Sorry, not my department

A chronic medical condition caused mental health problems for a middle-aged man but his multiple needs did not fit into any service categories. Social worker Tom Mahoney tells Graham Hopkins how he tried to tailor a solution

CASE NOTES

PRACTITIONER: Tom Mahoney, homeless/mental health social worker.
FIELD: Mental health.
LOCATION: North London.
CLIENT: George Dyson lived alone in a council tenancy, had chronic and acute psoriasis for 30 years which regularly led to lengthy hospital admissions.
CASE HISTORY: Dyson had built up a dependence on hospitals, their staff and treatment regimes. Although some of the topical treatments could be self-administered, he often failed to carry out this. When the condition became active, he experienced secondary symptoms of depression, paranoia and confusion. He used alcohol as a means of symptom control. He had no family nearby or friends and was isolated in his flat, which he allowed to deteriorate to such an extent, that environmental health was alerted. It was clear, given the poor hygiene conditions and his self-neglect, that Dyson was unable to maintain either himself or his property. He was referred to the homeless/mental health worker, and was admitted into a specialist skin ward, where he remained for six months.
DILEMMA: Although he identified residential care as a positive choice, his failure to fit into a “client group” seemingly prevented this.
RISK FACTOR: Dyson’s inability to secure a suitable placement and the withdrawal of funding for nursing care left him vulnerable.
OUTCOME: Having found accommodation and a stabilising routine, Dyson’s condition worsened following forced changes to his routine. He died of a heart attack shortly afterwards, aged 58.

Despite social work values of respect, individual worth and empowerment, we still rely on labelling people and pigeon-holing them into services. We can help you with your paranoia, but your drugs and alcohol use? Not us, I’m afraid, that’s someone else.

Many people have complex and multiple needs: not just a single need that can be conveniently categorised. The result is there is no net with which to catch them. People such as George Dyson, who with a psoriasis (an incurable skin disorder) so acute that it affected his mental health and his ability to care for himself, had spent six months in a specialist skin ward after being removed from his council flat because of environmental health concerns.

“Upon his discharge it was agreed with George that he was unable to fully care for himself and was becoming increasingly vulnerable,” says Tom Mahoney, a homeless/mental health social worker at the time but now part of the assertive outreach team. “He dismissed home support and care packages. He knew what he wanted: he wanted nursing care. He was clear about that.”

However, several care homes were reluctant to take Dyson. “This is where difficulties started,” says Mahoney. “He didn’t fit into any specific client category: he was too young for older people’s services, he didn’t meet the criteria for physical disability services, he wasn’t diagnosed as having a mental health issue and there was no specialist provision to cater for psoriasis and its psychological impact.”

When a care home was found, the placement soon broke down after disagreements with the manager. Dyson then spent a further lengthy spell in the specialist skin hospital. Another nursing home was later found and for two years, with health care support, he did not need a hospital admission. However, this placement also broke down.

Mahoney says: “George began to have disagreements with the manager and wasn’t happy, not only with the care he was receiving but also with the way his fellow residents were looked after. George was forthright in his views and made several complaints to me about this in which investigations were completed. Eventually, despite all our best efforts, he was evicted.”

The team moved quickly and placed Dyson in temporary accommodation while the search for a more permanent solution continued. “It turned out to be one of the most suitable settings he had lived in,” says Mahoney. “It was a very busy hotel-pub in central London catering for business people and holiday visitors. George had his own room at the top of the building and got breakfast and evening meals.”

The staff became attached to Dyson and kept in contact with Mahoney. “They socialised with him and acted as informal carers ensuring he was ok and had everything he required to enable him to feel comfortable, secure and accepted,” he says. “We also registered him with a supportive GP. Given the location, he had easy access to his skin specialist and attended day hospital for skin treatments, so preventing relapse.”

Dyson began to take more control over his condition. Psychological work was also arranged to enable him to break down the stigmas people attached toward his condition. Mahoney says: “For two years he had no hospital admissions, was fairly mobile in getting around London, and he started to build up a social life. After many years of feeling isolated and stigmatised, his confidence and humour returned.”

However, events conspired to undermine all the good work. “His consultant retired and the day hospital was closed,” says Mahoney. “He was expected to make his own care arrangements through his GP. Despite using independent advocates and seeking legal advice, we were told this would not change.”

As a result, Dyson’s physical and emotional health deteriorated. He rejected injections, as is the patient’s right, to control his skin condition because he was not prepared to take the risks of possible side effects and internal damage. The final six months of Dyson’s life were thus spent in generally poor physical health. He died of a heart attack in his hotel room. “The staff at the hotel felt if the treatment regime could have continued the secondary conditions he suffered may have been avoided,” says Mahoney.

“They call it ‘patient choice’, but I believe convenience, cost and the desire for a low-maintenance regime to treat his illness outweighed anything that George himself would have chosen.”

Independent comment
It is tragic that anyone’s life should end in discomfort and disappointment with the services he receives, writes Tom Dodd.

There are well-documented relationships between acute psoriasis and environmental factors, such as stress, alcohol and trauma; there are National Institute for Clinical Excellence guidelines concerning treatment, and research would suggest it is often intractable and unpredictable. The risk factors in treating this condition are well known, and include hypertension and cardiac failure.

Where needs are complex – and combine psychological and physiological factors – the issue of which service or individual practitioner takes responsibility is central.

Yes, decisions are often made where cost is an issue, and individualised care and choice are worthy values. The reality of everyday practice often means that we have to be more creative. Second choices are not necessarily second best – Tom Mahoney demonstrates that, for at least two years, Dyson seemed to live a better quality of life, finding other more inclusive ways of achieving the safety and security that he needed.

How can this case change things in the future? Support and guidance for practitioners who are increasingly advocating within the systems they are part of would be constructive.

And for clients and their support systems? A transparent and open dialogue about what choice really means within service provision would be a good starting point.

Tom Dodd is national lead for community teams and co-lead for dual diagnosis, National Institute for Mental Health in England.

Arguments for risk