Week 5

Context

"Depending on the local context, certain individuals and groups in society may be placed at a significantly higher risk of expe- riencing mental health problems.These vulnerable groups may [but do not necessarily) include members of households living in poverty, people with chronic health conditions, infants and children exposed to maltreatment and neglect, adolescents first exposed to substance use, minority groups, indigenous populations, older people, people experiencing discrimination and human rights violations, lesbian, gay, bisexual, and transgender persons, prisoners, and people exposed to conflict, natural disasters or other humanitarian emergencies. The current global financial crisis provides a powerful example of a macroeco- nomic factor leading to cuts in funding despite a concomitant need for more mental health and social services because of higher rates of mental disorders and suicide as well as the emergence of new vulnerable groups [for example, the young unem- ployed). In many societies, mental disorders related to marginalization and impoverishment, domestic violence and abuse, and overwork and stress are of growing concern, especially for women's health" (World Health Organisation, 2013).

Mental ill health is the largest single cause of disability in the UK, contributing almost 23% of the overall burden of disease compared to about 16% each for cancer and cardiovascular disease. The economic and social costs of mental health problems in England are estimated at around £105 billion each year (Department of Health, 2012). The World Health Organisation’s Mental health action plan (2013-2030) estimates the economic consequences could amount to US$ 16.3 million million.

Content

Mental Health Policy

In the UK, policy around mental health is led by the Department of Health, although there are a number of other organisations that feed into this process. These include professional bodies like the Royal College of Psychiatry, the British Association for Counselling & Psychotherapy, and the Royal College of Nursing. Independent bodies like the Centre for Mental Health (formally the Sainsbury Centre for Mental Health), also play a significant role in the formation of policy.

This activity has led to a number of central and local Government initiatives:

Equality and Excellence: Liberating the NHS (DoH, 2010)

This initiative set out the Government's plans for the NHS, "First, patients will be at the heart of everything we do. So they will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care. Second, there will be a relentless focus on clinical outcomes. Success will be measured, not through bureaucratic process targets, but against results that really matter to patients – such as improving cancer and stroke survival rates. Third, we will empower health professionals. Doctors and nurses must to be able to use their professional judgement about what is right for patients. We will support this by giving front- line staff more control. Healthcare will be run from the bottom up, with ownership and decision-making in the hands of professionals and patients" (Department of Health, 2010: p1) .

No health without mental health (DoH, 2011)

This act was aimed at "putting people who use services at the heart of everything we do – ‘No decision about me without me’ is the governing principle. Care should be personalised to reflect people’s needs, not those of the professional or the system. People should have access to the information and support they need to exercise choice of provider and treatment; focusing on measurable outcomes and the NICE Quality Standards that deliver them rather than top-down process targets; and, empowering local organisations and practitioners to have the freedom to innovate and to drive improvements in services that deliver support of the highest quality for people of all ages, and all backgrounds and cultures" (Department of Health, 2012: p3).

Payment by results (PbR)

Before PbR, commissioners tended to have block contracts with hospitals where the amount of money was fixed irrespective of the number of patients treated. PbR was introduced to:

support patient choice by allowing the money to follow the patient to different types of provider
reward efficiency and quality by allowing providers to retain the difference if they could provide the required standard of care at a lower cost than the national price
reduce waiting times by paying providers for the volume of work done
refocus discussions between commissioner and provider away from price and towards quality and innovation

This will give service providers an opportunity to better understand the needs of people that are accessing their services and ensure that their responses to those needs are high quality. They will measure the quality ensuring that it is safe, effective and a positive experience. Service providers will also need to evidence the fact that they are offering good value and this will only be able to be evidenced if they are productive and effective.

'Borough Teams' - Integrated Care Pathways

The ICP is structured around the ‘variance tracking tool’ (real time audit) and it describes a process for a discreet element of care, for example, primary care, admission, acute care, rehabilitation or discharge. These elements build together to construct a unique journey for each individual patient according to their needs, based on professional judgement. It sets out anticipated, evidence-based, best practice and outcomes that are locally agreed and that reflect a patient-centred, multi-disciplinary, multi- agency approach. It must be noted that although certain elements of care can be entirely ‘unidisciplinary’, they cannot be constructed without the knowledge and input of the whole multidisciplinary team. The Government has declared that all local health and social care services will be integrated by 2018; described as an ‘end to people being passed around the health and social care system’. For this to happen, we need to create a culture of robust partnership working between health, social care, public health, other local services and the voluntary sector. This has led to the creation of 'Borough Teams' which draw together care providers at the local level into cross organisational teams to create an integrated care pathway.

IAPT Services

Improving Access to Psychological Therapies is an NHS programme rolling out services across England offering interventions approved by the National Institute of Health and Clinical Excellence (NICE) for treating people with depression and anxiety disorders.

Mental Capacity Act

The Mental Capacity Act is a “framework” Act. In many instances it does not say what is lawful or unlawful, but what framework must be followed for decision making, so it can be harder to say categorically this is or is not lawful. It will always depend on individual circumstances. The Act covers a wide range of decisions and circumstances, but legislation alone is not the whole story. The Act needs to be supported by practical guidance, and the Code of Practice (Department of Constitutional Affairs, 2007) is a key part of this.

Five basic principles from the Act:

When assessing someone’s mental capacity

1. A person must be assumed to have capacity unless it is proved otherwise, and

2. Until all practicable steps have been taken to help someone make a decision without success, they cannot be treated as lacking capacity, and

3. An unwise decision does not in itself indicate a lack of capacity

When acting or making decisions on behalf of someone lacking capacity

4. Any act or decision must be made in the person’s best interests, and

5. Any act or decision must be the least restrictive option to the person in terms of their rights and freedom of action

The 'Code of Practice' 2007

The legal framework provided by the Mental Capacity Act 2005 is supported by the Code of Practice, 2007 ('the Code'). The Code has statutory force, which means that certain categories of people have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves.

Definition of Mental Capacity

To have capacity to make a decision, someone must be able to:

Understand the information relevant to the decision, and
Retain the information, and
Use or weigh up the information to arrive at a choice, and
Communicate the decision

During Carol Price’s journey, when did you observe any changes in her mental capacity?

Consent

the right to consent is based on the ethical principle of respect for autonomy. An autonomous person has the right to decide what may or may not be done to him/her. Any treatment, investigations or deliberate intervention (such as holding/touching) without consent may constitute a battery (civil wrong (tort) or a criminal offence of assault or battery).

How did you respond when you saw the Police intervening with Carol in the shop (Video: Journey: Episode 4: Crisis Point)? What allows the police the right to withhold a person against their will? When Carol runs off at the hospital before seeing her therapist (Video: Journey: Episode 5: Finding A Way), what do you think might be her rights at this point? When would it be appropriate for someone to intervene and prevent her leaving the building?

Mental Health Act

In England, there is the Mental Health Act (1983), which allows a person to be withheld against their will. The vast majority of people receiving treatment in psychiatric wards are in hospital on an informal basis and have usually agreed to come into hospital – they are called informal patients or voluntary patients. About a quarter of people, however, are in hospital without their agreement. This is because they have been ‘sectioned’ (or ‘detained’) under the Mental Health Act 1983. They are called formal patients. If you are in hospital as a formal patient you will not be free to leave and will lose some other important rights available to informal patients.

The Mental Health Act 1983 gives approved mental health professionals (AMHPs) the power to make an application to admit someone to hospital under a section of the Act if they consider it necessary and the best way of ensuring they receive the right care and treatment. Before doing this, the AMHP must interview them and be satisfied that detention in hospital is, given all the circumstances, the most appropriate way of providing the care and medical treatment they need. They must then make the application for admission within 14 days of the interview. The person's nearest relative also has the right to apply for them to be detained under the Act but, for practical reasons, the AMHP usually makes the application, which is what the Mental Health Act Code of Practice advises.

If someone is being sectioned under section 2, the Act says that two doctors, after examining them, must confirm that:

(a) they are suffering from “a mental disorder of a nature or degree that warrants detention in hospital for assessment” (or assessment followed by medical treatment) for at least a limited period; and
(b) they ought to be detained in the interests of their own health or safety, or with a view to the protection of others.

If someone is being sectioned under section 3, the Act says that two doctors, after examining them, must confirm that:

(a) they are suffering from a “mental disorder of a nature or degree” that makes it appropriate for them to receive medical treatment in hospital; and
(b) “appropriate” medical treatment is available for them; and
(c) it is necessary to detain them for their own health or safety, or for the protection of others, that they receive such treatment and it cannot be provided unless they are detained under this section.

References and Further Reading

Department for Constitutional Affairs (2007) Mental Capacity Act 2005 Code of Practice. London: DfCA

Department of Health (2010) Liberating the NHS. London: DoH

Department of Health (2011) No health without mental health. London: DoH

The Mental Health Act (1983) as amended by the Mental Health Act 2007) London: The Stationary Office

The Mental Capacity Act (2005) as amended by the Mental Health Act 2007) London: The Stationary Office

World Health Organisation (2013) Mental Health Action Plan 2013-2030). Geneva: WHO