DoLs, IMHAs and CQC

Lots of jargon and initials today. I should apologise in advance but they are certainly new phrases and words that will be becoming ever more familiar.

image Sidelong @ flickr

As, 1 April 2009 sees the implementation of three new nuggets of legislation which will have differing levels of impact on my day to day work.

I have written extensively about the introduction of the Deprivation of Liberty Safeguards (DoLs) introduced as an amendment to the Mental Capacity Act 2005. This will, without doubt, be of significant relevance to our team and my personal work – firstly because I am trained now as a Best Interests Assessor meaning that I will be actively involved in the assessments which form a part of the decision-making regarding whether someone without capacity can be lawfully ‘deprived of their liberty’ can be authorised or not. Secondly because I work in a team where we work a lot with capacity or rather, lack of it.

Not really sure where this will go in the longer term but I am almost looking forward to my first opportunity to put into practice some of the information that I studied about. Although the general feeling is that there will not be a flood of assessments, it is something I will, I expect, be in a good position to feed back on this site.

I had almost forgotten about the mandatory provision for IMHAs (Independent Mental Health Advocates) until I read The Shrink’s post on it last week. Subsequently, on Monday, I think, we had a mass email sent around the Trust reminding us of the implementation of the IMHA system with contact details and a reminder of who and when to refer people. I was both surprised and comforted. Surprised because I had not had any information about this service prior to Monday and comforted because obviously although we were completely oblivious to it, some work was being done somewhere to prepare people for this!

And finally RIP CSCI (Commission for Social Care Inspection), Healthcare Commission and MHAC (Mental Health Act Commission). These three organisations merge into the Care Quality Commission today.

The Guardian print a piece about the merger today. In the article there is a quote from Barbara Young, the CQC chair from last year where she says

the HCC (Healthcare Commission) had taken a “big brain” approach to regulation, using intelligence systems to identify risks in the NHS and target inspections accordingly. The CSCI approach was more about “running the finger around the toilet bowl”. It had thousands of care homes to regulate and fewer statistical tools to identify where problems might lie. So, inevitably, it relied more on regularly visiting establishments.

Young was not trying to characterise social care inspectors as brainless people who spent all their time in toilets, although some of them chose to interpret her that way.

Well, I have news for Barbara Young. CSCI have been undertaking ‘desk inspections’ for a few years now. If only they would actually visit residential and nursing homes regularly as they used to – carrying out regular announced and unannounced inspections – then their may be a better service all round.

If only the CSCI inspectors actually DID have the ‘running the finger around the toilet bowl’ sense of thoroughness and were given the opportunity to spend time in each and every registered residential home in England in order to collate extensive and thorough reports – we would have a lot more faith in the system.

Anyway, I’m getting waylaid and possibly a bit mean-spirited again. Good luck CQC. We REALLY need good regulation and checking systems in place.

Looking for beds

The new president of the Royal College of Psychiatrists, Professor Dinesh Bhugra, will according to the Guardian use his inaugural speech to lament the problems caused by the shortage of acute psychiatric beds in the system.

This is something we hear a lot about, and indeed, something described on There and Back Again’s blog about waiting for a hospital bed as an inpatient on leave when the ward is running a 150% occupancy rate recently.

Hospital beds in the hospital empty chamber. Kharkov, Ukraine.



Image via Wikipedia

Bhugra suggests that

No ward should ever be more than 80 per cent full if patients are to be safe, properly treated and cared for.

and while the sense of this can be obvious, it is rarely, if ever, the case in practice – or certainly isn’t in my own, admittedly limited, experience.

So something has to be done and Bhugra has a suggestion

‘ (Bhugra)..  is calling on the government to introduce a compulsory kitemark system of accreditation for all acute, inpatient psychiatric wards: ‘Until there is a compulsory kitemarking scheme, my prediction is that, as overcrowding increases, funding becomes more stretched and morale of patients and staff fall, overall conditions are likely to continue to deteriorate.’

Interesting. I know I rant against target-based practice but in can work in some areas. Perhaps if Trusts are told that funding will be cut or increased on the basis of their ability to find these beds – or that the levels of occupancy will be monitored by the Mental Health Act Commission and there will be financial penalties for applying poor standards – there will be more incentives to hospital managers to actually work on a solution – which doesn’t seem to be being done at the moment.

This Kitemark would measure against other standards such as staffing ratios as well and, indeed, in another article in the Guardian which focuses on current inpatient care, a spokesman for MIND says

‘A compulsory kitemark is a fantastic idea; these wards slip under people’s radar and that’s dangerous,’ she added. ‘When patients are sectioned, they literally have no choice at all about where they go. This makes it vitally important for society to be 100 per cent aware if these vulnerable people are ending up in wards where conditions don’t meet the minimum acceptable standards.’

Beds have been reduced as the focus has been on community care but the fact remains that some people need inpatient care and there isn’t always a reasonable substitute.

And with the incoming President of the Royal College of Psychiatrists in stating that

‘Acute psychiatric wards are now so poor, he (Bhugra) has admitted in an exclusive interview on the eve of his appointment, that he would not use them himself – nor allow a member of his family to do so.’

That is, perhaps, the saddest indictment of all.

Its pleasing that at least the situation is getting some more attention and will get even more when Bhugra actually makes his speech on Wednesday but one of the criteria that I have consistently tried to work on when considering placements for residential care is ‘would I be prepared for a close family member of mine to go to that home?’ and if the answer is no, I at least look for alternatives as I won’t use a home that I wouldn’t be prepared for a family member of mine to go to – or at least without offering the families and prospective residents an alternative option (which isn’t always taken or perfect for other reasons, like location but that’s another discussion for another day)

However as far as psychiatric wards go, that’s another matter.

Running acute wards at a 100% + occupancy doesn’t do anyone any favours in the long run and can lead to possibly longer or more frequent inpatient stays.

Where I work, I am fortunate in that I have a lot of faith in the psychiatric wards I normally use when people I work with are admitted.

Certainly on the over 65s wards where I know the staff much better, I can confidently say, I would be happy to spend time on those wards and would, without doubt, be happy for my father (only close family member I have that is over 65!) to go there. Because I know the wards are well-managed by an excellent nursing and medical team.

The other wards in the hospital, that I’ve had a bit less interaction with, have given me at least some faith in my interaction and observations of the interactions between patients and nursing and medical staff. I do know that this hospital is perhaps ‘one of the better’ ones.

Until I was on my placement in a different borough in my ASW course, my current hospital was the only psychiatric hospital I’d been to – I know that people had said it was a pleasant enough hospital but I didn’t know what to compare it to.

On placement I assessed and organised  an admission for a patient to a hospital I had heard about but never been to. We arrived. I was genuinely shocked myself about the look and feel of the ward. She was taken to her room and I honestly didn’t realise that there were wards like that around still. I think and have thought about it a lot. It has to change.

And the more publicity and public attention that is focused on the quality and care that is provided on some (but by no means all) of the psychiatric wards, the more hope that there will be for some change.

As for the running at over-capacity – the only solution in my own, simplistic mind, is more beds which means more money. Not very popular, I fear.