February 2012 Archives

Chief inspector of prisons Nick Hardwick has given a speech warning that there has been too little progress in improving outcomes for women prisoners since a review five years ago that demanded a complete overhaul.

Here are key lines from a speech he gave today to mark five years since the review by Baroness Corston, which called for women's prisons to be replaced by a network of smaller, local centres, and for most women currently in jail to receive a combination of community sentences and support:

"The number of women in prison has remained almost constant and too little has yet been done to develop and fully utilise community alternatives to custody - and what has been done is not secure. There are too many women in prison who simply do not need to be there."

"And inevitably, despite the improvements I have listed, prisons are still run largely with the 95% male population in mind and because practice on the ground too often fails to recognise the difference between women and men prisoners, the outcomes for women prisoners are worse than men."

"What I am absolutely convinced by is that we have not made sufficient progress, we can't go on like this, and we will not make further progress on Baroness Corston's agenda without senior, visible leadership, with real authority and resources to push things through."

Community Care held its latest dementia conference last week, which I hope proved useful to all who attended. There were some significant - and familiar - messages around the need to improve training for care staff in dementia awareness and to really work on the person-centredness of care for this group.One thing that struck me was the significance of NHS support for the social care system, and care homes in particular, in determining outcomes for people with dementia.


Delegates spoke about how in-reach support from community psychiatric nurses has helped care homes reduce their use of antipsychotic drugs for residents with dementia and provide more therapeutic forms of support instead.

However, the conference also heard, from Dr Sunil Shah of St George's in London University, how common repeat and long-term prescribing of antispychotics by GPs is for care home residents, despite the drugs being designed for short-term use only. Research he has been involved with also finds that recording of the reasons behind such prescriptions by doctors in primary care is poor.

Other speakers spoke about how, sometimes, GPs and other medical professionals do not appreciate the skills of nurses and senior care staff in care homes in relation to dementia, despite the fact that it is they who know the patients best. NHS and care home staff need to appreciate each other's roles more, said Dr Elspeth Mathie of Hertfordshire University, drawing on research she and others have done into end-of-life care and dementia.

The Care Quality Commission is due to produce a report shortly on the quality of healthcare support for care homes, so hopefully that should shed some more light on this issue. We will be reporting the CQC's findings when the study comes out.

(Image from Rex Features)

An e-learning tool for social care practitioners on the Mental Capacity Act has been launched by the East Midlands Adult Safeguarding Board. The tool (currently available on this link but not for long) covers the principles of the act, assessing capacity, decision making on behalf of a person and deprivation of liberty. It takes 20-30 minutes to do.

As we have reported before, these are issues that continue to cause problems for professionals, so more training resources would seem to be helpful.

Buddy from sidekick studios on Vimeo.

Check out this video for more information on Buddy, an app that enables mental health patients to digitally record their mood and changes in it, that is reportedly improving outcomes for them and enabling practitioners to support them more effectively.

Users keep a daily diary, can use web tools to help them reflect on their moods, can set goals and have prompts to help them achieve them, and have appointment reminders to enable them to keep dates with practitioners.

It was developed by start-up company Sidekick Studios and South London and Maudsley NHS Trust, and following a trial in London, it is being rolled out across 10 areas.

I've been sent a bunch of positive quotes about it but won't bother with those as it's probably better for people to see for themselves what its' like.

There's a new blog out on mental health and mental capacity law that I spotted this morning (rather belatedly, admittedly, as it was launched last month), from the School of Law at the University of Nottingham. It seems clearly written and to cover issues of significant interest to social care practitioners, such as the distinction between a person lacking capacity and making an unwise decision, and the Care Quality Commission's approach to regulation and its role as the watchdog for mental health patients.

This guest blog is written by Mike Birtwistle, managing director at MHP Communications and former Department of Health adviser, who is speaking tomorrow at Community Care's annual conference on dementia care.

Among the claims and counter-claims, the summits, pauses and consultations it can be easy to forget about the range of measures contained within the government's NHS and social care reforms that both supporter and opponent would have little difficulty agreeing on.

Even those who cry foul of the Health and Social Care Bill would struggle to object to the White Paper's original ambitions of improving outcomes, bringing care closer to home and revolutionising the collection and publication of data in the NHS and social care.  Amendments to the Bill to focus on integration rather than competition also reflect a shared ambition.

With the legislation still likely to go through, albeit heavily amended, the focus of those working in the NHS and local authorities is already switching to how the reforms can deliver improved care in key areas at a time of funding constraints.

Dementia is one such area where improvements will be needed if the reforms are to be judged a success. Dementia already costs an estimated £20 billion a year and by 2021 the number of people in the UK with the condition is set to rise to one million.  As our recent work with the Alzheimer's Society found, the reforms do provide health and social care commissioners with a range of tools to deliver improved dementia care.

People with dementia often find their care fragmented. The focus in the reforms on integration particularly through health and well-being boards at a local authority level, presents an integration imperative that can provide more joined-up care for people with dementia, reducing costs and delivering care closer to home.

Data on dementia are patchy and of poor quality, hindering attempts to assess the effectiveness of services. Plans for an "information revolution" in health and social care data should allow commissioners to mark areas for improvement and support patients and carers in exercising informed choice.

The lack of good data also hinders attempts to quantify the cost of dementia across the care pathway.  Existing structures and budget silos further hamper funding arrangements and the creation of more joined-up working through the health and well-being boards should help create a forum to deliver more innovative and joint funding methods for dementia services, simultaneously improving outcomes and delivering necessary efficiencies.

Finally the mantra of "no decision about me, without me", coupled with plans to increase the use of personal budgets, should help ensure that care is more person-centred, as well as allowing frontline staff to deliver care that is more tailored to an individual's needs.

Whilst there is no doubt that the reforms and the legislation behind them remain a political football, that game will soon end and a new process of delivering improved care will begin.  How they deliver for dementia will ultimately be a key barometer for whether or not they are a success.

Sorry to be late on this but health and social care staff are being urged to sign up to a "dignity code" governing the treatment of older people by none other than care services minister Paul Burstow and Labour shadow Liz Kendall, among others.

The code is a response to the string of bad news stories around the indignities faced by older people in some hospitals and care homes.

Drawn up by the National Pensioners' Convention its precepts are core social work and social care values. For example:

• Respect for individuals to make up their own minds, and for their personal wishes as expressed in 'living wills', for implementation when they can no longer express themselves clearly.
• Respect for an individual's habits, values, particular cultural background and any needs, linguistic or otherwise.
• The use of formal spoken terms of address, unless invited to do otherwise.
• Comfort, consideration, inclusion, participation, stimulation and a sense of purpose in all aspects of care.

The code has been backed by regulators (the General Social Care Council and Care Quality Commission), charities (Age UK and Action on Elder Abuse) and workforce representatives (Unison and the Royal College of Nursing) and signatories want to see it displayed "in every GP surgery, social services department, hospital ward and nursing home".

It would be easy to be churlish and point to the co-existence of undignified care with pre-existing codes of practice for care staff, including those that carry regulatory requirements; however, it can do no wrong and may hopefully bring about some good as a statement of minimum expectations of services.

(Image on Flickr from hweiling)

Reablement has long been seen as a crucial weapon in managing demand for long-term council-funded adult social care. But its very success in doing helping people to regain independence after crisis, such as a hospital admission, seems now to be translating into job cuts for social workers and other staff in field social work teams, if the experience of Hertfordshire is representative.

The following questions occur to me:-

• Is reablement leading to reduced demand for longer-term council support, nationally, or simply stemming the demand arising from demographic change?
• If reablement is leading to reduced demand - and hence lower caseloads for field social work teams - are there other responses than job cuts? Could social workers be redeployed into other areas (safeguarding, Mental Capacity Act work) and thereby improve outcomes for service users?
• Does the job cuts response simply reflect local authorities' current financial position? That is to say, in better times, would redeployment have worked effectively?
  

I'm sure there are other questions but it would be interesting to hear people's thoughts and whether Herfordshire is not alone in going down this route.

Obviously, we do not want less reablement: it's clearly good for service users and for the public purse. But we do need to debate its impact on the workforce in general and social workers in particular to decide whether responses such as Hertfordshire's are or are not the right ones.

(Update 1.45pm) I've just had some thoughts on the issue from Ruth Cartwright, BASW's England manager.

"In getting rid of social workers, Herts is falling into the trap of assuming that the social work role is mainly about assessing need and helping someone access services. Social workers can do so much more, particularly in the context of reablement, in helping a person come to terms with and adapt to a disability and access other community services.  Herts could use the opportunity to allow professionals do some real social work with individuals, families and communities in true pursuit of personalisation"

She also says getting rid of social workers is a "very short-term measure" because demographic pressures mean more demand is coming through for social care.

There's also been some chatter on Twitter, particular from Rich Watts (@rich_w), director of policy at Essex Coalition of Disabled People. He says the impact on social workers of certain developments, including reablement, "gets to the heart of the major (perceived) difficulties of personalisation.

Well, the government has been keen to have a TripAdvisor-style site to enable people to rate the care services they or their families receive, and now we have the Good Care Guide.
Launched at the weekend by charities United For All Ages and My Family Care, people are already using it to rate older people's and childcare services out of five (for quality, cleanliness and value for money).

The site, which currently covers England only, also provides access to Care Quality Commission reports and services' websites.

Social care training manager Tony Butcher has given the site the thumbs-up in a blog today, which argues that "social care providers will need to be much more aware of customer service skills and the potential impact of giving bad service to care users and their relatives".

Looking at the site, what looms largest on the profile of any service is its consumer rating. It could receive a glowing account from the CQC and be relatively appreciated by the majority of users and families but a poor review from a single individual - often anonymous - may well be what any potential customer takes away from the site. Conversely, a service that is delivering poor care may appear better than it really is by its consumer rating.

This effect is magnified at the moment as so few people have posted reviews. This time next year the site should hopefully provide a richer account of many of the services listed by having multiple ratings that (presumably) would be averaged out to create an overall score.

However, it would be good to see consumer ratings placed alongside other pieces of information (from CQC, local authority/NHS commissioners, local involvement networks etc) at the front end of the site, rather than people having to click through to access this other information.

This may be less straightforward - and much more work to develop - but it arguably provides a fairer account of each service.

In his blog, Butcher adds: "Comment has been made that one malicious comment could ruin a business, that is certainly true, however the issue has to be that providers will need to monitor the comments they are receiving and act accordingly."

Maybe. But the ability to monitor comments and respond accordingly may well be unevenly distributed between providers, based on their size and economic backing.

I don't want to be a naysayer. But I think we need to consider these issues as we seek to inject consumer power into social care.

I've just been alerted to a campaign being run by a man who cares for his mother, who has dementia, to raise awareness of the plight of families afflicted by the condition in Scotland.
Tommy Whitelaw, whose campaign is backed by Alzheimer Scotland, spent nine months touring Scotland, collecting letters from carers about their experience of dementia, which he presented to deputy first minister Nicola Sturgeon last November. Last week he met Sturgeon again to further his campaign, which rumbles on. This video and his blog explains all.

Learning disabled people still face institutional discrimination at the hands of the NHS, Mencap warned today, five years after it laid bare the issue with its Death by Indifference report.
This focused on six cases of people the charity had said had died prematurely due to NHS failings, and sparked an independent inquiry into healthcare for people with learning disabilities, which reported in 2008 and confirmed that the client group was getting inadequate treatment from the health service.
Though Sir Jonathan Michael's inquiry sparked a range of actions from government to improve matters, Mencap's report today, Death by indifference: 74 deaths and counting, finds progress has been slow and that the government has failed to implement many of Michael's recommendations.

For instance, the charity reports no progress on establishing mandatory training in learning disability for health professionals, which it says is at the discretion of training bodies, a failure to collect data to identify people with learning disabilities in the health system and wide variations in the availability of annual health checks for people with learning disabilities from GPs.

This is very much one for NHS professionals and policy makers in government, but it may be worth people in social care taking a glance at this report to inform their dealings with health colleagues around people with learning disabilities.

Here's the latest official verdict on councils, health boards, care homes and hospitals' performance on the Deprivation of Liberty Safeguards in Wales, from the country's health and social care inspectorates.

These are the key findings for the 2010-11 financial year:-

• Fall in applications: Numbers fell from 547 in 2009-10 to 488. There was a particularly big fall in applications for people aged under 65.
• More applications are being authorised: 277 applications became standard authorisations; 203 in social care and 74 in health. This is higher than last year.
  
• Wide variations between areas in numbers of applications and authorisations. For
  example, the rate of authorisations per 100,000 population in local authorities
  ranged between 0 - 26 and in health boards between 0 - 8.
• Higher than anticipated levels of urgent authorisations (where care homes and hospitals deprive someone of their liberty for seven days without council or NHS authorisation).
• Lack of family involvement: Provisions allowing family members and others to ask for a review, highlight concerns or challenge authorisations continued to be used infrequently, due to a lack of information available to the public.
• Lack of access to advocacy: Councils and health boards rarely offer to provide access to Independent Mental Capacity Advocates.
• Performance monitoring. Councils and health boards need to have systems in place to monitor their performance and report this at the highest level in their organisations.
• Lack of training. The inspectorates repeated their concerns about the fact that best interests assessors do not need to complete an accredited course in Wales (unlike in England).
• Lack of capacity. The inspectorates noted an over-reliance on a small pool of staff to carry out assessments and warned that reductions in resources among some teams were increasing pressures and causing delays.

This is probably of most interest for people in Wales. However, it's interesting to note that the Care and Social Services Inspectorate Wales can look across the piece at performance by the care homes (managing authorities) who apply for the Dols and the councils (supervisory bodies) who authorise them, as it still has a remit to inspect councils.

By contrast, the Care Quality Commission's remit only extends to managing authorities, meaning its role in assessing progress with Dols has to be based on its findings from care homes (and hospitals) and not on assessments of councils (and PCTs).

Have a look at this Valentine's video from Time to Change, the anti-mental health stigma campaign, to highlight the issue of stigma within relationships. The campaign has found that 75% of people with a mental health problem would be scared to tell a partner about it for the first time - which is the subject of this video. It's quite amusing - and has a happy ending!
Time for Change is looking for people to pledge to talk about mental health - full details on this link.

"Everyone gets older. We celebrate getting older every year with our birthday. Some things are good about getting older. Some things are difficult about getting older. It is different for everybody."

This comment from Pat (above), who has learning disabilities, sums up the message of a campaign launched today by the Joseph Rowntree Foundation to encourage society to recognise ageing in all its diversity and listen to the perspectives of those growing older on the margins of society.

The JRF has launched a website today, A Better Life, featuring reports of what it is like as an older person with learning disabilities or dementia, from South Asian communities, from Gypsy heritage or if you are lesbian, bisexual or gay.

Among those whose stories are told is Pal (above), who has been a widower for 28 years and lives on his own, though receives daily visits from his son and grandson. He used to access statutory day care services but stopped going because of the introduction of charges. However, he retains a positive mental attitude:

"Never get depressed, I don't focus on what I don't have. Always keep your heart
full. I have fallen on my face many times in life but I had to get up."
Sylvia and Maggie (above) are civil partners living in Kent, who suffered bullying and hostility in sheltered housing when they disclosed their status. After no action was taken and suffering from stress, they were forced to move.

It may have passed you by but we are just coming to the end of Apprenticeships. Workforce development body Skills for Care has reported that 40,000 new apprenticeships were started in social care last year. It has produced a useful guide to apprenticeships, with information for employers and potential apprentices.
But if you don't want to read through all of that here are a couple of videos of apprenticeships in action in social care, courtesy of learning disability provider New Boundaries and the Field House care home in Shropshire. More videos are available from Skills for Care.

The above comes courtesy of the Social Care Institute for Excellence and captures its Mental Capacity Act expert Rachel Griffiths talking about one of the main issues that comes up in her work helping providers implement the Act: whether staff can sign medical treatment consent forms on behalf of service users.
I presume you all know the answer but have a listen if not. Here's the advice in written form.

Three Winterbourne View care workers today pleaded guilty to the ill-treatment of residents at the now closed learning disability hospital in Bristol, reports the BBC.
Wayne Rogers, 31, Alison Dove, 24 and Holly Draper, 22, pleaded guilty to nine, seven and two counts of ill-treatment under (I think) the Mental Capacity Act at Bristol Crown Court today.

This is not the end of the road. The three are due to be sentenced on 16 March and eight further defendants are due to be dealt with next month as well.

This video may cheer you up if you have a spare few minutes - it collects some short clips of carers, parents of disabled children and service users talking about things they have achieved in their communities off the back of In Control Partners in Policymaking courses. These provide training in support planning, influencing policy and organising support groups for users and carers locally, among other things.

A report this week revealed that people in more deprived areas are more likely to die in hospital than those from more affluent places.

In this guest blog, National End of Life Care Programme social care lead Tes Smith argues that social workers have a key role to play in narrowing these inequalities in death.

Fairness is much in the news at present, not least in the shape of the stubborn gap between rich and poor. As in life, so in death it seems. This week, the National End of Life Care Intelligence Network identified that people living in deprived areas are 7% more likely to die in hospital than those residing in the most affluent areas.

Surveys consistently show that most of us would prefer to die at home or in another community setting, such as a hospice, rather than hospital.  Reducing the percentage of deaths that take place in hospital is a key objective of the Department of Health's national end-of-life care strategy.

A small fraction of the gap identified in this week's report - one seventh - can be accounted for by differences in factors such as the cause of death and life expectancy. Individuals affected by some conditions that affect more people in deprived areas, for example chronic obstructive pulmonary disorder, sometimes prefer to be cared for in their final days and hours in hospital.

However the report does raise issues around equity of access to housing and care services that allow people to exercise choice over where they are cared for and, ultimately, where they die. Social care professionals can do something about that.

Social worker role

Yes, death might come after months or even years of high tech medical interventions - whether pharmacological, surgical or technological. However, social care services often have regular contact over a long period with an individual as they become more frail - and with their family or informal carers.

We can liaise with services such as housing and occupational therapy to ensure the individual's home is both decent and equipped with any aides and adaptations needed to support them in their final days, weeks or months.

More powerfully however, we can support individuals nearing the end of life and their carers so they can access the services that will allow them to die at home or in a hospice if that is their wish. This can involve putting in place a package ranging from transport services to specialist pain relief services and community nursing.

With our assessment, communication, co-ordination and care planning skills we should be working with health colleagues in hospitals and the community. We can advocate on behalf of clients who might lack either the verbal skills or self-confidence to effectively pursue such care packages themselves and co-ordinate the delivery of services. With ethnic minorities over-represented amongst the most deprived in our community, there might be language barriers that we can help overcome.

Sharp elbows

The broader social care profession should be working with specialist palliative care social workers in hospices and hospitals to champion the interests of those whose voice might otherwise be lost.

When asked why he thought his new National Health Service would survive, Nye Bevan is said to have replied that the 'sharp elbows of the middle classes' would make quite sure they and their families had access to high quality free healthcare.

Perhaps it is part of the social care professional's role to play the sharp elbows of those less able to voice their wishes and preferences for care in this age of choice. Care provision at the end of life might be a good place to start.

There's an interesting report out today from the King's Fund about the costs (to patients and the NHS) of treating physical and mental health problems separately given the large number of people with long-term conditions who also have mental illnesses.

It finds 46% of people with mental health problems have a long-term condition and 30% of people with a long-term condition have a mental health problem, amounting to 4.6m people.

However, the report says: "A separation of mental and physical health is hard-wired into institutional arrangements, payment systems and professional training curricula. As a result, co-morbid mental health problems commonly go undetected among people with long-term conditions, and where problems are detected the support provided is often not effectively linked or co-ordinated with care provided for physical problems."

The result is poorer patient outcomes and significant cost to the NHS and the wider economy. What's worse is that people with these co-morbidities are disproportionately found in deprived areas, where they lack access to services and resources.

The report has some interesting ideas for bridging the gap:

• Greater involvement of mental health specialists in primary care.
• Much greater investment in liaison psychiatry services in acute hospitals to identify people with mental health problems.
• Training for physical healthcare staff in basic mental healthcare.

There is less about the role of social care professionals in this report, beyond stating that they have a role to play, particularly in relation to people with dementia and long-term conditions.

It would be good for this to be fleshed out as social workers and other care professionals have a crucial role in identifying people with co-morbidities, taking a holistic view of their condition and co-ordinating their support. Hopefully, this is something that can be addressed.

On Friday, The College of Social Work held a summit on the future of adult social work attended by senior managers, civil servants, academics, social work representatives, users and frontline practitioners.

There was a remarkable degree of consensus about what needed to happen: practitioners needed to be liberated from bureaucracy, rationing and risk aversion to exercise professional judgement to better support service users.

But there was less clarity about how we should get to this point.

No Munro review for adult social work

Children's social work has had its own inquiry - the Munro review - to address the self-same issues of bureaucracy and the erosion of professional judgement. But no such review is in the pipeline for adult social work.

The College is keen to influence the forthcoming White Paper on adult social care in a more social work-friendly direction. And the signs on this front are good.

Care services minister Paul Burstow said last week that social work would be at the heart of the paper, with an emphasis on community development, not care management. His message was echoed at Friday's summit by DH official Glen Mason but there was no more detail on what the White Paper would say.

No reserved tasks for social workers

Indeed, Mason was clearer on what the White Paper would not say: that there would be no legislation to establish specific roles and tasks that only social workers can do. This was in response to one summit attendee who felt that such provisions would help carve out a status for adult social work, drawing on the experience of statutory child protection work in raising status.

This means that, whatever the White Paper says about social work, it will be up to individual organisations - particularly local authorities - to put this into practice.
Mason said he felt that most directors of adult social services understood the importance of social work.

However, some in the audience did not share his optimism, particularly in relation to directors who did not have a social work background.

(Image from Rex Features)

Since care services minister Paul Burstow scrapped annual assessments of council adult social services in November 2010, performance management of councils in this area has rather disappeared without trace at a national level.

It's not that it isn't happening: we have a Promoting Excellence in Councils' Adult Social Care Board, whose role is to keep track of performance in all councils and work with authorities to drive improvement. It embodies "sector-led improvement" (i.e. local authorities taking responsibility collectively for improved performance) and includes representatives from the Local Government Association, Association of Directors of Adult Social Services, the Care Quality Commission and the Social Care Institute for Excellence.

But while there is a short paragraph on the board on the LGA website, you'd be hard-pressed to find out much about its work online.

This is in stark contrast to the previous system in which the Care Quality Commission produced an annual report on local government performance in adult social care, with separate reports and performance scores for each council.

The sad thing is that sector-led improvement work is happening. The LGA is conducting peer reviews of councils, where people from within local government go and assess performance in an authority, and there is more targeted support for councils that have been previously deemed to be falling short.

But finding information on progress and the outcomes of peer reviews is next to impossible (well, I've found it next to impossible). Again, this would not have been the case in respect of inspection reports when we had a national system of annual assessment.

At a local level, councils are supposed to be producing local accounts of their performance to provide citizens with a means of scrutinising what is going on. Here are a few that have been published for 2010-11 - Stockport, Hackney, Rotherham - to give you a flavour.
In all cases of published local accounts, I have no doubt, there has been a transparent process locally, where the report has been published prominently, scrutinised by backbench councillors and had input or a critique from the user-led local involvement network.

However, what we don't know is whether all councils have published such a report, or whether any independent judgement has been reached on their quality i.e. the extent to which they involve a genuine self-assessment, rather than a public relations exercise.

I'm not calling for a return to national assessment of council adult social services by the independent regulator. Well, not necessarily. I just think that the system of sector-led assessment needs to prove itself to be something other than a way of making performance assessment cheaper. And for that, we need much more transparency, nationally.

Charities are warning that disabled people are facing abuse on the streets and accused of faking their conditions due to the government's cuts to benefits for the group, reports The Guardian.
Some are declining to use disabled parking bays lest they accused of not being worthwhile recipients of support for their impairment, with people with less visible disabilities at particular risk of abuse.

Here's a reminder of those cuts to benefits and services for disabled people (though one of the 10 listed here - the cut to mobility benefits for people in residential care - has been dropped), illustrating just how stark they are. The government has an opportunity to make concessions after a number of its benefit cuts, in the Welfare Reform Bill, were overturned by the House of Lords; however, ministers just reimposed the cuts in the House of Commons.

And there seems to be no let-up to the twin narratives that there are many thousands of people claiming or applying for sickness benefits who should be looking for work, and that disability living allowance is just too expensive and going to people who aren't really that disabled.

However, the disability movement has been fighting back with a vigorous campaign, illustrating the difference these benefits make to people's lives and the genuine need of claimants. For those of you with a bit of time on your hands, here's a recent dispatch from that campaign: an e-book written by leading campaigners against both the Coalition's reforms to welfare and those of its Labour predecessor.

(Image on Flickr from Byzantine_K and taken from Disabled People Against Cuts poster)

To state the obvious, there are few more significant statutory interventions than the use of compulsory powers under the Mental Health Act, and one concerning trend in the last couple of years has been the rising use of these powers.

All of this means that how information is collected in relation to the use of these powers is of vital importance, so it's worth putting away any aversion to statistics and responding to a consultation on this topic from the NHS Information Centre.

This is looking at the case for scrapping the existing standalone data collection on Mental Health Act powers (or KP90 to its friends) and instead collecting this information instead through the Mental Health Minimum Dataset (MHMD), which collects a host of other data about the use of specialist mental healthcare.

As I understand it, the key advantages of the change are:-

• Better information about the care pathways taken by people detained under the Act or placed on community treatment orders and about how long people are detained. Information on this could help improve the commissioning and design of services in local areas.
  
• Breaking down the use of compulsory powers under the Act by employment status, diagnosis and, crucially, ethnicity, rather than just gender, as the KP90 collection currently does.

So it's worth answering the consultation questionnaire if you get a moment.

We reported yesterday on calls to enhance guidance and training for professionals on best interests decision making under the Mental Capacity Act, but I thought it would be worth trying to pull out some of the key lessons from the study in question.

About the research

The research seems pretty solid and is based on an online survey, and telephone and face-to-face interviews with social care, health and legal professionals about best interests decisions they have taken under the Act.
It comes courtesy of charity the Mental Health Foundation, which has done a lot of work on how professionals can apply the Act (for example), and two of the country's major research centres into the two key client groups involved, the Norah Fry learning disability centre at Bristol University and the Bradford Dementia Group.

Though its focus was on best interests decisions, many of the most interesting findings relate to assessments of capacity. (Do see our guide on conducting a capacity assessment, which is based on work by the Mental Health Foundation).

Lack of understanding of MCA

A major finding was that the principles of the Mental Capacity Act were not being adhered to in a significant minority of cases. While people should be presumed to possess capacity, not assumed to lack it on the basis of disability, diagnosis or age, and have the right to make unwise decisions, about one-quarter of best interests decisions followed apparently flawed assessments of capacity related to perceived unwise decisions or to someone's disability, age or diagnosis. Though this finding was based on an online survey - and so may not reflect the complexity of cases - these issues remained when researchers probed deeper through interviews.

Impairments dominating assessments

Researchers found in some cases conclusions were drawn about a person's lack of capacity because of their inability to communicate verbally or respond to the presence of other people.
"In all these cases, it seemed that the impairment did dominate, and that practitioners had some difficulty in adhering to the principle of presumption of capacity," said the report.

Lack of capacity based on lack of 'insight'

An assessment that someone lacked capacity was in some cases based on the finding that they lacked 'insight' into their care needs, particularly in relation to people with dementia. So, for instance, if professionals believed that a person would be better off in a care home and the person disagreed, this apparent lack of insight translated into an assessment of incapacity to decide. But the research points out that 'insight' is not a word mentioned in the Mental Capacity Act code of practice and that lack of insight in this sense does not equate to a lack of capacity. In one striking passage, it says: "Whether a person with dementia accepted a particular course of action recommended by professionals (frequently admission to a care home) influenced whether an assessment of capacity was initially undertaken and, in turn, if a finding of capacity was made."

Making best interests decisions

Some interesting findings on this:

• Best interests decisions in social care were most frequently carried out through a series of multi-disciplinary team meetings. Typical features of successful practice were good chairing and organisational skills, clarity in defining the decision to be made, and an overriding concern for engaging the client at the centre of the process.
• Social care decisions more often related to safeguarding and changes of accommodation, rather than care reviews, direct payments or care planning.
  
• Though best-interests decision makers should consider the person's expressed wishes, feelings and values, the researchers only found a few cases where these had been influential in the decision.
• Outcomes for people were not just based on their best interests but on resources and available services. As a result, for instance, temporary admissions to care homes for people with dementia were often made permanent.

Recommendations

The research makes a number of significant recommendations. Here are a few key ones:-

• Revising the MCA code of practice to clarify the distinction between a lack of capacity, on the one hand, and unwise decisions and lack of 'insight' on the other.
• The code should include case examples that reflect the complexity of the cases experienced by practitioners, as well as examples of successful good practice.
• Pro formas for conducting mental capacity assessments and best interests decisions should also be added to the code.
• Providers should carry out regular audits of compliance with the MCA by staff.
• Care homes should hold weekly reviews of assessments of capacity and best interests decisions.

Hopefully this research should provide a springboard for practice, guidance and training improvements in relation to the MCA. Do have a read.

In these straitened times, effective charities, like their less effective counterparts, are struggling to keep hold of public funding, putting a greater premium on private donors.
But where should philanthropists be putting their money in relation to social care services?

A report out today provides a guide to investing in employment support for people with mental health problems. It comes courtesy of New Philanthropy Capital, which researchers the effectiveness of charities. NPC says this is an area that private donors have neglected in the past, leaving government to take the lead, but says philanthropists have real potential to make a difference.

It looks at the case for investing in four services, providing donors with an idea of which charities are potentially most effective, costs, risks and returns. One service that comes out well, in terms of relatively low risk for high return, is individual placement and support, under which employment advisers are placed in mental health teams to integrate treatment and employment support and service users are, ideally, placed in a job and supported to retain it. (This piece has a bit more about IPS).

However, no charities examined by NPC delivers IPS so may need support to develop the model. Which is where private donors come in. Bill Gates, can you help?

(Image on Flickr from IssacMao)