As a part of my clinical SSC, I had to do visits to a variety of mental health care settings: 1 visit to River House at Bethlem Royal Hospital
1 visit to Scutari Clinic at St Thomas’ Hospital
1 visit Cheyne Ward at King’s College Hospital
4 visits to 190 Kennington Lane Clinic
These visits broadened my knowledge about mental health care and the services provided. In each placement, I observed at least one consultation and had an opportunity of talking to a variety of health care professions about mental health care services and patient care.
This reflective account discusses my experiences in the mental health care and the things that I observed.
A Brief History on Psychiatry
Psychiatry can be defined as the study of mental illnesses, their diagnoses, management and prevention (Oxford Medical Dictionary) and when this is carried out in the community, it is called community psychiatry. Here is a brief timeline of transformation from mental asylums to community based care:
In 1601 the Poor Law was established which stated that individuals who were unable to care for themselves should be supported (History of Mental Health and Community Care- Key Dates, Mind.org.uk).
In 1800s, introduction of the County Asylums 1808 allowed the asylums and psychiatric hospitals to be established, treating mentally ill patients (History of Mental Health and Community Care- Key Dates, Mind.org.uk).
The number of bed allocated to patients with mental health problems was at its peak in 1954 (152,000 beds). However, with the introduction of new treatment plans, such new anti psychotic medication, rehabilitation in community, the numbers of people being admitted to psychiatric hospital reduced (ABC of Mental Health, 2nd Edition and History of Mental Health and Community Care- Key Dates, Mind.org.uk).
Mental health care centres were the one of the steps taken in terms of the implementation of mental health care policies in 1980s (Sayce et al. 1990).
1990s, mental health care in the community was reformed and implemented a form of community mental health team which is a team of professions including a psychiatric, psychologist, social worker, occupational therapist and care coordinator, manage people with mental illnesses in the community settings (ABC of Mental Health,2nd Edition).
Community Mental Health Team and Other Services
Mental health problems are normally managed by primary health care, e.g. GPs, and referrals can be made to either community mental health teams or secondary health care if needed (ABC of Mental Health Care, 2nd Edition and Mental Health Policy Implementation Guide: Community Mental Health Teams, 2002).
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The majority of the patients who use the services provided by community mental health care teams have time limited problems and will be referred back to their general practices once they have made the necessary recovery (Mental Health Policy Implementation Guide: Community Mental Health Teams, 2002). Reflecting back upon a consultation that I observed at Kennington Lane Clinic, a patient was discharged from the clinic after having used the services as there was a significant improvement in her condition.
One of the reasons for the referral to community mental health care team is that primary health care may not be able to offer services such as cognitive behavioural therapy or rehabilitation, required for patients with certain mental disorders, for example obsessive compulsive disorder (Mental Health Policy Implementation Guide: Community Mental Health Teams, 2002). Once the referral is done, patient is risk assessed and assigned a care coordinator, who would support, advice and have a regular contact with the patient. At Kennington Lane Clinic, the care coordinator whom I spoke with stated that when one of his patients do not attend a scheduled appointment, then he would go to visit this patient at his/her home so in other words, providing a continuity of care and support.
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During my time at River House, a medium secure hospital, one of the doctors that I have met articulated the fact that medium secure hospitals fill the gaps that are created by both the psychiatric units of general hospitals and the high secure hospitals. Since the patients admitted to medium secure hospital are not suitable for both: high secure hospitals may not accept these patients because they are not dangerous or insane enough and psychiatric units of general hospital may find these patients dangerous enough to refuse the admission. Therefore, medium secure hospitals are solely developed to accommodate such patients. The same principle can be applied to community mental health teams as they are thought to form a bridge between primary and secondary health care (ABC of Mental Health Care, 2nd Edition).
During the transformation to community based psychiatry, it was thought that the prevalence of homicide carried out by psychiatric patients after deinstitutionalisation was going up but in fact these claims were not accurate (Fakhoury and Priebe, 2007).
Deinstitutionalisation and allowing patients with psychiatric problems to be managed and cared for in the community settings intended to lessen and curtail social stigma related to patients with mental health problems, to integrate these patients into the community, and importantly to reduce and prevent long term hospital stays (Fakhoury and Priebe, 2007). So, one can conclude the fact that Community health care teams allow patients with mental disorder to stay in the community and have a life that as normal as possible.
However, Fakhoury and Priebe, 2007 stated that community psychiatry has not quite achieved its goal in terms of social integration as most of the psychiatric patients in the community are unemployed, live in a sheltered accommodation or even homeless. During my time at Kennington Lane Clinic, I met a patient whom I will be naming as Mr. A due to confidentiality code. This patient looked depressed and was complaining about having nightmares, unpleasant thoughts and phobia of using public transport. He also mentioned having thoughts of self harming and suicide. On further questioning, he revealed that he did think about committing suicide by overdosing himself with his antidepressants but could not do it as he could not find a place to do it: he is unemployed, homeless and lives with his elderly parents and occasionally with his daughters both of whom are married.
In terms of what observed and felt at Kennington Lane Clinic, patients whose files that read or met were either using street drugs or having housing problems compared to the patients that I saw at Scutari Clinic in St Thomas’ Hospital, however this may not be the case in general since I cannot generalise what I observed during my time at both places to the rest of the country.
One of the main difficulties experienced by the community mental health team is that the DNA (Did Not Attend) rates are very high in comparison to out-patient clinics at hospitals. I visited Kennington Lane Clinic four times in total but managed to observe only two consultations so I had to read the patient files and talk to their care coordinator instead. At the Scutari Clinic, I noticed that almost all the patients did attend their scheduled appointment with the doctor. I could not help but ask the duty doctors about the rate of DNAs both at the community based clinics and hospital based outpatient clinic levels and the answer that I received did confirm what I observed.
I believe that one of good things about community mental health teams is that they facilitate home visits which are not normally offered for the patients attending out-patient clinics. I agree with William R. Breakey, the author of Integrated mental health services: modern community psychiatry, that home visits allow clinicians to see patients in their own surroundings and to allow them plan an appropriate care plan for a particular patient.
Of course, there is a variety of services dedicated to patients with mental health problems: an appropriate choice of service would be chosen for the patient’s best interest. Reflecting back on my time at Kennington Lane Clinic, I came across Mr B’s file from which I read his past medical history and discussed this patient with a social worker who was involved with this particular case. On discussion, I found out that he was originally referred to the clinic by his GP and treated by this clinic quite a long time but unfortunately was relapsing and not compliant with his medication. When something like this is the case, patients can be detained at hospital against their own will under the Mental Act legislation (Rethink, Factsheet, 2010). This particular patient was going to be detained under Section 2 for 28 days. In order to carry this out, the patient had to be seen by 3 professions (2 psychiatrics and 1 social worker) in the presence of police. These three professions are specialised in mental health care that would assess the patient’s mental state and make a decision.
In addition, during my time at Cheyne ward, I shadowed a senior registrar who was on call in A&E. I managed to observe a consultation which lasted about 30 minutes. Mr C was complaining about low mood and was self-harming. Having learnt that his father had a history of long term depression and his relationship with his father is not good, he was suggested to stay in hospital in order to carry out a full mental assessment. End the end of the consultation; he was happy to go ahead with this decision.
As can be seen, the main difference between these two cases (Mr B and Mr C) is the way of the admission process: one is being admitted to hospital by force and the other one is giving consent. Mr C is an example of ‘informal’ patient who is admitted to hospital with his own will and not detained under the Mental Health Act legislation, whereas Mr B is sectioned under the Mental Health Act legislation and cannot have the right refuse treatment.
All in all, this revolution of change from hospital based treatment to community based treatment played an important role modernising the mental health services in the UK. Community mental health care provides help and support to those with mental illnesses at the community settings and appropriate patients are referred to this service. From what I observed and read, I can confidently say that community mental health services provide a care that is continuous and offer advice.
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