MEMORANDUM BY THE ROYAL COLLEGE OF NURSING
OF THE UNITED KINGDOM
PROVISION OF NHS MENTAL HEALTH SERVICES (MH
21)
TERMS OF
REFERENCE
To examine the provision of NHS mental health
services for people, including children and adolescents, with
mental illness or personality disorders, including consideration
of the relationship with secure units, high secure hospitals and
prisons
The report will cover the following issues:
— Current Government definitions and
categorisation of mental illness.
— The ability of care in the community
to cater for people with acute mental illness.
— The transition between acute and
secure mental health sectors.
— The transition between adolescent
and adult mental health services.
EXECUTIVE SUMMARY
The field of mental health provision has recently
been the subject of a variety of consultations with the likely
result that it will change considerably over the next few years.
In the National Service Framework and elsewhere,
ambitious proposals for improving mental health services across
all areas have been set out. These can only be beneficial if they
are tested thoroughly and if there are the right number of skilled
nurses in the NHS to ensure their proper implementation.
The RCN supports the Government's aim of enabling
patients to remain in the community so long as this is in the
best interests of the patient and, wherever possible, reflects
the choice of the patient, and where there is adequate support
for patients and their carers.
Treatments should not be imposed on a patient
unless the patient lacks the capacity to decide whether to accept
or refuse treatment and such treatment is in their best interests.
The RCN has concerns over the association of
stigmatising words such as "dangerous" with personality
disorders.
There is a need for the different sections of
mental health service provision to work closely together in order
to provide a seamless service for patients.
Any review of mental health services should
explore all aspects of the mental health infrastructure and not
just the high profile specialities.
The role played by mental health nurses is vital
in maintaining a high standard of care, and it is essential that
the contributions of both nurses and patients are considered in
the planning, implementation and evaluation of mental health services.
1. INTRODUCTION
The Royal College of Nursing (RCN) is the UK's
largest professional association and trade union for nurses, with
over 320,000 members. Approximately three-quarters of RCN members
work in the NHS. The RCN works locally, nationally and internationally
to promote high standards of care and the interests of patients
and nurses, and of nursing as a profession. The RCN is a major
contributor to the development of nursing practice, standards
of care and health policy.
The Health Select Committee's inquiry covers
a very broad remit in respect of mental health service provision.
The RCN represents members working in the key areas of adult mental
health, child and adolescent mental health, secure settings and
in the community. The RCN Mental Health Forum, the RCN Forum for
the Development of Mental Health Nursing, the RCN Forensic Nursing
Forum and the RCN Child and Adolescent Mental Health Forum between
them have approximately 30,000 members. Mental health nurses work
with people with mental illness and those with personality disorders.
The RCN gave more detailed evidence on the latter group in our
written and oral evidence to the Home Affairs Select Committee
inquiry into The Government's Proposals for Managing Dangerous
People with Severe Personality Disorder. It is important to
note that people with mental illness also have physical health
needs, and nurses work with people who are mentally ill in primary
health care teams, accident and emergency departments, acute hospitals
and maternity facilities.
While the RCN is pleased to provide this memorandum,
it is important to note that there is currently a plethora of
frameworks and consultations in respect of mental health provision;
and it is likely that a re-structuring of services and new policies
will emerge as a consequence. We are currently completing our
detailed response to the Green Paper Reform of the Mental Health
Act 1983. Our memorandum is therefore commenting on a changing
system. As the timeframe for providing written evidence is short,
we have restricted our commentary to the key issues in the provision
of NHS mental health services.
We have structured our written memorandum to
reflect the issues identified by the Committee's terms of reference.
2. CURRENT GOVERNMENT
DEFINITIONS AND
CATEGORISATION OF
MENTAL ILLNESS
The RCN's comments in this section reflect our
evidence to the Home Affairs Select Committee inquiry into The
Government's Proposals for Managing Dangerous People with Severe
Personality Disorder and to the Expert Committee chaired by
Professor Genevra Richardson during consultation on the review
of the Mental Health Act.
Definition of "mental disorder" in
the Green Paper Reform of the Mental Health Act 1983. The
proposed definition of mental disorder[1]
is very broad and would replace the much more restrictive definitions
of mental disorders under the 1983 Act.
This was recommended by the Richardson Committee
and accepted by the Government. A diagnosis of mental disorder
is one of a number of criteria which must be satisfied for compulsory
detention and treatment of a patient. Although a wide definition
of mental disorder is to be welcomed, questions remain as to the
impact this will have on an already overstretched service.
The role of "capacity" in determining
compulsion. In its discussion of the criteria for compulsory care
and treatment, the Richardson Committee considered that the capacity
of the patient to consent to treatment should be considered. The
Committee recommended two alternative criteria for the implementation
of compulsory powers, making a distinction between cases where
patients retain capacity and where they lack capacity.
The Green Paper casts doubt on this approach:
"The principal concern about this approach
is that it introduces a notion of capacity, which, in practice,
may not be relevant to the final decision on whether a patient
should be made subject to a compulsory order. It is the degree
of risk that patients with mental disorder pose, to themselves
or others, that it is crucial to this decision. In the presence
of such risk, questions of capacity—while still relevant
to the plan of care and treatment—may be largely irrelevant
to the question of whether or not a compulsory order should be
made (page 32)."
Contrary to this view, the RCN believes that
the issue of capacity is central to the question of whether or
not a patient should be subject to compulsion. As a matter of
ethics, nurses must respect a patient's autonomy. The only justification
for imposing treatment against the patient's will is if the patient
is so ill or disabled as to be mentally incapable of making the
decision whether to accept or refuse treatment.
The Government's proposals for managing "dangerous"
people with severe personality disorder. In our written response
to the consultation on these proposals we argued strongly against
the poor use of terminology in respect of personality disorders.
We expressed serious reservations about the use of the term "dangerous
severe personality disorder" as there is no such clinical
diagnosis and no commonly accepted and scientifically validated
measure of "dangerousness". The use of the term "dangerous
severe personality disorder" without precise definition causes
confusion. The RCN believes that such ill-defined phrases could
cause the process of clinical assessment and diagnosis to be confused
with criminal or social judgements. Both the Royal College of
Nursing and the Royal College of Psychiatrists have grave concerns
about the stigmatising effect of attaching the term "dangerous"
to that of "personality disorder", which in the media
and the public eye is likely to be attached further to people
with any type of mental illness.
3. THE ABILITY
OF CARE
IN THE
COMMUNITY TO
CATER FOR
PEOPLE WITH
ACUTE MENTAL
ILLNESS
The new National Service Framework for Mental
Health and the response to the Green Paper Review of the Mental
Health Act 1983 are likely to have a large impact on community
care provision, both in terms of service models and the legislative
backdrop to community mental health care.
The RCN supports the Government's aim of enabling
people with acute mental health problems to remain at home as
long as possible, and to return home from in-patient care as soon
as possible. However, home care should only occur so long as there
is adequate support and high quality care available to the patient,
and to their carers. This is not necessarily a cheap option. Nurses,
and particularly community psychiatric nurses, have a key role
in providing high quality care and the right number of specially
trained and skilled nurses will be essential to achieving the
targets set out in the National Service Framework.
Opportunities are identified within the National
Service Framework to improve services for people with acute mental
health needs in the community through early intervention work
with psychosis, relapse prevention models and assertive outreach.
However, the RCN believes there is a need for additional research
and development work to carefully examine the impact of these
approaches. Adequate resources for training in the new therapeutic
approaches and models of service deliver will also be necessary,
such as the Thorn Nursing Programme[2]
which affords a clear opportunity for nurses to gain skills in
care management, medication management, family and educational
approaches to care of people with mental health problems. Of particular
concern to the Royal College of Nursing is the risk of token multi-disciplinary
and inter-agency provision without the resources provided at local
level to enable new models to be rigorously implemented and evaluated.
The RCN would like to draw the Health Select
Committee's attention to the Standing Nursing and Midwifery Advisory
Committee's Report Mental Health Nursing: Addressing Acute
Concerns and guidelines on Observation of Patients at Risk
and Assertive Community Treatments (June 1999). The
report emphasises the current stresses on in-patient settings,
and recommends investment in acute mental health nursing educational
opportunities, and development of a career structure with attention
to the therapeutic and skills base of this group of nurses. The
Royal College of Nursing believes that successful care in the
community can only be beneficial if good quality care, access
and patient choice are also available in an in-patient setting.
The lived experience of a patient may mean that they do not differentiate
between hospital and community-based medicine in the same way
as the service providers, and the development of models of care
with a real patient/carer focus should reflect this perspective.
The RCN has concerns about Government proposals
for compulsory care in the community which will directly affect
people with acute mental health needs. In practice, the RCN believes
that new powers might lead to:
— Compulsory assessment and treatment
taking place in the community, due to lack of hospital beds, when
the patient ought to receive hospital care.
— Compulsory medication being used
as a substitute for adequate mental health care.
— An overburdening of, and potential
danger to, carers and community staff.
The RCN calls for effective safeguards to ensure
that this does not happen. There is a need to ensure that compulsion
only occurs in the best interests of the patient, that adequate
access is provided to a choice of services, and that where active
resistance to community care is demonstrated, that patient be
transferred to in-patient care until the situation warrants further
assessment of need.
Information systems will be crucial to the success
of community care to enable communication within and between teams
and agencies so that best practice can be shared. Information
must be accessible by health care practitioners at all levels
including those working at the front line of care. Effective information
systems are also crucial to ensure an evidence base for mental
health care. There are additional resource and training needs
in both these areas. It is worth noting that staff from health
and social care agencies have been working alongside each other
for many years, often very successfully. Bringing these agencies
together at a strategic evaluation level will be crucial to move
these existing relationships forward and provide a cohesive service
from the service user perspective. This, in the RCN view, is a
key need.
4. TRANSITION
BETWEEN ACUTE
AND SECURE
MENTAL HEALTH
SECTORS
The RCN believes that a real difficulty remains
the under-provision of and lack of access to secure beds, and
the shortage of staff to work in secure wards. Not all people
in secure settings, even high secure settings, require long term
care and so discharge facilities need particular attention to
ensure they are efficient and of a high quality. If it is to become
at all feasible to return people to the community from medium
or high secure settings it is also essential that experienced
staff and adequate resources are available in less secure residential
settings and in the community. There needs to be an impetus within
mental health trusts to engage with high security services (medium
secure clinics, high security hospitals and in some cases prisons)
to enable models of transition to be piloted and evaluated.
The need for long term medium secure provision
for women is especially urgent. A significant proportion of women
in high secure hospitals in England could receive care at a lower
level of security. This would not only be more cost effective
but would offer greater opportunities for gender sensitive care.
Women-only beds would need to be ring-fenced in sufficient numbers
to avoid women being isolated in male wards. This view is supported
by Women in Special Hospitals (WISH), the Mental Health Act Commission
and the majority of clinicians in high security environments.
In its evidence to the Home Affairs Select Committee
Inquiry Managing Dangerous People with Severe Personality Disorders,
the RCN emphasised the need for a "whole systems" approach
to managing patients with severe personality disorder. The joint
report by the Prison Service and National Health Service Executive
Working Group The Future Organisation of Prison Health Care
(March 1999) acknowledges the need for liaison between health
and prison settings and the need for new arrangements for referral
and admission to high and medium secure psychiatric services.
Models of care for any person moving between a secure setting
to less secure settings, or to the community, need to take account
of pre-discharge planning and community follow-up and review.
A further consideration must be the adequate
provision of in-patient beds in acute and intensive psychiatric
care. A joint RCN and Institute of Psychiatry census of inner
London acute care beds carried out 1997-98 identified serious
problems in relation to inadequate staffing levels[3],
unacceptably high levels of percentage occupancy[4],
a distinct lack of therapy options, cultural sensitivity problems
and limited support for clinical staff. The RCN Mental Health
Nursing Strategy, launched in 1999, concentrating on purposeful
acute in-patient service provision was a direct response to this
research evidence. The RCN strongly recommends that any review
of services explores all aspects of the mental health infrastructure
and not just the high profile specialities. There are approximately
36,000 psychiatric acute beds in England and these constitute
the backbone of the service. Without them, or without them functioning
effectively, the rest of the service simply cannot operate.
5. THE TRANSITION
BETWEEN ADOLESCENT
AND ADULT
MENTAL HEALTH
SERVICES
In evidence to a previous Health Select Committee
on Health Services for Children and Young People (1997),
and in discussion with the Secretary of State, the RCN has expressed
concern over the lack of "joined up services" for child
and adolescent mental health services and has suggested the need
for a National Service Framework for all children's health. Part
of the difficulty is the lack of co-ordination between education,
social services and health services, and this is reflected in
the lack of properly managed transition arrangements between child
and adult services. The RCN argues for age-appropriate services
for young people, particularly in respect of providing sufficient
and appropriate in-patient facilities. Very few in-patient mental
health units for children exist and children admitted to these
units, often far from home, can suffer difficulties in maintaining
family contact.
The National Service Framework for Mental Health
touches on the needs of children and young people. While some
examples of good practice are highlighted in the document, these
barely scratch the surface of the real work which must be done
in identifying the needs of 16-22 year olds with often long term
mental health problems, and sometimes with associated offending
behaviour. RCN members have expressed their dismay at seeing young
people arrive at adult services, whether mainstream or forensic
centres. The RCN calls for separate transitional in-patient facilities
appropriate for this group's needs and staffed by appropriately
trained health professionals.
The RCN notes that the Health Select Committee
makes no mention in its terms of reference to mental health services
for older people. The National Service Framework for older people
should address the mental health needs of this group. As with
the transition between child and adult mental health services,
it is important to focus on a patient-led model of care in order
to provide a seamless service.
6. CONCLUSIONS
AND RECOMMENDATIONS
In conclusion, the RCN believes that much work
remains to be done in implementing and testing models of care
in all sectors of mental health.
Models for transition between different branches
of the mental health services (adolescent and adult, acute and
secure, in-patient and community) need additional development
in order to provide a more seamless, user-led service for the
patient.
The RCN is concerned that people with personality
disorders or mental illnesses, who are competent to make decisions
about their treatment, might be denied this choice under current
Government proposals.
The RCN strongly recommends that any review
of services explores all aspects of the mental health infrastructure
and not just the high profile specialities. Psychiatric acute
beds constitute the backbone of the service. Without them, or
without them functioning effectively, the rest of the service
cannot operate effectively.
Care and support for people with mental illness
is rightly provided though a multi-professional and multi-agency
approach, with a very important contribution from the voluntary
sector. However we believe that the role played by mental health
nurses is vital, and we urge the Government to acknowledge this
by providing sufficient resources to support nursing practice
development and research activities in order to ensure a continuing
high standard of care. The RCN believes it is essential that the
contributions of both nurses and patients are considered in the
planning, implementation and evaluation of mental health services.
February 2000
1 Green Paper Reform of the Mental Health Act 1983
4:1-6, p 18. Back
2 This course is currently offered by a number of English Universities
and the Royal College of Nursing Institute. Back
3 Official Government figures for NHS psychiatry nurses in March
1999 reported that there were 1,858 vacancies-the equivalent of
over seven empty hospitals. Back
4 Average ward occupancy rates in London were at 113 per cent but
some wards were as high as 184 per cent. In-patient mental
health services in inner London February 1998 RCN Institute
and Institute of Psychiatry. Back
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