I have avoided writing about mental health services so far, because the subject is too close to my heart and the situation such that I don’t know where to start. But this morning I had an upsetting call from a family member, A, a young nurse on an elderly mental health ward. Since the pandemic started, she has been working extra hours, at first to cover for so many of her colleagues being off sick, more recently because of the more than usually demanding nature of the work on the ward. The majority of mental health patients, of all ages, in the community have been left with a skeletal service since the virus started to overwhelm other considerations – in many cases, no service at all. No surprise that three months on, this neglect has started to take its toll and patients are presenting with florid, untreated psychiatric symptoms. (To get the true grimness of this picture, you should know that adjectives like ‘skeletal’ described the state of mental health services six months ago, but everything is relative, and they are now even more skeletal if that is possible – I clearly need another metaphor) Having been emptied of as many in-patients as they could back in March, the wards are now full, so full that this ward, for the assessment and care of very frail elderly people, was pressured into taking a man in his forties with a drug-induced psychosis.
Alongside this, the nurses are having to manage the risks of Covid19, testing all new patients and keeping them isolated, or, if they can walk, pressured to stay in their rooms, until their Covid19 status is confirmed. I wrote about the concept of ‘moral injury’ in my last blog. I have no doubt A and her colleagues are struggling with the dark conflicts involved, just as much as the clinicians on ITU. Two ethical principles underpin good practice when working with people with dementia: to make the environment feel as safe as possible and to restrict freedom as little as possible. It is hard to make a confused elderly person feel safe when you have to approach them in mask and visor and then stick a swab deep into their throat and high into their nostrils. And to, in effect, lock them into a room on their own feels barbaric and goes against every impulse that made nurses like my niece choose to work on such a ward in the first place.
Most of the patients’ tests come back as negative, but last week someone developed a high temperature after a few days on the ward and his second test came back as positive. The other patients had to be retested, but for reasons that no-one with any intelligence can understand, the nursing staff are not allowed to be tested unless they develop symptoms. “Just lie and tell them you do have symptoms” I tell her, exasperated by what I’m hearing and having long since learnt that stupid policies and people sometimes just have to be by-passed. But no: if you have symptoms, you have to take sick-leave and A and her colleagues are too conscientious to leave their team-mates in the lurch.
In fact, A is now on ‘holiday’ but has had to cancel her plans, that she had been eagerly anticipating, worried that she might carry the virus and would infect the people she was hoping to meet. She has arranged for a home testing kit to be posted, spending ages sorting this out on line, waiting for it to arrive, planning to post it back tomorrow and then anticipating waiting for at least 48 hours for a response. A hell of a holiday for a young woman who has been returning after work, often in in tears, to her flat, where she lives alone!
Stories of clinical staff finding it difficult to get tested were common at the start of the pandemic when there simply weren’t enough tests to go round. If you remember, there were sarcastic comparisons made about Boris Johnson and Matt Hancock getting quick access to testing whilst clinical staff, desperate to get back to work, queued for hours at drive-throughs many miles from home. But now, one of the Government’s boasts is the ready availability and number of tests being processed. Accordingly, staff in ‘acute’ hospitals seem to be able to get them quickly , so why should it be the case that staff in a psychiatric hospital have to show ‘symptoms’ to qualify for a test at work. This makes no sense at all for a condition where a significant percentage of cases show no symptoms. What’s more, it puts individual clinicians in a ridiculous bind and risks Covid19 being spread by staff through our mental health wards. So much for ‘parity of esteem’ – the principle that mental health should have equal weighting with physical health.
Testing is on everyone’s mind, especially here in Leicester where we have a spike of cases and where we are waiting to hear if the city, or parts of it, are to be locked down. Incredibly, it took seven whole days after Matt Hancock took us all by surprise and announced Leicester’s spike before the Government’s outsourced testing system gave the city council, including its public health lead, the detailed information of cases it needed, including post-code and occupation. And at least two weeks where vital testing and quarantine measures could have been intelligently targeted on specific factories, schools, shops or streets. Meanwhile, the Government have placed extra mobile testing units run by the army in many of our parks, but the one near us has hardly been used because few people know it’s there.
I don’t know what more to say. The policies around testing lack both intelligence and kindness. It breaks my heart to see staff like A treated in such a way. And I feel utterly furious at the position Leicester has been put in: the city council forced to work blind for lack of crucial, centrally held information; and the hundreds who have caught the disease when effective track and tracing might have put a stop to the initial spike four weeks ago.
The suffering caused is so bloody unnecessary. In the case of mental health staff, managers should be doing everything they can to ensure their policies are fit for purpose and their staff can access the same quick and responsive testing as staff in ‘acute’ settings. They have a duty of care. In the case of Leicester, local authorities just need to continue to pressure the government and push the principle – backed by the majority of medical bodies – that track and tracing will only work if the resources are devolved, so that local knowledge, networks and all-important relationships can be exploited to the full.