AFTER GRENFELL Current Challenges & Opportunities – A GP’s perspective

PAQUITA DE ZULUETA GP LEAD, NHS GRENFELL OUTREACH TEAM Imperial College PCPH Department Jan 17th 2018 The Morning of 14th June 2017 The Immediate Aftermath Relief centre at EARLY COMMUNITY RESPONSE

• Makeshift health desk manned by GP volunteers. “Grenfell Medics” WhatsApp group, coordinated by LCWUCC administrators. • Working alongside RBK&C workers, Red Cross, Grenfell Muslim Response Unit, CNWL workers etc. • Pretty chaotic to start with – became more organised. • After a few weeks, support services moved to The Curve. • NHS Outreach Team set up. Recruitment of specialist mental health staff. PSYCHOLOGICAL FIRST AID

• Aims to assess immediate needs & concerns, reduce initial distress & to foster immediate and long term adaptive functioning and coping. By Promoting: • SAFETY - Protect from further harm • PRACTICAL care & support – food, clothing, phones, etc • CALM – provide comfort, normalise distress • CONNECT to relatives, services & social support • SELF-EFFICACY – focus on what they can do for themselves • HOPE DISASTER PREPAREDNESS • FIRE SERVICE – Huge amount of resources deployed but slow back up and lacked aerial ladders. Senior fire officer: “We had never encountered anything like this before” • AMBULANCE SERVICE well prepared • HOSPITALS – Major incident protocol. Highly organised and efficient. • 999 CALL SERVICE – unfortunately gave wrong advice in the circumstances – relied on ‘compartmentalisation’ of fire. • MORTUARY set up in Westminster – forensics highly organised. • COMMUNITY RESPONSE & RBK&C – huge number of volunteers, but lack of leadership, strategic planning/response. DISASTER PREPAREDNESS : THE IMPORTANCE OF COMMUNITY RESILIENCE

• “Community resilience has extraordinary value as a strategy for disaster readiness” [Norris et al, 2008] • Emerges from 4 sets of adaptive capacities: 1. Economic development (equitable distribution of resources) 2. Social Capital (strong networks, social support, citizen participation) 3. Information (trusted & accurate) & good Communication 4. Community Competence (collective action & decision making) Grenfell Health & Wellbeing Service The evolving service model

Outreach Services

Adult CAMHS Services Services THE OUTREACH TEAM Who are we? 21 healthcare professionals + 4 administrators (part of much larger Grenfell response team) based at St Charles Centre for Health & Wellbeing. Composed of: • 1 GP (part time) • 1 senior nurse, deputy borough director mental health • 6 Nurses (3 specialised in mental health) • 3 social workers (mental health) • 2 Occupational therapists • 3 assistant psychologists • 1 art therapist • 4 support workers WHO IS AT RISK OF LONG TERM MENTAL HEALTH ISSUES? • GRENFELL SURVIVORS • BEREAVED • WITNESSES • NEIGHBOURS & OTHERS • VOLUNTEERS & FRONTLINE STAFF (51% LAS involved in major inc) • CALL HANDLERS • BUT HEALTHCARE WORKERS, KEYWORKERS, LAWYERS WORKING WITH SURVIVORS ALSO AT RISK OF ‘VICARIOUS TRAUMA’. RISK FACTORS FOR PTSD

• Gender (female: male 2:1), prior trauma, pre-existing mental health problems, lack of social support, duration of trauma, SEC, ethnicity.

• But what happens during and after the trauma may be more important (Brewin) e.g loss of home, lack of support. “THE SCREEN & TREAT” PROGRAMME

• 10 point Trauma screening questionnaire (TSQ) incorporated into interview. • Involves pro-active engagement including ‘street screening’. • Based on Brewin’s research post Paddington Crash & 7/7 (2005). • Huge population ‘at risk’ – estimated at @ 11,000 but not all will develop PTSD – some estimate risk may be as high as 50%. • Has raised some disquiet & ethical concerns. Should not be a ‘tick box’ exercise. THE TSQ

10 point Self-reporting tool. Simple and quick. Cut off >=6/10 = Screen positive. -> 86-91% diagnosed PTSD

If < 6/10 no PTSD in 92-93%

But misses out those who have dissociation and are ‘shut down’. 3 Stage Model of Treatment

• Phase 1: Stabilisation and Psychoeducation • improving symptom management, self-soothing and addressing current life stressors to achieve safety and stability in the present. • Phase 2: Trauma Processing • Trauma or bereavement -focused work using a range of evidence based treatments available across a range of sites and venues • Phase 3: Reintegration, reconnection and recovery • Re-establishing social and cultural bonds, enabling people to develop greater personal and interpersonal functioning. Links with community events and networks OUTCOMES FOR SCREEN & TREAT

• Adult screen & treat @1,100 referrals. @100 finished treatment. • @ 260 declined treatment • Outreach team – accepted contacts: 3,850 (declined:60)

• Children: 225 referrals to CAMHS – 60 completed treatment • 35 referral or assessment refused. Therapeutic Services

Services offering practical NHS: support to Take Time to Talk people Single Point of Access affected CAMHS

Charities RBKC MIND Grant-funded CRUSE provision: new and expansion of existing Victim Support providers

Telephone Educational Services Psychology Samaritans Support in Schools NSPCC Childline THE PERIPATETIC GP • Initially Provided ‘one-stop’ service, but not a sustainable model of care. Limited what can provide. • Need scripts, equipment, access to System1. • Cannot order Xrays, MSU, blood tests etc • Influx of bereaved relatives who have difficulty accessing care because of non-residency status. Facilitate registration. • Working with and in GP practices best model. Supporting GP’s with patients who have complex problems. MDT meetings to ensure ‘wrap around’ care & close links with other support workers. • Provide link between GP’s, NHS outreach & mental health services. CHALLENGES

• Very hard to obtain accurate population data – where people lived. • Population widely dispersed in hotels, out of borough, with relatives.. • DEEP MISTRUST by residents of people who were there to help them • Intrusive Media, ‘trauma tourists’, politics… • Large numbers of voluntary organisations, charities, volunteers, lawyers involved. Quality control? • People working in silos, competition, duplication, fragmentation • RBKC in meltdown – huge turnover of staff, high levels of stress • Identifying trusted authentic community leaders • Bureaucratic inertia. Incompatible IT systems – System 1, IAPTUS, JADE… OTHER CHALLENGES

• Housing – big issue • Not everyone wants “talk, talk” therapy • Many feel they are ‘not ready’ – waiting to be rehoused • Somatisation – “the body keeps the score” (van der Kolk) – Other therapies may be more efficacious? • Gender issues – men less willing to admit mental health issues. “have to be strong” • Marital breakdown. Risk of increased domestic violence? • Long term impact on children COMMUNITY OUTREACH • Community Leaders & existing community organisations • Resident Associations & Local Councillors • , Angels of Grenfell • Faith leaders – Methodist Church, Al Manaar Islamic Cultural Centre, St Clements Church. • Other charities especially Hestia, Journey of Hope, CRUSE, MIND… • Other organisations – RBKC, Police family liaison officers, • GP’s, West CCG • Schools – teachers, school nurses… A SYNERGISTIC APPROACH

Damage limitation Treat PTSD & traumatic grief

Improve Wellbeing & Resilience OPPORTUNITIES

IMPROVE & ENHANCE:

1. Economic development (more equitable distribution of resources). RBKC the most inequitable borough in the country. 2. Social Capital (strong networks, social support, citizen participation) 3. Information (trusted & accurate) & good Communication 4. Community Competence (collective action & decision making) OTHER OPPORTUNITIES?

• Valuable research opportunities • Valuable lessons to be learnt • Make housing safer countrywide • Spur a radical rethink re housing in this country? • Rethink our economic system to reduce inequalities?? CONCLUSION

• The fire represents for many a symbol of a corrupt and inequitable socio-political system leading to preventable loss of life. • It is the largest fire since and the traumatic repercussions will run deep and for a long time to come. • We can only hope that this terrible tragedy will be an opportunity for rebuilding the community such that its citizens enjoy a better quality of life than before and that they receive restorative justice. Thank you for listening Selected References

• Brewin CR, Scragg P, Robertson M, Thompson M. Promoting Mental Health following the London bombings: a screen & treat approach. J Traumatic Stress 2008; 1:3-8 • Brewin CR, Rose S, Andrews B, et al. Brief screening instrument for post-traumatic stress disorder. BJPsychiatry 2002; 181:158-162. • Dent Coad E. After Grenfell. Housing & inequality. 2017 • Norris FH, Stevens SP, Pfefferbaum B, Wyche KF, Pfefferbaum RL. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. Am J Community Psychol 2008;41:127-150 • Van der Kolk. The Body keeps the Score. Penguin London:2015.