which I found online. We had to nominate each other and one award was for; ‘achieving the most by doing the least.’ The agenda behind this was to promote the idea of recovery from mental illness as a personal journey. It is the person who has been unwell who must do most of the work to recover their wellness. Workers are doing a good job if they stand back and let the person take faltering steps. Watching someone struggle is not easy and we experience an urge to rush in, to take over, to do the task ourselves and make sure it is done properly.
Suddenly my attention was brought back to the business meeting and I sat up to listen. Making an entry in our electronic clinical record is a contractual requirement. The commissioners will get a report showing how many of which kinds of clinical intervention we have made. So if someone is assessed as falling within a particular cluster, under the Payment by Results structure, we are paid a given amount of money for each six month period of treatment. If we have not delivered and recorded the agreed amount of ‘evidence based interventions’ in that period, then the commissioner will not pay. I am thinking now, is there any evidence that achieving more by doing less is effective? This is not just about the risks involved in having infrequent contact with someone while they recover their mental health, we are told; “If we are not actively delivering treatment then we must discharge!”
When delivering an Assertive Outreach intervention, I have always valued the daily handovers. In a flexible approach we agree, day by day, which service users need to be seen and supported. For periods some will be seen daily, others might just need a weekly phone call and a visit every few weeks, while their mental health is stable. But, if we are taking the money, we should be seeing them and doing some active form of therapeutic intervention. If we don’t see them, that is like committing fraud, isn’t it? We can’t take the money for doing nothing! “But what about the people who disengage?” I asked. “Should we continue in our attempts to maintain contact with them, to monitor and to offer treatment, trying to avoid a relapse, trying to prevent a further admission?”
What is the evidence base for looking through their letterbox, driving through town while keeping an eye out for them, waiting by the bus stop they use, phoning their family and friends? The whole day can go by without a ‘face to face’ contact. Then there is all the liaison, with; Probation, the Police, the ward, the Benefit Agency, the landlord, the Vocational Specialist, the carer’s assessment we do, the Safe Guarding meeting, the Social Circumstances Report and the complex case review. The whole week has gone by and we have not actually seen the service user themselves. Where is the evidence base which proves that those interventions are effective?
Year on year our funding has been cut but we have continued to deliver Assertive Outreach style interventions. This Payment by Results structure is another challenge; “Right,” I said, “So starting next week we are discharging anyone who does not turn up and engage with evidence based interventions; start building some more inpatient wards.” But I will of course continue to work at reaching out.