I was asked about making inpatient mental health services safer and better. I don't have experience as a patient of inpatient care, but I've spoken to lots of people who have, and so I put together this list of common themes. These are my opinions. I may have misremembered what people told me, or I may have forgotten important details.
Sometimes when a person is admitted to a mental health hospital they're seen as a diagnostic coding, as a commissioning cluster, and the organisation is interested in the bits of the patient they get paid for, and everything else is someone else's business. The organisation wants to fix the deficits that they've decided the person has. This is not holistic person centred care. Many people feel that they are being warehoused until their illness is controlled enough that the service feels it’s safe to discharge them, and then they’re dumped back into a community MH team with an ambiguous care plan.
We've all had the experience of asking a member of staff "Can I..." (Can I have my phone, can I have a Pepsi Max, can I go outside for some fresh air, can I get leave for my child's first ever day of primary school, can I have a pen, can I have a sanitary pad, can I substitute a different food in place of broccoli because I've always hated it, can I...) and the staff member says "no", and then you can see they're trying to justify that with post-answer rationalisations. Most staff cannot back down from their initial "no" response, they can't say "actually I was a bit hasty there, let me go ask people", and so they'll say "no, because health and safety" or "no, there's not enough staff" or they'll say "no, that's bad for you" / "no, you could harm yourself with that". It's infuriating. I believe it leads to human rights abuses (ECHR articles 8, 9, 10).
Staff will say that this is exacerbated by pressures on the ward and by lack of available staff. I don't care what excuse provider organisations come up with for the interference in patient human rights – it's not acceptable and needs to stop. Pressures on the ward are not a sufficient reason for this level of control over every detail of people’s lives.
Too many staff are confused about what their role is. That role must not be exercising control over the patient unless there is no alternative. To be clear I don’t just mean about the big stuff – whether I can decide to be a patient, or to take medication. I’m also including the small stuff of everyday life – whether I have sugar in my tea, how I wear my hair, what time I go to bed, (this is a very long list). The difference between this and “Stop saying no” is that here the staff have good intentions. They see the person doing something that is mildly unwise and they want to step in and make what they think is a helpful suggestion. But they don’t see how paternalistic this is.
To overcome the excessive control that staff exert over patients we have the concept of “positive risk taking”. This allows staff to ease back a bit on trying to control every aspect of a person’s life, allowing the person more control over day to day stuff. But the meaning has shifted from “give the person more freedom” to “withhold care from the person”.
There are far too many examples of people being denied access to services, including inpatient services, because of the misuse of positive risk taking. Sometimes because of pressures on the service people are discharged too early into situations that are high risk under the pretence of positive risk taking. Be honest with me. Tell me that you’re discharging me to a crisis team and a community mental health team because you don’t have enough beds for the increased acuity of the local population. Be really honest with me, tell me that services have stigmatising and harmful attitudes to people who’ve been given the diagnosis of personality disorder and that services don’t know what to do with this group of people. Don’t lie to me and tell me this is good for me. We all know it isn’t.
Some wards love imposing blanket restrictions. Sometimes an organisation will create a policy that makes it harder for these blanket rules to be created and imposed. But a blanket rule may exist that your organisation is calling something else or isn't aware of. I think there's not enough recognition of "de facto blanket rules" that are implemented by a single clinician with no scrutiny or oversight. For example, the doctor who tells most patients to not post to social media - this is a blanket rule, being imposed by a single clinician, and the rule isn't subjected to any kind of scrutiny or oversight.
Organisations should have at least one person who has enhanced training in human rights who can provide a brief analysis of the human rights implications of each blanket rule before it’s introduced. That person could also provide a brief analysis for each new policy the organisation brings in.
Non-executive directors of NHS Foundation Trusts should have a list of all of the blanket rules that are in place in the organisation so that they can hold the organisation to account for not removing the blanket rules in a timely manner when they’re no longer needed.
Healthwatch needs to start asking organisations about blanket restrictions, and start using their powers to “enter and view” to check on blanket restrictions.
Wards can be busy and noisy. But they can also be chaotic and scary. I have a human right to have a family life, and my children have human rights (in more than one convention) to have a family life with me. Hospitals need to have nice, cosy, separate, well-provided, family rooms.
Some mental health wards are pretty barren and there’s nothing to do. This is not a good therapeutic environment. There have been change here – many trusts have introduced a range of activities. But pandemic caused chaos. Services used to have a stepped approach to activity (only on the ward facilitated by MH professionals; in a mainstream setting supported by MH professionals; in a mainstream setting with robust reasonable adjustments; in a mainstream setting), covid collapsed those to activities only being provided on the ward.
Activies should cover a spectrum - they should include things that are calming, as well as physical exercise, as well as things to get my brain working.
As public bodies with draconian powers it's simply not good enough to say "The Mental Health Act was created to be compatible with human rights, and so we focus our attention on compliance with the mental health act and that’s enough”, because 1) You don't always follow the law (complying with the law is tricky, which is why we have the code of practice to the MHA and it’s why there are successful appeals against detention in tribunals) 2) Many of your patients are not held under the MHA and 3) if the MHA was any good we wouldn't have needed the Wessley Review nor Senni's Law. Our understanding of human rights is developing, and case law is being created, and the English MHA isn’t keeping up. Also, you following the MHA does little for my family’s rights. My children have rights to see me – how many organisations have articulated how they’re protecting the rights of the child to a family life?
Sometimes being in hospital for a long time can mean I lose my home. This can be traumatic. What always makes it worse is when it happens in an unplanned way and so I do not have time to get help to get my possessions. I can lose access to prized heirlooms with great sentimental value. My important original paperwork (passports, birth certificates, educational qualification certificates, etc can all be destroyed). I was illegally evicted from a flat and I lost so much – over 500 books, my small but important to me collection of vinyl, family photos that cannot be replaced, small trinkets that I had grown up with. It sucked. Worrying about keeping your home while you’re in hospital means you’re distracted from therapeutic activity.
This applies to a range of social stuff – education, employment, etc.
When we ask staff if the person has a plan for discharge they’ll say “yes” and when we ask the person they’ll say “no” and this is because the organisation focuses on ticking the boxes in the electronic patient record. It is fulfilling the bureaucracy, but it’s not focussed on the patient. In many of my suggestions I’m desperately trying to let nurses get back to nursing – building therapeutic relationships with patients.
Hospital admission can be really destructive to someone’s life. You may have lost your home, connection to friends and family, connection to your local community. Some people will need support to remake those connections, and it’s a good idea to start planning that support while people are in hospital.
There often feels like a disconnect between in-patient staff teams and community MH teams. (Do community MH team members ever attend multi-disciplinary team meetings with the patient while the patient is an in-patient?)
When you admit me to hospital you should ask me what I think I need to work on while I’m there. Ask me what’s important to me for recovery.
And when I’ve been discharged and I am back at home someone should ask me if the admission was therapeutic, if it achieved anything useful, if I met my goals.
We talk about involving the patient in their care plan, but how can we be really doing that if we’re not asking patients what they want to achieve from treatment and then asking them whether they think it worked or not.
When we look at the restraint event and the 15 minutes either side of it we see that some people find it easy to justify the use of restraint. Here’s the narrative:
There was a risky situation on the ward. A person was at imminent risk of harming themselves or someone else. Restraint and probably rapid tranquillisation was applied. Harm was avoided.
At least, that’s what services tell themselves. There are problems with this narrative though. Staff and patients are frequently physically harmed by the use of restraint. Staff and patients are often mentally harmed by the use of restraint, and sometimes that harm won’t be apparent until months after the person has been discharged from services. Some restraint is used to prevent violence or manage aggression, but plenty of restraint is used to provide care or provide treatment. In that situation the violence is initiated by the organisation, and not by the patient. Services sometimes tend not to ask themselves how that risky situation arose, nor what else they could have done to avoid it. We’ve seen in tv documentaries that some staff goad or provoke (actually, abuse) a person until a restrainable response is created by this abuse, and then they pin the person to the floor. We need to be careful about the cause and effects happening behind closed door.
When we ask services about their use of restraint they say a range of things. They’ll start by saying “Our use of restraint is very similar to other units”. Sometimes they’re wrong, and they use more restraint than other units. And even if they use the same amount, I don’t care. It’s wrong and it’s always too much. Then they’ll say “You have to compare similar types of units, you can’t just compare different types of units. We’re an X unit (eg eating disorder), you can’t compare us to Y units (eg PICUs).” They say this no matter what type of unit they are. Some staff believe that their type of unit is special and will always use higher rates of restraint. When we show them that their unit is using higher rates of restraint than other similar units (or we persuade them it doesn’t matter, restraint always needs to be reduced even if their unit is better than other units) they’ll say “well, okay, but that was Bob, he was very unwell when he was admitted”. They almost never talk about the staff on the ward - whether they had the right skill mix, the right number of staff, if all staff had the right training, if all staff have the right values, etc.
I am concerned that some non-executive directors and chairs of NHS foundation trusts appear to be more tolerant of restraint than executive directors are. I do not understand how a NED can hold the organisation to account when the NED is less concerned about a thing than their ED colleagues.
When I talk to you about restraint and rapid tranquillisation please stop telling me “we only use it when absolutely necessary”. I do not get reassurance from what you say. I get reassurance from what you do. Everyone says they only use restraint as a last resort. They said it in all those places that were on television documentaries; they say it in all those places that patients talk about; they say it no matter what their level of restraint usage is. Show me what you’re doing to reduce your use of restraint. Show me how your non-executive directors hold your organisation to account for the amount of restraint being used. Show me the quality improvement projects you’re running. Show me the networks you’re building with similar wards or similar trusts. Most importantly, show me the reduction in use of restraint.