Domestic abuse, substance use and mental ill health are complex safeguarding issues, all of which are reported to have been exacerbated by the pandemic. To support the social workers helping families and vulnerable groups to manage these problems, and more, Community Care is making a number of specialist subscription resources freely available to all practitioners.

As of today, all social workers have access to an expert-written guide on working with domestic abuse, substance use and mental ill health. Written by researcher and trainer Jennifer Holly, for Inform Children and Inform Adults, the guide is available as a free, downloadable PDF.

The guide briefly explores the prevalence of co-existing domestic abuse, substance use and mental ill health, and the impact of multiple parental difficulties, before providing a list of indicators that a child is living with these three issues It contains questions to ask that may help you identify problems, examples of conversations, case studies and practice tips.

Click here to download the guide to working with domestic abuse, substance use and mental ill health.

What’s in the guide?

The guide is written by Jennifer Holly, who is a researcher and trainer, who has worked in the domestic and sexual violence sector, both in the UK and abroad, for more than 15 years. Since 2010 she has led on Against Violence and Abuse (AVA)’s work to develop improved responses to survivors and perpetrators of domestic abuse who are also affected by substance use and mental ill health problems. The guide includes:

• An understanding of why domestic abuse often co-exists with parental mental health problems and substance use.
• The impact that living with multiple parental difficulties has on children’s and young people’s physical health, emotional and psychological wellbeing, cognitive abilities, behaviour, and educational and social development.
• How to comprehensively risk assess parents.

The guide considers key evidence, policy, guidance and law to inform managers on the identification, consequences and ways of working with domestic abuse, substance use and mental ill health.

Click here to download the guide on domestic abuse, substance use and mental ill health.

More from Community Care Inform

Community Care Inform Children and Community Care Inform Adults provide online resources for subscribing social workers and social care professionals. If you have a licence through your employer or institution, you might also find the links below particularly useful at this time.

Self-care and Covid-19: podcast and transcript

Use of self and emotional intelligence: quick guide for practice educators

Managing fear in social work

Fear and social work: podcast and transcript

Loneliness and isolation during the pandemic: podcast and transcript

Not sure if you have a licence?

A large number of local authorities and universities work with us so do ask your manager, principal social worker or learning and development team if you have access, or contact our helpdesk by email or phone (0203 915 9444). You can also enquire about new subscriptions.

You can read extracts from other Community Care Inform resources here.

The government will drop Coronavirus Act provisions weakening Mental Health Act protections that have not been needed during the pandemic.

The Coronavirus Act, which was passed at great speed in March before the peak of the pandemic, provides for an application to detain a person under sections 2 or 3 of the act can be based on a single recommendation from a doctor, rather than two, if seeking a second recommendation was “impractical or would involve undesirable delay”.

The act also includes provisions to extend Mental Health Act time limits, allowing doctors and nurses to detain patients already in hospital pending assessment to 120 and 12 hours, up from 72 and six respectively, while also allowing the police to detain a person in a place of safety for 36 hours under section 135 and 136 of the MHA, up from the current 24.

None of the measures have been used during the pandemic to date.

‘Always measures of last resort’

Health and social care secretary Matt Hancock announced the decision to drop the provisions to the House of Commons during Wednesday’s Coronavirus Act debate.

“I hope that that will reassure colleagues that we take a proportionate approach to these measures and that we want to make sure that we have the measures that we need, but where we don’t need the measures then we will set them aside,” he said.

“These were always powers of last resort and I was not persuaded even in the peak that they were necessary because our mental health services have shown incredible resilience and ingenuity.

“So I’ve decided these powers are no longer required in England and will not remain part of the act.”

The government would shortly bring forward the secondary legislation needed to remove the provisions, he said.

Care Act easements to continue into 2021

The announcement comes after it was revealed that the chief social workers for adults had advised ministers to keep legislation suspending certain Care Act 2014 duties in place through the winter, to ensure local authorities are able to meet urgent and acute needs.

The advice from Fran Leddra and Mark Harvey – the joint interim chief social workers – was set out in the government’s adult social care winter plan, published last month. This indicates that the government will keep the so-called Care Act easements in place until March next year, despite no councils currently making use of them.

The easements enable authorities to suspend Care Act duties to assess, develop and review care plans, carry out financial assessments and meet needs – subject to ensuring people’s human rights are not breached.

Statutory guidance under the Coronavirus Act  – which councils are required to have regard to – says councils “should only take a decision to begin exercising the Care Act easements when the workforce is significantly depleted, or demand on social care increased, to an extent that it is no longer reasonably practicable for it to comply with its Care Act duties”.

They should also notify the Department of Health and Social Care (DHSC) when they start or cease using them.

Separately, the DHSC published an ethical framework for adult social care to inform council decision-making during the pandemic, including in prioritising resources. The framework, which councils are also required to have regard to, sets out a number of principles for decision-making, including that they involve treating people with respect, minimising harm, inclusiveness, accountability, proportionality and reasonableness.

In the two-monthly report on the status of the non-devolved provisions of the Coronavirus Act 2020, published in September, the DHSC said: “Our chief social workers have had conversations with local authorities who have operated under easements. They are satisfied that authorities complied with the ethical framework for adult social care,” the report reads.

New inspections focusing on children’s mental health will include in-depth examinations of how agencies assess and support 10-15-year-olds in care or involved with social workers, Ofsted has announced.

Six joint targeted area inspections (JTAIs) involving Ofsted, the Care Quality Commission (CQC), HMI Constabulary and Fire and Rescue Services, and HMI Probation will begin in September, with a remit to explore multi-agency responses to children with mental ill-health.

The inspections will include an evaluation of front-door services in order to assess how local partnerships identify children’s mental health issues and whether they intervene promptly.

Guidance published yesterday said this would include scrutiny of professionals’ responses to all forms of abuse, neglect and exploitation.

Inspectors will also take a “deep dive” look at how agencies assess and support the mental health of children aged 10-15 who are subject to child in need or child protection plans, or are looked-after, Ofsted said.

Crisis point

Earlier this month the Local Government Association (LGA) warned of a “children’s mental health crisis” in the face of rising statutory interventions and massive cuts to early help services such as children’s centres.

LGA figures showed there were 205,720 cases where a child was identified as having a mental health issue in 2017/18, compared with 133,600 in 2014/15 – a rise of 54%.

Meanwhile statistics published by the NHS in 2018 showed that one in nine children aged 5–15 had a mental health disorder.

A package of measures relating to mental health announced last month by the outgoing prime minister Theresa May included a pledge to revamp social workers’ professional standards to increase their expertise, but provided no detail about how this would work in practice.

Yvette Stanley, Ofsted’s national director for social care, said that in the context of local authorities and other services facing resourcing pressures, it was important that children’s mental health needs were being met.

“We are all responsible for children’s mental health,” Stanley said. “We don’t expect frontline practitioners to diagnose conditions, but we do expect them to be able to identify concerns and to know where to turn to for advice and support.

“These inspections will help us to see where children’s mental health needs are being met and where things need to improve,” Stanley added.

This year’s Community Care Live 2019 boasts over 30 free learning sessions to equip you to face the key challenges in social work practice today. You can also sign up to any of our eight legal learning sessions to help ensure you have the legal literacy your role requires. Register now to ensure you don’t miss out. 

Social work professional standards will be revised to increase practitioners’ knowledge and skills when working with people with mental health needs.

The pledge came today as part of a package of measure on tackling mental health issues announced by prime minister Theresa May, which includes the publication of a white paper heralding the replacement of the Mental Health Act 1983 (MHA) before the end of the year.

There was no detail offered today on how professional standards would be revised to take greater account of mental health. The knowledge and skills statement (KSS) for child and family social workers has one standard relating to understanding the impact of mental ill health in adults on their children, but doesn’t cover children’s mental health. The KSS for adult social workers makes a number of brief references to mental health, including in relation to knowledge of the MHA and the need to understand the impact of mental ill-health as part of assessments.

Delay in responding to MHA review

It is over six months since the Independent Review of the Mental Health Act 1983, commissioned personally by May, reported, setting out a blueprint for replacing the MHA. At the time, in December 2018, the government accepted two of the report’s 154 recommendations:

• to replace the nearest relative role, in which a patient is allocated a relative to be involved in decisions about their care, with that of a nominated person that they would choose;
• to allow people to make statutory advance choice documents setting out their preferences for inpatient treatment, which clinicians must honour unless there are compelling reasons not to.

It said it would give a full response to the review ‘in the New Year’. Today’s announcement gives no more detail on the government’s response, saying that it would produce a white paper – a policy document setting out plans to legislate on an issue – before the end of this year.

Chair of the review Sir Simon Wessely welcomed today’s announcement but stressed that the review’s recommendations now needed to be acted upon.

More support in schools 

Other announcements made today include:

• training for all new teachers on how to spot the signs of mental health issues, backed up by updated statutory guidance to make clear schools’ responsibilities to protect children’s mental wellbeing;
• support for school mental health leads so they can help children struggling with self-harm and risk of suicide;
• extra funding to support local authorities to strengthen and deliver local suicide prevention plans so that they better meet the needs of the people they serve.

May, who will leave Downing Street next month, said the emphasis of her plans was on prevention.

“It’s time to rethink how we tackle this issue, which is why I believe the next great revolution in mental health should be in prevention,” she said” “The measures we’ve launched today will make sure at every stage of life, for people of all backgrounds, preventing mental illness gets the urgent attention it deserves.”

A council ‘reneged on an agreement’ with the Local Government and Social Care Ombudsman by failing to implement in full the watchdog’s recommended changes in support for two vulnerable siblings in a special guardianship placement.

The ombudsman said Lancashire council had undermined the trust of the special guardians after they had to make a second complaint about the authority’s failure to provide appropriate support for their nephew and niece, because agreed changes from the ombudsman’s first investigation had not been actioned.

Issuing a second report within two years on the case, both of which found the council at fault for causing injustice, the ombudsman, Michael King, said: “It is extremely disappointing that the council failed to implement all our previous recommendations within a reasonable period of time and, in that failure, reneged on an agreement with us.

“This undermines the complainant’s trust in the council and calls into question [its] willingness to accept fault and put it right.

Lancashire council agreed to implement the ombudsman’s recommendations following the 2016 investigation. However, a second investigation has found that the council failed to properly implement the original recommendations, leaving the family without appropriate support.

Previous treatment 

The two children, known as V and W, moved in with their uncle and aunt, Mr and Mrs B, in December 2014 under a special guardianship order, after having been in foster care.

The council set out a support plan which established what services would be provided to them, and agreed to pay Mr and Mrs B £253.95 a week – equivalent to the basic boarding out rates for fosters carers – which would be reviewable annually based on any change in circumstances.

The plan did not identify any need for therapeutic services or respite care. No training was identified as necessary for Mr and Mrs B, though some had been identified by child and adolescent mental health services (CAMHS) and social workers

However, soon after the children went to live with Mr and Mrs B, they began to make disclosures about the treatment they had both experienced when they lived with their mother and said they had been assaulted by their previous foster career.

W exhibited concerning sexualised behaviour to the extent that professionals considered it was not safe for the children to be left alone together. This caused a lot of pressure on Mr and Mrs B, who had to change their routines to ensure they were always available to W.

Respite care provided 

A CAMHS report in May 2015 highlighted a number of issues with the children, including diagnoses of post-traumatic stress disorder (PTSD), attachment disorder, autism, attention deficit hyperactivity disorder (ADHD) and learning difficulties, all of which post-dated the 2014 support plan.

In January 2016, the council accepted it would have to provide respite care for V and W but struggled to identify a suitable location for W because of his significant sexualised behaviour, but also did not provide respite for V.

Following the disclosures, the support plan was reviewed in a report by an independent social worker, on behalf of the council, in October 2016.

The social worker thought Mr and Mrs B should receive additional funding, but the council said it could not do so because it only paid a flat fee to special guardians.

In September 2016, Mr B complained to the ombudsman, claiming that the council had failed to provide help and support for V and W. He added that after the SGO was granted, the council failed to assess their needs or provide additional support.

Initial findings

In August 2017, following the ombudsman’s first investigation, Lancashire council was found to be at fault for a number of failures, causing injustice to Mr B and Mrs B. The council agreed to the watchdog’s 11 recommendations, which included:

• identifying additional training for Mr and Mrs B by conducting a training needs analysis and paying the couple £200 for failing to provide training that was suggested by professionals.
• identifying appropriate out of county respite provision for W (there was none available within the council area) and respite provision for V and to backdate payments for missed respite to January 2016, when it promised to provide this service.
• make a clear decision on the level of financial support needed by the family by September 2017 and backdate any increases to October 2016, when the independent social work report was published

However, in February 2018, Mr B complained to the ombudsman again, claiming it had failed to implement some of the original recommendations. He was also critical of the way the council had communicated with him and said a new report on the family’s needs was not sufficiently thorough.

Failed to meet expectations

Following a second investigation, the ombudsman found that, while Lancashire had implemented most of the original recommendations, some had not been actioned.

Firstly, the council did not conduct a training needs analysis for Mr and Mrs B. While some training, on sexualised behaviours, had been provided by the council, other recommended or requested training had not been. The ombudsman said that an analysis would have determined what training was necessary and that the council was at fault for failing to carry one out.

It said the council should carry out a needs analysis without delay and apologise for its failure to do so before.

Secondly, while respite was provided for V, respite could only have been arranged for W following a risk assessment. However, while the council agreed to do one it delayed doing so, which the ombudsman said was a fault, as was the failure to provide appropriate respite in line with the watchdog’s original recommendations.

Now the risk assessment had been carried out and its findings available, the ombudsman said the council should take steps to arrange a suitable placement for W within a month, and pay the family £250 each month until it identifies somewhere appropriate.

The council’s failure to complete a risk assessment to determine if W could receive respite care was also identified as fault by the ombudsman.

Thirdly, the ombudsman found that the council had not made a clear decision on the level of financial support Mr and Mrs B needed. Initially, following the original ombudsman report, the council said it could not pay additional money because its policy was to pay special guardians at a set rate. The council then undertook a full assessment of the family, including a means test, but the ombudsman found that it was at fault for the delay in doing so.

The council then accepted that Mr and Mrs B were entitled to payments equivalent to ‘tier 3 foster carers’, which would attract £415 a week for W and £377 for V, inclusive of certain benefits. However, the ombudsman found that the council was not specific about the financial support it would provide the family, giving Mr B contradictory information about what it would provide.

The ombudsman said the council should backdate the correct allowance for the family to October 2016 and make these payments without delay, apologising to Mr and Mrs B for its failure to do earlier.

Recommendations:

Other recommendations made by the council, to be implemented within three months of the report, was for the council to pay Mr and Mrs B £300 for the distress caused by the delay in deciding to conduct a new assessment of the family, the delay setting up the assessment and the delay in identifying what support it would provide to the family.

Now that V has turned 18, meaning her special guardianship order has expired, the ombudsman recommended that the council calculate what support the family was entitled to now W was the only child in the home. It should also consider, with the council for the area in which the family now live, what support Mr and Mrs B will need to support V in the holidays.

Shortcomings to be addressed 

A spokesperson for Lancashire council said: “We are very sorry for the distress our failings have caused and we have apologised fully to the person involved and their family.

“We accept the actions recommended by the Local Government Ombudsman and have drawn up an action plan to address the shortcomings identified in the report.”

By Daniel Smith 

One of the main reasons I chose to be a social worker was a desire to improve care for people with mental health problems. But if there was one thing I worried about before starting the Think Ahead training programme, it was completing paperwork – I never wanted to do a desk job!

At the minute, I’m learning on the job in a medium secure in-patient psychiatric unit. It’s quite an unusual placement and it means spending less time with service users in comparison to other participants on the programme, who work in community mental health teams.

There is also quite a lot of paperwork in my role. I write reports for tribunals, I process benefits claims, and I conduct assessments with people who want to visit the units. If I’d known this was going to be the case before I started, it probably would have put me off applying to be a social worker as there’s nothing worse than carrying out bureaucratic tasks when you could be out there helping people.

But my attitude towards paperwork and how I approach it has recently changed – thanks to one particular service user, who made me realise what a difference it can make to a person’s life.

Feeling at ease

One week, I was tasked with writing a social circumstances report ahead of a tribunal for a service user with a complex dual diagnosis. The individual had been in a secure unit for around a decade and staff were considering whether they should be moved to a lower security unit.

The report needed to include a lot of information – a summary of the individual’s forensic history and the circumstances that led to them being detained, as well as their personal background. It also needed to make recommendations on what should happen next.

During the writing process, I spent time with the service user and carried out an interview. Other social workers have found it hard to establish a connection with this individual in the past as they can find it difficult to speak to new people.

I focused my questions around how they felt being placed in the unit and what they would like to happen in the future. I thought it was really important to make them feel like they had the right to say whatever they thought and to speak freely.

To my delight, the interview process really helped me to build up a rapport and allowed the service user to open up to me a little. We were then able to work together to identify goals for a better quality of life, working towards discharge.

They also explained that they would really like to reconnect with their family, and others.

Getting a call back

A few days later, I got a phone call from a senior social worker on the ward saying that the service user had asked to continue working with me to identify people who could visit them. We have since identified several people, and we’re working towards arranging visits, setting out realistic but ambitious goals – this feels really positive!

When I’d initially been assigned to the case I thought, “oh, that’s another bit of paperwork to complete”. However, realising how this piece of paper in front of me was positively changing the life of the service user made me think again. By adjusting my approach and focusing on the outcomes, that bit of paperwork had allowed us to have a really meaningful conversation.

Although I don’t yet know the outcome of the tribunal, I do know that it was a really critical moment for the service user – it brought out things they had never said before, and it identified a new pathway towards their discharge. It also led towards the service user deciding that they would like to engage with therapy to help better manage their emotions and develop coping strategies.

And, on a personal level, it made me realise how meaningful reports, and paperwork in general, could be and had been in this scenario – sometimes you have to do a bit of paperwork to give someone freedom!

Considering social perspectives

However arduous, I now see how paperwork enables me to make a real difference to the people I work with.

As well as allowing me and the multi-disciplinary team I work with to provide good person-centred care, ensuring service users have a good quality of life and giving them more autonomy, paperwork helps me to identify what social determinants and structures might have contributed to the person becoming unwell and being detained.

Paperwork often helps me to highlight the social issues that contribute to someone’s mental health problems, so I am able to get my multi-disciplinary colleagues to consider social perspectives and the person’s wider situation, rather than just their diagnosis – this has made a real difference to people’s care, and to the care plans we’ve developed.

Daniel Smith is a Think Ahead participant working in a medium secure in-patient psychiatric unit. The author’s name and details about the service user mentioned in the account have been changed to protect their identities.  

Supporting families with children placed out-of-area and improving guidance on how practitioners can share information about patients who have been detained are two recommendations being considered by the Mental Health Act (MHA) Review team.

Last month, a group of service users and relevant professionals, including social workers and lawyers, scrutinised the review’s draft recommendations around the treatment and care of children and young people detained under the MHA at a workshop in London.

Those in the room agreed with the review’s initial thinking that more had to be done to ensure that children and young people detained under the MHA were able to keep in contact with families and carers, particularly at a time that is distressing for all involved.

Improving guidance on sharing information with parents and carers was another key recommendation suggested by the review team, which has until 12 December to submit its findings to government.

In addition to speaking about the treatment of children and young people under the MHA and how this could be improved, the workshop discussed other recommendations surrounding several other key focus areas, including community treatment orders and the role of the police.

However, discussions around the care of children and young people promoted rich conversation when groups reconvened to share their thinking on the draft recommendations.

Aiding separated families 

One of the key issues identified by May’s interim report centred around the placement of children and young people detained under the MHA. Focus groups that fed into the report said patients often encountered “difficulties in accessing appropriate services close to home in a timely” manner when detained. Moreover, it was said that some children and young people were being placed in hospitals “far away from their families”, which was making it hard for them to stay in touch.

Where hospital admission is necessary, the MHA code of practice says the child or young person “should be placed as near to their home as reasonably practicable”, recognising that “placement further away from home increases the separation between children and their family or carer”.

When child patients or young people are placed out of area, local authorities are asked to “consider whether it would be appropriate to provide financial support to enable families to visit children and young people placed in hospital”, especially if the family is on low income.

But the code lacks further detail as to what practitioners can do if patients are struggling to maintain social relationships because they have been placed far away from their families.

Considering feedback given by services users and sector professionals, the review is planning to address the issue of a loss of contact between children and their families when they are placed out of area by ensuring support is provided to enable contact.

In addition, hospitals will be required to alert the Care Quality Commission (CQC) within 24 hours of a child or young person being placed in an adult ward that is out of area as part of potential new measures.

Speaking to Community Care, a spokesperson for the review explained the thinking around the draft recommendations of the topic group:

“Maintaining social relationships whilst in detention is important for all patients. This is particularly the case for parents and their dependent children and young people and may be challenging as children and young people are more likely to be placed out of area.

“The patient safety and dignity topic group recognised this and proposed that the review consider a recommendation that parenting should be valued and that efforts should be made to maximise and support contact between parents and dependent children.

“This could be achieved in a number of ways, for example, through the use of technology such as Skype, allowing freer use of telephones or supporting parents to visit children and young people in detention.”

Call for specialised funding 

There was agreement from those in attendance that all efforts should be made to ensure children and young people detained under the MHA are able to maintain contact with their families.

One delegate said there should be more support for families who have to visit people in out-of-areas hospitals because “quite a lot of families [aren’t] able to afford [the cost of] travel, or it’s far to go”.

“Maybe there should be specialised funding for families who have to see their child because if not, not having a parent around isn’t going to give lots of support to that child,” they added.

Conflicting information 

Members of the review committed to examining “issues of parental involvement and decision making” after concerns regarding information sharing and legal complexities surrounding admission and consent to treatment were identified in the interim report.d

Meetings with dedicated focus groups found some young people were being “told different things” about their mental illness and care to that shared with their parents or carers. The review said this “had an impact on their recovery” when they heard alternative explanations at a later time.

As with adults, children and young people have a right to confidentiality under the MHA. Where children under 16 are competent, or young people aged 16 or 17 have the mental capacity to make decisions about using and sharing information they have provided, their views should be respected.

However, in certain circumstances confidential information about the patient may be disclosed without their consent, for example, if there is reasonable cause to believe that the child or young person is suffering, or at risk of suffering significant harm.

In these situations, the code of practice offers guidance to practitioners and advises them to encourage the child or young person to involve their parents, unless it is not in their best interests. It adds practitioners should be proactive in discussing the consequences of their parents not being involved.

Looking at improving guidance

Under recommendations being explored by the topic group, the review is proposing that guidance is improved to better instruct practitioners on how they can provide sufficient information to parents and carers.

This change would help to ensure that children and young people, and their families – where consent is given by the patient – have access to the same information, allowing families and carers to provide better care and support.

“One of the key concerns which the review heard in relation to children and young people was that information provided to parents and carers of children and young people was not always sufficient or consistent with that told to the child or young person,” said a review spokesperson.

“The review heard this could cause distress, foster a lack of confidence in services and could lead to issues with, for instance, discharge where parents were not given enough information to support their children.

“To address this, one of the proposals being considered is whether there should be improved guidance on information sharing to support professionals in their decision-making.

“This could give advice, for instance, on how best to ensure parents and carers have sufficient information to provide care and support, and on navigating conflicts between the wishes of parents and their children,” they added.

‘You need everybody onboard’ 

Those in attendance at the workshop agreed parents and carers needed to be given greater access to information around children and young people’s care and treatment, with the point of assessment being identified as particularly important.

One delegate said, in their experience, medical professionals tended to be “very, very nervous” about sharing information with parents and carers because of “the implications of the mental health system”.

“If you go into hospital with an elderly relative, the medical professionals are very happy to show [you] information [about a relative] because it’s so obvious that, if you have an elderly relative with dementia, you need everybody onboard to give them the support.

“When you have a young person, there’s more confusion because the young people themselves can be very convincing and very articulate in insisting they are fine and don’t need the support when it’s not the reality.”

Another member of the group echoed this opinion and agreed “more precise guidelines” on what parents and carers are and are not allowed to know should be created.

Providing legal power 

In regard to problems surrounding admission and consent to treatment, the review is considering drafting into legislation that parents and carers cannot consent to admitting or treating children or young people who have the ability to make decisions for themselves.

The thinking comes after the topic group that looked at issues relating to children and young people found there was limited statutory provision under the MHA, despite the code of practice offering a large amount of detail.

In relation to a consenting 16 or 17-year-old, who has been informally admitted to hospital, the code of practice states “parental consent should not be relied upon [in relation to the proposed admission and/or treatment] when the child is competent, or the young person has capacity to make the particular decision.” This helps to ensure that the child’s wishes are respected, and the wishes of their parents do not carry greater weight or respect.

The code continues to say that “it is inadvisable to rely on the consent of a person with parental responsibility to treat a young person who has capacity to make the decision and has refused the treatment”.

Brevity leading to ambiguity 

In contrast, the MHA is brief in its content on the involvement of parents in decisions about the treatment of children. Section 131 states: “If the patient does not consent to the making of the arrangements, they may not be made, carried out or determined on the basis of the consent of a person who has parental responsibility for him.”

As a consequence of the brevity of the MHA, the interim report stated there have been ambiguities around this area of the law. This is one of the reasons why it is looking to include in legislation that parents and careers cannot consent to admitting or treating children who can decide for themselves.

A spokesperson for the review explained why the review was looking to change legislation so that it offered more clarity around this area of the MHA:

“[The topic group] felt that the current position was unnecessarily complicated and proposed that the review consider a consistent approach to this issue,” said a review spokesperson.

“This would mean that children and young people who have capacity or are competent cannot be admitted or treated informally against their wishes on the basis of parental consent but will instead come under the provisions of the MHA.

“This could clarify the position for clinicians, children and young people and their parents and ensure that children and young people with competence or capacity who do not consent to be admitted or treated have access to the safeguards of the MHA.

“I’m not sure if I would have ended up doing social work if it wasn’t for Think Ahead. The mental health aspect was huge for me.”

Sonya Chee has just completed the Think Ahead programme. Following two years of intense academic training and on-the-job learning, she is one of a group of almost 100 first cohort participants who have recently secured permanent positions within mental health social work.

Working in an early intervention in psychosis team in Hackney, East London, Chee says she is “really happy” to be operating in such a diverse community where she is able to “do something meaningful”. Yet Chee, who graduated from university with a degree in psychology and neuroscience, was not always destined for a career in social work.

Before enrolling on the scheme, Chee worked for the Royal College of Psychiatrists’ research and audit department, but admits she found it “difficult to see the direct effect” of her work. It wasn’t until after volunteering at a refugee and asylum seeker healthcare clinic, and discussing the rewards of frontline work, that she first unearthed a desire to get involved with social work.

“I was speaking to my friend, who is a psychologist, and I was explaining to him that I enjoyed mental health; thinking about the psychology of people and how I really enjoyed the [volunteering] role. He said to me, ‘it sounds like you want to be a mental health social worker’, [but] I didn’t even know what that was – a profession, a career?”

“So, I Googled ‘mental health social work’ and Think Ahead came up. It was about a year and a half before they launched the applications, so I started reading more about it and then waited for [the programme] to open to apply.”

‘Hard to conceptualise’ until on placement

Heading into the scheme, Chee says she was unsure of what to expect from a career in mental health social work despite having read around the subject: “Social work is all about supporting people with their needs, providing the holistic style of care and advocating for people’s rights. I think all those things are quite vague until you see them in practice, so it was quite hard to actually conceptualise what it would be until I was in the placement.”

Starting with a six-week residential course in Leeds, in which participants receive academic training on mental health and its legal and policy framework, Chee knew she had to hit the ground running with only a matter of weeks before she started her first-year placement in a community mental health team in Hackney.

During this time, Chee helped to support people with longer-term severe mental health conditions, such as schizophrenia and bipolar disorder. This involved working with people who were well enough to be out of hospital, but needed additional support.

“I was with [the team in Hackney] for a year, with the other three people on my unit. By the end of the placement, I think we had a caseload of about ten people each. During this time, we had to do placement support, direct observations and write academic essays. We also had teach-in days and we had a lot of reflective sessions.”

“At the end of the first year, we all got twelve-month contracts for the next year as full-time care coordinators. Three of us got placed in Hackney and one of us got placed in Newham.”

Accelerated learning

For Chee, the fast-track scheme was a perfect opportunity to switch career path and make and make an impact quickly. For this reason, she says learning at an accelerated rate suited her.

“One of the things that frustrated me about university was that I spent a lot of time not being that productive, learning something and then doing an exam on it six months later and forgetting everything – that’s just not the way I function.”

“I think when you’re a career changer like me, I wanted to change jobs as quick as possible. I didn’t really have the time or finances to go back for another three years, start over again, get a loan and get into even more debt.”

Speaking about the achievements of the first cohort, Think Ahead’s co-chief executive, Natalie Acton, tells Community Care about how the intense nature of the two-year scheme appeals to some.

“The fast-track element of our profession offers people the opportunity to very quickly make an impact… for people who have just come out of university, and don’t necessarily want to spend another two years in the classroom, it’s an ideal opportunity to learn on the job while getting academic training.”

Acton adds she has been delighted at how the scheme has been able to attract candidates who possibly would not have considered a career in mental health social work before finding Think Ahead. She says this is particularly relevant in the current climate, with Skills for Care predicting an 650,000 extra jobs will be needed in the adult social care sector by 2035.

“One of our aims as an organisation was to bring in mental health social workers who would not have considered it [a career]  – and nearly 95% of our cohort have not applied to social work via any other route, so we really are capturing people who wouldn’t have thought of it otherwise.”

‘Relentless’ but ‘well-supported’

Like Sonya, Alex Botham has enjoyed the fast-paced nature of the government-funded programme. Botham, who is currently working in an older adults’ mental health team in Brighton, says he’s got “a huge amount” out of the programme after joining in 2016.

“I think it’s been a hugely developmental couple of years for me. I think you have to learn things very quickly and pick things up. It’s been a bit relentless maybe – quite fast-paced – but I’ve felt quite well supported.”

“One of the real draws of Think Ahead for a lot of people is how quickly you are on placement and spending time directly with people. You’re learning through practice and reflection very early on in the course.”

Studying philosophy, politics and economics at university, Botham says applying for the programme “felt like the right fit” after completing a course on social innovation with Year Here. In particular, he says the scheme’s focus on mental health social work was particularly import to him.

“The thing that really appealed to me about Think Ahead was what it’s doing in terms of mental health services, bringing a social work understanding of mental health, pushing against that medical model and how we think of people’s wellbeing. That mission is really valuable and a large part of why the course appealed to me.”

“For a lot of people, it’s good to be able to focus on mental health and I think that allows you to get some really specialised teaching and learning in regard to that,” he adds.

Reflective supervision

During the first year, Botham had the opportunity to work in two mental health teams. During his first placement, he worked in an older adults’ team, which focused on mental health diagnosis. He says this gave him the chance to work around dementia, unlike a lot of placements which “focus on more traditional care working”.

Often dealing with complex, emotional situations, Botham says he looked for support during the programme from his team and tutors. In particular, he highlights the importance of having reflective supervision. This is where participants share their experiences and talk about how they have been affected by cases they have found particularly difficult.

“Having regular time with another social worker to reflect on the experiences you have and your emotional reaction to things [is important]. It gives you a bit of space to process that and work through the experiences that were brought up for you and why they affected you in the way they have.”

“Part of the competency to do this work is to have that emotional ability, you are going out and empathising with people and to be able to do that you have to be able to emotionally present. If you are worried about other things or stressed about other things, you can’t do the job properly.”

For Chee, her fellow participants were there to support her during the two years. Those who enter the programme are placed in a unit with three other participants, which is led by a consultant social worker.

Chee explains the benefits of having this support system: “The unit set-up is one of the best things about Think Ahead because you immediately have this support group that are going through exactly the same thing as you are. I imagine it may be a bit more difficult if you don’t get on, but we all got along really well and that was invaluable for me – I needed them throughout the year.”

Support from peers

Appreciating the challenging nature of mental health social work, Acton says Think Ahead has worked to ensure participants are well supported throughout the scheme, with access to a consultant social worker, tutor and other experienced social workers.

She says the scheme has also received positive feedback about its decision to allocate participants into groups. “We’ve found that the participants have really appreciated the support they get from their peers as well as their consultant social workers and their academic tutors.”

“What we look for when we are recruiting participants is motivation and an adaptability. We really want people who are able to look after themselves during the process as well as looking after those service users that they work with.”

Perhaps one of the most challenging parts of the scheme is the second year as students juggle their caseload, the Assessed and Supported Year in Employment (ASYE) programme and a research master’s. degree

During her second year, Chee was placed in an early intervention in psychosis team and looked close to home when thinking of a topic for her thesis. “Within our team we were doing a quality improvement project on trying to reduce the number of black men under our service that are readmitted to hospital. So, I tied my research project into that.”

‘Evidence base’ for mental health social work

Acton says the programme is doing more than simply producing mental health social workers.

“One of the things that we set out to do was not only to recruit and retain fantastic people into the social care profession, but also add to the evidence base for mental health social work, and we were just so gratified to see this fantastic range of incredibly high-quality academic theses on mental health social work.”

Now having finished the programme, Chee offers her advice to other participants on the Think Ahead scheme, who work in the same office as her. She said she would be keen to do some tutoring work in the future.

“Don’t take on too many things, don’t take up too much stuff in that year. Give yourself a break and, at the same time, make sure you are giving yourself the time to do exercise or other things to relax.”

With a permanent contract in an older adults’ team, Botham says he plans to stay where he is for the foreseeable future. He shares that he would like to gain some experience working in different areas of practice in the future. “But I’m in no rush to go anywhere.”

“Different courses will be right for different people in terms of what they want to get out of it, but the thing to consider, and the specific things in Think Ahead, are a focus on mental health and the intensity of the course. But if those things are what you want, then it’s a great thing to do.”

There is “no evidence” that professional misuse of the Mental Health Act (MHA) is a factor in the growth in detentions in recent years, the Care Quality Commission (CQC) has found.

The regulator’s review of detentions under the Act did find that staff in wards caring for older people, many of whom have dementia, had “turned increasingly” to using the MHA. This was due to long delays in visits from assessors to grant authorisation for hospital stays under the Deprivation of Liberty Safeguards (DoLS).

There had also been a “shift in culture to avoid de facto detention” in all services, the CQC said, and the 2014 Cheshire West Supreme Court ruling on deprivation “may have sharpened” a “steady decline” in informal patients – those who are in hospital voluntarily – in recent years.

The review said that every patient on some older people’s wards was detained, and some areas reported that 80% of patients on acute wards were now detained.

The number of detentions in England under the Mental Health Act increased by 40% from 2005-06 to 2015-16, to 63,622.

The CQC said this could be because more people with severe mental health problems were living outside of hospital settings as bed numbers have fallen, placing them at greater risk of being detained.

It also suggested that admissions, which could have been preventable in the past, are not being prevented because less restrictive alternatives in the community are not available.

No ‘gaming the system’

It found “no evidence that professionals had been misusing the Mental Health Act in any way”; such as attempting to “game the system” by detaining people who do not meet the criteria so that they could be guaranteed an overnight bed in hospital.

There would be a rise in the number of successful appeals against detention if people who did not meet the criteria were being detained just to obtain a bed, the regulator said, but data from the First-tier Tribunal (Mental Health) showed no such increase.

The report was based on a review of available data, visits to eight NHS trusts, two independent mental health service providers and 23 local authorities, and conversations with patients and representative bodies.

Risk culture

Patients attributed increases in detention to  “a culture based on the level of risk the person poses to themselves and others, rather than a culture that focuses on their recovery”, as well as a lack of 24-hour practical, face-to-face help.

Some professionals “thought it likely that some of the increase in uses of the MHA reflect a trend towards repeated, short periods of detention for treatment for some patients, who in the past might have experienced fewer but longer hospital stays”. They said this could be due to “pressures on beds causing premature and inappropriate discharge”.

However, the CQC added, repeated admissions “might represent good practice” for some patients and “the less restrictive alternative to prolonged stays in hospital”.

The overall increase in detentions, and the fact that people from Black and minority ethnic groups are much more likely to be detained than those from White British groups, prompted the government to launch an independent review of the MHA last year.

It is chaired by Professor Sir Simon Wessely, a former president of the Royal College of Psychiatrists, and is due to report by autumn 2018.

Health system ‘under strain’

Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals (lead for mental health), said some of the factors behind the rise in detentions were “also signs of a healthcare system under considerable strain”.

“Detentions under the Act can be influenced by gaps in support and provision in the system,” he added.

“This includes limited hospital bed availability, which means that people cannot easily be admitted as voluntary patients early in the course of their illness. This is a particular problem if it is coupled with limited support for people in the community, which can prevent a person’s mental disorder from deteriorating to a point that detention under the Act is necessary.”

He added: “Changes to the law must happen alongside action to address the wider problems.”

Professor Wendy Burn, president of the Royal College of Psychiatrists, agreed there were “limitations” to relying on legislative change to reduce detentions under the MHA, and said the report was “further evidence that declining access to community services is leading to more people reaching mental health crises”.

She added: “The government is right to look at why detentions under the act have risen and why some ethnic groups are detained more often than others in the Mental Health Act Review. But they must remember that the best way to prevent someone being detained is to prevent them from falling into a crisis in the first place; to understand that poverty, poor housing and poor physical health impact on a person’s wellbeing and psyche.”

People in deprivation of liberty cases could have their rights safeguarded by an expert report on their best interests if no one is available to represent them, a judge has ruled in a move that could help clear a backlog of more than 300 cases.

Mr Justice Charles’s decision states that in applications to deprive a person of their liberty in care arrangements in the community to which they cannot consent, it would be lawful to direct a Court of Protection general visitor to report on their best interests if no friends, family members or professional advocates are available to represent them.

General visitors are Mental Capacity Act experts who the Court of Protection can commission to visit the individuals and agencies involved in deprivation of liberty cases and report back their findings.

The option of using general visitors could enable the Court of Protection to proceed with at least some of 330 deprivation of liberty cases that have been put on hold due to a lack of representatives for the individuals concerned.

‘Short-term’ fix

But Mr Justice Charles warned that this option – put forward by the government – was no more than a ‘short-term’ fix to the problem of ensuring individuals in deprivation of liberty cases have their right to liberty under Article 5 of the European Convention on Human Rights protected.

He said this is because the Ministry of Justice has failed to clarify any details about the extra resources it said it has given the courts service to support the use of general visitors in this way, including the amount of money and how long this money would be available for.

Despite his concerns about the sustainability using general visitors, Mr Justice Charles concluded that the Court of Protection should take up the option of using general visitors “for as long as it is available in practice” so that halted cases could proceed.

‘Cheshire West’

The problem of safeguarding the Article 5 rights of people who may be deprived of their liberty has been mounting since the Supreme Court’s 2014 ‘Cheshire West’ judgment, which effectively lowered the threshold for what counts as deprivation of liberty.

The judgment led to a surge in cases concerning deprivations of liberty outside care homes and hospitals, which require a Court of Protection order. In 2013 there were just 109 such cases, in 2016 there were 3,143.

In cases where the service user is not a party to the proceedings, the Court of Protection rules provide for a representative to be appointed on their behalf to report on their best interests. These representatives, known as Rule 3A representatives, would typically be a family member, a friend or a professional advocate.

However, the surge in deprivation of liberty safeguards cases, along with the introduction of Care Act advocacy in 2015, has dramatically reduced the capacity of advocates to take on new work and in some cases the service users have no friends or family who can become their Rule 3A representative.

Deprivation of liberty safeguards

This lack of Rule 3A representatives led to a 2016 decision by Mr Justice Charles on four test cases where deprivation of liberty authorisation was sought despite the lack of a Rule 3A representative on the grounds that the application was not contentious.

In that decision Mr Justice Charles ruled it would be unlawful for the applications to proceed and that it was the duty of central government, not local authorities, to find a solution to the lack of safeguards for the service user due to the lack of a Rule 3A representative.

He then put the four cases on pause and made the government party to the cases to prompt ministers to come up with an answer to the problem. Since that decision the number of similar cases on hold has risen to around 330.

General visitors

In April 2017 the government proposed using Court of Protection general visitors when no Rule 3A representative was available and said it had provided additional funding to the courts service to enable this option to be used, prompting Mr Justice Charles to re-examine the four cases.

He concluded that using general visitors in this way would comply with Article 5. General visitors would fulfil their safeguarding task by producing a report for the court under section 49 of the Mental Capacity Act.

This report, said Mr Justice Charles, should examine whether a person had capacity to consent to the care package, his or her attitude to the care package and whether he or she wanted to play a part in the proceedings. The report should also explore whether the care package is in the person’s best interests, whether a court hearing is required, and whether the restrictions in that package are inappropriate and should be changed.

However Mr Justice Charles criticised the government’s lack of clarity on the extra money it was providing to fund the use of general visitors in these cases. “I have concluded that the present offer of resource is not likely to provide anything but a short-term solution,” he said.

Pass the parcel

Mr Justice Charles also criticised the government for attempting to push the responsibility for addressing the shortage of Rule 3A representatives back onto local authorities in a October 2017 submission to the court.

“I am sorry that I have to conclude that the evidence in these cases shows that it can be expected that history will repeat itself and the Secretary of State will persist in taking an avoidant and unconvincing ‘pass the parcel’ approach to the problems, which he has a statutory duty to resolve alone or through a constructive approach with the local and other public authority applicants,” said Mr Justice Charles.

Responding to the ruling a government spokesperson said: “We note the judgment and are considering it carefully.”

The government declined to answer Community Care’s request for details about the extra funding to enable the use of general visitors in deprivation of liberty cases where no Rule 3A representative is available and that it would only consider releasing the information after receiving a request under the Freedom of Information Act.

Indefinite waits

Christina Blacklaws, vice president of the Law Society, said: “The judgment shines a light on a largely hidden area of our justice system where people suffering from dementia, Alzheimer’s or a learning disability wait indefinitely for their cases to be heard because of a lack of funding for representation.

“The 330 stayed cases at the Court of Protection represent a fraction of the thousands of people around the country who we believe are being deprived of their liberty without proper judicial oversight, in contravention of their rights under the Human Rights Act.

“As Mr Justice Charles makes clear, the state can no longer abdicate responsibility for providing funding – either to local authorities or to the Ministry of Justice – to protect some of the most vulnerable people in our society.”