Examination of Witnesses (Questions 240-259)
MR PHIL
WHEATLEY CB, MR
PAUL FOWEATHER,
MR PAUL
THAIN, MR
IAN HULATT
AND MR
PAUL CORRY
17 NOVEMBER 2005
Q240 Dr Naysmith: So would you be
happy with the legislation as it is proposed, giving you an exemption,
or would you really prefer something a little bit stronger?
Mr Thain: I think I would be happy
as it is because that will allow us to move forward, but I do
not want any exemption for mental health services. I am not quite
sure what you are asking, but that is my view.
Q241 Dr Naysmith: You do want an
exemption, did you say?
Mr Thain: I do not want an exemption.
Q242 Dr Naysmith: So that would mean
that you would want the legislation to be a bit stronger, not
exempting mental health?
Mr Thain: Yes.
Q243 Dr Naysmith: Do you think there
are things that you could say to Mr Corry? I know you said that
you could only speak for your own Trust, but could these lessons
be transferred more widely?
Mr Thain: Certainly. In fact I
invite anybody to come and have a look around our Trust. What
I would say though is that we have had now an 18-month/two-year
lead-in and we have been working at it and working with our service
users and that has given us, I guess, as we sit here at this point
in time an advantage over others who may not have started.
Q244 Chairman: Could I just ask you,
Mr Thain, on smoking cessation in particular and co-operation
with the PCT—do you have it?
Mr Thain: We do, and a totally
different position from the one the Committee has heard of already
from elsewhere. Yes, our primary care trust has been extremely
supportive and, I have to say, as commissioners some 18 months/two
years ago were, I suppose, part of the process that brought us
to make a decision to move in this direction. In fact we were
one of the first, in fact I think we were the first secondary
trust in our area to move in that direction with full support
from the primary care trust who sat on our steering group and
provided us with some financial support.
Q245 Chairman: Mr Corry, you talked
about the issue of home visits in particular which is an area
which could cover yourselves and many other organisations as well.
Do you have any policy where you sort of get messages out prior
to one of your people going along that people should not perhaps
smoke for an hour or whatever or do you think it is just not feasible
to be able to make that type of request?
Mr Corry: We do, and we also encourage
staff to be proactive in asking to meet people within the house
in a smoke-free area. I think you had some evidence in one of
your earlier sessions that it can actually have the effect of
appearing to be a smoke-free environment in the sense that it
does not smell of smoke, but some of the particles themselves
may remain in the air, so it does not offer full health and safety
protection for our staff. We are in a situation at the moment
on home visits where we leave it very much up to the discretion
of staff to negotiate with the service user about how to handle
that situation, but I do not think it is a happy situation or
one that has actually met its full conclusion yet.
Q246 Chairman: Do you feel that you
do get co-operation in the most part?
Mr Corry: From the individuals?
Q247 Chairman: Yes.
Mr Corry: Yes. One of the things
we pride ourselves on, and indeed mental health services do generally,
is about being a people service and building up strong personal
relationships with people. It can actually be quite a useful way
to break the ice, a negotiating tactic and a trust-building exercise
to negotiate around something like that. On the whole, I think
we get co-operation, yes.
Q248 Chairman: Mr Thain, do you have
an opinion about it?
Mr Thain: Yes, I do. We, on our
letters that go out to people regarding appointments, make it
very clear that we do not expect our staff to have to enter a
room where people are smoking and we instruct our staff that they
have the right not to if somebody should insist that they are
going to smoke in their presence. Our staff themselves, just to
make it clear, when they are acting on behalf of our Trust and
when they are on duty, are asked not to smoke even when they are
out visiting people in their homes, so we would not allow our
staff to go into a smoke-filled room. The issue about whether
in fact there are chemicals left over is one that we have pondered
and I believe under the Act we can only do what is reasonable,
and we believe we have done as much as we reasonably can. We cannot
go in with special equipment and check out a room every time,
but we have taken it that far and we are very clear on that, and
we have received co-operation from patients and the public.
Q249 Anne Milton: Before I ask Mr
Hulatt some questions, I would like to say I am very impressed,
Mr Thain, and I did notice you shaking your head as Mr Corry was
talking. I should, before I ask you some questions, Mr Hulatt,
declare an interest because in fact I am a member of the Royal
College of Nursing. Perhaps we could have your perspective on
whether nurses in psychiatric institutions are subjected to second-hand
smoke more than in other situations?
Mr Hulatt: I think that the RCN
position on this, which relates to that question, is that to exclude
psychiatric institutions is to perpetuate health inequalities
that are not acceptable for people with mental health issues.
I think the mental health nursing constituency, if you like, is
challenged very much at the moment to promote the wellbeing of
individuals with serious mental health issues and to challenge
the previously accepted normality that people smoked which was
not challenged, yet we know that people with serious mental illness
diagnoses, such as schizophrenia, will die ten years younger than
someone without that label, we know that twice as many people
are obese in that group and up to three times as many people will
have diabetes. I think the mental health nurses are currently
challenged in our review under the Chief Nursing Officer in that
we are very keenly debating the overlooked area of physical health
and how we need to address that seriously. I think what we are
talking about is almost "denormalising" smoking, not
seeing it as an accepted part of the package of being a mental
health client. I think that where concerns have been raised and
where we do have concerns is how this is "operationalised"
in our places of care and that that needs to be done in a sensitive
and patient-centred way, by which I mean not a Draconian way such
that people would disengage from services because that is an anxiety.
Q250 Anne Milton: So what you are
actually advocating, which would be proper, is a holistic approach
to people with mental health problems?
Mr Hulatt: Yes.
Q251 Anne Milton: In other words,
you do not just treat their mental health problems?
Mr Hulatt: No.
Q252 Anne Milton: Particularly having
sat between Mr Thain and Mr Corry, do you feel that stopping smoking
in psychiatric institutions would be practicable?
Mr Hulatt: Yes, being in the middle,
as nurses often are, I think—
Q253 Anne Milton: Hear, hear!
Mr Hulatt:— the view would
be that it is practicable and I think it is achievable, but I
think we have to remember that it is the nurses who will be required
to manage and enforce this policy and I think it has to be one
where they can do so humanely and reasonably. I think that there
are situations in extremis, and Mr Thain has alluded to
this, where someone can be admitted under section, extremely distressed,
possibly suicidal and very unwell, so is that the most appropriate
time to commence smoking cessation? I think these are the questions
that have to be carefully considered. I think it is a goal that
can be achieved, but it must be done appropriately and humanely.
Q254 Anne Milton: In what way do
you feel nurses are exposed to second-hand smoke?
Mr Hulatt: Well, those that do
not smoke, I suppose, may well be exposed to smoke in settings
such as when one is closely observing the individual who is at
risk and who wishes to smoke and currently may be able to, so
if one is closely observing an individual within arm's length,
for example, and that person wants to go into the smoking room,
then is it safe to be away from that person? Probably not, but
your health is at risk while you are with them.
Q255 Anne Milton: So there are special
difficulties?
Mr Hulatt: There are difficulties.
They are very practical, operational difficulties that need to
be thought through very carefully and they are very specific to
the environment in mental health institutions.
Q256 Anne Milton: But maybe with
the long lead times that Mr Thain was talking about, that is how
it is achievable.
Mr Hulatt: Absolutely. When I
have been talking to colleagues who are in trusts that are engaged
in this, they are talking very much about moving towards, and
taking practical steps towards, this ambition and they see it
as achievable, but it needs to be carefully managed not only for
the vulnerable individuals within those institutions for whom
smoking is adding to their social exclusion anyway and who are
also impoverished financially, and it is a difficult habit to
maintain from that point of view, but also for the staff who are
going to police and manage this. It needs to be done sensitively,
but it can be achieved.
Q257 Anne Milton: Just moving to
home visits of nurses into homes of clients who might well be
smokers, do you know if there is any evidence to suggest that
that contact that nurses have in people's homes is doing their
health any damage?
Mr Hulatt: I am not able to provide
evidence now. That is certainly something that I could look at
and supply to the Committee, but I think that we have a situation
where it is culturally considered almost inappropriate to challenge
the client not to do it and it is things like that that need changing.
Q258 Anne Milton: I think that is
when it gets even trickier really.
Mr Hulatt: Yes, and what we do
not want is people disengaging from services because that adds
to the risk and to the negative effects to their health and the
relationship with the people providing the care.
Q259 Anne Milton: Do you think that
sometimes there are groups of people who are difficult to hang
on to?
Mr Hulatt: Yes.
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