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06th February 2016

The Highway Code of mental health

I’ve been reading the latest annual report from the Care Quality Commission (CQC) into the use of the Mental Health Act (MHA), which you can download here.

The CQC and the MHA

The Care Quality Commission took over the role of monitoring the operation of the MHA some years back after it was previously undertaken by the specialist Mental Health Act Commission. This annual report is a collation of all of the inspection visits that the CQC has undertaken to units where people are detained under the MHA. Their information comes from looking at documentation, interviewing staff, managers, service users and their carers.

A lot of the focus in this report is on how well hospital providers have responded to the new Mental Health Act Code of Practice. There’s a lot of criticism about failures of hospital providers to meet the many requirements of the Code of Practice. You may know the Code of Practice was substantially revised in 2015 with a much wider scope. My copy issued in 2008 is just 388 pages of A5 size, compared to the new version of 459 pages in A4 size!

There’s a stark reminder of staff responsibilities in the introduction to the CQC report: "Staff who work with people who are liable to be detained have a personal responsibility to learn about the MHA and elements of the Code of Practice that are relevant to their job."

What is the status of the Code of Practice?

It’s not the law itself, but it is a statutory guidance, drawn up by parliament. If you do something different than is described in the guide as to how you should operate in the field of mental health, then you could be severely criticised. You should at least have justification for doing something different than is outlined in the Code. So it’s a bit like the Highway Code. If you drive a car, or are a pedestrian, you should be aware of the Highway Code. Well, I’ve got all the previous editions of the Mental Health Act Code of Practice, but I haven’t got a copy of the Highway Code!

The five guiding principles

At the start of the Code of Practice is a list of five guiding principles. The CQC report looks at those principles and how these should be applied. The principles are:

  • Least restrictive alternative and independence
  • Empowerment and involvement
  • Respect and dignity
  • Purpose and effectiveness
  • Efficiency and equity

What are some of the criticisms of providers of how they’ve failed to follow the Code?

Not enough patients being informed of their rights. Or more accurately nothing in writing to document that patients had got that information (remember if it’s not written down, it didn’t happen!)

Nearly a third of the records the CQC looked at showed no mental capacity assessments on newly admitted patients. We need to know if people have the capacity to consent to the treatment being administered. The CQC also noted that people might be being cared for or treated under the Mental Health Act, or under the Mental Capacity Act. Sometimes the ways these operate, or which should be used, can be very difficult to judge, but the CQC called for more training to discuss how the two pieces of law fit with each other.

A quarter of records that were looked at showed no patient involvement in care planning . User involvement is of course a key principle of good care planning – there can be many ways of doing it, again recording is our evidence. What are the views of the patient? Care plans should include much more than just what the professionals are going to do. The CQC gave instances of other ways in which care plans by-pass user involvement, such as lots of jargon or acronyms, and having lots of care plans covering different areas of someone’s care, without have an easily identifiable over-arching plan. Are there ways of promoting carer involvement in those care plans? The report highlights some good practice where units were proactive in getting carers on board, rather than waiting for carers to ask for more information.

There was lack of evidence of discharge planning. We all know the principles: effective discharge planning starts on admission. The CQC found no evidence of discharge planning in 29% of the records they looked at. The Code of Practice stresses the importance of good physical health care and that this can be part of discharge planning. The Code of Practice examines what good after-care should be about. That’s not just mental health treatment and monitoring. It should encompass a wider view of someone’s life, and their needs.

Patients were not well enough informed about the role of the IMHA and how to access it. The introduction of Independent Mental Health Advocates was a key element in changes to the Mental Health Act 8 years ago. These provide independent support to people subject to the Mental Health Act. One of the criticisms of the report was that patients were not well enough informed about the IMHA role and how to access the service. Access to IMHAs is just one of many rights that people who are detained should be aware of. The CQC said the vast majority of people received information about their rights but pointed out that the Code of Practice says this should be done as a regular reinforcer throughout someone’s hospital stay.

There was a lot of evidence of wards applying blanket restrictions of people, for example around access to kitchens, or bathrooms. Now there might be good reasons for this for some people, but maybe not all. Are there ways these restrictions can be lifted safely which helps improve the experience of day to day living for people?

The importance of good quality interaction between staff and patients was noted. Sometimes the CQC said that the idea of a good relationship might slip into familiarity, which might become inappropriate. The CQC points out that good relationships mean maintaining professional standards.

Now, our requirement to be aware of the Mental Health Act Code of Practice really depends on our level of involvement with people subject to the Mental Health Act. However, we could all usefully read Chapter One - the Guiding Principles.

View the whole CQC report (Monitoring the Mental Health Act in 2014/15) here 

David Beckingham – QCS Expert Mental Health Contributor


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