In community mental healthcare we have a lot of visits and meetings to fit into each day and it does not help that there is nowhere to park. We did have several small community bases with convenient parking, but these old Victorian properties cost too much to maintain. The new hospital sites all charge for parking, if you can find a space. Getting about is now more difficult and to ease the pain I listen to podcasts; while stuck in traffic or waiting for the train. I recommend Claudia Hammond’s All in the Mind: I always seemed to catch this programme half way through on the way to my last call of the day, but with the podcast I can listen any time.
I learnt about Complexity Theory this week, in another Radio 4 podcast. A complex system was described as something that has different outcomes, depending on the point at which the system starts to run. Apparently, if someone gets out of bed just five minutes late a chain of events can cause problems; missing the bus, getting to work late, not getting on top of tasks, and so on. Perhaps that’s why am getting to work earlier and earlier. But I was delayed one morning this week. I had not checked my emails and did not pick up messages before driving to a discharge planning meeting; only to find that is was postponed.
I had also missed the morning handover meeting and that is never a good idea. Sometime later that day I called on a service user to make a routine visit. His mother was surprised to see me as he had been admitted the day before. So I was not looking or feeling very professional; I could have spoken to him at the hospital if I had known.
Community mental health teams are a complex system in which there are many conflicting agendas and targets. Our handover meetings are crammed with information sharing as everyone is trying to work with each other to achieve multiple outcomes. I struggle to hold all this information in mind as I try to set priorities. Surely if I start each day with a rational plan I would be able to meet the targets I am set, but somehow it never works out that way.
Maybe I am just trying to be positive about my disorganisation but having time to waste on the ward is helpful. Falling into conversations in an unstructured manner is of benefit. Review meetings often run behind schedule and while waiting I chat with ward staff, building relationships which help ease the tensions. We are caught in conflicting agendas, often they want to free up a bed and I want to take time to get the discharge arrangements right.
On the day that the meeting was postponed I fell into conversation with a patient, Robert. He is referred to our team and admissions are a good time to engage, as symptoms become more stable and needs are met. I was filling time with nothing to do so my conversation with Robert was quite slow and unpressured. I believe that I learnt more about him in that twenty minutes than in all the time I spent reading his files, or assessing him by asking formal and structured questions.
Assertive Outreach is supposed to be targeted at people who have not engaged with standard community services. We were told that Robert had not engaged, but from his perspective, no one had made much effort to get to know him or help him meet his needs. Several of his appointment letters had gone to the wrong address. He had contact from a series of duty workers who all repeated the same questions. Perhaps people like Robert are failing to engage because our community teams are so stretched that an adequate service has not been provided.
Failing to engage with community mental health services is not only an outcome of a ‘lack of insight,’ or ‘non-compliance with treatment.’ People might sometimes disengage because these services do not appear to them to be of any value. So should I refuse to accept Robert as a referral and insist that the Recovery Service try harder? Well we have been working very closely with colleagues in this Recovery Service. Many of them had been off with stress related illness. Managers are talking again about integrating the Assertive Outreach Team with the Recovery Service but I hope that we can find more creative solutions.