Jeremy Forrest and the Abuse of Trust

A couple of years ago, I was working as a nurse in child and adolescent mental health services (CAMHS) with a 16 year old girl. One day, out of the blue, she confessed an attraction to me.

My immediate response – other than to put in a referral to an optician’s, obviously – was to politely but firmly remind her that I was her nurse, that there was no prospect of anything but a professional relationship, and to suggest to her that she look for a boyfriend her own age. I also made sure that I didn’t work with her again unless there was a female colleague present.

Despite what you may think from Mills and Boon novels (those aren’t grounded in social realism? Who knew?) sexual relations between nurses and patients are strictly verboten under the Nursing and Midwifery Council Code.

20. You must establish and actively maintain clear sexual boundaries at all times with people in your care, their families and carers

If I hadn’t kept my boundaries, I wouldn’t have only been committing serious professional misconduct. I would also have been committing a criminal offence. The girl was 16, and therefore over the age of consent. However, she was in my care, and that would make it a crime under the Sexual Offences Act of “abuse of a position of trust”, which runs up to the 18th birthday. There are good reasons for this. The power of a teacher, nurse, social worker or children’s home worker over a young person can be enormous. With that comes the capacity to do enormous damage to vulnerable kids if boundaries aren’t respected and trust is abused.

I mention this because of a depressing slew of responses – often left in the comments threads to online newspaper articles – accusing the police and media of “hounding” a “young couple in love”. Some of those people seem to think if Jeremy Forrest had waited a few months then it all would have been fine – and for the reasons listed above, it wouldn’t. Others seem to regard the girl as some sort of teen seducer.

Have a look at this comment piece in the Independent. The author, quite rightly, takes the Daily Mail to task over a tacky, voyeuristic article that dissect’s Forrest’s relationship with his wife and with his pupil, by trawling their social networking accounts. If the Independent piece is good and well-argued, the comments left underneath are…..Oh dear.

As his lawyer said, his only crime was that he fell in love with a 15yr old…he was stupid the way he went about it, but I don’t think there will be any more than 5-10% of anyone who knows about this story that thinks he did it with any malice or force/manipulation of the girl, and that she didn’t know what she was doing. Again we’re casting judgement…but all I’m said is that I agree with Martin – love has no boundaries.

Was this a manhunt for murderers and war crimials or just a besotted couple? ………….Sad sad journalism indeed.

There’s been a few surprising voices added to this chorus. Peter Tatchell, for example, is someone I often agree with.

I subsequently had a Twitter exchange with Mr Tatchell. In all fairness, he was very clear that his view was that he’s not defending Forrest, and if he had a sexual relationship with his pupil, then he should be prosecuted for it. Mr Tatchell insisted his only objection was use of the word “abduction” for taking her to France.

Fair enough, but does Mr Tatchell really think any parent would agree that a teacher should be allowed to take their 15 year old daughter out of the country without their knowledge or permission?

Ironically, it’s the tacky Daily Mail article that gives a few hints that describing them simply as a couple in love is dubious to say the least.

[The girl], who describes herself on Twitter as a ‘self-loathing, music-loving, art and fashion-obsessed nostalgic loner’ was reported missing last Friday after failing to turn up at her school in Eastbourne.

A “self-loathing loner”? Admittedly it’s entirely possible to read too much into somebody’s Twitter profile. Even so, it does beg the question of whether that sounds like the self-description of a confident, beckoning Lolita.

One could argue – and admittedly this is speculation on my part – that it  sounds more like a girl who may be quite vulnerable. Perhaps even someone who might be susceptible to grooming.

Ultimately these are questions that will be decided in a court rather than in blogs, tweets and online comment threads. Even so, it ought to give those who depict the girl as an equal partner – or even a teenage seducer – some pause for thought.

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Professionals, Patients and Social Media

Earlier this week I met up for a pint with Victoria Betton, author of the Digital Mental Health blog. This turned into quite an in-depth conversation about social media, and the way it’s used by people who work in or use mental health services. After we met I decided to jot down some of the thoughts and ideas we were bouncing about, and put them up in a blog post.

Where are the subversive professional blogs?

Victoria commented that apart from the Not So Big Society and The World of Mentalists, she hadn’t come across many subversive blogs run by professionals (or in the case of The World of Mentalists half-run by a professional, since I co-edit it with Pandora). I must confess that I was pleasantly surprised that either of those blogs would be considered subversive. Once I’d recovered from the unexpected compliment, I did find myself agreeing that a certain chill has set over the health blogging world – from the professional side anyway; the patient side is flourishing. I’m not saying there aren’t good-quality, subversive bloggers out there – look at Stuart Sorensen and the 20 Commandments for Mental Health Workers. Even so, when you look back to the spleen-venting polemics of NHS Blog Doctor, Dr Rant and Militant Medical Nurse, it’s hard not to feel that professionals are increasingly cautious about what they stick on a blog or a tweet. I’ve felt this myself, and I’ve noticed that there’s things I might have said online three or four years ago that nowadays I just wouldn’t say.

Don’t get wrong, I’m not suggesting we all go out and start swearblogging. There are, after all, good reasons why professionals are more cautious. When I first started blogging on the now-defunct Mental Nurse, there were no guidelines from regulators about social media. Then one day an article appeared in the NMC News, basically saying it’s okay to blog, so long as you don’t breach confidentiality or bring the nursing profession into disrepute (gratifyingly, they recommended Mental Nurse as a good example of how to blog). Then a paragraph or so of guidance was issued. That paragraph has become increasingly detailed, mainly in the wake of people getting into trouble at work through social media.

As a result, professionals are now nervous about blogging or tweeting. In many cases they’ve interpreted “be careful about how you engage with social media” as “don’t use it at all”, which in fact regulators like the NMC have made clear is not their suggestion.

Which professionals are using social media well?

Something I commented on, which Victoria seemed to agree on, is that of the various professional groups using social media, one that seems to do it particularly well are the police. This especially seems to be the case on Twitter, for reasons I’ve yet to fathom. Possibly it may be partly due to the institutional sense of humour of police officers, which seems to translate well into tweeting.

It also strikes me that Chief Constables seem to trust their officers with social media in a way that perhaps directors of NHS trusts and social services departments might not. Nightjack is an obvious exception to that, though in his case he allegedly had the misfortune to be utterly shafted by the Times, to make it look like he’d breached confidentiality when he hadn’t.

If anyone has any additional thoughts on why the police seem so good at tweeting, I’d be interested to hear them.

The Ascent of Twitter

I’ve noticed a change in my approach to social media. Previously I thought of myself as a blogger who has a Twitter feed to promote the blog. Increasingly I think of myself more as a tweeter who also runs a couple of blogs. Interestingly, when I mentioned this to Victoria she felt she’d undergone the same change. Conversations that might have taken place on the comments thread to a blog post will now be tweeted after reading the post.

This goes to show that social media is still evolving. Different platforms come and go (Goodbye Livejournal! Hello Tumblr!) The way we engage with it is also involving, and becoming more multi-platform in nature.

Anonymous versus Non-Anonymous

I’ve generally felt more comfortable expressing myself anonymously as a nurse. This isn’t just because of worries about something I might say causing trouble with my employer. There’s been times when stuff I’ve blogged about has led to individuals trying to make problems for me in meatspace.

I do also have a non-anonymous Twitter and blog. Victoria seemed surprised when I said that I’m actually more careful about what I say under my anonymous Zarathustra alter ego than my non-anonymous one. I think the difference is that as Zarathustra I self-identity as a nurse, whereas the other identity is just me being me. So, if I want to say, retweet a rude joke, I’d do it non-anonymously, but also non-professionally.

Might professional cautiousness swing the other way?

As I said that at the beginning of this posts, some professionals are starting to avoid social media. I’m wondering if the trend might reverse. Just recently in the wake of the Twitter Joke Trial fiasco, the Crown Prosecution Service has issued statements suggesting they’re rethinking the extent to which they prosecute people for what they say online. In the case of the Twitter joke, they caused a man to lose his job, and squandered large sums of public money for something that was monumentally trivial. Their recent statements suggest they now recognise a need for balance to protect free speech.

If the CPS are starting to backpedal, and realise that they don’t need to run around prosecuting left, right and centre every time someone says something stupid on Twitter, perhaps that might lead to a climate in which people might become more comfortable in communicating online. I don’t dispute the need for social networking guidelines from bodies like the NMC, but I think it’s also important to recognise that professionals can use social media to communicate in a responsible, ethical and at times slightly subversive way. When they do, good things can come out of that.

World Alzheimer’s Day 2012

Purple

Today, September 21st 2012 is World Alzheimer’s Day. The purpose of World Alzheimer’s Day is to raise awareness particularly of Alzheimer’s which the more common type of dementia.

I have a particular interest in Alzheimer’s and dementia. I think there can be a drive in policy to both marginalise those who have dementias and to increase the pressures on their families (where they have involved families) particularly as the amount of money in the ‘pot’ to deliver social care is reduced.

In the light of drugs companies announcing that they may be cutting back on investment in dementia research, it becomes more important to ensure that awareness of the needs of those with or who may in the future have a dementia remain at the forefront of the agenda of health services.

I think it’s important that amid the distress that an illness causes, we remember that a diagnosis of a dementia is not a sentence to misery. It is important that the quality of life factor is researched as well and that we don’t focus on the ‘misery’ of dementias as forgetting and losing the ability to remember is a very frightening thing.

Dementia still carries a stigma. I know the government refers to a ‘dementia challenge’ – subtitled ‘Fighting back against dementia’  but generally  I like to think of it as an opportunity to think about the way that society responds in different way. What are we fighting? Shouldn’t we be working with and walking alongside dementia?  We talk about an ‘ageing population’ and a ‘tsunami of people with dementia’ with an inherent negativity. While most dementias are not reversible, it’s importance that the tenets of ‘recovery’ are not lost in terms of losing hope around a person and promoting a more positive quality of life and environment for those with dementia and for their families where they have them.

By referring to a ‘dementia challenge’ and framing dementia as ‘one of the greatest challenges we face’ I worry that we remove the responsibility of society to promote a less stigmatising environment around people with dementia. It’s that social model of mental health again. Often dementias are forgotten by traditional mental health organisations because there are some differences but I’d like to see a lot of the developments in terms of user voice in mental health extended to dementia services and particularly towards users as well as carers as there is a propensity,  particularly in older adults services to assume  that the user and carer voice will be one and the same and can be interchangeable. I’ve been working in services long enough to know the importance of capturing user voice separately from carer voice and think that ‘lazy’ engagement is much easier than engagement which seeks out those who may have more difficulty communicating.

We need to ally Alzheimer’s and dementias with hopes and a focus on the person and not the illness. Not all dementias, nor all Alzheimer’s are experienced in the same way and the importance is the ability of services – as with all mental illness – to respond to the person and not to the diagnosis.

In my work it is one of the things I find most frequently – people (professionals who really should know better) make an assumption about someone with a dementia diagnosis – about what they can and can’t do/want/achieve. I want the stigma with the NHS and from adult social care to be challenged – that’s my ‘dementia challenge’ if I must use the government’s language.

I want the challenge to be held to statutory services. I want the challenge to be picked up by the NHS and Adult Social Care. I want funding to be appropriately focused to promote better quality of life for those with dementia. I want people with dementias to have a better say in their own services. I want residential, nursing, home and hospital care for people with dementias to be so good we don’t have to worry about it and we can have a confidence that services will be delivered which will help and not hinder personalities to be nurtured when the memory fades. We can deliver better services but the services have to be flexible enough at their core to accept and respond to different ways of doing things. That’s the failing of the system so far. There is a external fascia of ‘personalisation’ but the core of the services, commissioning and attitudes have not changed.

Social Care services for older adults have been struggling far behind, in terms of funding, those adults of working age. There needs to be a greater push on these discriminatory systems which act against people who have dementias and the government can solve it’s own ‘challenge’ by focusing on these issues.

We can make things better but the stigma of those who have dementia needs to be acknowledged by the public but also by the government, by the institutions of state that are responsible for the delivery of services, academic courses which train health and social care workers need to promote ageing positively rather than as a series of ‘problems’ and we all need to look for opportunities rather than ‘challenges’ of Alzheimer’s, dementia and old age.

Some good resources to read about Alzheimer’s and dementia

Modules from OpenLearn (Open University – free modules)

Fisher Center for Alzheimer’s Research Foundation

Alzheimer’s Society UK

SCIE Dementia Gateway

Dementia Resources – NHS Health Scotland

Register an interest in participating in research into Alzheimer’s (for those who have Alzheimer’s and carers) – via DeNDron

photo by Allie’s Dad @ Flickr

Consulting on the CQC

Frimley Hospital UK

I’ve been generally critical of the CQC (Care Quality Commission) since it’s establishment. I’ve been particularly critical of what I have seen to be the failings of a regulator for health and adult social care services where I have felt that there has been an impact, by the lack of robust regulation, on the lives of people who use and need the services which are provided.

My main concerns have been about a move away from regular announced and unannounced inspections and a move towards desk-based inspections. However the CQC has been re-evaluating this approach and with a new Chief Executive in David Behan and an outgoing Chair – I wonder if it’s time for me to evaluate my own attitude to the regulator for health and adult social care services in England.

I could never understand how Cynthia Bower was appointed in the wake of the Mid-Staffordshire scandal. It seemed to be a strange appointment. Starting a new agency by merging the functions of the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission was always going to be hard. This combined with new responsibilities to regulate services in different ways seemed to have led the eye to be taken off the ball as far as current standards went with the focus being on bringing new regulatory frameworks in amid low staffing.

As far as social care is concerned (and that’s the area i know best) this move away from  regular on-the-ground inspection of services combined with cuts in funding both to the organisation and to local authorities who might have had their own, more robust, monitoring teams, led to concerns about quality in the services being provided.

However, the CQC seems to be moving on in terms of re-establishing consistent and regular unannounced visits to services and there seems to be a shift in terms of the priorities which they are placing on promoting quality of care over merely meeting the lowest acceptable standards.

I read through the consultation for the strategy of the CQC between 2013-2016 (and, incidentally provided feedback because it is, after all, a consultation!) and it left me more hopeful that the sector might be developing a regulator that it needs.

Six ‘priorities’ are laid out for the next three years.

1. Making greater use of information and evidence to achieve the greatest impact

In this section the CQC acknowledges the move back to regular unannounced inspections and explains the way that information gathered relating to risk has fed into the way that inspections are conducted and that this needs to continue and strengthen in the future.

‘Building an evidence base’ about what works in regulation includes looking at overseas models. Obviously, I’d welcome a fuller evidence-based approach with the caveat that sometimes past excellence can change to present mediocrity by one new member of staff and there will always be some random elements at play in this sector – an area where I think the CQC has failed in the past by simply judging future potential risk by past performance.

The CQC is increasingly going to look at regulating different services in different ways with the same (presumably) framework as inspectors are professional regulators rather than experts in specific sectors. GPs and Dentists need to be monitored in a different way from a nursing home, a large general hospital or a private ambulance service. It seems to make sense.

Using information from different sources is also crucial. The CQC report mentions this. I expect they would feed heavily from local authority complaints in the field of social care and the information we (as LAs) get regarding care providers and particularly our contracting team which monitor quality and complaints. If someone from the CQC came into our LA and spoke to social workers directly about different home care providers and residential homes, I expect they might get a broader view.

2. Strengthening how we work with strategic partners

Here the CQC mention the changes coming in the NHS and the need to link with organisations such as ADASS, Monitor, presumably new Clinical Commissioning Groups and professional organisations.

I hope there will be a strong voice for Social Work in the form of the College of Social Work in feeding information back to the CQC. I might be on a bit of a theme here but I think the CQC can learn an enormous amount about adult social care from social workers and I think they really need to utilise the knowledge we have of local areas and areas around quality. While I will contact the CQC with major concerns/complaints about residential homes, I’m not asked to feedback about niggles or, for that moment about fantastic services. I’d love to see these links work not just at a managerial level but between inspectors and social workers in the locations they regulate.

3. Continue building better relationships with the public

For a regulator to have public confidence, the public have to know what they do, what they are responsible for and what they are not responsible for. The CQC can do their best but if people don’t know about it or have different expectations, they are unlikely to get the message across positively.

New ‘Healthwatch’ organisations will promote local links and input into inspections and the CQC is building on its ‘Experts by Experience’ programme building people who use services and carers of those who use services into the framework. I watched a video from an inspector where she talked about using an ‘expert by experience’ and referred to a carer of a person with dementia who helped her in an inspection of a residential care home. I’d hope that people who have dementia and may have cognitive impairments are also built into the process of being experts by experience. It is vital that users and carers are involved and different models built to encourage this involvement but that assumptions are not made that because someone may  have a cognitive impairment that they cannot speak for themselves.

Improving access to reports would also be good. Improving the searchability of the CQC site would be a massive bonus. It’s become increasingly difficult to search and find information and seems to constantly take steps backwards in terms of usability.

I think it would be helpful if there were comment forms under each service for public to send information from the website directly to the relevant inspector. Inspectors could have a greater visibility online and using broader social media to communicate with the public – not just through PR people.

I want to know what inspectors do every day. I’d love to see a regular blog from an inspector (without needing to mention any specific services but just with broad themes – generally frontline blogs are more interesting than management blogs!)

4. Building relationships with organisations providing care

This is an area I probably have less experience in. It explains that the organisation wants to provide quality reports and improve the feedback given to providers by inspectors. It’s often about links and nurturing positive links over time but not allowing that to impede judgement when there are problems.

5. Strengthening the delivery of our unique responsibilities under the Mental Health and Mental Capacity Act

As an AMHP (Approved Mental Health Professional) and a BIA (Best Interests Assessor) I have a particular interest in matters relating to the Mental Health Act and the Mental Capacity Act.

I feel particularly the CQC have disappointed me (I know that will upset them!) about their knowledge or rather their lack of knowledge about Deprivation of Liberty Safeguards. I think good and thorough knowledge of DoLs should be a core question in every single inspection in every residential and nursing home and hospital in which they may apply. I  have come across too many home managers who really should know better show an appalling lack of current knowledge about DoLs and believe that there are many many unauthorised deprivations of liberty that inspectors should be able to challenge homes and hospitals about.

Personally, I’ve made a number of third party referrals for assessments under DoLs and that’s just by people either allocated to me or situations I come across when visiting people in care homes or hospitals – there must be many many more that go unchallenged because the law is so fluid and complicated and I don’t have any faith that the CQC and those representing them on the ground know it.

I’d like to see better links between inspectors and Best Interests Assessors after all, we (should) have significant expertise in applying the DoLs and perhaps we could shadow inspectors and ask the questions that they don’t know to ask until they are trained up at least.

This is three years too late.

6. Continuing our drive to become a high-performing organisation

This section is about building a learning organisation and working out ways to measure progress. I know the organisation works with ‘professional regulators’ but I think something has been lost in not using people with expertise in health and social care to carry out inspections and to rely on generic ‘auditing’ experience but I can’t see that changing.

I do think there are hopeful signs though in these new priorities and wish the organisation well – we need a good, strong regulator that has the faith of the sector and I feel we will need it all the more as the NHS changes.

I am increasingly thinking that more link, better conversations and more co-production are the ways forward for the CQC and for health and adult social care in general.

Do feedback on the consultation though – we need lots of voices. The CQC say that they welcome feedback through social media – so this is my own response!

photo by vivido @ Flickr

Vote in Mind’s poll on the most important mental health issue

Mind are getting ready to head to the party conferences, where they’ll be lobbying on a variety of mental health issues, including mental health at work, the benefits system, discrimination and crisis care.

They’re asking people to vote in their online poll as to what are the issues that matter most to them. The poll is illustrated with a handy infographic to help people make up their minds.

Personally I voted for “fairer benefits” as the most important issue in mental health at the moment, though all the issues mentioned are deeply important. Arguably, given the current government’s barely-disguised contempt for the most vulnerable in society, there’s never been a time when it’s more important for people to stand up and shout about mental health issues.

Go vote.

 

Shortlist announced for Mind Media Awards

It’s that time of year again, and Mind have just annnounced the 2012 shortlist for their media awards.

Last year The World of Mentalists co-editor Pandora won the Mark Hanson Award for Digital Media for her Confessions of a Serial Insomniac blog. This year there’s at least two of my favourite bloggers nominated – namely Inspector Michael Brown aka Mental Health Cop and Independent blogger Ilona Burton. Both of those are very deserved, and I’m looking forward to browsing the other nominees and getting to know their work a bit better.

Other than the Mark Hanson Award, I’m also pleased that the superb This is England 88 is nominated for Best Drama, and that Patrick Strudwick has been shortlisted for Journalist of the Year for his coverage of psychotherapists offering “gay cures”.

Back in July Mind asked me to write a blog post encouraging people to submit nominations. At the time I wrote,

I’ve submitted a nomination in the Digital Media category. I won’t say who I’ve nominated, other than it’s not any website that I work on. Feel free to submit your favourites too.

Now that the shortlist has been announced, I’ll say that it was Chaos and Control. I nominated her for a saga in which she was stopped by staff from blogging while an inpatient. After some considerable wrangling with the NHS trust PALS service, she seemed to spark some genuine reflection on the part of the trust. She didn’t make the shortlist, but I certainly appreciated it.

Good luck to all the nominees.