Recently in Mental health Category

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.

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.

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)

It's long been understood that cultural understanding is a vital component of good care and support for people with mental health problems, but a study just out suggests just how important it is.

Clinicians reported increases in overall functioning among patients who had benefited from a "cultural consultation service" as part of their treatment, while service contacts reduced. So what's a cultural consultation service?

The study in question refers to the work of the Tower Hamlets Cultural Consultation Service, who were commissioned by the local PCT over 18 months to develop the local mental health workforce's cultural capability by "developing general aptitude, attitudes and skills for working with culturally diverse populations". The THCCS also delivered consultations to service users directly and worked with commissioners to help shape services.

A link to the report should be here in the relatively near future. I'll let you know if I hear anything further on this.

The next phase of mental health anti-stigma and discrimination campaign Time to Change was officially launched yesterday by deputy prime minister Nick Clegg.
With funding of £16m from the Department of Health and £4m from Comic Relief until 2015, its forthcoming work includes tackling stigma among children and young people, supporting black and minority ethnic communities and encouraging people from all backgrounds to talk more openly about mental health problems (through adverts such as the one above).

The consensus among ministers, sector leaders (such as the NHS Confederation's Mental Health Network) and celebrity endorsers, such as Alastair Campbell, Marcus Trescothick and Fiona Phillips is that Time to Change has made a big impact on attitudes since it started work in 2007. Though positive interim findings have been issued, it is worth awaiting further results from the ongoing evaluation by London's Institute of Psychiatry.

An interesting looking paper from the National Development Team for Inclusion argues that current plans to introduce payment by results for mental health services risks undermining personalisation for the group.
It suggests some ways in which the two policies can be made compatible and mutually supportive.
The NTDi has also launched a discussion forum on the issue.

The ongoing battle over the government's cuts to (or reform of) disability living allowance is reaching crisis point.
Today, as the House of Lords prepares to debate the proposals in the Welfare Reform Bill, 16 charities have written a letter pressing the government to call a halt to the bill and subject its plans to replace DLA with a cheaper personal independence payment to review.
This follows a feverish day yesterday in which the government announced one concession - agreeing to keep the qualifying period for the benefit following the onset of disability at three months, rather than doubling it to six - while also confirming the sheer scale of the change it is proposing. Replacing DLA with PIP would mean that 500,000 fewer working-age adults would be receiving the benefit by 2015-16 than with the status quo.

Meanwhile, the mainstream media, and not just the Guardian, has taken hold of the issue, with a head-to-head on this morning's Today programme between disability minister Maria Miller (left) and reform critic and disability activist Lord Low over the way forward.
The Lords have already shown themselves ready to give the government a bloody nose over disability benefits cuts, inflicting three defeats on its sickness benefit plans last week.

There is also an amendment to the bill today that will seek to achieve what the charities are calling for by ensuring PIP is piloted before being rolled out.

I'm not nearly close enough to the politics to know whether it will succeed, though I understand that Labour and many crossbench peers - the same coalition who inflicted last week's defeats - will back it.

But what exactly are the issues?

The government's chief beef is that it believes many people are claiming DLA wrongly because they have not been reassessed on their eligibility following an initial claim. Some 70% of claimants effectively get DLA for life.

The campaigners - disabled people, charities and others - believe that the government has not proved its case, and that by pursuing its current course, many thousands of people could be robbed of the opportunity to live independently and free of abject poverty. They also claim that this will not serve to help the government reduce its deficit as cutting DLA will shunt costs onto health and social care.

Reassessing people on their eligibility for DLA or PIP seems fine, so long as the assessment itself is robust and fair.

Disabled people's past experience - based on the hated work capability assessment for employment and support allowance - is that the assessment is likely to be anything but. WCA is now subject to annual reviews to ensure that it improves.

So why not pilot the PIP assessment and see whether ministers' case stacks up?
I imagine that view has some sympathy within the DWP, but the Treasury's demand for the promised savings from setting up PIP to be delivered may make it a non-starter.

(On another note, not all disabled people are opposing the government. Former Community Care columnist Simon Stevens has given a dissenting view, in which he claims that campaigners against reform want disabled people to have "rights without responsibilities").