Our mystery mental health worker writes about difficulties in engaging people while meeting service targets.

We heard last week that a former service user, Joe, is back in town. He has been seen wandering in and out of the local shops. Most people will view Joe as a typical homeless beggar, with his wild long hair, his beard and his multiple layers of clothing. But some members of our team nursed him years ago in our psychiatric hospital, when his appearance was very different. Back in the day Joe was successful, running a local business, with a ‘work hard – play hard’ attitude. It was the excessive use of alcohol and substances which led to increased admissions.

This week Joe called to me as I walked through town, he seemed pleased to see me. We spoke about the different towns he visits and he wanted news of fellow patients he knew from his time on our wards. Now and then when his attention wandered he made an odd twitching movement with his head, he seemed to be spitting out half articulated swear words. I asked him if he needed anything; should I arrange for him to see a doctor? Joe said he was fine, no problems at all, and he certainly did not want any of our medication.

Back at the office I wondered how to record this contact. Joe is closed on our electronic records and opening his case would trigger a possible breach in the Trust’s contract with commissioners. We would need to have an assessment recorded by a certain date and a care package agreed. Joe would come under Cluster 16, Dual Diagnosis. He should be offered interventions such as motivational interviewing, physical healthcare checks and treatment for psychosis. I had noticed, however, that his most pressing need was treatment for his feet. He was clearly in pain when he walked. One of our nurses mentioned a Podiatrist who sometimes treats patients in a room at a local drop-in. A referral would be needed via a G.P., but Joe had been taken off his last G.P.’s list when he caused ructions at the surgery; he is hard to manage when he is intoxicated.

In handover we recalled that in the past Joe was popular with his outgoing personality and his tall stories. However, friends and family fell away as his drug and alcohol binges grew longer and his business suffered. But he had always played the fool and he treated detention under mental health law as just one big joke. In their talk team members were almost collusive, celebrating Joe’s skills in subverting the system, beating the tax man, making money for nothing and scamming his way out of trouble. For example, when he was told that he suffers from psychosis he used this to avoid prosecution for benefit fraud. He explained that his claims for multiple benefits, under different names, were a consequence of his delusional belief that he was several different people.

When he was last in town Joe was denied support from mental health services. It was thought that he was inducing psychosis through this use of substances, or faking symptoms to gain advantage. He is not an easy man to help and if you do not give him space when he shouts he will hit you. But during a brief stretch in prison, his failure to manage led to him being treated and he accepted help. He was placed on discharge in Supported Accommodation. This time Joe was grateful, emotional even, and he cried when we put him back in contact with members of his family. Things went well until we helped him reinstate his benefit claim. A large back payment arrived and Joe could not resist returning to his party lifestyle.

We have some targets to meet around physical health. If we take Joe onto our caseload we must record that he smokes and that we have offered him support in smoking cessation. We need to record his BMI and, while he is clearly stick-thin, if he were overweight we would need to record our efforts to promote healthy eating and regular exercise. These targets make sense somewhere in our management structures but they are not going to enable us to help Joe.

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