Written evidence from moMENtum Devon CIC (PCC0070)

HOUSE OF LORDS INTEGRATION OF PRIMARY AND COMMUNITY CARE SELECT COMMITTEE INQURY

 

 

 

 

3rd May 2023

 

To the Special Enquiry committee on the Integration of Primary and Community Care

 

 

I am making this written submission in response the call for evidence by the Special Inquiry Committee on the Integration of Primary and Community Care in mental health services.

 

I am putting this forward with the following experiences and knowledge base:

Devon Partnership Trust Trauma-Informed Steering Group , Psychological Therapies clinical reference group, NHS Pathfinder Project on sexual abuse and violence, Devon Trauma Network.

 

 

 

My representation and lived experience evidence concerns the gap in provision between primary care, Secondary care and community mental health services.

 

 

Key aspects I look to address the following based on your questions.

 


 

I will look at the different criteria for services leave people in gaps and how a siloed approach is only helpful for organisational boundaries but not for client need. I will explore how the lack of attention and understanding in relation to trauma is damaging to staff and clients and costly to the country’s economy. I will look at resistance to integration and new practice and show

examples of integration of care.

 

 

Does the current model secure parity for mental health provision?


 

There is a Gap in out mental health services between primary and secondary care with the consequence that we cannot ensure parity for mental health provision for all.

It is not new, it has been present for many years.

 

In terms of current service structure what is causing this gap ?

 

Here in Devon, Primary Care mental health support is largely provided by IAPTS, Talk Works. The focus is on mild to moderate anxiety and depression. It provides short term intervention through CBT counselling and EMDR. They can offer Hi intensity support to people with a single incident trauma event.

They are not equipped to work with people struggling with complex traumas that result from childhood abuse, where presentations are often complex, with difficulties with emotional regulation.

When originally established, the political driver of the IAPTS service was to enable people with mild to moderate anxiety and depression to get back to work. There was also intended to be a middle service between primary and secondary mental health to work with people affected by trauma but this was not enacted.


 

Secondary mental health services are there to work with people with severe and enduring mental ill health. They work largely on the basis of psychiatric diagnosis, e.g. Bi-polar disorder,  Psychosis. These are however considered by researchers such as Besel Van der Kolk, often to be signs of childhood abuse and trauma for many clients. They are presenting with symptoms of their struggle to cope with and their responses to, repeated trauma. In the Trauma and Adverse Childhood Experiences Study Head Start - Trauma and Adverse Childhood Experiences (ACEs), there is a clear link between childhood trauma and mental distress and physical ill health.

 

Children Who Experience Four or More adverse childhood experiences (ACE) are:

10–12x at greater risk for Intravenous Drug Use and Attempted Suicide

2–3x at greater risk for developing Heart Disease and Cancer

32x more likely to have learning and behavioural problems

8 out of 10 of the leading causes of death in the U.S. correlate with exposure to four or more ACE.

 

In England, childhood abuse and trauma are not criteria to be seen by mental health services.

People with complex trauma as a result of childhood trauma and abuse often do not receive NHS support.

 

Of the men we see at moMENtum, there are those who gain initial support in Primary Care but it is not sufficient or their issues are not understood or recognised. Sometimes they do gain support in a secondary mental health service but it is not trauma-informed or their abuse is not asked about.

The aspect I want to emphasis in relation to this inquiry, are the people who fall into a gap at the interface of services.

 

Is there mental health support for all on the NHS ? Who misses out and why ?Is the current primary care mental health support model fit for purpose and servicing the needs of patients?

 

This is an excerpt from a report sent to moMENtum Devon CIC by the local primary mental health service:

 

3.1: The following groups of presentations are seen regularly at assessment within DAS but do not fit within our inclusion/exclusion criteria nor do they meet the criteria for step 4 ( secondary mental health criteria).

1. Emotional Instability/emotional deregulation: This is the primary group – people who often present with high levels of distress, have fluctuating mood, and are often impulsive around harm to themselves . They may have anger/violence to others, or impulsive self-harming or suicidal behaviour, often in response to social/family stressors. However they are not considered to have a personality disorder so are not see by step 4.

• 2. Complex Trauma, with no current risk: People who have abusive childhoods, and are presenting with this as the main issue, and with symptoms of PTSD in relation to the complex/type 2 trauma. No clear risk issues and functioning reasonably well in adult life. This group of people would not be able to access step 4, as there is complexity, but not significant risk.

• 3. Instability, not yet ready for psychological therapy: People who present with very recent acts of significant self-harm or suicidal actions, often precipitated by some instability within their life circumstances. This group of people is not yet stable enough for DAS, nor are they necessarily complex presentations for step 4.

. • 5. Anger Difficulties: GPs often request anger management; anger in itself is not a diagnosis. Many of the people, often men, who present with anger difficulties, do so within the context of general emotional instability, so would fit with group number 1 or who have a complex PTSD presentation as in group 2. unless there was a significant risk to others. The above presentation groups of emotional instability, complex trauma and not yet stable for a psychological intervention frequently overlap. Patients are seen often within Liaison/Crisis or MHAT, but their difficulties do not reach the threshold for a severe and enduring mental health difficulty. 4. Recommendations: Within the groups of presentations described, the first three groups are the most common in presentation to DAS. There are treatment approaches and protocols which would be helpful and effective. Currently the workforce within DAS is not resourced trained and competent to provide these approaches. The remit of DAS as an IAPT service, is seeing people with a mild/moderate common mental health difficulty. In order to address the gap in provision, it is important to identify the main groups, as above, and to explore evidence-based approaches to these difficulties. The groups described (especially groups 1 &2) often present with a degree of complexity and risk within their difficulties, which is on-going. As a result of this instability, they may require support from generic mental health services in order to access therapy. The gap in provision, should therefore not just be seen within the context of psychological therapy provision, but as part of wider mental health services.

 

The service does not classify yet as Trauma-informed or have a policy in relation to childhood sexual abuse. Yet one in four girls and one in six boys are considered to have been sexually abused in childhood. A recent audit I was involved in showed there is not a consistency of support with a disclosure of childhood sexual abuse.

 

Here are some case histories from men we see at our survivor support group, in relation  to the interface with mental health services. Names have been altered.

 

 


One person I advocated for was considered suitable for support by the Community Mental Health  Team by the Assessor that saw him a Senior Mental Health Practitioner and a Psychiatrist. However he  was turned down for support without explanation. He was struggling, living in a mess, often in terror, even hiding under his bed and was having suicidal thoughts. Finding it hard to regulate his emotions, a call to police by a concerned individual led not to mental health support but a night in police cells. Locked in a room as he was as a child waiting to be sexually abused, triggered the trauma again. A few weeks later, in a phone call from Secondary care, I was informed that whilst it was acknowledged he had complex trauma, he did not have a serious mental health condition. I was told by Primary Care however, that he was not stable enough to be seen.


 

Glen, as a child, was taken away from his family due to poor care and violence. He was placed in children’s homes where he was regularly beaten and sexually abused by various staff over the years. His GP referred him to Talk Works in Primary Care. His issues and level of sexual abuse were considered too complex for their service and he was referred to secondary mental health. He had to wait many weeks to be seen. The people assessing him did a timeline, asking details about his abuse. Not knowing these people, he found it retraumatising and exposing. This was all writing down and sent to him and it was explained he did not meet the criteria for the service but he did have support from moMENtum and he was given contact details for the Samaritans. 


 

Peter had suffered extreme sexual abuse at the hands of a priest as a chorister at school. Later in life his struggles became so acute, he was no longer able to continue work. The fears from his abuse were so profound he suffered terror after he had disclosed, fearing what might happen to him. This had no basis in what was happening currently but were from the threats he had received as a child. Peter turned to help from moMENtum and we have been supporting him over four years now. It’s been a gradual process that’s needed much care and a gentle pace. We were Peter’s only support. He had started EMDR counselling in a Primary care service in relation to his traumas for ten sessions, a relatively short period for such complex work. After five sessions, it was decided he was disassociating so badly that the counselling had to stop. NICE guidelines state only single incident trauma is suitable for EMDR in primary care. He then had to wait to be seen by secondary care but was turned down. There was not consistent care and support for Peter and the rejection by services was then an additional area of support we had to work on with Peter.

 

John suffered a mental health breakdown following the sexual abuse of children in his care at a boarding school by two other staff. He had himself been sexually abused as a child and had never told anyone. His mental health declined and he received psychiatric support but when he moved to a different area of the country, despite psychiatric admissions, he was told he did not meet the criteria for secondary mental health support and was too complex to be seen by primary care . He was left on psychiatric medications but given no service.


 

Jim had been seen by secondary mental health services due to Psychosis.

He had been receiving support for childhood sexual abuse by a relative including therapy. However  he was attacked in the town and he felt helpless and vulnerable. Nightmares and panic attacks started again and his mood swings made it difficult for his family to cope. His GP made two referrals; both were turned down without seeing Jim. The  GP was also concerned his psychotic medications needed altering but felt that need to be done with the expert knowledge of a psychiatrist. This was refused, even though it was first prescribed by a psychiatrist. In desperation Jim’s family paid for a private psychiatrist who indeed found his medication did need altering due to adverse effects and was alarmed that he had been refused mental health support.

 

These are the people we support but no NHS funding comes with this and we have to raise the funding ourselves. We have received temporary funding form the National Lottery, MoJ and OPPC. we have to operate on a shoestring at times and are unable to grow to meet increasing demand, despite the interest and praise we receive from services.

 

Mental health provision is suffering from acute lack of capacity can integration and working together change this. Can we use the funding differently ?

 

The concern here is that these problems are well known, as is the need for trauma-informed services geared to help people heal. However, we continue to see people assessed and often labelled with a disorder but left without further support for recovery.

This creates a burden on third sector organisations and charities such as moMENtum as people are increasingly referred to us with the lack of NHS support.

The CSA centre have recently released a report about this, Challenges with Meeting Demand

 

The lack of attention and understanding in relation to trauma is damaging to staff and clients and costly to the country and economy and the difference it can make. It has a detrimental impact on staff trying to work with trauma with a lack of resources, trauma informed leadership and high case loads causing burnout and vicarious trauma.

 

It also creates a burden as trauma is not being addressed, resulting in higher rates of physical illness with the effects on the body and poor self-care, greater drug and alcohol use and young men in particular, being drawn into crime. This has a massive impact on our health service and economy.

 

Currently men that are seen by mental health services in Devon are not able to be seen by drug and alcohol services and vice versa but as one homeless man said, “They keep going on about my drinking but I can’t stop, I was sexually abused by different step-Dads, it’s the only way I have to cope”. moMEntum acts to work with men from where they are rather than having to fit in with criteria.

 

It is often cited, it is too expensive to support people around trauma.

My psychiatric care and medications cost £62,000, with no improvement in my mental health long term. But what did help me heal and get back to work after 12 years on an ill health pension was  a support group of fellow survivors, run on a shoestring and £4,000 of trauma therapy that I paid for.

 

There are example of attempts to provide integrated care between charities and organisations in primary and secondary care and we see trauma networks striving for change.

 

We are working alongside other agencies as follows:

 

 

We were approached by Canning Prison with a request to set up a  peer support group there as they had large numbers of men disclosing CSA. We are too small an organisation to expand there but this is a critical need. Support Needs for Male Survivors

 

Our nation is missing an opportunity to make great improvements in people’s wellbeing and health that would be cost effective by preventing the revolving door of unmet need leading to ever-growing demand on services.

 

Primary Care, Secondary Care and community care all needs to be working together with a common understanding around trauma. There is currently no assured understanding in practice , systems or policy in relation to trauma and lack of an interface between services.The scale of trauma is such that it can never be the responsibility of one service. Currently the siloed approach to these issues leaves gaps and wastes resources. There are pockets of expertise and excellent practice in NHS and charity vbased organisations around the country. The new mental health framework provides an excellent opportunity to bring this about but this has to be in partnership drawing on expertise and lived experience from the third sector.

 

John Slater

Co-Director

momentum Devon C.I.C

 

momentumdevon.org.uk

john@momentumdevon.org.uk

 

 

May 2023