"SCREAMING AND SHOUTING." "One in four people will suffer a mental health problem this year." "I just have a deep dislike of the concept of normality." "Last year over 53,000 people were detained under the" "Mental Health Act." "Cuts to mental health services have been higher than other acute NHS services." "3000 beds within the last five to six years have been cut." "We've got five males and three females requiring admission this afternoon." "I've got no beds whatsoever." "Are we just a sort of depository for people that no one else wants to deal with?" "We followed staff and patients in the of the UK's largest" "NHS Mental Health Trusts." "You're not entitled to treatment in this country." "Things are absolutely dire here at the moment." "Barnet, Enfield and Haringey Mental Health NHS Trust in North London serves nearly a million people." "Staff are preparing the 136 suite, the holding cell for people have been sectioned under the Mental Health Act." "The handcuffs will come off once you're inside because you've been a bit unpredictable to me, a bit aggressive." "You're going to have a mental health assessment." "Section 136 of the Mental Health Act allows officers to detain people who are a danger to themselves or the public and take them into protective custody." "Cooperate with staff, start making good decisions and this process will go really quickly." "You understand?" "The number of people detained in this way is now the highest ever recorded." "All over the country we are seeing a real surge in the need for mental health services and I think that's probably down to economic austerity, a reduction in some of the social services because there have been swingeing cuts to local authorities and there have been increasing" "numbers in our population." "The Trust has lost over a third of its beds in the last eight years and is running at over 100% capacity." "For every patient sectioned, a bed must be found, regardless of how full the hospital is." "Shall we make a start for Barnet?" "Heather runs the twice-daily bed management conference, with all eight wards in the Trust on the line." "The purpose is to free up beds." "One female bed?" "There's no beds." "If there are no beds available in the Trust, each ward manager must nominate their least unwell patient for potential discharge." "OK, can I just clarify you've identified the least well patient at the meeting this morning?" "No, the one I identified is the same as yesterday." "I know, I appreciate that, but looking at it from our point of view, we have potentially five males and three females requiring admission this afternoon and I've got no beds whatsoever." "Under section 136, you don't have any rights of appeal." "I wanted to discuss transferring somebody into that bed to create a vacancy for this patient." "Throughout the day, more patients are referred from GPs, hospitals and A departments." "All must be found beds." "Another one just came in, this patient was brought in under section 136." "Not only does the Trust have no beds, but none are available in the whole of London." "No patient is well enough to be discharged or moved on to a halfway recovery house." "The Trust has no choice but to pay for a private sector bed which could cost up to £1000 per day each." "I'm just ringing to find out if you've got any female vacancies." "The September surge, it happens most Septembers because of course you have all the people in the summer holidays, it tends to die down a bit but in September you get a massive uplift." "We've got about 12, 13 requests for a bed today, that's getting on for three quarters of a ward in one day." "I'm telling you, things are absolutely dire here at the moment." "Trent Ward has 21 beds for patients with serious mental health problems." "The aim is to get patients well enough to leave the ward as fast as possible." "The average stay is three to four weeks." "We treat many more people out in community settings." "Those people who now come in as an inpatient tend to be much more severely and acutely unwell." "Mel has been on the wards for nine months." "You've been here for such a long time." "You don't need to be here." "She has a personality disorder and a history of drug abuse and suicide attempts." "Staff want to transfer Mel to a specialist personality disorder unit but funding has been refused." "We can't understand what the reason is for declining funding, apart from the obvious financial restraints that everybody is operating under at the moment." "What's the meeting?" "It's a professionals meeting." "What does that mean?" "They're going to discuss what happens to me next." "What are the choices?" "Either you go to a PD unit, a personality disorder unit, or I could be discharged." "I do want to go back into the community again, try and start again." "But?" "There sounds like a but." "It's going to be hard for me to settle back into the community again because I've been in for so long, it's going to be hard for me to settle back in." "Are you worried, what are you worried about?" "I'm just worried that I'm not going to be able to cope on my own out there." "The ward is not a suitable place for her long-term." "She has to be moved out." "Either in the community or in rehab." "What's the next step?" "Of course we have to bear in mind she has been on our top delays list now for quite a while so, from a clinical point of view, she doesn't require an inpatient mental health facility." "She should not be on this ward." "She needs to be elsewhere." "Now, the clinicians are saying that they think that this rehab facility is the best place." "The commissioners are not agreeing to it." "In the meantime, if she doesn't need to be here, can she go home?" "It is looking at the risk to herself, the risk to others, but mainly, the long-term view is that she is going to continue with this behaviour." "The September surge is keeping the hospital at code black." "Jonathan is on the morning bed conference, trying to identify patients to be moved." "I have very ill patients." "Sometimes it might look quiet, it might look nice and suddenly there will be an explosion and we have to run out." "So the job is unpredictable." "It depends on how the ward is." "Because the patients are more priority than any other thing." "It's not like fixing a broken leg, delivering a newborn baby, a hip replacement where people skip out of the door and give you boxes of chocolates." "It's far more complex." "You're working with people who have had multiple abuses, neglect in childhood." "SHOUTING FROM OUTSIDE." "I don't want to sit down!" "Calm down, calm down." "Why won't you let me out?" "For 15 minutes grounds leave." "Why not?" "Why would you stop that?" "You don't need to be shouting." "I can't wait that long!" "I'm going to kill somebody and it's going to be you!" "You!" "Don't push me about." "ALARM SOUNDS." "Don't record." "Can we move outside?" "OK..." "Yep." "Do you have any nominations for private?" "Not at the moment." "The ward is quite disturbed." "I don't think any of our patients would really be fit for private at the moment." "OK, out of all those disturbed people, Jonathon, who is your most settled patient?" "Ben has been brought to the 136 suite by police after threatening to commit suicide." "Ben is already living in one of the Trust's recovery houses but he wants to be admitted to the hospital." "The ward, it gives you certainty sometimes, I think." "How would you describe your mood of the last few days?" "It's low, it's low." "Staff need to decide if his suicidal tendencies mean they should find him a bed." "They decide to send him back to the recovery house with increased levels of supervision." "I think the risk is there." "This is the second time he has come to the station but he is clearly seeking help." "He knew that he was at the station, he didn't want to jump in front of the train and create a scene and make other people go through a difficult situation." "And he is saying he doesn't want to end his life, he wants help." "The CRHT, or home treatment team, provide one to one support in the community and try to stop patients having to be admitted to hospital." "We've got people with depression, bipolar affective disorder, acute anxiety, paranoia, schizophrenia, suicidal patients, patients with self harm." "The most important part of the home treatment team and what we do is actually keeping people at home." "Not only does that have a reflection on beds and what happens there but it's important that people should be treated in their home." "It increases their recovery." "Let's get some water on the way out." "The next day Kelly and Charlotte are on their way to see Ben." "He hears voices and they increase quite quickly when he's feeling stressed or anxious and the voices tend to tell him he should kill himself." "Nice and tidy." "You're not having any thoughts today of what happened yesterday, going to the train station?" "No." "You're not having any thoughts to harm yourself or anything like that at the moment?" "No." "And your medication, you're not having any problems with it?" "There's no side effects or anything?" "You're just forgetting." "Yes." "All right." "So it would be helpful if we gave it to you?" "Just for now?" "Yes." "All right, my love, you take care, we'll see you tonight." "The increased demand for mental health services and the premium on beds means that more and more very ill people have to be looked after in the community." "At one stage the caseload was 80, I think between 80 and 90 at one point and it is just completely unmanageable." "One person will be going out and seeing anywhere between nine and 11 people in one shift and you can't do it." "You're basically going in, checking they're OK, giving them medication and leaving again." "You don't have the opportunity to sit and have some sort of therapeutic intervention with them." "In case Mel doesn't get the funding for her treatment, doctors are preparing for a return to the community by letting her out of the ward three times a day." "In the meantime, Mel's mother has come in to find out if her daughter will be discharged into the community or get the specialist treatment she and the doctors feel she needs." "She's been institutionalised in the mental health units for a long, long while now." "And I thought, when they brought up the thing, the PD unit, this would be her journey to get back into the community again." "Yeah." "The idea is to get to the root of the problem." "It's been a lot of years what she's had." "And a lot also depends..." "And she's never had this before, to get actually to the root of the problem." "So I've no choice to go or not, I've got no choice in this," "I've no say in this then?" "The PD unit is the same as Trent Ward." "I will put it that way because it's a locked door," "Trent Ward is a locked door." "I've been in hospital ten months." "I want to go into the community." "Let's wait until we see whether they approve the funding or whether they decline it." "One of the big concerns is if you go back into the community again, as your mother said, it would be a return, a cycle, and you would end up like this for a lot of your adult life." "Stuart has been in and out of hospital all his life." "He suffers from paranoid schizophrenia." "There is a lot of madness here." "At times it is relatively sane." "I used to have a deep dislike of the concept of normality because of my experiences at the hands of medical-model psychiatry." "It has been a painful journey for me." "To recognise the desirability of being sane." "With cuts to support services in the community, patients like Stuart find themselves more often in the hospital." "Most of the patients do suffer psychotic illnesses so they have a vulnerability to flip into a sort of state that is hard to understand." "You start wondering, well, are we just depositories for people that no one else wants to deal with?" "Is that a kind of social control?" "You are tormented a lot of the time that I have known you, really." "But also fiercely independent." "And always have been." "You know, the struggle we have got, you know, is that actually the issue over the last couple of years is that you have not coped for more than a couple of months at a time at home." "When you are at home on your own you become..." "You dangerously neglect yourself." "On a number of occasions now, had you not been admitted to hospital against your will you would not be here talking to me now." "It is my association with satanic cults in the past which still impinges on my interior life." "It's very difficult to cope with." "Anna is part of a team that tries to sort out support for patients when they leave hospital." "They have some housing support ready for them at the right time and they have the right level of social care support ready for them when they go out, and their GP and everyone else is lined up to accept them and move" "them onwards in their pathway." "And sometimes with some of the cuts that we have, seeing some of these things begin to be quite difficult." "I will see you later." "She also has the deal with people who are not entitled to social benefits or health care." "Today she is on her way to see Augustus, an illegal immigrant who had a psychotic breakdown, suffering paranoid delusions and hallucinations." "People believe if they come to the psychiatric hospital you will get everything because there is the expectation, this well-known saying that we do not discharge anyone into the street." "Because we don't discharge anyone into the street, the NHS hospital will foot the bill." "He has been receiving emergency treatment for the past three months, but he is now well enough to go home." "It's cheaper for the Trust to buy him a ticket back to Nigeria than keep him in a recovery house." "And it frees up a bed." "The only help we can offer you today as the NHS Trust - because you are here with us - is to basically help you get the ticket and to send you to Nigeria, but you don't need money to go to the doctor because we will" "give you three injections which will last a bit of time and it will give you time to see how you are." "Back home." "Where?" "You are not entitled to treatment in this country unless you pay privately, everything has to be paid for privately." "What you are getting now is what is called emergency treatment." "It is just dire, absolutely dire at the moment." "We have so many requests coming in for beds from the crisis teams." "We are already full and we already have patients from the private sector." "We have very little movement at all from the patient service." "It is about trying to manage the risk of keeping patients in the community whilst trying to get those who are more seriously at risk back to a hospital bed." "It is the fourth week of the September surge and the bed managers and crisis teams are battling over how to manage patients." "Hello." "Can you hear me?" "Right, OK." "There is no way even with intensive CRHT that the patient could be supported?" "How are the CRHT managing the situation?" "How many times a day is he being seen?" "We cannot keep referring to the fact that we're waiting forever because the private sector has minimal availability and in the Trust we have no availability." "We are going into unknown territory where the private sector is becoming full and when the private sector is full then we really do have to consider all of these different options about how to safely manage people." "Back on Trent Ward it looks as though Mel might be on track to get to the root of her problem." "She has been told she has got the funding for the Personality Disorder Unit." "It will not be a short-term placement." "So you could be looking at three, six months, nine months." "I would not want to put a figure on it." "I have some good news." "They said yes to the funding." "That is good." "Are you happy?" "I did not want to go but I will give it a shot, you know." "I have nothing to lose, have I?" "I haven't got nothing to lose if I just give it a shot." "And everyone is saying that I need to go in, so they can't be wrong." "I am just trying to fight it all the time." "It's not good." "I don't want to jeopardise it." "I go out and come back." "That's it." "Yes." "Love you, too." "Bye." "How was she?" "All right, yes." "How are you feeling?" "A bit mixed up, but OK." "What is next?" "I always said if I got the funding I would give it a shot and now I have." "It's a big thing?" "Yes." "In Enfield, it's time for Augustus to return home to Lagos." "He suffered from paranoid delusions and hearing voices." "Doctors are sending him home with enough medicine to stave off the symptoms for six weeks." "I will give you the ticket and the bit of money that the Trust gave and that's all - it's not much but that's what it is." "They only gave me £40." "That's not going to be enough." "£20, £30, £40." "OK?" "That is just for you..." "Thank you very much." "When you get there, you go to the local clinic for them to give it to you." "There are extra costs?" "Do they charge you to give an injection?" "Of course." "Why?" "I have told you how people die here and there." "I am not joking." "I must have the capital to go to the hospital." "Are you still feeling anxious?" "Can I just clarify that he has identified the least unwell patient?" "Nicolas, not at all." "Daniel, no." "It's all about capacity." "Beds, beds, beds." "Mel did not return from her latest leave." "Instead she called Jonathon." "Her main purpose of calling me was to say goodbye and that was quite difficult to take." "But I tried my best and I spoke to her and finally she said that she will not talk to me any longer and she banged the phone down on me." "We called the police." "Fortunately the police found her and brought her back to the ward." "You went out and you did drink and drugs?" "Yes." "Then what happened?" "Then I found myself on the roof." "I was contemplating whether to jump or not." "It seems that everyone wants this PD unit and I don't seem to want it." "Everyone is rooting for me to do it." "I'm not sure if I'm ready to talk about things from the past, you know?" "I think if I go there and open up it might affect me a bit badly." "What do you fear for Melanie?" "We fear that she could become a revolving-door patient." "And I only hope that that is not..." "The final result in her life." "I hope so." "I'm sorry." "Don't worry." "LAUGHTER" "That's a difficult question." "I don't really like these questions." "OK." "It's a tough job." "You wouldn't want to think about a bad end for your patient." "You have to not think about it?" "I really do hate it." "It does not make me comfortable but personally I feel that we as nurses, our best hope is to give people hope." "We need more investment." "Mental health is not like some of the other services in the health system." "We are really having to do very complex management and there are concerns about risk and protection and often trying to stop people from harming themselves, actually." "Far more than harming anyone else." "If we carry on just trying to meet the demand and other services are diminishing then yes, life is going to be really tough."