information about the UK situation then I also have a point to make
about the implementation of government policy and using measures to
ensure the policies actually do something. Please bear with me because I
have a tendency to ramble on a bit.
Just some information. It's relevant to what E said.
Most of the legal work directly related to the medico-legal framework is
to do with Mental Health Review Tribunals. These do not follow the
adversarial system of law. There is no judge or jury per se. There are
three people on one of these panels in my personal experience. A lawyer,
a doctor and a lay person. The patient can also request a lawyer be
provided for them and this is funded by the government and will continue
to be funded by the government after the cuts to the civil legal aid
system. These tribunals are there to challenge the decision to use a
section of the Mental Health Act. My personal experience is having a 5
minute interview with a South Asian doctor who was the medical person on
the panel. During this interview he made reference to my ethnicity while
there was a nurse in the room. He said something like this wouldn't have
happened to me (being sectioned or being mentally ill) had I stayed in
Sri Lanka. (I think he said it to try to make me angry) In 5 minutes he
could not know whether I was mentally ill or not.
The IMHA and IMCA patient advocates are not required to be trained
lawyers. From a couple I've spoken to they are constantly fighting the
power of psychiatrists. As far as I am aware they have no power themselves.
The 2007 amendments in the Mental Health Act 1983 and the Mental
Capacity Act have some good and bad points. The negative points are the
introduction of the Community Treatment Order. This force a person to
take medication in the community. In the first year it was overused 10
times more than expected. It is also disproportioately used on black
people who are also sectioned more and diagnosed with schizophrenia more
than the average. They're dosed with higher levels of medication and
have chemical restraint used more often too. The UK and the US are
responsible for significant levels of overdiagnosis of schizophrenia in
black men compared to their white counterparts. This doesn't happen in
the Caribbean. (If anyone needs an example of how mental illness isn't
an illness but is a form of enforcing cultural norms using the paradigm
of a medical illness then this one is pretty good). The evidence showing
the use of antipsychotics in dementia patients reduces life expectancy
by 50% (reference available on request) and cases of
antipsychotic-induced agranulocytosis in drugs other than clozapine mean
I can say this is reducing black people's life expectancy and causing
physical illnesses as a side effect of enforcing cultural norms.
Anway, the amendments also simplified the definition to, in lay terms,
pretty much whatever we feel like considering a mental disorder. The
treatability test was also removed. This got rid of the need for
treatment to be available I think. People with intractible personality
disorders could be sectioned without treatment. The motivations are
explained in an article in the British Journal of Psychiatry.
Essentially the law was changed to hospitalise under section people with
"dangerous personality disorders" who may commit serious crimes (and I
think this means homicide). This means a person can be incarcerated
without treatment and without justice. There is only the judgement of
risk by a psychiatrist which means society's greatest punishment,
deprivation of liberty, can be used on a mentally ill person who has not
actually committed a serious crime. In my opinion. And I don't know if
it's been used in this way but I've informed one the UK's leading mental
health charities about the potential risk of punishing the innocent.
Sadly they're often as useful as used toilet paper at campaigning about
things like this.
http://bjp.rcpsych.org/cgi/content/full/180/2/110
J - I know you're an expert in the area of race and user research. I
think there's an important point I'd like to make which sort of ties in
with something you said.
Measures are important. I understand that these are very difficult to
make and Jayasree makes a point about the definitions of race and
culture, identify and labels. They're difficult to simplify into things
which fit in boxes of understanding. However without these concepts and
labels it is impossible to use a scientific approach or communicate.
What I mean specifically is the use of evidence to show something works
with respect to decisions and implementation of policy.
I used to work in children's social services in the UK in performance
management. They're leagues ahead of adult mental health measures. They
use a system called the Balanced Scorecard approach. Essentially it uses
a a spread of measures combined and weighted to provide a performance
assessment. The scorecards take time to develop to get the weighting and
the measures right. These can be combined into a simple measure of
overall performance and there are ways of making this visual information
like a speedometer dial. Essentially the system is an Anglophonic
version of the French system which I believe is called Tableau du Bord -
the dashboard. They've been using it since the mid-20th century but the
Balanced Scorecard approach is based on a book published by Kaplan and
Norton in the early 1990s (called the Balanced Scorecard Approach if I
remember right).
It provides proof that something is working. It is a management system
which allows decisions to be accountable. In the New Horizons mental
health strategy consultation they proposed using this approach for the
BME 'problem' but the strategy was scrapped then some of it brought
back. I'm not sure whether the balanced scorecard survived.
In children's social care one of the measures was how often a child
moved. If they moved more than 2 times a year on average in any area
this could affect the council's star rating which affects their funding
and freedom. This was one of for performance indicators which carried a
very high weighting.
The problem is this is an averages based approach. It is one which
dominates. It fails because of the worst case. What I mean is we have to
protect those who have the worst experiences and average-based measures
don't do this. They're useful for a general picture but, in the case of
children's services, they didn't protect the child who'd moved 14 times
in a year nor tell their story in the data which senior managers and the
government use for their reports and performance management.
They are also exclusively quantitative in the social care data returns
five years ago. I've had the experience of, briefly, being in a
children's home and a foster home when I was a child. I was lucky. I
could have ended up in a psychiatric ward. The experience taught me that
numbers don't tell the whole story. I'd have to go through response
forms from the children in my job. The government just wanted the kids
to tick boxes and that's all I could record for them. The children also
wrote things outside the tick boxes. "I just want to see my mum" for
example. I made sure the senior management team saw all of those
responses even though I couldn't include them in the data we supplied to
the government. Any system of measures needs this sort of information
too. A human's experience is not communicated in tickboxes and graphs.
Essentially any measures system used would be worth basing on the
balanced scorecard approach idea. It can be modified and it's very good
for 'soft' concepts like the life outcomes of a child looked after by
the state. By linking performance on a framework of measures to funding
and freedom it sort of has the health and social care system by the
balls. (Please excuse my language but I feel slang can be highly
communicative). There needs to be a qualitative component too. It's
important to include measures of worst outcome as well as averages. No
matter what the label of disability or difference I feel it is vital
that the worst off be protected and protected by these systems which
provide information on performance to the highest echelons of power and
make them accountable.
--
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http://www.justice-for-all.org.uk/
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