‘Is anyone in the red zone’? The question is asked each and every day at Lambeth’s forensic community mental health team’s staff meeting.
It refers to whether any of the team’s 154 forensic patients are showing signs of posing a danger to themselves or the public. These are people whose enduring mental health conditions have been linked to them committing offences of varying severity in the past, who are now (where possible) supported in the community.
“There may be symptoms or behaviour that suggests someone may need to be brought in quickly, such as someone expressing dangerous thoughts or ideas that they want to harm somebody,” he adds.
Risk and recovery
This dilemma of trying to do everything possible to help people stay well in the community while staying alert to any risk to public safety is what these social workers, and their nursing colleagues, face every day in their roles as care coordinators.
It’s no easy feat. Social worker Lorraine Spence explains that these care coordinators have seen “everything you could think of”, ranging from compulsive shoplifters to people who have committed violent and sexual offences.
“There are sex offenders, paedophiles, people that are deemed to have untreatable psychopathic disorders. We have seen people that have killed or committed violent offences, things like theft, armed robbery,” says Spence.
“Forensics is a whole different side to mental health. Sometimes people who come into it without experience can be shocked by what you read about people from all sorts of backgrounds. Anybody can become unwell.”
The community team sits within the South London and Maudsley NHS Foundation Trust (Slam). Most clients come to them after being discharged from River House, a medium secure unit at Slam’s Bethlem Royal Hospital. Some will previously have spent time at Broadmoor high-security psychiatric hospital.
‘You don’t know what someone has gone through’
The types of offences involved in some cases could see people bluntly demonised as ‘monsters’ in the two-dimensional world of the tabloid press, but social workers take a more holistic view.
Their job is to look at the person as a whole, not their offending or illness in isolation, and, as one of the team tells me, cases involving even the most serious offences are “rarely black and white”.
“The press doesn’t give people a balanced view. You don’t know what a person has gone through. When I read some histories, you see what someone’s parents did to them, what they were exposed to and it can be horrendous,” says Spence.
When she started in forensic social work, Spence made a point of meeting or contacting a client to get to know them a bit before reading their full offending history.
“I used to work in probation and there was one incident where I had to find accommodation for a serious paedophile and, to be honest, being a mother I found it really difficult. So when I went into forensic social work I decided I would take the person as I found them, meet them first, and then read their full notes afterward,” she says.
Paul Mukasa has been a social worker on the team for a few months and previously worked for five years at Broadmoor. He tells me it’s easy for people “to be influenced by what you read in the papers” and admits his wife often asks him (“using language I don’t want to use here”, he laughs) why he chooses to do this branch of social work.
“When you go into social work you want to try to help people. Some of these guys come from very dysfunctional families, some of them are very ill when they’ve committed an offence. That could happen to you or me,” says Mukasa.
Being a care coordinator
So what does being a care coordinator in this team involve? Mukasa explains that a lot of the role is about supporting people to access and link into community resources – employment support projects, community groups and the likes – alongside assessing various risks such as the likelihood of someone relapsing, reoffending or taking their own life.
There’s plenty of paperwork too, including Mental Health Tribunal reports, Care Programme Approach documentation, the HCR-20 forms that assess the risk of someone committing a violent offence. The team also have to provide regular updates to the Ministry of Justice on any clients who are on restricted discharge under Section 37/41 of the Mental Health Act.
Working with police and other agencies, including children’s social services, is also key. For example, tricky cases where patients with a violent or sexual offending history want to negotiate access to see their young children often demand input from multiple agencies.
“We might make a judgement about a person’s risk but child protection social workers might not always trust it or agree with it,” admits Mukasa.
Another element of the team’s work is engaging with patients’ families, explains social worker Yuk-King Wong. She says that people faced with the, often quite daunting, move from a medium secure hospital back into the community are “going to need their support mechanisms”.
“That can be very difficult. Families or relatives have to go through a process themselves if one of their relatives has done something that is quite hard for them. It could be anger, it could be shame, it could be guilt,” says Wong.
“And also, we have to go through a process with our clients to find out where they’re at in terms of their rehabilitation. A lot of the reasons people are in forensic mental health is because they have committed crimes when they were unwell.”
“So when they have been stabilised in their mental health they have to go through a process of realising and acknowledging that they have done something quite horrible when they were unwell so that’s another realisation for them to adjust to,“ she adds.
Rewards of the job
So what is the best part of being a forensic social worker?
For Aimee James, one of the team’s social workers, seeing people who have spent large parts of their lives in psychiatric institutions be supported back into life in the community is particularly rewarding.
“You’ve worked with someone’s family, their carers, their support workers and eventually you see them progress through the system and in a couple of years they’ve got their own flat. I think that’s one of the really positive things,” she says.
Wong says similar, and tells me that seeing one client who spent over 40 years in secure institutions “thrive” in the community has been a high point.
Inevitably, when discussion turns to the hardest parts of the role the unrelenting squeeze on both NHS and local authority resources crops up again and again.
The care coordinators’ caseloads are increasing as part of the NHS-wide drive to close psychiatric beds and shift more care into the community. At the same time the team’s capacity is falling. Spence’s social work post will not be replaced and, when I visit, a nursing vacancy needs filled. Access to occupational therapist and psychologist time is also patchy (the team used to have a part-time OT and full-time psychologist).
Some team members are concerned that the pressures to free up beds – an issue across England – is leading to some people being discharged too quickly only to end up back in hospital weeks later. Others feel their increasing caseloads have seen opportunities to do real community-based social work with clients overtaken by the risk management side of the job.
Social work manager Wilde tells me that this is the “toughest time” he’s experienced in terms of the resources (or shortage of them) available.
“The message from government about ‘doing more with less’ really has hit home,” he says. “We’ve got to try and work out how we deal with that. As part of a wider management team we’ve got to work out what we prioritise. One thing that is really important is that we have the staff to deal with the pressures.”
Wilde says that senior management at the mental health trust “recognise we’re an important part of the service” and says discussions are underway to try and resolve some of the issues the team is facing.
Various “exciting projects” are also in the pipeline such as a social-worker led initiative looking at placement options for challenging patients and some promising work with charities and housing associations, he adds.
“In many ways I feel inspired by the team and the way discussions are going about what the NHS and local authority would like to do with it,” says Wilde. “But everyone is waiting for changes to happen and not just have all of these good ideas on a board. They want to know that the cavalry is on its way.”
Andy McNicoll is Community Care’s community editor