APPENDIX 38
Letter from the Chief Executive, South
West London and St. George's Mental Health NHS Trust, to the Chairman
of the Committee (MH 71B)
It was a pleasure for our trust to host members
of the Health Select Committee on one of their study visits. We
hope that we were able to give some insight into the challenges,
and rewards, of providing a responsive mental health service in
inner-city London. I thought it would be helpful to follow up
with a brief memo on two specific issues that were discussed at
that meeting.
1. Homicide inquiries
Until last year we have thankfully had no direct
experience of such inquiries but currently have three in progress.
We fully endorse the need for a thorough investigation of such
tragedies, and that such investigations should be fully open to
public scrutiny. We are concerned, however, that the blame culture
they sustain is bad for patients (stigmatising them as violent)
and for staff. Indeed through their impact on morale and recruitment,
they may reduce the standards of care that they are intended to
improve. More specifically we drew to your attention the surprising
variation in both the terms of reference and procedures which
inquiries adopt. It has become clear to us that inquiry panels
are constituted from individuals who often only have experience
of one or two previous inquiries and often none. Despite the quality
of these individuals the process is often essentially "amateur".
The task they are set is very difficult and
requires both skill and experience if sensible benchmarking of
acceptable levels of practice is to be achieved. We recommended
in our discussion with your members that the model evolved for
the National Confidential Inquiry into Homicides and Suicides
has served the public and professions well. A similar approach
based on a National body (perhaps such as the Commission for Health
Improvement) would be able to build up sufficient expertise to
command respect from those involved and also conduct the inquiries
at considerable less cost, in term of time, money and morale,
than is current.
2. Extra contractual referrals to the private
sector
We have consistently prioritised the ability
to admit, without delay, any acutely unwell patient. This has
required rigorous, clinically led, bed management with continuity
of care, unambiguous clinical leadership and close working with
social services and primary care but it is essential to effective
community practice. It is also essential for safe and humane care.
Individuals are not separated by long distances from their families
just when they are at their most distressed. The National Inquiry
into Homicides and Suicides has reported that patients admitted
out of district (ECRs) are at significantly increased risk of
suicide immediately post discharge. They have identified this
as the most high risk period.
With trust mergers we have recently had to negotiate
the return of patients who had been "exported" either
to the private sector or to specific units within the NHS which
accept ECRs to offset deficits in the trust. We formed a distinct
impression that such units held onto patients longer than we would
have considered clinically essential. This may be because discharge
planning is inevitably much more difficult from a distance. However
the absence of the normal bed pressures and a potential perverse
incentive from a per-diem occupied bed payment system must have
some influence. We are strongly of the opinion that getting bed
provision in balance locally is both financially and therapeutically
essential and will drive clinically relevant prioritisation within
the broad remit of the National Service Framework.
26 June 2000
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