Documente Academic
Documente Profesional
Documente Cultură
Instructions:
Instructions:
Throughout this pathway if you click on
the Bookmarks tab to the left of the
screen and then click on the various
documents you will find additional
information to explain the steps in the
process
Presentation of Depression in
Primary Care Box 1
Screening
e
Nic 6
pg
Box 2
KEY
Step 1
Assessment
Box 3
Step 2
Patient Education
Box 4
Step 3
Step 5
Possible treatment
options
Box 7
Watchful Waiting
Box 8
e
c
i
N 7
pg
Signposting
Box 15
Exercise
Box 17
e
Nic 7
pg
e
Nic 7
pg
Further assessment
after 2 weeks
Box 9
Improving
Box 10
Consider another
Step 2 Option
Box 14
Discharge
Box 13
Treatment of Moderate
Depression
Box 21
Treatment of Severe
Depression
Box 22
Social
Interventions
Box 20
Consider referral/joint
working with Specialist
Mental Health Services Box
24
Treatment options
(consider patient choice)
Box 23
e
Nic 8pg 0
1
Anti depressant medication
(in moderate depression offer anti
depressant medication routinely before
psychological interventions
Box 25
Psychological
Interventions also
consider MBCT
(mindfulness based
cognitive therapy)
Box 19
e
Nic 7
pg
Completely improved
Box 12
Further assessment
after 2 weeks
Box 11
Consider move to
Step 3
Moderate or
Severe
Depression
Treatment of mild
depression
Box 5
Step 4
e
Nic 11
pg
Combination of Antidepressant medication and
individual CBT
(in severe depression a combination should be
considered as it is more cost effective than other
treatments on their own)
Box 26
e
Nic 12
pg
Depression.vsd
No
Box 32
Yes
Box 33
Straight to Step 5
Box 34
e
Nic 13
pg
Psychotic
Depression
Box 36
e
Nic 12
pg
Treatment Resistent
Depression
Box 37
e
Nic 13
pg
Recurrent
Depression
Box 38
Atypical
Depression
Box 39
e
Nic 13
pg
Pathway Principles
We will work in partnership with service users and their carers to support them in
remaining as well as possible and in maintaining and improving their health and quality of
life. Our services will focus on mental wellbeing as well as mental ill health.
People with mental health problems have the same rights as other citizens. In particular,
they have the right to be consulted and actively involved in the planning of their care,
regardless of their level of disability.
The service will, at all times, treat individuals with dignity and respect. This involves:
x
Being sensitive to issues of age, gender, race, disability and sexual orientation.
Respecting the rights of the individual and separate rights of carers and addressing
these rights separately, or together with, the cared for person.
X:\1 Service Transformation\Current Projects\Supporting Clinical Decision Making\Care Pathways\Authoring Teams\2009.04.07 Depression\LCFT
Pathway June\Pathway Principles.doc
Page 1 of 3
X:\1 Service Transformation\Current Projects\Supporting Clinical Decision Making\Care Pathways\Authoring Teams\2009.04.07 Depression\LCFT
Pathway June\Pathway Principles.doc
Page 2 of 3
Presentations of Depression
x
x
x
x
x
Vague physical symptoms tiredness, aches and pains, poor sleep, weight or
appetite change, poor concentration
Repeated consultation for minor physical symptoms
Patient whose symptom severity/disability is out of proportion to its causes
Social dysfunction drug/alcohol use, relationship failure, anger, aggression,
frequent absence from work
Bonding difficulties
Suicide Risk
x
X:\1 Service Transformation\Current Projects\Supporting Clinical Decision Making\Care Pathways\Authoring Teams\2009.04.07 Depression\LCFT
Pathway June\Pathway Principles.doc
Page 3 of 3
Depression Pathway
Guidance Notes
Box 1
Presentation
Individual presents in a primary care location for example, GP surgery etc
Box 2
Screening
NICE guidance recommends primary care routinely screens certain high risk groups
x Patients with significant physical illness
x Patients with other mental health problems, such as dementia
x Patients suffering major life events, eg. Childbirth, long-term/recent unemployment and
bereavement
x Patients with a history of relationship difficulties and physical, sexual or emotional abuse
Screening questions:
During the last month have you been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing
things?
Box 3
At least one of these, most days, most of the time for at least 2 weeks
3d Associated Symptoms
x
x
x
x
x
x
x
Disturbed sleep
Poor concentration or indecisiveness
Low self-confidence
Poor or increased appetite
Suicidal thoughts or acts
Agitation or slowing of movements
Guilt or self-blame
Box 4
Patient Education
There is a need for discussion with the patient about diagnosis and treatment options, with a
view to gaining agreement about the treatment plan. This will involve:
x Consideration of the persons capacity to consent
x Feedback to patient on the outcome of the assessment
x Providing patient information leaflets and other sources of information (eg. NHS Direct
website, Patient Advice and Liaison Service, NICE Patient Information Leaflet, Beyond Blue
website)
x Discussing treatment options
x Give patient information on who to contact if they have questions or concerns
x Consideration of any advance directives/statements or other expression of patient choice
x Provide information on recovery statistics
Box 5
Mild depression
x
Box 6
No further information.
Box 7
Possible treatment options mild depression
x
x
Box 8
Watchful waiting
x
x
Box 9
Further assessment after 2 weeks
Box14
No additional information
Box 15
Signposting
Help the individual to find appropriate local or national statutory or voluntary organizations,
depending on cause of depression and contributing factors
Box 16
Sleep and Anxiety Management
x
x
Box 17
Exercise:
Advise patients of all ages with mild depression of the benefits of following a structured and
supervised exercise programme. Effective duration of such programmes is up to 3 sessions per
week of moderate duration (45 minutes to 1 hour) for between 10 to 12 weeks.
Box 18
Guided Self Help
For patients with mild depression, consider a guided self-help programme that consists of the
provision of appropriate written materials and limited support over 6 to 9 weeks, including follow
up, from a professional who typically introduces the self-help programme and reviews progress
and outcome.
Box 19
Psychological Interventions:
x
x
x
x
Box 20
Social Interventions:
Social Services, Citizen Advice Bureau, Housing, Community work etc
Box 21
Moderate Depression:
Has 5-6 symptoms including at least 1 key symptom
Box 22
Severe Depression:
Has over 7 symptoms including at least 1 key symptom
Box 23
Possible Treatment Options:
x
Box 24
Consider referral and joint working with specialist mental health services if:
x
x
x
x
Box 25
Antidepressant medication
x In moderate depression offer anti depressant medication to all patients routinely before
psychological interventions. Refer to NICE Guidance, Page 8-10)
Box 26
Combination of anti depressant medication and individual CBT
x When individual presents initially with severe depression, a combination should be
considered as it is more cost effective than either treatment alone, (NICE Guidance, page
11)
Box 30
Step 4: Treatment by depression by mental health specialists including crisis teams
x Assess patients with depression referred to specialist care, including their symptom profile
and suicide risk and, where appropriate, previous treatment history. Where the depression
is chronic or recurrent, assess psychosocial stressors, personality factors and significant
relationship difficulties as well
x Consider re-introducing any previous treatments that were inadequately delivered to
adhered to
x Crisis resolution teams should be used as a means of managing crises for patients who
have severe depression and are assessed as presenting significant risk
Full Assessment
x
x
x
x
Symptom profile
Suicide risk
Consider social factors
Consider carer needs
Box 32-34
No additional information
Box 35
Discuss diagnosis and treatment options with patient, with a view to gaining agreement about
the treatment plan. This will involve:
x
x
x
x
x
Box 36
Special considerations
Psychotic depressions
x
For patients with psychotic depression, consider augmentation of the current treatment plan
with antipsychotic medication
Box 37
Treatment-resistant depression:
x
For all people whose depression is treatment resistant, consider the combination of
antidepressant medication with individual CBT of 16-20 sessions over 6 to 9 months
For patients with treatment-resistant moderate depression who have relapsed while taking, or
after finishing, a course of antidepressants, consider the combination of antidepressant
medication with CBT
Consider a trial of lithium augmentation for patients whose depression has failed to respond
to several antidepressants and who are prepared to tolerate the burdens associated with its
use
If venlafaxine has not been used before, it may be considered for patients whose depression
has failed to respond to two adequate trials of alternative antidepressants. The dose can be
increased up to BNF limits if required, provided patients can tolerate the side effects. See
step 3 for prescribing advice
When augmenting one antidepressant with another, monitor carefully (particularly for the
symptoms of serotonin syndrome), and explain the importance of this to the patient
Re-evaluate the adequacy of previous treatments and consider seeking a second opinion if
considering using combinations of antidepressants other than mianserin or mirtazapine with
SSRIs. Document the content of any discussion in the notes
Consider phenelzine for patients who have failed to respond to alternative antidepressants
and who are prepared to tolerate the side effects and dietary restrictions associated with its
use. Consider its toxicity in overdose when prescribing for patients at high-risk of suicide
Consider referring patients who have failed to respond to various strategies for augmentation
and combination treatments to a clinician with a specialist interest in treating depression
Dosulepin should not be used routinely because the evidence supporting its tolerability
relative to other antidepressants is outweighed by the increased cardiac risk and its toxicity in
overdose
Box 38
Recurrent depression and relapse prevention
Pharmacological treatments
x
Continue antidepressants for 2 years for people who have had two or more depressive
episodes in the recent past and who have experienced significant functional impairment
during the episodes
Maintain the antidepressant dose used for relapse prevention at the level at which acute
treatment was effective
Patients who have had multiple episodes of depression, and who have had a good response
to treatment with an antidepressant and lithium augmentation, should remain on the
combination for at least 6 months
When patients are taking an antidepressant with lithium augmentation, if one drug is to be
discontinued, this should be lithium in preference to the antidepressant
Box 39
Atypical depression
x
Consider prescribing phenelzine for women whose depression has atypical features, and
who have not responded to, or who cannot tolerate, an SSRI. Consider its toxicity in
overdose when prescribing for patients at high risk of suicide
All patients receiving phenelzine require careful monitoring (including taking blood pressure)
and advice on interactions with other medicines and foodstuffs, and should have their
attention drawn to the product information leaflet
Box 40
Step 5: Inpatient treatment for depression
Inpatient care
Inpatient treatment should be considered for people with depression where the patient is as
significant risk of suicide or self-harm
Crisis resolution teams should be considered for patients with depression who might benefit from
an early discharge from hospital after a period of inpatient care
Box 41
See Adult Admission/Discharge Pathway
Depression: management of
depression in primary and
secondary care
Amendment of recommendations concerning venlafaxine: April 2007
On 31 May 2006 the MHRA issued revised prescribing advice for venlafaxine*. This
amendment brings the guideline into line with the new advice but does not cover other
areas where new evidence may be available. NICE expects to make a decision on a full update
later in 2007.
The revised sections are marked in italics on pages 8, 9,10 and 12 of this quick reference
guide.
*See
www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&useSecondary=true&ssDocName=CON2023843&ssTargetNodeId=389
Contents
Contents
Which NICE guideline?
Step 1:
Step 2:
Step 3:
Step 4:
Step 5:
9
10
11
11
12
Treatment-resistant depression
Recurrent depression and relapse prevention
Special considerations
12
13
13
14
Inpatient care
Electroconvulsive therapy
14
14
15
Implementation
15
Further information
Back cover
ISBN: 1-84629-402-9
Published by the National Institute for Health and Clinical Excellence
April 2007
Artwork by LIMA Graphics Ltd, Frimley, Surrey
Printed by Abba Litho Sales Limited, London
www.nice.org.uk
National Institute for Health and Clinical Excellence, April 2007. All rights reserved. This material may be freely reproduced for educational
and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express
written permission of the Institute.
Yes
Enter depression
guideline
(this guideline)
No
Step 4:
Step 3:
Step 2:
Step 1:
Inpatient care,
crisis teams
Risk to life,
severe self-neglect
Medication, combined
treatments, ECT
Mental health
specialists, including
crisis teams
Treatment-resistant,
recurrent, atypical and
psychotic depression, and
those at significant risk
Medication, complex
psychological interventions,
combined treatments
Moderate or severe
depression
Medication, psychological
interventions, social support
Mild depression
Recognition
Patient preference
Consider patient preference and the experience and outcome of previous treatment(s) when
deciding on treatment. GPP
Information
Give patients and carers appropriate information on the nature, course and treatment of
depression, including the use and likely side effects of medication. GPP
Inform patients, families and carers about self-help and support groups, and encourage them
to participate where appropriate. GPP
Keep use of clinical language to a minimum and, where possible, provide interventions in a
language understood by the patient. GPP
Consent
Ensure that a patient can give meaningful and properly informed consent, especially when he or
she has a more severe depression or is subject to the Mental Health Act. GPP
Management of care
Where management is shared between primary and secondary care, establish a clear agreement
between all professionals on the responsibility for monitoring and treatment; this should be
shared with the patient and, where appropriate, with families and carers. GPP
Consider advance directives, especially for people who have recurrent severe or psychotic
depressions, and for those who have been treated under the Mental Health Act. GPP
Risk
Always ask patients with depression directly about suicidal ideas and intent, and advise patients
and carers to be vigilant for changes in mood, negativity and hopelessness, and suicidal intent,
particularly during high-risk periods such as during initiation of and changes to medication and
increased personal stress. Advise patients and carers to contact the appropriate healthcare
practitioner if concerned. GPP
Assess whether patients with suicidal ideas have adequate social support and are aware
of appropriate sources of help, and advise them to seek appropriate help if the situation
deteriorates. GPP
Where a patient presents considerable immediate risk to self or others, consider urgent referral to
a specialist mental health service. GPP
Make contact with patients with depression who do not attend follow-up. C
Bear in mind the potential physical causes of depression and the possibility that depression can be
caused by medication. C
Use two screening questions, such as: B
During the last month, have you often been bothered by feeling down, depressed or hopeless?
and
During the last month, have you often been bothered by having little interest or pleasure in
doing things?
Exercise
Advise patients of all ages with mild depression of the benefits of following a structured and
supervised exercise programme. Effective duration of such programmes is up to 3 sessions per
week of moderate duration (45 minutes to 1 hour) for between 10 and 12 weeks. C
Guided self-help
For patients with mild depression, consider a guided self-help programme that consists of the
provision of appropriate written materials and limited support over 6 to 9 weeks, including follow up,
from a professional who typically introduces the self-help programme and reviews progress and
outcome. C
Psychological interventions
In mild and moderate depression, consider psychological treatment specifically focused on depression
(problem-solving therapy, brief CBT and counselling) of 6 to 8 sessions over 10 to 12 weeks. B
Offer the same range of treatments to older people as to younger people. C
In psychological interventions, therapist competence and therapeutic alliance have significant bearing
on the outcome of intervention. C
Where significant comorbidity exists, consider extending treatment duration or focusing specifically
on comorbid problems. C
Antidepressants
Antidepressants are not recommended for the initial treatment of mild depression, because the
riskbenefit ratio is poor. C
Where mild depression persists after other interventions, or is associated with psychosocial and
medical problems, consider use of an antidepressant. C
If a patient with a history of moderate or severe depression presents with mild depression, consider
use of an antidepressant (see Step 3 on pages 8 to 11). C
Monitoring risk
See patients who are considered to be at increased risk of suicide or who are younger than 30 years
old 1 week after starting treatment. Monitor frequently until the risk is no longer significant. C
If there is a high risk of suicide, prescribe a limited quantity of antidepressants. C
If there is a high risk of suicide consider additional support such as more frequent contacts with
primary care staff, or telephone contacts. C
Monitor for signs of akathisia, suicidal ideas, and increased anxiety and agitation, particularly in the
early stages of treatment with an SSRI. C
Advise patients of the risk of these symptoms, and that they should seek help promptly if these are at
all distressing. C
If a patient develops marked and/or prolonged akathisia or agitation while taking an antidepressant,
review the use of the drug. C
Continuing treatment
See patients who are not considered to be at increased risk of suicide 2 weeks after starting
treatment and regularly thereafter for example, every 24 weeks in the first 3 months
reducing the frequency if response is good. C
For patients with a moderate or severe depressive episode, continue antidepressants for at least
6 months after remission. A
Once a patient has taken antidepressants for 6 months after remission, review the need for continued
antidepressant treatment. This review may include consideration of the number of previous episodes,
presence of residual symptoms, and concurrent psychosocial difficulties. C
Choice of antidepressants
For routine care, use an SSRI because they are as effective as tricyclic antidepressants and less likely to
be discontinued because of side effects. A
Consider using a generic form of SSRI. Fluoxetine or citalopram, for example, would be reasonable
choices because they are generally associated with fewer discontinuation/withdrawal symptoms. C
Treatments such as dosulepin, phenelzine, combined antidepressants, and lithium augmentation
of antidepressants should be routinely initiated only by specialist mental healthcare professionals
(including General Practitioners with a Special Interest in Mental Health). C
Consider toxicity in overdose in patients at significant risk of suicide. Note that the highest risk is
with tricyclic antidepressants (with the exception of lofepramine) but that venlafaxine is also more
dangerous than other equally effective drugs recommended for routine use in primary care. C
Be aware of clinically significant interactions with concomitant drugs (particularly when prescribing
fluoxetine, fluvoxamine, paroxetine, tricyclic antidepressants or venlafaxine). Consider consulting
appendix 1 of the British National Formulary. C
If increased agitation develops early in treatment with an SSRI, provide appropriate information
and, if the patient prefers, either change to a different antidepressant or consider a brief period
of concomitant treatment with a benzodiazepine followed by a clinical review within 2 weeks. C
St Johns wort may be of benefit in mild or moderate depression, but its use should not be prescribed
or advised because of uncertainty about appropriate doses, variation in the nature of preparations,
and potential serious interactions with other drugs. C
Tell patients taking St Johns wort about the different potencies of the preparations available and
the uncertainty that arises from this, and about the interactions of St Johns wort with other drugs
(including oral contraceptives, anticoagulants and anticonvulsants). C
Age
For older adults with depression, give antidepressant treatment at an age-appropriate dose for a
minimum of 6 weeks before considering that it is ineffective. If there is a partial response within this
period, treatment should be continued for a further 6 weeks. C
When prescribing antidepressants for older adults, consider:
the increased risk of drug interactions GPP
careful monitoring of side effects, particularly with tricyclic antidepressants. C
Psychological treatments
CBT is the psychological treatment of choice. Consider interpersonal psychotherapy (IPT) if the patient
expresses a preference for it or if you think the patient may benefit from it. B
CBT and IPT should be delivered by a healthcare professional competent in their use treatment
typically consists of 16 to 20 sessions over 6 to 9 months. B
Consider CBT (or IPT) for patients with moderate or severe depression who do not take or refuse
antidepressant treatment. B
For patients who have not made an adequate response to other treatments for depression (for
example, antidepressants and brief psychological interventions), consider giving a course of CBT
of 16 to 20 sessions over 6 to 9 months. C
Consider CBT for patients with severe depression for whom avoiding the side effects often associated
with antidepressants is a clinical priority or personal preference. B
For patients with severe depression, consider providing 2 sessions of CBT per week for the first month
of treatment. C
Where patients have responded to a course of individual CBT or IPT, consider offering follow-up
sessions typically 2 to 4 sessions over 12 months. C
Couple-focused therapy
Consider couple-focused therapy for people with depression who have a regular partner and who
have not benefited from a brief individual intervention. An adequate course is 15 to 20 sessions over
5 to 6 months. B
Chronic depression
In chronic depression, offer a combination of individual CBT and antidepressant medication. A
For men with chronic depression who have not responded to an SSRI, consider a tricyclic
antidepressant, as men tolerate the side effects of tricyclic antidepressants reasonably well. C
Consider offering befriending (by trained volunteers offering weekly meetings for 2 to 6 months)
as an adjunct to pharmacological or psychological treatments to people with chronic depression. C
Consider a rehabilitation programme for patients who are unemployed, or have been disengaged
from social activities over a longer term. C
11
Treatment-resistant depression
For all people whose depression is treatment resistant, consider the combination of antidepressant
medication with individual CBT of 16 to 20 sessions over 6 to 9 months. B
For patients with treatment-resistant moderate depression who have relapsed while taking, or
after finishing, a course of antidepressants, consider the combination of antidepressant medication
with CBT. B
Consider a trial of lithium augmentation for patients whose depression has failed to respond to
B
several antidepressants and who are prepared to tolerate the burdens associated with its use.
Before initiating lithium augmentation carry out an ECG.
C
If venlafaxine has not been used before, it may be considered for patients whose depression has
failed to respond to two adequate trials of alternative antidepressants. The dose can be increased up
to BNF limits if required, provided patients can tolerate the side effects. C See Step 3 (page 10) for
prescribing advice.
Consider augmenting an antidepressant with another antidepressant (there is evidence for benefits
of adding mianserin or mirtazapine to SSRIs). C
When augmenting one antidepressant with another, monitor carefully (particularly for the symptoms
of serotonin syndrome), and explain the importance of this to the patient. GPP
When augmenting an antidepressant with mianserin be aware of the risk of agranulocytosis,
particularly in older adults. C
Re-evaluate the adequacy of previous treatments and consider seeking a second opinion if
considering using combinations of antidepressants other than mianserin or mirtazapine with SSRIs.
Document the content of any discussion in the notes. C
Consider phenelzine for patients who have failed to respond to alternative antidepressants and who
are prepared to tolerate the side effects and dietary restrictions associated with its use. Consider its
toxicity in overdose when prescribing for patients at high-risk of suicide. C
Augmentation of an antidepressant with carbamazepine, lamotrigrine, buspirone, pindolol, valproate
or thyroid supplementation is not recommended in the routine management of treatment-resistant
depression. B
Consider referring patients who have failed to respond to various strategies for augmentation and
combination treatments to a clinician with a specialist interest in treating depression. GPP
Dosulepin should not be used routinely because the evidence supporting its tolerability relative to
other antidepressants is outweighed by the increased cardiac risk and its toxicity in overdose. C
There is insufficient evidence to recommend augmentation of antidepressants with
benzodiazepines. C
12
Step 4: Treatment of depression by mental health specialists including crisis teams continued
Psychological treatments
CBT should be considered for:
patients with recurrent depression, who have relapsed despite antidepressant treatment, or who
express a preference for psychological interventions
C
patients with a history of relapse and poor or limited response to other interventions
B
patients who have responded to another intervention but are unable or unwilling to continue
with that intervention, and are assessed as being at significant risk of relapse
B
B
Mindfulness-based CBT should be considered for patients with recurrent depression.
Special considerations
Psychotic depression
For patients with psychotic depression, consider augmentation of the current treatment plan with
antipsychotic medication. C
Atypical depression
Consider prescribing phenelzine for women whose depression has atypical features, and who have
not responded to, or who cannot tolerate, an SSRI. Consider its toxicity in overdose when prescribing
for patients at high risk of suicide. C
All patients receiving phenelzine require careful monitoring (including taking blood pressure) and
advice on interactions with other medicines and foodstuffs, and should have their attention drawn to
the product information leaflet. C
13
Electroconvulsive therapy
Electroconvulsive therapy (ECT) should only be used to achieve rapid and short-term improvement of
severe symptoms after an adequate trial of other treatments has proven ineffective, and/or when the
condition is considered to be potentially life-threatening, in a severe depressive illness. N
When considering ECT, review risks and potential benefits to the individual, including: the risks
associated with the anaesthetic; current comorbidities; anticipated adverse events, particularly
cognitive impairment; and the risks of not having treatment. N
Particular care is needed when considering ECT treatment during pregnancy, in older people, and in
children and young people, because the risks may be increased. N
Valid consent should be obtained in all cases where the individual has the ability to grant or refuse
consent. The decision to use ECT should be made jointly by the individual and the clinician(s)
responsible for treatment, on the basis of an informed discussion. This discussion should be enabled
by the provision of full and appropriate information about the general risks associated with ECT and
about the risks and potential benefits specific to that individual. N
Advance directives should be taken fully into account and the individuals advocate and/or carer
should be consulted. N
Clinical status should be assessed after each ECT session and treatment should be stopped when
a response has been achieved, or sooner if there is evidence of adverse effects. Cognitive function
should be monitored on an ongoing basis, and at a minimum at the end of each course
of treatment. N
A repeat course of ECT should be considered under the circumstances indicated above only for
individuals who have severe depressive illness, and who have previously responded well to ECT. N
In patients who are experiencing an acute episode but have not previously responded, a repeat
trial of ECT should be undertaken only after all other options have been considered and following
discussion of the risks and benefits with the individual and/or where appropriate their carer/
advocate. N
As the longer-term benefits and risks of ECT have not been clearly established, it is not recommended
as a maintenance therapy in depressive illness. N
14
Based on level II or level III evidence (well-conducted clinical studies but no RCTs) or
extrapolated from level I evidence
Based on level IV evidence (expert committee reports or opinions and/or clinical experience
of respected authorities)
GPP
Implementation
15
Further information
Distribution
The distribution list for this quick reference guide is
available from www.nice.org.uk/CG023distributionlist
NICE guideline
The NICE guideline, Depression: management
of depression in primary and secondary
care, is available from the NICE website
(www.nice.org.uk/CG023NICEguideline).
The NICE guideline contains the following
sections: Key priorities for implementation;
1 Guidance; 2 Notes on the scope of the guidance;
3 Implementation in the NHS; 4 Key research
recommendations; 5 Other versions of this guideline;
6 Related NICE guidance; 7 Review date. It also
gives details of the grading scheme for the evidence
and recommendations, the Guideline Development
Group, the Guideline Review Panel and technical
detail on the criteria for audit.
Information for the public
NICE has produced a version of this guidance
for people with depression, their advocates and
carers, and the public. The information is available,
in English and Welsh, from the NICE website
(www.nice.org.uk/CG023publicinfo). Printed
versions are also available see below for
ordering information.
Full guideline
The full guideline includes the evidence on which
the recommendations are based, in addition to the
information in the NICE guideline. It is published by
the National Collaborating Centre for Mental Health.
It is available from www.bps.org.uk/publications,
from www.nice.org.uk/CG023fullguideline and on
Ordering information
Copies of this quick reference guide can be obtained from the NICE
website at www.nice.org.uk/CG023quickrefguide or from the NHS
Response Line by telephoning 0870 1555 455 and quoting reference
number N1237. Information for the public is also available from the NICE
website or from the NHS Response Line (quote reference number N1238).
POLICY NO
DATE RATIFIED
NEXT REVIEW DATE
CL 012
AUGUST 2008
AUGUST 2011
x
x
x
x
1 of 28
CONTENTS
PAGE NO.
1.
2.
3.
Assessment
4.
Allocation of Co-Ordinator
5.
10
6.
7 Day Follow Up
12
7.
12
8.
Review
13
9.
15
10.
15
11.
16
12.
16
13.
Transition Protocols
17
14.
18
15.
22
16.
23
17.
Training
24
18.
Audit
24
20.
References
25
Appendix 1
Appendix 2
Appendix 3
26
27
28
2 of 28
1.
1.1
This document reflects the ongoing partnership between the Lancashire Care
NHS Trust, the Primary Care Trusts and Blackburn with Darwen, Blackpool and
Lancashire Social Services. All these agencies are committed to working
together to improve the delivery of Mental Health Services within the CPA
framework and the scope of this policy. Service Users, Carers and other
organisations delivering Mental Health Services, have also participated in the
process of developing this Policy.
1.2
The aim of this policy is to promote an optimistic and positive approach to all
people who use mental health services. The vast majority have real prospects
of recovery if they are supported by appropriate services, driven by the right
values and attitudes (The Journey of Recovery, Department of Health). It also
incorporates the guidance issued by the Department of Health on refocusing
the Care Programme Approach. From October 2008 the term Care Programme
Approach will describe the approach used in Secondary mental health care to
assess, plan, review and coordinate the range of treatment, care and support
needs for people in contact with secondary mental health services who have
complex needs and who are most at risk.
1.3
1.4
3 of 28
The new guidance does not make any fundamental changes to the values and
Principles that underpin the Care programme approach. These are
described in detail in the new guidance (see appendix 1) The new guidance
builds on existing policy and follows a national consultation.
The full document can be accessed at
www.nihme.csip.uk/our-work/reviewing-the-care-programme-appraoch-cpa-.html
The link also provides access to a range of best practice guidance.
1.6
One assessment and care plan will follow the service user through the whole range
of care settings.
The care plan must incorporate a full risk assessment and management plan
supported by crisis and contingency plan
The assessment will consider issues relating to housing, employment and Social
inclusion
All service users will have a HONOS (or Honos 65+ or HONOSCA if appropriate)
assessment completed at least annually
All service users will be provided with a Credit/Business Card which provides
information about their care coordinators contact number and details a number
they will contact in case of emergency
The care plan must provide evidence of service user involvement i.e. it is signed,
the service user has a copy and there is a record that this has taken place
A carers assessment should be offered to all carers, and where indicated a plan of
support should be in place. The clinical record must record the date of assessment,
the carers need for support and how this support will be provided. This must be
reviewed on a regularly basis. Again this is recorded in the clinical record.
The service users status is reviewed at every Care Programme Approach review
4 of 28
2.
2.1
This Policy will apply for all Service Users in contact with Specialist Mental
Health Services who are subject to the Care Programme Approach. However,
the application will differ across service networks. It is important to consider the
relationship with the Single Assessment Process (SAP) in Older Adult Services
and the very specific needs of CAMHS. Local procedures will be in place where
required. Service users treated by the Primary Care Mental Health Teams or
steps 2 and 3 are not subject to formal CPA.
Whilst Individuals are free to refuse services, (unless subject to certain sections
of the MHA 1983) they cannot refuse to be part of the CPA, as this is a locally
and nationally agreed process by which Mental Health Services are delivered.
2.2
For Service Users who are in contact with Drug/Alcohol Services or Learning
Disability Services, where there are no co-existing mental health needs
requiring Specialist Services, the CPA will not apply. Should Clients of these
services develop severe mental health problems and become involved with
Specialist Mental Health Services the CPA will apply as per Policy. In these
cases the Care Co-ordinator should ordinarily be a member of the Specialist
Mental Health Service and the case will need to be managed jointly.
2.3
From October 2008 the term CPA will no longer apply to those individuals who
have contact with one professional or agency providing mental health services.
2.4
From October 2008 service users with a severe mental health problem and the
following characteristics will be subject to the Care Programme Approach. (this
is taken directly from the national guidance)
x
5 of 28
3.
ASSESSMENT
Assessment of Health and Social Care Needs
3.1
3.2
4.
4.1
4.2
6 of 28
4.3
2.
3.
To develop with the Service User, Carers (usually with Service Users
consent) and others involved in the service users care (where
necessary), an agreed Care Plan that addresses the Service Users
Health and Social Care Needs, including the management of any
associated risks.
4.
5.
6.
7.
8.
9.
10.
To inform other members of the Team, the Service Users family (where
applicable), their GP and any relevant others such as a Probation Officer,
if the Service User is found to be missing.
7 of 28
11.
12.
13.
14.
To ensure that the Service User has regular physical health checks and
the process is clearly documented in the record.
15.
16
17
18
Allocation of role
4.4
The role of the Care Co-ordinator in respect of an Individual Service User will
already be agreed at the earliest opportunity. Before accepting the role of Care
Co-ordinator the Practitioner should be aware of the Service Users
presentation, their needs and their risk potential.
4.5
All Service Users must be allocated a Care Co-Coordinator and if disputes arise
this must be resolved quickly and safely through the Local Team Management
arrangements. If this fails to occur the matter must be referred to the Service
manager. In the event of an ongoing dispute the Service Manager will make a
decision over the allocation of Care Co-Coordinator and this will be binding.
4.6
The Service User has a right to request a change of Care Co-ordinator and
there should be flexibility to enable the Service User to exercise choice.
Requests for a change of Care Co-ordinator should be discussed at an
arranged CPA Review Meeting. Any change of Care Coordinator should be
kept to a minimum. Should a change occur it is the responsibility of the Care
Co-coordinator to ensure that a thorough handover takes place.
8 of 28
4.7
All members of the Care Team must be aware of whom the Care Cocoordinator is, and where they can be contacted and this must be stated in the
Care Plan.
4.8
Team Mangers need to ensure, and be able to demonstrate, that Staff in Care
Co-ordination roles are maintaining caseloads of suitable sizes dependant on
the needs of Individuals on caseload. Where workload issues are problematic
this must be brought to the attention of the Service Manager and/or Assistant
Network Director and if serious risks are identified then the Network Director
must be informed.
4.9
The views and wishes of the Service User and their Carers must also be given
due consideration with attention to gender, culture and language. If their wishes
or preferences still cannot be fulfilled then clear reasons why must be
documented and given in writing to the Line Manager.
Case transfer / Fostering Cases, Short & Long Term Absence / Reallocation
4.10
4.11
4.12
No Service User will be left in the position of having no identifiable Care Coordinator, and where possible a formal hand over involving the Service User
and, where appropriate the Carer, should take place.
4.13
It is the responsibility of the Line Manager and the Care Co-ordinator to ensure
that changes in Care Co-ordinator are recorded and passed onto the relevant
CPA Manager / Co-ordinator / Lead Officer.
9 of 28
The Care Co-ordinator should engage the Service User and/or their Carer(s) in
the Care Planning process by prompting the inclusion of Service User goals and
actions. Access to Advocacy Services should be included on the Care Plan as
well as an opportunity for the Service User to record their agreement or
disagreement with the plan.
5.2
The Care Plan should be formulated by the professional acting in the role of
Care Co-ordinator and detail the interventions of the Care Coordinator and of
other professionals engaging in the plan (as agreed with the Service User). The
Service User and, where appropriate his/her Care Coordinator, should be
involved in writing their Care Plan, and if this is not possible this must be clearly
documented.
5.3
The Service User must receive full information on the CPA process and a copy
of the agreed Care Plan.
5.4
10 of 28
The written Care Plan should be drawn up by the named Care Co-ordinator,
with the involvement of the Service User, and the Carer (where appropriate).
5.6
In all cases (with some possible exceptions due to risk factors) copies of the
Care Plan including Risk Management Plans and Crisis and Contingency Plans
should be given to the following people (in addition to the Service User) after
discussion with the Service User:
x
x
x
5.8
If the MDT has identified the need for follow-up, then a Care Co-ordinator
should be identified as early as possible within the admission process.
5.9
The responsibility for organising the final discharge meeting and ensuring that
all key personnel are aware of the date and time of the meeting, is the
responsibility of the Care Co-ordinator in liaison with the ward.
5.10
The final Care Plan will have developed over the period of the individuals stay
in hospital. The responsibility for formulating the Care Plan will now have
shifted to the Care Co-ordinator.
5.11
The final discharge Care Plan will be written by the Care Co-ordinator, who will
have ensured that the Service User and Carers are fully conversant with the
aftercare arrangements.
5.12
The Care Co-ordinator is also responsible for ensuring that all the required
information is contained within the Care Plan, including arrangements for 7-day
follow up. (or 48hour follow up when appropriate)
5.13
Particular attention will be made to the Care Plans of those Service Users at
risk of suicide and, where indicated, will include more intensive provision for the
first three months after discharge from hospital (or intervention at home).
5.14
All Service Users, upon discharge from In Patient care, should be provided
with a copy of their written Care Plan.
5.15
These arrangements should be detailed in the Discharge Care Plan. The MDT
must review plan within one month of discharge.
11 of 28
5.16
The discharge of Service Users from other NHS or independent facilities must
be In accordance with the process described above. The Principles and
Procedures associated with the CPA apply equally to those Service Users
treated outside the area or in the Independent sector.
5.17
Where a service user is not subject to CPA the professional involved will be
responsible for coordinating care. Formal designated paperwork for CPA will
not be required. However, a statement of care agreed with the service user
must be recorded. This will be clearly documented in the clinical record. This
documentation constitutes the care plan. This process must never be used
where more than one professional and/or agency is involved. All essential
information will be recorded on eCPA and there must be evidence of
assessment (including risk assessment), intervention and review. In Older
Adult Services those Service Users not subject to CPA will be managed by
SAP. In primary care separate arrangements are also in place. Both these
procedures are supported by separate procedural guidance.
5.18
The eCPA system is used in all cases for our Service Users regardless of
whether they are subject to CPA.
6.
7 DAY FOLLOW UP
7-Day follow up visits are an important intervention aimed at supporting Users
and Carers and promoting recovery, social inclusion and suicide prevention.
All Service Users on the care programme approach, discharged from an Acute
Psychiatric Inpatient Unit (including periods of Home Leave) must be followed
up through face-to-face contact with a Community Mental Health professional
within 7 days of discharge. (or 48 hours when appropriate)
Where Service Users are discharged to another district (i.e. from one trust to
another) the 7-day follow up becomes the responsibility of the mental health
provider in that area. However, it is important that the new provider is involved
in the planning of discharge.
If 7 Day follow up does not take place the reason why must be clearly
documented in the client record
7.
7.1
The Carers (Recognition and Services) Act 1995 places a duty on Local
Authorities to assess the ability of any persons caring for vulnerable Service
Users. Authorities are required to provide services to Carers if the assessment
indicates that the Carers efforts should be supplemented by Social Service
provision. In order that Local Services should meet Standard 6 of the NSF, Care
Co-ordinators and other Staff in contact with Service Users must offer Carers an
assessment of their caring needs.
The Care Co-ordinator should ensure that:
12 of 28
The NSF indicates that local arrangements should be made to ensure that the
Service User and Carers Care Plans are considered together. The Care Coordinator also has an essential role in informing the Service User and their
Carer of the Carer's right to request an assessment and also to ensure coordination of the Service Users and their Carers Assessment Plans.
7.3
In most cases the Care Co-ordinator is likely to be working with both the Service
User and the Carer and will therefore be the most appropriate person to
undertake the Carer Assessment and draw up the Carers Care Plan.
7.4
7.5
8.
REVIEW
8.1
Review and evaluation of the effectiveness of the Care Plan should take place
with the Care Co-ordinator as part of the Multi-Disciplinary Team (MDT), in
collaboration with the Service User and those others identified in the Care
Planning arrangements.
8.2
The Care Co-ordinator is responsible for ensuring reviews take place. (For In
Patient Services where a Care Co-ordinator has not yet been identified this
responsibility will fall to the Primary/Named Nurse.)
8.3
13 of 28
8.4
The timing or frequency of reviews should take place in response to the Service
Users needs and in negotiation with the Service User and their Carers, the
MDT, GP and other relevant parties in keeping with protocols and standards. As
a minimum requirement each Service User must be reviewed at least once in
every twelve month period. Separate arrangements exist for Service Users on
supervised community treatment orders.
8.5
Review and evaluation of the service users care plan should be ongoing. The
regularity of reviews will depend on the needs of the individual but should
always take into account care management requirements and the care team
should agree which issues will trigger emergency reviews (e.g. non
compliance). Review of risk is an ongoing process carried out on each and
every contact with the service user. In all circumstances, the date of the next
CPA review must be set and recorded at each review meeting, with the
knowledge and agreement of the Service User and the Care Team. This date
must include the time, day, month and the year.
8.6
8.7
The purpose of the review is to consider the progress the Service User has
made and how they have responded to the services provided, to consider ways
in which their needs may have changed and, therefore, the extent to which the
Care Plan requires amending.
8.8
Priority should be given to the review of the Risk Management Plan, identifying
those aspects that have been successful, those that have not and any
alternative strategies.
8.9
8.10
A member of the Care Team, the Service User or Carer, can call an early
review at any time via the Care Co-ordinator. The Care Team must consider
calls for an early review and, if this is not considered appropriate, then reasons
why must be given and documented.
A Review should be arranged when: significant adverse events occur, they are
requested by service user / carer, risk increases, inpatient admission, prior to
discharge, breakdown of current care plan, before services are changed
through withdrawal, reduction, transfer or transition.
14 of 28
9.
DISCHARGE
SERVICES
AND
RE-ACCESSING
SPECIALIST
MENTAL
HEALTH
9.1
9.2
For those Service Users who have previously been significantly disabled by
their mental health problem, and/or have had a diagnosis of severe and
enduring mental illness, clear Discharge Plans which inform how to reengage
with services in the event of signs of relapse/ deterioration must be in place.
9.3
Crisis and Contingency Plans must be as robust as possible and inform the GP,
the Primary Health Care Team, the Carers and the Service User how to reaccess Mental Health Services. These must be written, communicated and
understood before discharge can take place.
10.
10.1
Section 117 of the Mental Health Act 1983, places a statutory duty on
authorities to provide aftercare services of certain detained Service Users.
10.2 Section 117 aftercare only applies to those detained under Section 3, 37 and
transfer orders made under Section 45A, 47 and 48.
10.3
Given that the principles of CPA and after-care are the same, Section 117
needs should be incorporated into the CPA care plan. Therefore Section 117
care planning should be incorporated into the CPA review process. Section 117
runs in parallel and is complementary to the Care Programme Approach.
10.4
The duty to provide aftercare lasts until both authorities are satisfied that the
Service User is no longer in need of such Services.
10.5
When it is felt that the service user is no longer in need of Section 117
aftercare, the signature of both agencies, even where only one agency is
involved, is required. In all cases a Social Worker should consult with their
Team Manager before signing to agree that Section 117 aftercare is no longer
appropriate. The Social Worker will then complete the Section 117 discharge
form.
10.6
The Service User can refuse to accept the offer of aftercare services. Under
these circumstances the Care Coordinator should continue to attempt to
persuade the service user to accept the service until it is agreed at a formal
CPA review meeting that this is no longer appropriate.
10.7
10.8
15 of 28
11.
11.1
It is the responsibility of each worker to ensure that his or her part of the Care
Package is carried out. However, in some cases relationships between the
Service User and the worker can break down and jeopardise the Care Plan. In
this case the responsibility falls to the Care Co-ordinator to find out why the
service user no longer wishes to co-operate with the plan so that the situation
can be redressed to the satisfaction of all involved.
11.2
Service Users who meet the criteria for the CPA and have a history of severe
and enduring mental illness must not be discharged solely on the grounds they
are uncooperative. All possible efforts should be made by the Care Coordinator to stay in touch with the Service User and work at developing a
relationship that will enable increased care in the long term. The Care Plan
should acknowledge the MDTs difficulty in attaining engagement with the
Service User. This acknowledgement must be communicated with all those
involved in that Service Users care and documented.
11.3
11.4
When working with Service Users who have a history of rejection, refusal or
non-compliance, a thorough risk management strategy should be in place that
considers the range of actions that should be taken at times of greatest
concern.
11.5
12.
12.1
If a Service User fails to attend for an appointment or is not at home for a prearranged visit, consideration should be given to the Service Users previous
reliability with respect to such arrangements. If contact cannot be reestablished, the Care Co-ordinator should be informed and the appropriate
action taken. This may include contacting a third party such as relatives, the
GP, support agencies or the police.
12.2
For those Service Users with a history of a loss of contact, trigger factors should
be identified and action should be documented within the risk management
strategies recorded on the Care Plan in relation to relapse. This would ensure
that all professionals involved would respond in the same way without periods
of time elapsing without action.
16 of 28
12.3
A CPA Review meeting should be called as soon as the Service User loses
contact with services to share information and determine action.
12.4
It will be necessary to take into account the Service Users current mental state,
previous history; potential and actual risk to self or others and the other
available support networks, in order to plan intervention.
12.5
Where a Service User seems to disappear from Services there is a duty of care
to make all reasonable efforts to locate them to negotiate arrangements for their
care and treatment. Actions to achieve this should be clearly recorded.
12.6
The Care Co-ordinator should contact any Carers, other members of the Care
Team, relatives and known associates to try to locate the Service User and to
offer support and monitor their wellbeing. Use of the National Tracking Service
may assist in checking their location via GP registration.
12.7
Where there are dependent children within the household of a Service User
with mental health needs, special consideration should be given to the
implications this may have for those children. Childrens welfare is a paramount
consideration for all professionals. Where there are issues of concern, the
Trusts Public Health Advisor for Children and Families and the relevant Child
Care Services from the transferring and receiving district should be involved in
the planning arrangements for the transfer, so that childrens needs may be
properly identified and managed.
12.8
13.
TRANSITION PROTOCOLS
13.1
Periods of transition in the care process represent a time of increased risk. For
this reason a number of transition protocols are in place to support the delay of
effective and efficient clinical services. These protocols must be read in
conjunction with this policy and all operate in accordance with the framework
provided by the CPA. The transition protocols are as follows: x Protocol for the transit of Clients from Child & Adolescent Mental Health
Services.
x Protocol for the transition of Clients between Adult & Older Adult Mental
Health Services.
x Protocol for the transition of Clients between HM Prison (Lancashire
Locality) and Mental Health Services (Lancashire).
17 of 28
x Protocol for good practice in the transfer of Service Users care between
districts.
14.
14.1
14.2
14.3
Where a Service User is not in formal contact with the criminal justice system,
but is assessed as being a potential risk to others, careful liaison with the Police
to manage any immediate risks is necessary. In this context it is important to
note that the common law duty of confidence requires that, in the absence of a
statutory requirement to share information provided in confidence, such
information should only be shared with the informed consent of the Individual.
However, this duty is not absolute and can be over-ridden if the holder of the
information can justify disclosure as being in the public interest (including a risk
to public safety). The Caldicott Principles and Data Protection Act 1998 should
be adhered to at all times.
Further guidance on the operation of the common law is included in the DH
publication HSG (96) 18 The Protection and Use of Patient Information.
Decisions to disclose information against the wishes of an individual should be
fully documented and the public interest justification clearly stated.
Service Users considered as High Risk to Others
14.4
Some Service Users of mental health services will also have co-existing risk
issues, which may or may not be diagnostically related. Service Users who
present a significant risk to the public and have previous convictions for
assaultative, abusive or threatening behaviour may also be subject to MAPPA
protocols and procedures. Mental Health Services have a responsibility to
participate fully within the MAPPA framework to ensure protection of the public.
Most high risk mentally disordered offenders will be registered as Level 2
MAPPA cases, unless a multi-agency decision, particularly the police and
probation consider the case as highly dangerous requiring very close
18 of 28
However, there are also a number of Service Users who appear to present a
considerable risk to others, family, staff and the public, but who do not have
recent, relevant or significant previous convictions, which precludes them from
registration and monitoring under the MAPPA framework; i.e. Level 1. This
means that the responsibility for Care Delivery and monitoring lies with Mental
Health Services, specifically the RMO and Care Co-ordinator. For further
information regarding MAPPA Framework i.e. levels 1, 2 and 3 refer to the
Criminal Justice Act 2002.
Multi-disciplinary, Cross Agency CPA Reviews Incorporating Risk
Assessment/Management
14.6
CPA Reviews encourage attendance of all Staff involved in the care of the
Individual Service User, in addition to the User and the Carer. However, it is
difficult for partnership agencies to prioritise CPA Reviews when they do not
fully understand the CPA process are not formally invited by letter and if
reviews do not take account of the individual agencies remit and Service
objectives.
14.7
In order to develop effective risk management plans for Mental Health Service
Users it may be beneficial to invite the police, probation and other agencies e.g.
Child Protection Social Workers. Clearly, these Staff will not necessarily have a
direct interest or involvement in the review of the Mental Health Care Plan.
Therefore, it would be advantageous to hold a CPA Review, which directly
focuses on Risk Management a CPA/Risk Review.
Multi-Disciplinary Risk Review
14.8
14.9
14.10 The Care Co-ordinator will formally invite all relevant parties involved with the
Service User and Carer, if appropriate. NB. Due to the level and nature of the
risk presented by the Individual Service User, it may be necessary to hold
professionals only meeting (or have a closed section of the meeting). Where
possible, efforts should be made to provide feedback to the service user and
carer. The Care Co-ordinator in discussion with the Multi-Disciplinary Mental
Health Team should determine who needs to attend the Risk Review:
14.11 Examples of possible invitees include the local Community Affairs Inspector (or
nominated deputy) to represent the police, the local Senior Probation Officer (or
19 of 28
x
x
x
x
x
x
20 of 28
14.15 The above structure is designed to focus CPA meetings on the multi-faceted
management of Individual Service Users who may present significant risks to
themselves or others and require the construction of a robust risk management
plan owned by representatives of relevant agencies.
Service Users not registered under the CPA
14.16 A&E and Criminal Justice Liaison Teams for example; may encounter Service
Users who appear to display significant risk features, but are not registered
under the CPA. The above system is applicable for such Individuals and the
Team Leader/Manager should determine who is most appropriately placed to
take on the co-ordination role to arrange the Risk Review.
Prison Based Health Care
14.17 Prison based Health Care staff and NHS Mental Health Services share
responsibility for ensuring appropriate liaison on the care of mentally disordered
prisoners. It is particularly important that effective links are made to ensure
sound discharge planning when prisoners are released from prison.
14.18 If a Service User is being held on remand or has received a sentence shorter
than twelve months, the Care Co-ordinator must ensure that they maintain
contact with the Service User and review the care and treatment they receive
when they enter the prison system, thus ensuring the continuity of the care.
14.19 As soon as the Care Co-ordinator is made aware that a Service User has been
detained or entered the prison system early communication of his or her
involvement must take place. This communication will be followed up by a fax
message (number to be made available to each Line Manager). The name of
the Health Care Staff member with whom communication has taken place must
also be recorded.
14.20 The Care Co-ordinator will discuss the arrangements for an early CPA review
with those involved including the identified Mental Health in reach team or
prison based Health Care Staff where possible. Particular emphasis should be
made to risk assessment and management.
14.21 Following review, a Care Plan should be agreed with the service user (and if
appropriate, their carers and others involved in their care) prior to release from
prison with contingencies in the event of early release.
14.22 In particular the Care Co-ordinator needs to make sure that they are, wherever
possible, aware of the Service Users prison establishment and location and
likely release date, so that appropriate planned care can be implemented when
they are released.
Discharging Service Users who enter the Prison System
14.23 If a Service User has been sentenced and is likely to be detained in prison for
longer than twelve months the existing Care Co-ordinator in most cases is
21 of 28
Specific Policies and Procedures must be in place within the Community Mental
Health Services in particular, and the rest of Mental Health Services for those
Service Users who have dependent children and/or children who are
identified as being in need or where there are Child Protection concerns. It
is important that reference is made to the Adult Mental health and Child
Protection guidance and Multi-Agency protocol
15.2
The relevant Child Protection Procedures must be followed where there are
concerns for the welfare/safety of children and young people.
Service Users who may pose a risk to Children and Young People
15.3
During the assessment and provision of care, it may become known that the
Service User may pose a risk or potential risk to children/young people or
adults. The protection of children and vulnerable adults is paramount and
integral to the provision of any Healthcare Service.
15.4
The Care Co-ordinator and all Staff providing care must be made aware of any
disclosures made and Police Public Protection Unit notified as well as
Childrens Social Care, in line with LSCB procedures. Staff must identify if
Multi-agency Public Protection Arrangements (MAPPA) have been put into
place.
15.5
In a ward environment staff must consider any young person currently being
cared on the same ward who must be protected from disturbed and/or
dangerous situations and arrangements should be sought to find alternative
22 of 28
16.
16.1
The implementation of CPA does not affect the service users right to
confidentiality in any way. All information relating to service users remains
confidential within the usual exceptions.
16.2
In order to deliver appropriate care for those Service Users, it is vital that those
involved have ready access to the information necessary for the safe, sound
and supportive implementation of the care package. However, it is also
important that Service Users and their Carers can trust that personal
information will be kept confidential and that their privacy will be respected.
16.3
16.4
16.5
16.6
It is the responsibility of the Care Co-ordinator to seek out and relay the
relevant information to other agents who have a legitimate need to know. This
is particularly important in circumstances where there may be family and child
welfare issues, probation, or housing, health and social issues involving other
agencies.
16.7
16.8
23 of 28
consent to their information being shared, the decision should be made on the
Service Users behalf by those responsible for providing care, taking into
account the views of the Service User and Carers with the Service Users best
interest being paramount.
17
TRAINING
17.1
17.2
All recording and mandatory training will be undertaken in line with the
requirements sent out in the Statutory Training Policy
18.
AUDIT
18.1
18.2
All Staff and their Managers have crucial roles in respect of providing audit
information for Service Users on their caseload, they must be aware that
completion of the audit is mandatory.
18.3
The responsibility for auditing the quality of care plans lies with each
departmental manager in line with the NSF. Utilising supervision mechanisms
together with other audit initiatives, they will ensure that standards for Care
Planning are met. The CPA leads will support these processes.
18.4
Evidence of CPA audit activity must be built into the activity of both Clinical
Governance and Best Value as part of both each organisations drive towards
continuous improvement. Also evidence of any required actions stemming out
of these audits must be made available when required.
18.5
Audit will be on an annual basis and will be based on the standards outlined in
this policy
24 of 28
REFERENCES
DEPARMENT OF HEALTH: The National Service Framework (1999). L46/01 16575
com 30k 1P Sep 1999
THE MENTAL HEALTH ACT (1983)
DEPARTMENT OF HEALTH: Effective Care Co-ordination in Mental Health Services Modernising the Care Programme Approach, NHSE (1999).
DEPARTMENT OF HEALTH: The Care Programme Approach (1991). (Joint Health &
Social Services Circular HC (90) 23/LASSL (90) 11)
DEPARTMENT OF HEALTH (2007) Best practice in managing risk
DEPARTMENT OF HEALTH (2008) Refocusing the Care programme Approach
SOCIAL SERVICES INSPECTORATE: Still Building Bridges (1999) C1 (1999).
An Audit Pack for the Monitoring of the Care Programme Approach (2001)
The CPA Handbook The CPA Association (2001)
NATIONAL HEALTH SERVICE EXECUTIVE: Audit Pack for Monitoring the CPA,
(HSG (96) 6).
NATIONAL CONFIDENTIAL ENQUIRY INTO SUICIDE AND HOMICIDE BY PEOPLE
WITH MENTAL ILLNESS (1999)
25 of 28
Appendix 1
Table 1
The approach to individuals care and support puts them at the centre and promotes
social inclusion and recovery. It is respectful building confidence in individuals with
an understanding of their strengths, goals and aspirations as well as their needs and
difficulties. It recognizes the individual as a person first and patient/service user
second.
Care assessment and planning views a person in the round seeing and supporting
them in their individual diverse roles and the needs they have, including: family;
parenting; relationships; housing; employment; leisure; education; creativity;
spirituality; self-management and self-nurture; with the aim of optimising mental and
physical health and well-being.
Self-care is promoted and supported wherever possible. Action is taken to encourage
independence and self-determination to help people maintain control over their own
support and care.
Carers form a vital part of the support required to aid a persons recovery. Their own
needs should also be recognized and supported.
Services should be organised and delivered in ways that promote and co-ordinate
helpful and purposeful mental health practice based on fulfilling therapeutic
relationships and partnerships between the people involved. These relationships
involve shared listening, communicating, understanding, clarification, and organization
of diverse opinion to deliver valued, appropriate, equitable and co-coordinated care.
The quality of the relationship between service user and the care-coordinator is one of
the most important determinants of success.
Care planning is underpinned by long-term engagement, requiring trust, team work
and
commitment. It is the daily work of mental health services and supporting partner
agencies, not just the planned occasions where people meet for reviews.
26 of 28
Appendix 2
Table 2
Service users needing (new) CPA
An individuals characteristics
Complex needs; multi-agency input;
higher risk.
See detailed definition in Table 1.
27 of 28
Appendix 3
28 of 28
POLICY NO
DATE RATIFIED
NEXT REVIEW DATE
CL 022
Feb 2009
Feb 2012
Executive Summary
Subject
Applicable to
Date Issued
Dates Policy reviewed
Next review due date
Policy written by
February 2009
February 2009
January 2012
Public Health Advisor Children and Families/
named Nurse Child Protection / LCFT
Safeguarding Practitioner
Executive Directors
Senior Management Team
Safeguarding Committee
Safeguarding Committee
Director of Nursing
Consultation
Approved by
Authorised by
Signature
Related procedural documents
Vulnerable
Adult
Contents
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
17.0
18.0
19.0
20.0
21.0
Page
Summary
Introduction
Standards
Definitions
Scope
Principles
Duties
Confidentiality
Capacity and consent
Concerns Regarding Poor Practice Whistle blowing
Record Keeping
Concerns about Abuse from staff
Concerns regarding Abuse from one Vulnerable Adult to Another
Abuse/concern within the Home Environment
Training
Support for staff
Monitoring
Equality and Diversity Impact Assessment
Review
Other associated Policies and Procedure
References
References
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
4
4
4
5
7
7
7
10
10
10
11
11
11
11
11
11
12
13
13
13
13
15
27
28
29
30
31
1.0
Summary
The Department of Healths No Secrets document (DoH, 2000) provides guidance that
requires all agencies to have arrangements in place to effectively safeguard, protect and
respond to known or suspected abuse of vulnerable adults. Lancashire Care Foundation
Trust (LCFT) Policy and Procedures have been developed in line with current evidence and
follows the principles outlined in the following Local Authority Procedures:
x
x
x
2.0
Introduction
This policy aims to promote the protection of vulnerable adults, who are at risk of all forms
of abuse, and ensure that they receive a safe, sound and supportive service, through the
process of identifying, investigating, managing and preventing such abuse.
3.0
Standards
LCFT Safeguarding Adult practice reflects the standards within the national framework for
Safeguarding adults October 2005 - Produced in Oct 2005 by the Association of Directors
of Social Service (ADSS)
x
Each partner agency has a set of internal guidelines, consistent with the local multiagency Safeguarding Adults policy and procedures, which sets out the
responsibilities of all workers to operate within it
The Trust will work in partnership with the local authority and other agencies as
needed, where Adult Safeguarding incidents are identified
The safeguarding procedures are accessible to all adults covered by the policy.
Safeguarding adults is the responsibility of all agencies and cannot exist in
isolation. It must be effectively linked to other initiatives, as part of a network of
measures aimed at enabling all citizens to live lives that are free from violence,
harassment, humiliation and degradation. (ADSS Framework)
To ensure all adult protection incidents are recorded, reported and investigated in
line with Trust serious untoward incident and risk management arrangements
Manage the risks associated with Adult Safeguarding in line with the Trust Adult
Safeguarding procedure in Appendix 1.
4.0
Definitions
Safeguarding adults is defined for the purpose of this policy and its procedure as:
x
x
x
Adult at risk is a person aged 18 or over and who may already be in receipt or in need of
community care services by reason of mental or other disabilities, age or illness. This
person may be unable to take care of him or herself, or unable to safeguard themselves
against significant harm or exploitation.
The concept of significant harm introduced in the Children Act can be applied to the
consideration of harm to vulnerable adults. This suggests that:
Harm should be taken to include not only ill treatment (including sexual abuse and forms
of ill treatment which are not physical) but also the impairment of or an avoidable
deterioration in physical or mental health, and the impairment of physical, intellectual,
emotional, social or behavioural development.
Emotional harm can be caused by a vulnerable adult being exposed to domestic violence
or being aware of domestic violence within the home.
Neglect is the persistent failure to meet an adults basic physical and / or psychological
needs, likely to result in the serious harm to that persons health and welfare. The
consequences of neglect can have a life long impact.
Safeguarding adults encompasses all aspects of adult protection.
Abuse is a violation of an individuals human and civil rights by other person or persons.
Abuse may consist of single or repeated acts. It may be physical, verbal or psychological, it
may be an act of neglect or an omission to act, or it may occur when a vulnerable person is
persuaded to enter into a financial or sexual transaction to which he or she has not
consented, or is unable to consent to. Abuse can occur in any relationship and may result in
significant harm, or exploitation of the person subjected to it.
Abuse may take one or more of the following forms:
x
x
x
x
x
x
x
5.0
Scope
This policy must be followed by all staff employed and independently contracted by
Lancashire Care Foundation Trust (LCFT). This policy is supplementary to and not a
replacement for individual Local Safeguarding Adult multi agency policy and procedure
and must be read in conjunction with them.
x
6.0
Principles
In the provision of services to all Trust service users, the Trust has a commitment to deliver
these services in a non-discriminatory manner.
No assumption can or should be made that people with mental health problems, those in
receipt of substance misuse services or those with a learning disability constitute a risk to
children simply by virtue of their difficulties.
Vulnerable adults have the right to be protected from harm and to receive services when
their health or welfare is at risk. All interventions should enable an adult "who is or may be
eligible for Community care services" to retain independence, well being and choice and to
access their human right to live a life that is free from abuse and neglect (No Secrets).
Protection will be provided to those who do not have the mental capacity to access it
themselves in line with:
Human Rights Act 1988,
Mental Capacity Act 2005
Mental Health Act 2007 & Mental Capacity Act Amendments Deprivation of Liberty
Standards
Domestic Violence Crime and Victims Act 2004
7.0
Duties
7.1
Chief Executive
The Chief Executive as the Accountable Officer has overall responsibility for ensuring the
implementation of effective Safeguarding Adult arrangements and meets all statutory
requirements. Executive responsibility is delegated to the Director of Nursing.
Date of issue March 2009
7.2
Director of Nursing
x The Director of Nursing is the executive lead for LCFT and reports directly to the Chief
Executive on related issues and is a representative on the local authority safeguarding
boards.
x
The Director of Nursing also has responsibility for ensuring the Trust as a partner
agency meets the standards for good practice embodied in No Secrets D.H. 2000 and
the ADSS National Framework and ensures that local arrangements and protocols are
in place to support compliance with local authority multi agency adult protection policy
and procedure.
Providing assurance to the Trust Board of compliance with this procedure via the
Governance report
7.3
Deputy Director of Nursing
Line manages the LCFT Safeguarding Team and sits on local authority safeguarding
boards.
7.4
Public Health Advisor Children and Families/Named Nurse Child Protection
and the Safeguarding Practitioner general responsibilities include:
x Liaison and links with local authority Safeguarding Adult leads
x Ensuring that the Safeguarding of Adults and Children are linked and considered
together
x Development of safeguarding practice
x Provision of safeguarding advice and support
x Identification of safeguarding/vulnerable adult training needs and facilitate access to
appropriate
training
x Facilitating advice on legal matters in conjunction with the Trusts legal advisors
x Close liaison with the management structures within LCFT and other agencies to
address both strategic and operational issues relating to the safeguarding adult agenda
x Providing assurance to the Safeguarding Committee of compliance with this procedure
x Developing an action plan to address issues of non compliance with this procedure
7.5
Network Directors are responsible for:
x Ensuring policy implementation in their service area
x Ensuring staff receive proper supervision in relation to safeguarding incidents in line
with the Trusts Supervision Policy
x Ensuring that Adults Safeguarding issues are a standing item in all service meetings
x Ensuring that local arrangements and protocols are in place that supports compliance
with the local multi-agency Adult Protection Policies and that they are adhered to by all
managers and their staff
x Ensuring that all serious Adult Safeguarding Incidents are managed in line with the
trust incident reporting procedures
x Ensuring and monitor that all staff in their area are appropriately skilled and have up to
date knowledge of Safeguarding procedures through their KSF and PDP outline
Date of issue March 2009
7.6
Service Managers, Modern Matrons, Professional Leads, Senior Nurses and
Managers are responsible for:
x Ensuring staff receive proper supervision in relation to safeguarding incidents in line
with the Trusts Supervision Policy
x Ensuring all adult protection alerts are reported in line with local authority multi agency
safeguarding adult policy and procedures
x Responding to instances of suspected or actual adult abuse in a clinical proactive way
to ensure the protection and safeguarding vulnerable adults
x Coordinating investigations, chair adult protection strategy meetings and ongoing
investigations in line with local authority multi agency safeguarding adult policy and
procedures
x Ensuring that all Team Leaders and Ward Mangers are aware of local authority multi
agency safeguarding adult policy and procedures through their KSF and PDP outline
7.7
Team Leaders and Ward Managers are responsible for:
x Ensuring that staff are aware of local authority multi agency safeguarding adult policy
and procedures through their KSF and PDP outline
x Ensuring that all staff are aware of the process for raising an adult protection alert
x Ensuring that staff have access to the Trust Intranet Safeguarding and Protecting adult
page
x Ensuring staff receive proper supervision in relation to safeguarding incidents in line
with the Trusts Supervision Policy
x Providing support for staff involved in any incident relating to vulnerable adults
x Ensuring staff receive training as highlighted in the trusts Training Needs Analysis
7.8
Safeguarding Champions These are identified practitioners in teams who liaise
and work closely with the Safeguarding Team and they are responsible for:
x Appraising existing care plans to ensure safeguarding issues are included and that they
are sensitive to the current needs of the child and family
x Clarifying roles and responsibilities of staff in line with LCFT and LSCB procedures
x Establishing that practice is compliant with national and local safeguarding policies,
procedures and guidance
x Providing appropriate supervision and support, to enable safe and effective practice
x Promoting professional development, identifying with the practitioner, gaps in
knowledge and skills and directing staff into appropriate training
x Ensuring that there is close communication with the Safeguarding Team/line managers,
regarding safeguarding and protecting issues arising from practice
7.9
All Staff are responsible for:
x Protecting and safeguarding vulnerable adults.
x Understanding and implement the Trust Safeguarding and Protecting Vulnerable Adult
Policy and Procedures
x Familiarising themselves with the risk factors and signs/symptoms of abuse, and to be
aware of the action to be taken should such an incident present itself
x Attending training as required by the Trusts Training Needs Analysis
7. 10
Receiving assurances that this policy is being implemented, also EMT Governance in
respect of receiving assurance from the safeguarding committee and providing assurance to
the Trust Board
7.11 EMT Governance
EMT Governance is responsible for:
x Receiving assurance of compliance with this procedure from the Safeguarding
Committee
x Providing assurance to the Trust Board of compliance with tis procedure via the
Director of Nursings Governance Report
7.12 LCFT Safeguarding Committee is responsible for:
x To oversee the development, implementation and monitoring of systems, processes and
policies to ensure Children, Young People and Vulnerable Adults are safeguarded
whilst accessing services provided by LCFT
x To approve performance processes and agree strategic direction for Safeguarding
within LCFT
x To monitor implementation of current legislation and policy in relation to Safeguarding
Children and Vulnerable Adults
x To agree quality standards, audit priorities/tools and support a training strategy for
Safeguarding Children, Young People and Vulnerable Adults
x Reporting to the Trust Board and will provide assurances that Safeguarding Children,
Young People and Vulnerable Adults procedures are implemented according to the
committee structure in the Risk Management Standard the Safeguarding Committee
reports to EMT Governance
8.0
Confidentiality
Information regarding Safeguarding of Adults must be handled in line with the Trusts
Policy for the lifecycle management of records. All staff and practitioners must protect all
confidential information concerning patients and clients obtained in the course of
professional practice and abide by their professional codes of conduct
9.0
All capacity and consent issues will be handled in line with the Mental Health Capacity
Act 2005 and the Mental Health Act of 2008
10
11.0
Record Keeping
Record keeping will be handled in line with the Trusts Record Keeping Policy. Further
guidance helpful to record keeping for Safeguarding incidents is included in the procedure.
12.0
Inappropriate behaviour by a staff member towards any patients will not be tolerated and
will be dealt with in line with the Trusts Disciplinary Procedure.
15.0 Training
Staff will be trained in line with the Trusts Training Needs Analysis See statutory and
mandatory training procedure.
Attendance and non attendance will be monitored in accordance with the statutory and
mandatory training procedure.
Expertise and knowledge levels of staff will be monitored in line with KSF and PDP
outlines. Links to further training are available via the Trusts Safeguarding and Protecting
Adult intranet site.
All managers have a duty to respond and take appropriate action, to provide support for
staff and implement strategies to manage subsequent actions and care strategies to
manage subsequent actions and care in line with LCFT Procedure for Supporting Staff
following Traumatic/Stressful Incidents, Complaints or Claims.
x Occupational Health is available for counselling and staff can either self refer or be
referred by their manager.
Further support please is available via LCFT Safeguarding Team
Date of issue March 2009
11
17.0
Monitoring
The process for monitoring the effectiveness of these procedures and of the safeguarding
arrangements for children within the Trust will be by the Trust Safeguarding Committee.
An Annual Report from the Safeguarding Committee will be submitted to the Executive
Management Team (EMT) Governance who will feedback to the Trust Board each year.
The Trust Board has overall accountability for ensuring these procedures are in place.
The Trusts Safeguarding and Protecting Adults procedures and compliance will be
monitored through a number of means, which are outlined in the following table.
Standard
Duties
Timeframe/
Format
Annually in
report to the
Board
Review of reported
safeguarding incidents to
establish themes and trends
Quarterly in
reports to the
Board
Annually in
report to the
Board
Local Safeguarding
arrangements are being
followed
Quarterly in
reports to the
Board
How
Whom
Review of a sample of
EMT and Safeguarding
Committee minutes,
Local Authority training
records and LCFT Oracle
Learning Management
system (OLM), work
plans, objectives
Quarterly reports,
reported incidents and
SUIs regarding concerns
about an adults safety,
reviewed.
Attendance records
Quarterly training reports
Public Health
Advisor
Children/Families
Review of Incident
reports, minutes
Safeguarding Committee
meetings, Safeguarding
Champions meetings.
LASB meetings and
subgroups
LCFT Safeguarding
Annual Report,
programme of audit.
Public Health
Advisor
Children/Families
Public Health
Advisor
Children/Families/
Training and
development
Manager
Public Health
Advisor
Children/Families
LCFT
Safeguarding
Committee
12
Supporting Staff
Annually in
report to the
Board
Public Health
Advisor
Children/Families
LCFT
Safeguarding
Committee
18.0
See appendix 7
19.0
Review
This procedure will be reviewed every 3 years or earlier if there is a change in NHS or DH
Guidance.
20.0
x
x
x
x
Procedure for the reporting and management of incidents including the management of
serious untoward incidents
No Secrets in Lancashire: A Joint Strategy to Protect Vulnerable Adults From Abuse
Blackpool Vulnerable Adults Committee, Code of Practice and Procedures and
Blackburn with Darwen Adult Protection Policy and Procedures
21.0
x
References
Blackburn with Darwen Inter Agency Policy and Procedures For the Protection of
Vulnerable Adults From Abuse (April 2004)
Blackpool Borough Council & Social Services, Blackpool Vulnerable Adults Committee
(2004), Code of Practice and Procedure
Date of issue March 2009
13
14
Appendix 1
PROCEDURE FOR
SAFEGUARDING AND
PROTECTING VULNERABLE ADULTS
STATEMENT/KEY OBJECTIVES:
The Trust has procedures in place to support LCFT policy 022
to promote the welfare of vulnerable adults and ensure their safety and protection.
15
Contents
Page
1.0
2.0
3.0
17
18
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
Introduction
Capacity & Consent
Local Arrangements and Procedure for Risk where Abuse is
Recognised or Suspected
The Alert
The Investigation
Strategy/Discussion Meetings
Case Conference/Safeguarding Planning Meeting
Action/Safeguarding Plans
Case Monitoring and Review
Record Keeping
Abuse/Concern from one Adult to another
18
21
23
23
24
24
24
25
25
References
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
27
28
29
30
31
16
1.0
Introduction
This document covers the procedures and actions to be taken when an allegation of abuse is
made. In line with LCFT Safeguarding and Protecting Adults Policy CL022, LCFT is
required to maintain procedures for ensuring instances of adult abuse are reported and
investigated. These procedures are in place to support compliance with local authority
multi agency adult protection policy and procedure.
These procedures should not be read in isolation but used in conjunction with the LA
Safeguarding and Protecting Adult Procedures. Across the geographical area covered by
LCFT, these are:
x
x
x
The Local Authority are the lead agency co-ordinating the response to adult abuse
allegations. They have an important responsibility to work closely with other agencies and
organisations including health.
When a situation is discovered in which a vulnerable adult reports, or is thought to be at
risk of abuse, then agencies will act quickly in a co-ordinated manner to address issues and
concerns. LCFT recognises the potential for people to be discriminated against on the basis
of race, culture, gender, age, disability or sexual orientation, and is committed to working
with vulnerable adults in a positive manner that values people as individuals.
The first priority of staff should be to ensure the safety and protection of the vulnerable
adult. Service users should be made aware of the limitations of and exceptions to
confidentiality in relation to adult protection, and that information will be shared if they or
others are at significant risk. They should be assured that they will be treated in a fair and
equitable manner.
Those who have a role in working with adults identified as vulnerable who may be
parents/carers must consider any risks to children within the home, family or who they may
have caring responsibility for. Where there may be risks identified that impact on a
child/young persons welfare, staff must ensure that appropriate referrals are made to
Childrens Integrated Services (CIS) or partner agencies, in line with LCFT and Local
Safeguarding Children Board Procedures.(Refer to LCFT Procedures for Safeguarding and
Protecting Children CP001) .
All mental health/substance misuse services including forensic services have a role to play
in assessing the risk posed by adult perpetrators, and in the provision of treatment services
for perpetrators.
Date of issue March 2009
17
18
3.2.1 Both actual and potential risks should be considered together with interventions
aiming to reduce risk to the vulnerable person. Staff must establish the current risk to the
individual, staff and/or other people including children.
3.2.2 The vulnerable person could be the carer. Consider too that the challenging
behaviour of a vulnerable adult could lead to acts of abuse towards their carer, who is also
vulnerable within the definitions of "No Secrets".
3.3
Where there is concern that a crime has taken place the Service Manager must
ensure that the local multi agency policy and procedures are followed and the incident
reported to the police as appropriate. The Director of Nursing, Network Director and
Associate Director must be contacted and notified that the police have been contacted.
3.4
x
x
x
When allegations meet the criteria for referral laid down within local authority procedures
staff must inform Adult Social Services of concerns or allegations to initiate a multi agency
adult protection investigation
3.5
Other relevant policies and procedures that may need to be accessed as a result of
the incident are for example the LCFT:
x
x
x
x
x
3.6
The Trust has a duty of care to all its patients and a clear mandate to intervene
whenever care provided does not meet expected standards. If the abuse of a patient is
suspected by staff working within the Trust, staff are required to raise an adult protection
alert with their line manager, following the locally agreed multi agency Adult Protection
Procedures. However, there will be a presumption that other patients might also be at risk
or be likely to be affected.
3.6.1 Adult protection issues can also be identified through other LCFT Trusts structures
and must be raised where identified through:
Date of issue March 2009
19
x
x
x
3.6.2 All staff have a duty to raise concerns with their line manager through the above
processes if they are made aware of adult protection issues. The line managers should raise
this concern in the first place with the Network Director who will agree the level of
investigation in line with local and Trust policy and procedures.
3.7
x
x
N.B. Inform and support the patient/client on the appropriate actions and medical attention
required
Date of issue March 2009
20
3.10 If a vulnerable adult makes a disclosure, focus on what the person is saying. Do not
make comment other than to be sympathetic and reassuring. Do however allow the person
to speak freely and remember to make an accurate written record of the content of the
disclosure as soon as possible. Do not however attempt to interview the patient/client or
suggest words/phrases to describe what has occurred.
3.11 In cases of actual abuse the protection and preservation of evidence is critical to the
investigative process. Failure to secure evidence may result in a failed investigation and
lack of prosecution of an offender. Early reporting is therefore essential. Forensic
examinations in cases of suspected sexual abuse will be conducted by designated police
surgeons in accordance with local protocols as arranged by the police and subject of
appropriate consent. Either the patient/clients GP or hospital staff as necessary will
conduct examinations of suspected physical abuse.
3.12 When complaints about alleged abuse suggest that a criminal offence may have
been committed the Police must be informed immediately. Early referral or consultation
with the police will enable them to establish whether a criminal act has been committed.
Referral can be made either by the professional involved, the line manager or social
services. Referral of physical and sexual abuse should be to the local Public Protection
Unit (PPU).
A CRIMINAL INVESTIGATION BY THE POLICE TAKES PRIORITY OVER
ALL OTHER LINES OF ENQUIRY.
4.0
Alert
Alerting is the first stage in the safeguarding adult process. It is the responsibility of any
member of staff if they suspect abuse of an adult is likely or has taken place. It is a formal
process to raise a concern.
4.1
Staff must seek advice from the MDT, line manager as appropriate providing this
does not cause significant delay in referral.
4.2
Staff must arrange for emergency medical attention if required. For IMMEDIATE
medical treatment dial 999 for an ambulance.
4.3
Members of staff must, with immediate effect, inform an appropriate team or line
manager. Where appropriate, with the adults consent, you as an individual officer, or you're
team or line manager will make the Alert to the appropriate Adult Social Care Services or
the Emergency Duty Team (out of hours) including weekends and bank holidays.
Contact details :
Lancashire
0845-053-0028
www.lancashire.gov.uk/safeguardingadults
Date of issue March 2009
21
If the person is a vulnerable adult as defined within local Authority Policy and
Procedure
If abuse is likely to have taken place
The risk factors
To inform the vulnerable adult and carer of concerns
To gather views from the vulnerable adult and carer concerning the allegation of
abuse and what has happened
To make preliminary assessment of the mental capacity of the vulnerable adult
x
x
x
x
x
x
4.7
All those involved in the provision of care within LCFT are committed to providing
follow-up support to all service users who continue to require health needs.
4.8
Where English is not the first language of the adult concerned, and communication
is necessary for the purpose of safeguarding and promoting the adults welfare, the use of
an interpreter must be considered. If the use of an interpreter is dispensed with, the reason
for doing so must be recorded in the records.
4.9
Advice must be sought from staffs line manager or named social worker prior to
discussion with families and carers, however they should be informed of the incident
immediately, if it is agreed safe to do so. The partner/relative/carer of the alleged abused
person should only be informed if it is felt that such information will not place the
individual in increased danger, nor will it prejudice the investigation or in rare cases,
prompt a suicide.
4.10 It is important that service users are aware of procedures at all times, and that they
are enabled to express their own fears/concerns/points of view.
22
4.11 The alert will be communicated and forwarded to the locality Adult Social Care
Team Manager who will identify an investigating officer to gather information, consider
any immediate actions and have initial discussions with the alerter and partner agencies.
4.12 It is the decision of the investigating officer as to whether a referral to Safeguarding
Adult Procedures is made.
4.13 If it is suspected that a child/young person (under 18) may be at risk of harm then a
referral must be made in line with LSCB and LCFT Safeguarding and Protecting Children
Procedures.
5.0
The Investigation
6.0
Strategy Discussion/Meetings
The primary aim of the meeting is to discuss in a multi-disciplinary setting any information
which has come to light as a result of a referral, complaint, assessment, any other
information pertinent to the investigation or safeguarding arrangements, or any other
intervention, and amounts to an allegation of or suspicion of the abuse of a vulnerable
adult.
6.1
The Professionals attending the meeting will consider what, if any, response should
be provided by their respective agencies in the light of the reported/suspected abuse and
agree how any further actions, enquiries or investigations should be handled and by whom.
6.2
Establish facts
Establish if the incident amounts to a criminal act and warrants a criminal
investigation
Deal with any immediate risk(s)
Gather further information
Assess needs and what actions need to be undertaken to prevent the risk of further
abuse of the patient/vulnerable adult or others who might be vulnerable
Decide on what action is to be taken in respect of the alleged abuser
23
x
x
x
x
x
7.0
This is required to review the outcomes of the investigation, draw conclusions and develop
a Safeguarding Plan (please refer to Local Authority Safeguarding Adult Policy and
Procedures).
LCFT must attend as requested and provide a written report of their service involvement,
care, interventions and findings of their own investigation.
8.0
Action/Safeguarding Plans
Local procedures and protocols will make clear the agency responsibility for co-ordinating
the multi agency response to an adult protection concern, and all agencies retain their
statutory responsibilities.
8.1
Agencies assigned to undertake specific tasks within the agreed action/safeguarding
plan remain responsible for ensuring these are completed.
8.2
Any unachievable actions agreed within the action/safeguarding plan should be
communicated to the chair of the Professionals/Strategy meeting as a matter of urgency.
9.0
24
x
x
x
x
x
x
x
12.0 References
x
Blackburn with Darwen Inter Agency Policy and Procedures for the Protection of Vulnerable
Adults from Abuse (April 2004)
Blackpool Borough Council & Social Services, Blackpool Vulnerable Adults Committee
(2004), Code of Practice and Procedure
Date of issue March 2009
25
26
Appendix 2
Referral is taken by
Investigation starts
within 24 hours of the strategy meeting
Case Conference is convened
within 15 working days from the strategy meeting
Minutes and Protection Plan to be circulated
within 10 working days of conference
27
Appendix 3
NO
Respond Sensitively
YES
NO
28
Appendix 4
Blackpool Flowchart for Investigation of Safeguarding Adult Concerns
Alert :Refer to Social Services Direct tel (01253) 477592
Referral
Decision
Strategy Formulation
Review
Social Services - Who To Refer To
Situation
Refer to
29
APPENDIX 5
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
FEMALE
BODY MAP
SKIN MAP
30 of 33
APPENDIX 6
SKIN MAP
adult male
31 of 33
Department/Function
Safeguarding Adults
Person responsible
Contact details
01772 645790
Name of policy/procedure/service
to be assessed
Date of assessment
4 February 2009
Existing
32 of 33
Gender
Disability
Religion/belief
Sexual orientation
Age
33 of 33
CP 001
February 2009
February 2011
Executive Summary
Subject
Applicable to
Date Issued
Dates Policy reviewed
Next review due date
Policy written by
Consultation
Approved by
Authorised by
Signature
Related procedural documents
Executive Directors
Senior Management Team
Safeguarding Committee
Safeguarding Committee
Director of Nursing
The Public Health Advisor Children and Families/
named Nurse Child Protection will be responsible
for monitoring this procedure and will provide
assurance to Safeguarding Committee and EMT
Governance via quarterly and annual reports the
Risk Management Annual Report
Safeguarding Committee
Policy & Governance EMT
Patrick Sullivan
Director of Nursing
Working Together to Safeguard Children 2006,
Local Safeguarding Board Procedures, CP002
Policy for Safeguarding Young People Admitted to
Adult Wards, CP003 Policy on Children Visiting
Wards and Other Clinical Areas Within Lancashire
Care Trust Premises
CONTENTS
PAGE NO
1. Summary
2. Introduction
3. Definitions
4. Rationale
5. Scope
6. Principles
7. Duties
8. Confidentiality
13
9. Local Arrangements/Procedures
13
17
18
21
23
23
24
25
25
26
26
26
27
27
28
28
29
29
29
29
30
31
31. Support
31
32. Training
31
32
32
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix 10
Appendix 11
34
37
38
40
43
45
46
47
48
49
51
1.0 Summary
The purpose of these safeguarding children procedures is to enable the Trust to:
x
Provide a structured approach for all healthcare staff with regard to arrangements for
safeguarding children. Working Together to Safeguard Children A guide to interagency working to safeguard and promote the welfare of children (2006), sets out how
organisations and individuals should work together to safeguard and promote the
welfare of children.
Provide a mechanism that will allow audit of Child Protection compliance with
Section 11 of the Children Act (2004), national standards e.g. National Service
Framework (DfES 2004), Every Child Matters, (DOH 2003).
Provide necessary interventions for the child and family, an understanding of multidisciplinary partnerships and the systems that may be utilised to safeguard children.
2.0 Introduction
2.1 Lancashire Care Trust (LCFT) staff have a duty of care to safeguard and protect children
at risk of harm and neglect from the subsequent negative outcomes and enable all children to
reach their full potential. Every child has the right to be protected from potential significant
harm.
2.2 LCFT also takes into account the standards within the National Service Framework for
Children, young people and maternity services and reflects the requirements of Statutory
guidance on making arrangements to safeguard and promote the welfare of children under
section 11 of the Children Act 2004.
Section 11 of the Children Act 2004 states that NHS Trusts must make arrangements for
ensuring that its functions are discharged having regard to the need to safeguard and promote
the welfare of children.
The Children Act 1989 places specific duties on agencies to co-operate in the interests of
vulnerable children. The Children Act 1989 introduced the concept of significant harm as the
threshold that justifies compulsory intervention in family life in the best interest of the
children. Decisions about significant harm are complex.
2.3 The Department of Health (DOH) guidance listed below is issued under Section 7 of the
1970 Local Services Act, which means it is secondary legislation and therefore must be
complied with unless local circumstances indicate exceptional reasons, which could justify a
variation. It advises further involvement of Health Professionals by collaborating and
working together with Social Services.
These procedures are based on:
x The principles of the Children Act 1989 and 2004
x The UN Convention on the Rights of the Child
x The Human Rights Act 1998
x The Data Protection Act 1999
x The Adoption and Children Act 2002
x Local Safeguarding Childrens Boards guidance and procedures
2.4 These procedures apply to all children up to their 18th birthday, whether the children are
service users of the Trust in their own right, or children cared for by adults who are receiving
services from the Trust.
Children of Service users may be providing an active caring role and this must be considered
in assessing and providing interventions through Care Programme Approach Policy.
2.5 Staff working with adults with carers responsibilities for children are now clearly viewed
as part of the childrens workforce in terms of safeguarding. Local Safeguarding Children
Boards have been given statutory powers to ensure that agencies comply with this statutory
guidance
2.6 Each case should be informed by careful assessment of the childs circumstances and
discussions between the statutory agencies and with the child and family. Where the question
of whether harm suffered by a child is significant, their health or development shall be
compared with that which could reasonably be expected of a similar child.
3.0 Definitions
3.1 Safeguarding and promoting the welfare of children is defined for the purpose of these
procedures as:
The Adoption and Children Act 2002 broadens the definition of significant
harm to include the emotional harm suffered by those children who witness
domestic violence or are aware of domestic violence within the home
3.3 Neglect is the persistent failure to meet a childs basic physical and / or psychological
needs, likely to result in the serious impairment of the childs health or development. The
consequences of neglect can have a life long impact.
3.4 Safeguarding children and young people encompasses all aspects of child welfare an child
protection.
These procedures are intended to be followed by all staff employed and independently
contracted by Lancashire Care Trust (LCFT).
This policy is supplementary to and not a replacement for individual Local Safeguarding
Children Board procedures and must be read in conjunction with them. (Links to all the
LSCB procedures here)
It is not a replacement for one to one consultation, discussion, support or supervision with the
LCFT Safeguarding Team (Appendix 9)
Be healthy;
Stay safe;
Enjoy and achieve;
Make a positive contribution; and
Achieve economic well-being
4.3 The Common Assessment Framework (CAF) promotes more integrated multi-agency
working, where information is shared and service planning and delivery is coordinated, and
provided at an early stage to ensure the child meets the 5 outcomes from Every Child Matters
(see 2.1).
4.4 Information Sharing promotes multi-disciplinary and multi-agency working at an early
stage in order to identify and provide services to children in need of additional support before
their needs escalate.
4.5 Adult mental health services, including those providing general adult and community,
forensic, psychotherapy, alcohol and substance misuse and learning disability services, have a
responsibility in safeguarding children when they become aware of or identify a child at risk
of harm. This may be as a result of services direct work with those who may be mentally ill,
a parent, a parent-to-be, or a non-related abuser, or in response to a request for the
assessment of an adult perceived to represent a potential or actual risk to a child or
young person.
6.0 Principles
6.1 In the provision of services to all Trust service users, the Trust has a commitment to
deliver these services in a non-discriminatory manner.
6.2 No assumption can or should be made that people with mental health problems, those in
receipt of substance misuse services or those with a learning disability constitute a risk to
children simply by virtue of their difficulties.
6.3 Childrens needs are best met when parents are supported, but the needs of the child
remain paramount.
6.4 The Children Act 1989 established an unambiguous principle the Paramountcy Principle
that states that the welfare of the child is paramount.
6.5 Children have the right to be protected from harm and to receive services when their
health or development is at risk.
6.6 Service users should be made aware of the limitations of, and exceptions to
confidentiality in relation to child protection.
7.0 Duties
7.1 Each NHS Trust has to have a named Doctor and Nurse with appropriate Child Protection
expertise, to take a lead on Child Protection matters.
These roles and responsibilities are in line with Working Together to Safeguard Children
2006 They will take the professional lead within the Trust on safeguarding matters.
7.2 Chief Executive
The Chief Executive as the Accountable Officer has overall responsibility for ensuring the
implementation of an effective Safeguarding and Protecting Children Policy and Procedure
and meeting all statutory requirements. The Chief Executive delegates executive
responsibility to the Director of Nursing
7.3 Director of Nursing
The post holder is the lead director and holds the executive lead for the safeguarding and
protecting childrens agenda within LCFT and reports directly to the Chief Executive on
related issues. The post holder is a member of Lancashire Safeguarding Childrens Board.
The Director of Nursing is responsible for providing assurance to the Trust Board of
compliance with this procedure
7.4 Deputy Director of Nursing
The post holder directly line manages the LCFT Safeguarding Team and reports to the
Director Nursing.
7.5 Public Health Advisor Children and Families/Named Nurse Child Protection and
Safeguarding Practitioner
Their general responsibilities include:
Liaison and links with Designated Nurses and local Safeguarding Childrens
Boards
Development of safeguarding practice
Provision of safeguarding advice and support
Identification of safeguarding training needs and the co-ordination/provision
of appropriate training
Participation in single and multi-agency safeguarding training.
Initiating and facilitating the monitoring and audit of safeguarding practice
Facilitating advice on legal matters in conjunction with the Trust legal
advisors
Facilitating the provision of child protection clinical supervision to
practitioners as appropriate
The management of internal child protection/ safeguarding reviews relating to
child protection practice and contribute to multi-agency serious case reviews
when a child has died or been seriously injured and abuse or neglect is known
or suspected to be a factor
Close liaison with the management structures within LCFT and other agencies
to address both strategic and operational issues relating to the safeguarding
agenda
Close liaison with LCFT Safeguarding Teams in the PCTs and acute Trusts,
to address and implement local and national responsibilities and practice
10
The needs of these children in terms of parenting capacity, family and environment and
childs developmental needs must be considered and documented.
7.9.2 Requests for information regarding children in the families staff care for, must be
handled sensitively, in the context of the need to complete a holistic assessment to best
identify any risks, stressors and meet the needs of the service user in terms of appropriate
advice and support.
7.9.3 Those who have a role in working with these parents/carers must ensure that both the
expertise of adult mental health workers and childcare workers is used to inform any
assessment regarding the welfare of the children
7.9.4 All mental health/substance misuse services including forensic services have a role to
play in assessing the risk posed by adult perpetrators, and in the provision of treatment
services for perpetrators.
7.10 Safeguarding Champions
These are identified practitioners in teams who liaise and work closely with The
Safeguarding Team.
The role of the Safeguarding Champion is to support staff working with child welfare / child
protection issues in a planned, proactive process by: Appraising existing care plans to ensure safeguarding issues are included and
that they are sensitive to the current needs of the child and family
Clarifying roles and responsibilities of staff in line with LCFT and LSCB
procedures
Establishing that practice is compliant with national and local safeguarding
policies, procedures and guidance
Providing appropriate supervision and support, to enable safe and effective
practice
Promoting professional development, identifying with the practitioner, gaps in
knowledge and skills and directing staff into appropriate training
Ensuring that there is close communication with the Safeguarding Team/Line
managers, regarding safeguarding and protecting issues arising from practice
7.11 Trust Board
The Trust Board is responsible for:
x Ensuring robust systems and processes are in place for safeguarding children
x Receiving assurance of compliance with this procedure from EMT
Governance
7.12 EMT Governance
EMT Governance is responsible for:
x Receiving assurance of compliance with this procedure from the Safeguarding
Committee
x Providing assurance to the Trust Board of compliance with tis procedure via
the Director of Nursings Governance Report
11
12
Chief Executive
Medical
Director
Director of Nursing
Named Doctor
Designated /
Named
Professionals
within the
PCTs
(PCTs have
overarching
responsibility
for
Safeguarding
and Protecting
Children)
PHACF/Named Nurse
Child Protection
Safeguarding Practitioner
Managers/Snr Nurses
/Lead Professionals
Safeguarding
Champions
All Lancashire
Care Staff
13
9.2 If staff have concerns that a child is suffering or, is at risk of suffering abuse or neglect or
has suffered abuse or neglect a telephone referral must be made to Childrens Integrated
Services (CIS) in line with the LSCB procedures within one working day.
9.3 Any staff member who is involved in any case where there is child protection concerns
must follow the flow chart diagram in What to do if you are Worried a Child is Being
Abused outlined in Appendix 2 and follow the Local Safeguarding Children Board (LSCB)
14
procedures. Local flow charts are available on LCFT Safeguarding and Protecting Children
Intranet page.
9.4 Staff should consult their line manager or the Safeguarding Team unless to do so would
cause undue delay.
On making a referral to Childrens Integrated Services staff must routinely enquire if the
child or family is already known to the department or if the child/children are subject to a
child protection plan.
Staff must always send a copy of referrals made to the LCFT Safeguarding Team
9.5 When making enquires or consulting regarding a child welfare issue either in house or
external to the Trust, practitioners must clearly identify the name, role of the person consulted
with, whether this was in person or by telephone along with the time and date the
consultation took place. This information should be recorded in the service users records.
9.6 Staff must always follow LSCB procedures for a Child Protection referral. Telephone
referrals must be confirmed with a written referral within 2 working days
9.7 Staff must liaise appropriately with universal services involved with the family and
General Practitioner when concerns are identified and child protection referrals are made.
9.8 Where English is not the first language of the child concerned, and communication is
necessary for the purpose of safeguarding and promoting the childs welfare, the use of an
interpreter who is not a family member must be considered. If the use of an interpreter is
dispensed with, the reason for doing so must be recorded.
9.9 A chronology of significant events must be compiled (see appendix 7 and 8 for guidance
and form template)
9.10 Each Local Safeguarding Children Board(LSCB) have developed their individual levels
along the welfare continuum. Levels of need and risk may change in response to changes in
family circumstances, illness and lifestyles. Staff should be sensitive to those changes and
reassess risk as required. Within Lancashire the following definitions are used:
Most operate within four levels as defined nationally (Levels 1, 2, 3 & 4):
Level 1 Children and Young People whose needs are met by universal
services which every child/ family is offered i.e. midwife, health visitor, GP,
school nurse, school
Level 2 Children and Young People who are at risk of poor outcomes and
thus in need of extra support from services. This could be provided by a single
agency, but where multiagency working is required then the CAF process
should be initiated
Level 3 Children and Young people who meet the threshold for statutory
assessment and a multi agency response is required. (Section 17 of the
Children Act 1989)
Level 4 Children and Young People who are in need of protection and
require intensive support. Those at risk of significant harm or who have
suffered significant harm (Section 47 of the Children Act 1989). Other
15
16
x
x
9.12 Referring a child and family for family support (section 17) (level 3 see app 2)
9.13 When a member of staff has concerns about the welfare of a child, a request for other
services may be appropriate when they meet the threshold for statutory assessment and a
multi agency response is required
9.14 Referrals should only be made after discussion and with the consent of the family.
Families must be made aware that a referral constitutes consent for CIS to contact them to
facilitate the provision of services and enables CIS to make enquiries of other agencies.
9.15 To refer a family/child with needs, the appropriate referral form for the area should be
completed and attached completed risk assessment. All relevant information held by the
professional must be included on the form and forwarded to CIS.
All out of hours concerns regarding child protection should be referred to the local CIS out
of hours duty social work team in line with local procedures .
9.16 Referring a child and family for a Common Assessment Framework (CAF)
level 2
9.16.1 The Common Assessment Framework (CAF) is a key part of delivering frontline
services that are integrated and focused around the needs of children and young people. The
CAF is a standardised approach to conducting an assessment of a child's additional needs and
deciding how those needs should be met.
9.16.2 The CAF promotes more effective, earlier identification of additional needs. It is
intended to provide a simple process for a holistic assessment of a child's needs and strengths,
taking account of the role of parents, carers and environmental factors on their development.
9.16.3 Part of the process will be completion of the CAF form and liaison with local CAF coordinator. Please see LCFT Safeguarding and Protecting Children intranet site for flowcharts
and CAF contact details
9.16.4 Practitioners will be able to agree, with the child and family, about what support is
appropriate. The CAF will also promote co-ordinate service provision.
17
18
19
20
21
11.9.4 CIS have a statutory duty to make enquiries and they need the help from other
agencies to do this effectively. When approaching Health Professionals for information,
consent for disclosure of information would normally be sought.
11.9.5 In certain circumstances, disclosure is necessary in the interests of others. Adults who
pose a risk of harm to a child and children, who may be the subject of abuse, are included in
circumstances where information can be released, without the consent of the patient or client.
11.9.6 It is good practice to share information with the Health Visitor/School Nurse if a
service user has care of a child. Good practice would indicate the service users consent is
sought although there may be times that information is shared on a need to know basis to
exclude risk to children /young people.
22
If, however, any member disagrees with the conclusion of the conference he/she has a
responsibility to declare his/her dissent and reasons and ensure that dissent has been recorded
by reviewing the Minutes.
The date of the child protection review conference will be arranged.
12.1.6 Following a Child Protection Conference if the child is to have a child protection plan
a Core group will be formed. The procedure, roles and responsibilities for members of the
Core Group are detailed in Local Safeguarding Children Board procedures. Attendance at
Core Groups and subsequent Child Protection Reviews with a written report must be
prioritised.
A date and time for the first core group meeting will be agreed and should be within 7
working days of the conference.
12.1.7 Minutes will be sent to all conference attendees. If you consider the Minutes are not a
true record and corrections are necessary, inform the Child Protection Conference chair in
writing within one week of receipt of the Minutes.
The outcome of the Child Protection Conference must be documented in the appropriate
client records. Child Protection conference Minutes must be filed in the records. Where
electronic records are in use, minutes must be scanned and saved in line within line with
LCFT CL027A A Framework For Professional Clinical Record Keeping Standards and
CL027 Policy For Professional Clinical Record Keeping record keeping policy.
12.1.8 If any health practitioner is concerned that a person who may be attending a case
conference may pose an aggression, intimidation or violence risk to other conference
attendees the chairperson should be made aware, if possible prior to the conference. This will
enable the chairperson in their decision making as to whether the person exhibiting the risk
behaviour should be excluded. In the event of a conference member exhibiting violent or
aggressive behaviour during the conference that person be asked to leave the proceedings by
the chairperson.
12.1.9 Other Child Welfare Meetings
There are times that staff may wish to hold multi agency meetings to discuss and share
concerns and develop actions. These may fall below the threshold for Child Protection
Conferences e.g. Child in Need meetings and strategy meetings. The service user must be
informed of the meeting and outcomes.
12.1.9.1 Where the outcomes of a meeting are ,that it may be suspected a child may be
suffering or likely to suffer significant harm, an immediate referral must be made in line with
these procedures.
12.1.9.2 Attendance at meetings should be prioritised and should involve three basic steps:
A clear record of the discussion of the meeting should be completed and
circulated to all those present and all those with responsibility for an action
point
A list of action points should be drawn up, including time scale and person
responsible
A mechanism for reviewing completion of the agreed action must be specified.
The date upon which the first such review is to take place should be agreed
and documented
23
24
14.6 Any employee of LCFT may be in a position of trust in relation to a child, young person
or their family. It is illegal to abuse this position of trust. It is illegal for anyone in a position
of trust to groom or have a sexual relationship with a young person less than 18 yrs of age.
14.7 In line with LSCB Procedures a multi-disciplinary strategy meeting will be convened to
decide on the multi-agency response to the referral.
14.8 The police may also need to conduct criminal investigations. Internal investigations
should not compromise the criminal process. Advice should be sought via the Trusts legal
advisor and Human Resources.
14.9 In order to discharge the duties outlined in Working Together to Safeguard
Children 2006, any allegations or concerns about staff members must be reported to Human
Resources
The Local Authority, has an identified person known as the Local Authority Designated
Officer (LADO) who is central to conducting investigations and is required to make
judgements about a persons suitability to work with children.
14.10 In all cases of suspected professional abuse coming to the attention of managers the
LCFT Safeguarding Team must be contacted. The LCFT Safeguarding Team will work
collaboratively with the manager, human resources and the LADO ensuring that the
appropriate Local Safeguarding Children Board procedures and LCFT policy/procedures are
adhered to.
25
18.0 Service Users who are admitted under a Section of the Mental Health
Act 1983 and have carers responsibility for a child
18.1 If a service user needs to be sectioned under the Mental Health Act 1983 consideration
must always be given to any carers responsibilities that person has and appropriate measures
put in place regarding the safety and well being of the child. Consideration always needs to
be given to the safety of any children with the Approved Social Worker consulting and
liaising closely with childrens services within the local authority.
18.2 If the service user has a child the safeguarding team at the PCT should be informed so
that they can share the information with key staff. This information may be communicated in
some areas by the paediatric liaison team.
18.3 A childrens social worker may need to be involved in the planning and or
implementation stage of a section. If the service user to be sectioned is the sole carer for the
child and/or there is potential risk to the child, police presence must be considered when the
section is administered in line with Trust policy.
Arrangements between Approved Social Workers, Police and Child Care Social Workers
must be robust.
26
27
The calculation is based on the child being resident with the carers for a total of 28 days or more at any one time.
This means if the intention is for the child to stay with the carer for over 28 days but during this period they return to
have a break with their parents for a few days and return to the carers then this remains a private fostering
arrangement.
However if the child stays with carers on a regular basis for respite for a few days, even though over a year this might
accumulate to over 28 days this does not constitute private fostering.
(ref Surrey CC v Battersby 1965 1 AIIER 277.Cited in Hershman & McFarlan
28
23.2 Requests must be made via Line Manager or PHACF/Named Nurse for Safeguarding.
Staff member may be accompanied by Line Manager/PHACF/Named Nurse for Safeguarding
if required. Sight of the final report should be requested.
A written request for information is required, a verbal request is not acceptable. Relevant
information may be given either by a prepared written statement or by an interview for the
purpose of preparing a statement. Statements should be discussed with and seen by the LCFT
Safeguarding Team and the Trusts Legal Advisor prior to submission. If taken by interview
the named nurse/line manager or a nominated representative must be present. The statement
should be signed and dated and a copy kept with the records.
23.3 Sharing of information with the Police may be necessary in the childs best interests as
part of the Trusts legislative duty to co-operate. Advice must be sought prior to releasing any
information from the Trust Records Manager, LCFT Safeguarding Team, Line Manager, one
of which will accompany staff when being interviewed or giving statements. Statements must
be checked and signed by the practitioner on each page. The Trust record Manager and Line
Manager must be notified of any requests for records.
24.0 Statements for Legal Proceedings where there are child welfare issues
24.1 If a member of staff receives a request for a statement for court where there are child
welfare issues they should contact their manager and the LCFT Safeguarding Team Trust
who will advise and support the staff member.
29
notification form and forward it to the panel. This applies to children who are not in the area
at the time of death as well as those who die within Lancashire.
27.2 Some of the children reported to the panel will have died as an immediate or longer-term
consequence of abuse or neglect.
The CDOP panel will then decide whether the case meets the criteria for a Serious Case
Review.
where there has been subject to particularly serious sexual abuse, or their
parent has been murdered and a homicide review is being initiated,
where the child has been killed by a parent with a mental illness,
where the case gives rise to concerns about inter-agency working to protect
children from harm.
or
or
or
Establish whether there are lessons to be learned from the case about the way
in which local professionals and agencies work together to safeguard children
Identify clearly what those lessons are, how they will be acted upon, and what
is expected to change as a result and as a consequence
To improve inter-agency working and better safeguarding children
28.4 Immediately it is suspected that a case may become the subject of a serious case review
the LCFT Safeguarding Team will arrange to secure all records.
28.5 Cases not meeting the criteria for a Serious Case Review may be subject to an internal
management review if it is felt that lessons can be learnt regarding multi agency working
(Working Together to Safeguard Children 2006).
28.6 LCFT Safeguarding Team will:
Ensure all notes and files relating to child/family are secure.
Liaise with manager and consider the circumstances of the incident death and
decide whether it needs reporting in line with LCFT Serious Incident/Patient
Safety Incident Reporting and Management Procedure HS001
Compile LCFT chronology of service involvement with all relevant family
members
30
liaise with the the Designated Nurse/Doctor (PCT) who will compile the
composite health chronology and analysis and alert Chief Executives or
nominated representative within the involved health organisations of the need
for review of the case.
Liaise with the Trusts Legal Advisor
28.7 Review report (report from each discipline must be completed within the timescale set
by the LSCB serious case review panel)
Designated Nurse/Doctor, Named Nurse/Doctor for Safeguarding working with Service
Managers/Named Nurses will ensure each discipline carries out the following management
objectives:
Establish a factual chronology of all actions/interventions taken by
professionals involved with the child/ren family
Assess whether actions/interventions in the case areas are per Trust
policies/procedures
Analyse and identify any significant gaps in organisational systems, service
provision and or professional practice
Recommend appropriate action
31
For further information refer to the Procedure for supporting staff involved in traumatic /
stressful incidents complaints or claims
32.0 Training
In order to protect and safeguard children, all clinical staff need to have a basic awareness of
how to recognise, child in need/child protection issues, how to respond to their findings, and
how to refer to social services if necessary.
Safeguarding Children and Young People: Roles and Competences for Health Care Staff
April 2006 provides a recognised framework for all health care staff to meet the needs of
specific practitioners depending upon their particular role in relation to Safeguarding children
and Young People.
Training Levels
Staff groups will have different training needs to fulfil their duties, depending on their degree
of contact with vulnerable families, parents, children, young people and their level of
responsibility. (Safeguarding Children and Young People: Roles and Competences for Health
Care Staff April 2006) .Training for staff will be provided in accordance with the Trusts
Training Needs Analysis.
Attendance and non attendance will be monitored in accordance with LCFT statutory and
mandatory training procedure.
32
33.0 Implementation/compliance
33.1 Managers at all levels are responsible for ensuring that their staff are trained in the use
of these procedures and that staff are aware of the location of LCFT and LSCB Safeguarding
and protecting Children procedures and that this information is given to all new staff on
induction. They are also responsible for keeping staff up to date about any changes to these
procedures. All Safeguarding and Protecting Children Procedures are available on the Trust
Intranet.
33.2 The process for monitoring the effectiveness of these procedures and of the safeguarding
arrangements for children within the Trust will be by the Trust Safeguarding Committee.
34.0 Monitoring
34.1 The Trusts Safeguarding and Protecting Children procedures and measures will be
monitored through a number of means, which are outlined in the table below.
Standard
Duties
Review of reported
safeguarding incidents to
establish themes and trends
Preparation of an annual
safeguarding action plan that
includes actions arising from
corporate, national and local
safeguarding requirements and
developments
Timeframe/
Format
Annually via
the
Safeguarding
Annual Report
How
Whom
Review of a sample of
minutes of relevant
committees training
records, work plans,
objectives
Quarterly via
Quarterly reports
quarterly
Reported incidents and
reports to EMT SUIs regarding concerns
Governance
about a childs safety,
reviewed.
Annually
Training reports
Attendance lists
Training calendar
Training needs regularly
reviewed via evaluation
forms
Annually via
Review of Action Plan
the
Review of copies of
Safeguarding
referrals to Childrens
annual report
Integrated Services and
Annually
CAF activity
33
Public Health
Advisor
Children/Families
Public Health
Advisor
Children/Families
Public Health
Advisor
Children/Families
Public Health
Advisor
Children/Families
Local Safeguarding
arrangements are being
followed
Quarterly via
quarterly
reports to EMT
Governance
Public Health
Advisor
Children/Families
Supporting staff
Annually via
the
Safeguarding
Annual Report
Review of investigation
reports / feedback reports
form staff
Public Health
Advisor
Children/Families
36.0 Review
This procedure will be reviewed every 3 years or earlier if there is a change in legislation or
guidance.
References
34
www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenSe
rvices/ChildenServicesInformation/fs/en.
35
Appendix 1
A GUIDE TO MEETINGS HELD IN RELATION TO PROTECTING
AND SAFEGUARDING CHILDREN
Health professionals working with vulnerable children and their families involved with LCFT
will be invited to attend a variety of multi-agency meetings to share relevant information and
develop plans to safeguard children. These multi-agency meetings are the forum for agreeing
services for vulnerable children and their families and should be held at regular intervals to
review the risks the child is facing and the range of support services provided. Decisions to
commission new services or to withdraw services should be reported to the meetings. These
meetings should be formally recorded and the Minutes distributed to all those involved. All
health staff should record the action plan in the clients records immediately following any
multi-agency meeting they attend.
Practitioners attending meetings within the safeguarding and protecting childrens agenda
should fully participate in the multi-agency discussions which include constructively
challenging decisions that the professional does not consider to be in the best interest of the
child. Practitioners should be prepared to take responsibility in the management of the
meeting by supporting the chair.
Strategy discussion/meeting
The discussion or meeting takes place when there is reasonable cause to suspect that a child is
suffering or likely to suffer significant harm. It may take place by telephone (within 24 hours
of the initial assessment being completed) or by a meeting of all related professionals within
5 working days.
It is not usual for family members to take part in strategy discussions/meetings. Strategy
meetings are chaired by the team manager, or a senior social worker, from the Social Services
Department. The meeting will decide the intervention felt to be appropriate to an individual
family. The information shared at this time is crucial to the decision on whether a Section 47
enquiry (see 7.0) will be initiated, how the enquiries will be handled, what action is needed to
investigate and how best to protect the child/children. A report with a chronology of
significant events may be required.
Initial Safeguarding Conference
The conference brings together family members, the child where appropriate and
professionals involved with the child and family following the completion of Section 47
enquiries (where a child is considered to be at risk of significant harm). It is chaired by an
independent reviewing officer.
Its purpose is to collate information obtained about the childs health development and
functioning and the parents capacity to ensure the childs safety and promote his/her
health and development. From this, the conference will decide whether the child is at risk of
36
significant harm in the future and decide what action is needed to safeguard the child and
promote his/her welfare.
A multi-agency decision is made regarding the level of concern and the need to place/not to
place the child/childrens names on the Safeguarding Register and under what category of
abuse. A safeguarding plan is outlined and will usually involve health professionals. All
members of the meeting will be involved in this decision-making and planning process.
All initial safeguarding conferences should be attended. Where the practitioner is on leave, a
colleague should attend on their behalf. A written report is required. This report should be
shared with the family prior to the conference if possible. This is especially necessary if the
familys first language is not English and a translation via the interpreter service is required.
Core Group Meetings
These are held at monthly intervals in respect of children currently on the Safeguarding
Register. The first core group meetings should be arranged at the end of the initial
safeguarding conference and should be held within 7 working days of that conference. The
core group led by the Children and Family key worker (social services) is responsible for
developing and implementing the safeguarding plan as outlined at the safeguarding
conference. All practitioners involved in core groups should work in line with and therefore
be in receipt of the protection plan.
The relevant health professionals identified at the safeguarding conference should attend. A
written report is not required if the identified health professional is in attendance and can
contribute verbally. If the identified health representative cannot attend, a report must be
prepared and submitted to the key worker prior to the meeting. It is also advised that a
representative for the health professional attends the meeting.
Review Safeguarding Conference
Once a childs name is placed on the Safeguarding Register, a date for a first review
safeguarding conference is usually set for 3 months time. Subsequent review conferences will
always be planned, unless there has been a change in circumstances, in which case the
conference can be brought forward. Health professionals should attend all Review
Conferences. A written report is required. The report should be shared with the family prior
to the conference if possible.
Transfer in Safeguarding Conference
When a child on the Safeguarding Register moves to another area, the social services
department in the receiving area will convene a safeguarding conference within 14 working
days. The transfer conference will decide whether the registration in the new area will
continue. All practitioners should liaise will their colleagues in the receiving authority and
depending on the distance and/or circumstances, should either attend the conference or
provide a report detailing involvement to date. All liaison conversations should be
documented.
Family Support Meeting
This meeting is convened and chaired by the Named Social Worker following the completion
of the initial assessment. It should be attended by professionals and agencies involved with
the family, an agreed action plan to support the family should be formulated and individual
roles and responsibilities to meet the childs needs should be agreed. Family members are
invited to the meeting. Further family support meetings should take place approximately
every 2 months to evaluate the support package and monitor the progress of the action plan.
Invited health professionals should attend these important meetings. A written report is not
37
required if the relevant health professional attends the meeting and contributes verbally. If
they are not able to attend, a representative must attend in their place and a report must be
submitted. The agreed action plan must be recorded in the childs records by the health
representative immediately following the meeting. Staff should also ensure they receive a
copy of the Minutes of family support meetings to complete their records.
Initial Statutory Review (Looked after Children)
The meeting is arranged by the social worker and the review and protection chairperson as
soon as possible after a child is accommodated. All relevant agencies and the family
members are invited. The meeting is to clarify and consider a childs care plan whilst in the
care of the local authority. Invited practitioners should attend. A concise report on the childs
health and development, information on how the child has settled in the placement and any
observations on the interaction between the foster carers and child or parents and child should
be presented at the meeting. This report can be written or verbal depending on the individual
circumstances.
Statutory Review (Looked after Children)
A meeting to review the childs health/education/development and placement and ensure
needs are being met is held one month after the placement. Invited health professionals
should attend. Planned regular reviews are held thereafter or on demand if there is a change
of circumstances. A report as above is required.
Professional Abuse Strategy Meeting
This meeting is chaired by the independent reviewing officer from the Social Services
Department. Its purpose is to clarify whether any further enquiries are required in relation to
the safety and welfare of the children, any police investigation into a possible crime and the
employers disciplinary procedures, which may be invoked.
38
Appendix 2
What To Do
If you are worried a Child is Being Abused
Practitioner
Practioner refers
refersto
toSocial
Social
Services,
Services,following
following
upupininwriting
within
writing
48 within
hours 48 hours
39
Appendix 3
DRAFTING A STATEMENT FOR COURT: A STEP BY STEP GUIDE
Remember the following key points:
1. To write a successful statement you must be very clear about the kind of information, which is required.
You need to ask yourself a number of questions:
a.
b.
c.
d.
e.
2. All statements must firstly be prepared in draft form and discussed with your line manager/Child
Protection Nurse Specialist.
3. Legal advice from is available via the Trust Legal Advisor /Named Nurse Safeguarding and should
always be sought in preparation for writing a court report and prior to submission.
4. Think before you write anything down and refer to all your records.
5. Statements must be accurate and written in chronological order.
6. Write down the statement in English, using uncomplicated language. Be clear, comprehensive and
concise in your writing skills. Check your spelling and punctuation are correct.
7. Statements must be factual, that is based on what was said, what was heard, what was observed and
what was done. What was the result of your assessment? Ensure your assessment is within your own
professional limits. What were your concerns? Key events/incidents must be written up in full detail.
8. You may need to include headings and sub-headings to make your statement clearer, particularly if it is
a lengthy document. Dates and times of home visits/other contacts should be recorded with a brief
summary of what happened, what you observed on each occasion and your action plan.
9. Do not forget to record No access visits and the action you took following these.
10. Non-contentious entries in nursing records can be summarised by entries in the following style:
Between 1.9.92 and 10.10.93, home visits continued and no problems were identified.
11. Professional opinion and judgement is valued by the court; however they should be clearly
differentiated from fact.
12. Do not include unsubstantiated opinions or assumptions as facts. There is no room for hypothesis or
conjecture. (Barnes et al, 1989)
13. Try to make the statement as brief and concise as possible.
14. Be truthful.
15. Before signing the statement you should consider the content carefully and make any necessary
amendments.
16. Sign and date the final draft.
Date of Issue: March 2009
40
17. Keep a copy of the statement for your own reference this is very important.
18. Prior to submission ensure the Trust legal advisor and The Named Nurse For Safeguarding view the
report.
WRITING A STATEMENT FOR COURT: A SUGGESTED FORMAT
To:
Date:
From:
Name:
Designation:
Professional Qualifications:
My experience has been:
Work address:
Work telephone number:
Stages of the Statement
1. Introduction
I first became involved with the family/child (ren) in:
(Statements must be written in chronological order)
2. Main body of statement
The main body of the statement will be a series of dated paragraphs summarising the corresponding entry in
your records.
Give an account of the contacts and events in chronological order from your records.
Each section should have a date as the heading.
Statements must be factual. Opinion should be stated as such.
Each section must include what was observed, heard, your professional assessment and any actions taken.
Signature:
Date:
41
Appendix 4
THE COMMON ASSESSMENT FRAMEWORK
42
Health
Include growth and development as well as physical and mental well-being. Includes whether appropriate
health care has been accessed, i.e. immunisations, appropriate health assessments, hospital/GP/other medical
appointments including dental and optical care. Include centile charts, and Chronology of significant events.
Education
Include all significant issues relating to the childs cognitive development e.g. opportunities for play and
interaction, attendance at school.
Emotional and Behavioural development
Include the nature and quality of attachment to parents/carers, and the childs ability to adapt to change, his
response to stress etc.
Identity
Include the childs sense of himself as a separate and valued person (self-image and self-esteem). Include issues
relating to race, religion, age, gender, sexuality and disability.
Family and Social relationships
Include whether the child has a stable and affectionate relationship with parents, caregivers and siblings and
whether they have age appropriate friends.
Social Presentation
Include whether the child is dressed appropriately for their age, gender, culture and religion and discuss
cleanliness and personal hygiene.
Self-Care Skills
Include whether the child has developed age appropriate self care skills, if not, why not?
DIMENSIONS OF PARENTING CAPACITY
Are the parents/carers capable of meeting the childs basic needs including requirements for secure,
secure, stable and affectionate relationships?
Are the parents/carers ensuring the child is adequately protected from harm and setting appropriate
boundaries?
Are the parent/carers providing a sufficiently stable family environment?
Basic care
Include whether the childs basic needs are being met i.e. are they receiving appropriate medical and dental
care? Do they have adequate provision of food, drink, warmth, shelter and appropriate clothing.
Ensuring Safety
Include whether the child is being adequately protected from harm or danger e.g. are hazards and dangers in the
home recognised by parents, is the child protected from unsafe adults etc?
Emotional Warmth
Include whether the childs emotional needs are being met e.g. appropriate physical contact, comfort and
cuddling sufficient to demonstrate warm regard, praise and encouragement.
Stimulation
Include whether the childs cognitive development and potential is being stimulated through interaction,
communication, talking, play, attending school etc.
43
44
Appendix 5
NAME OF CLIENT:
SURNAME
FORENAME
D.O.B.
DATE.
ADDRESS
CHILDREN
SIBLINGS
MOTHER
FATHER/HUSBAND
CO-HABITEE
45
Venue
The use of the Framework for Assessment should be seen as a positive opportunity to identify and respond to any needs
of the children and family identified. It should identify the strengths as well as difficulties. You may only have limited
information under some of the headings e.g. Childs developmental needs - but when all the information is put together in
the format of the Framework for Assessment at case conference a fuller picture is available to aid the decision making
process.
The body of the report should include a health profile based on the Assessment Framework (DOH 2000).
x
Parenting Capacity
The Summary: should include an analysis of the issues of concern including the risk and protective issues. A conclusion
should be reached followed by your professional recommendations regarding future involvement, service provision and
anticipated outcomes. Evidence that may have informed your professional judgement may be indicated.
SIGNED DATE
SUPERVISOR / TEAM LEADER DATE.
Date of Issue: March 2009
46
APPENDIX 6
ASSESSMENT STAGE
47
WHAT TO DO
Principles:
Childrens whose parents/carers have severe and/or on-going mental health needs/ substance misuse problems will usually be children in need in their own right. As
part of the assessment Practitioners need to consider how the adults illness/problems impacts on their children or those children with whom they have regular contact.
By law, the welfare of the child is paramount this means that childrens needs always override those of the adult and that the welfare principle enshrined in the
Children Act 1989 takes precedence over the Mental Health Act 1983 in all events.
APPENDIX 7
Chronology Of Significant Events
A chronology lists in date order all the major changes and events in family, or a child
or young person's life.
It is seen as a trigger to enable a quick reference to the date and time in the records
where a full entry of events is recorded.
Using a Chronology
A chronology can be a useful way of gaining an overview of events in a family that
impacts on a child or a young person's life.
The chronology should be used by practitioners as an analytical tool to help them to
understand the impact, both immediate and cumulative, of events and changes in
clients lives which affect the child or young person's developmental progress.
The type of changes and events that should be included in a chronology would
include;
x Changes in the family composition, significant events and changes in the
circumstances of the child and family
x Change in address, GP.(School if client of school age)
x Changes in the child or young person's legal status within the family.
x Periods of hospitalisation or other significant medical treatment
and any injuries (accidental or non-accidental), hospital and A&E
attendances.
x History of any offences;
x Self harm, suicide attempts or overdose
x Multi agency meetings attended/ case conferences etc.
x Changes in the family, new births/deaths.
x Post natal depression, clinical assessment and liaison with Health Visitor.
x Non-compliance with health care/treatment/care plans. Missed appointments,
DNAs.
x Domestic abuse/violence incident.
x Social Incidents, homelessness, housing, financial problems.
The Chronology records all significant events and changes in the life of a service user
with parent/caring responsibility, a child or young person or those who pose a risk to
children and young people.
The Chronology is an analytical tool designed to help understand the impact, both
immediate and cumulative, of events and changes affecting the child/ young person. .
A Chronology can help structure information to inform analysis and decisionmaking.
It should draw on various sources of information.
48
DOB:___________________________
APPENDIX 8
06/8/2002
08/8/2002
17/8/2002
21/08/2002
COMMENTS / ACTION
SIGNATURE
49
N.B. Definition of significant harm: A compilation of significant events, both acute and long-standing, which interfere with a childs on-going
development, and interrupt, alter or impair physical or psychological development or affect parenting capacity
29/7/2002
Example of recording
OCCURRENCE / EVENT
AGE
14/7/2002
DATE
To include Accident and Emergency attendances, where known, injuries, accidents, self harm, known, GP contacts, complaints, missed appointments,
inappropriate minding, changes of address / school / carer, safety issues.
NAME OF CLIENT__________________________________
CHRONOLOGY OF SIGNIFICANT
APPENDIX 9
Olivia Guly
Consultant Psychiatrist
Named Doctor Safeguarding Children
olivia.guly@lancashirecare.nhs.uk
Sharon McDonagh
Administrator
Tel:01772 645794
Sharon.mcdonagh@lancashirecare.nhs.uk
statutory role, taking a professional lead on all aspects of the Trust contribution to safeguarding
children
promote good professional practice within the Trust, and provide advice , support and supervision for
staff
provide expertise in local arrangements for safeguarding and promoting the welfare of children
work closely with clinical governance to ensure safeguarding children is integral to the Trust
governance arrangements , monitoring and audit of quality
work closely with LCFT risk department and support staff in risk management issues pertinent to
children and young people
provide skilled professional involvement in child safeguarding processes, in line with LSCB
procedures, and in serious case reviews.
as part of serious case reviews ,review practice and learning
ensure and provide safeguarding training and strategy is in place and is
delivered .
contribute, develop and implement policies and procedures
If you have a concern regarding a childs welfare dont hesitate to contact the team
50
Tel:
(01995) 607624
Mobile: 07801 398778
Email: alice.marquis-carr@northlancs.nhs.uk
51
Alice Marquis-Carr
Named Nurse, Safeguarding and Vulnerable Childrens Team
North Lancashire PCT, Garstang Clinic, Kepple Lane
Garstang, Preston PR3 1PB
Tel:
Mobile: 07788 416457
Email: anne.kopcke@northlancs.nhs.uk
Tel:
(01253) 651265
Fax: (01253) 651258
Email: janet.edwards@blackpoolpct.nhs.uk
Tel:
(01253) 651262
Mobile: 0781 3108252
Fax: (01253) 651258
Email: cathie.turner@blackpoolpct.nhs.uk
Tel:
01772641471
Fax:
Email: liz.thompson@centrallancashire.nhs.uk
Tel:
(01695) 598113
Fax: (01695) 598163
Email: maria.coll@centrallancashire.nhs.uk
CONTACT DETAILS
Maria Coll
Named Nurse for Safeguarding and Protecting Children (West Lancs )
Central Lancashire PCT, Ormskirk and District Hospital , Wigan Road
Ormskirk L39 2AJ
Liz Thompson, Named Nurse
Central Lancashire PCT, The Willows, Peddar Lane, Preston
NAME
APPENDIX 10
Tel:
(01254) 263611
Mobile:
Email: kath.thomson@bwdpct.nhs.uk
Tel:
(01772) 645790
Mobile: 07507847567
Email: bridgett.welch@lancashirecare.nhs.uk
52
Tel:
(01772) 645794
Mobile: 07500 020312
Email: bridget.boyle@lancashirecare.nhs.uk
Tel:
(01254) 263611
Mobile:
Email:
Tel:
(01282) 699857
Mobile: 07976 878993
Email: melanie.hartley@eastlancspct.nhs.uk
Tel:
(01282) 699857
Mobile: 07976 878984
Email: jane.carwardine@eastlancspct.nhs.uk
Tel:
(01995) 607623
Mobile: 07795 445309
Email: janette.abbotts@northlancs.nhs.uk
Janette Abbotts
Named Nurse, Safeguarding and Vulnerable Childrens Team
North Lancashire PCT, Garstang Clinic, Kepple Lane
Garstang,, Preston PR3 1PB
Jane Carwardine
Bridgett Welch
Public Health Advisor Children
and Families/Named Nurse
Child Protection
Bridgett Welch
Public Health Advisor Children
and Families/Named Nurse
Child Protection
March 2009
Lead
person
March 2009
Timescale
N/A
N/A
Costs
53
All completed actions to be fed back to the Equality and Diversity Lead to inform the relevant equality and diversity working group.
Action
Appendix 11
Update
from meetings
Appendix 11
LANCASHIRE CARE TRUST
INITIAL EQUALITY IMPACT ASSESSMENT
Department/Function
Trustwide
Person responsible
Contact details
5 Fulwood Park
Caxton Road
Preston
Tel 01772 645790
bridgett.welch@lancashirecare.nhs.uk
Name of policy/procedure/service
to be assessed
Date of assessment
1/11/07
The Trust has procedures in place to ensure the safety and protection
of all children and Young People under the guiding principles within
the Children Act 1989 , Statutory guidance on making arrangements
to safeguard and promote the welfare of children under section 11 of
the Children Act 2004.and Working Together to Safeguard Children
2006.
Children, young people, parents/carers.
Local Safeguarding children,s Boards.
Childrens Social Care.
54
Women or men
Including trans people
People with disabilities or
long term health conditions
N
Y
55
The legislation , protection and provisions under the Children Act 1989
and 2004 apply to all children and young people across the country.
N No
Signature of assessors
Date of assessment10/10/08
56
In collaboration with
7889
Foreword
The workforce is key to opening up life opportunities for people who
experience social exclusion. In order to make inclusion a reality for people
using mental health services, the National Social Inclusion Programme (NSIP)
has worked with core mental health professionals to develop a set of
capabilities, capturing best practice in order to drive the transformation
of services and promote socially inclusive outcomes.
In producing these capabilities, NSIP have worked closely with the National
Institute for Mental Health in England (NIMHE) National Workforce Programme.
This has provided the necessary engagement of staff organisations and enabled
the work to link in a complementary way with the key workforce development
initiatives already underway. Through this collaboration, there is a need to
ensure that effective and positive change in the lives of those with whom
services work is secured and sustained.
These capabilities for socially inclusive practice are intended to be a resource
for reflection, challenge and practice change. Their purpose is to enable the
range of organisations and practitioners involved in mental health, whether as
commissioners, providers or educators, to make the values of recovery and
inclusion a reality. We hope this framework will support people, who use
services, to realise their aspirations as contributors to their communities,
advancing their choices, independence and participation.
David Morris
Programme Director for the
National Social Inclusion Programme
Roslyn Hope
Programme Director for the
National Workforce Programme
Contents
Foreword
Executive Summary
Introduction
12
16
19
23
27
30
33
36
39
41
References
44
Executive summary
The National Social Inclusion Programme (NSIP) has coordinated the delivery
of the action plan in the Social Exclusion Unit report Mental Health and
Social Exclusion (2004). This report showed that many people with mental
health problems experience exclusion and lack equal access to a range of
opportunities in society, including paid employment, volunteering, housing
and education. This is not only unjust but it lowers self esteem and self
confidence. However, improving opportunities for people with mental health
problems will enhance recovery, bring hope to people and their families, and
ultimately reduce dependence as people are enabled to contribute, in multiple
ways, to society and their community.
A key action in making this happen is the development of a workforce capable
of delivering inclusive opportunities to people using mental health services.
Working closely with the National Workforce Programme, NSIP has adapted
and developed The 10 Essential Shared Capabilities (ESC) which remains valid
as a framework for socially inclusive practice.
Consultation on the framework involved a representative from each of the
core professional groups in the mental health workforce nursing, occupational
therapy, psychiatry, psychology and social work. A reference group including
these professions discussed, reviewed and refined the work, supporting their
evolution as a set of inclusion capabilities. The capabilities which include both
organisational and individual dimensions, contain ideas for the ways in which
they might enhance practice and add value to service development and delivery.
To give the capabilities clear meaning and personal application to the people
delivering services the organisational capabilities are mapped to the core
and developmental standards of the Healthcare Commission as described in
Standards for Better Health (2007), and the individual capabilities are mapped
to the core dimensions of the Knowledge and Skills Framework (KSF) (2004).
Progress in changing practice is best made when people have the opportunity
to engage with issues and to contribute their ideas and energy to the formation
of a local response. These capabilities can be used by Universities and
training bodies, managers and supervisors, training leads, organisational leads,
professional bodies, commissioners and practitioners as a resource in that process.
Introduction
The Social Exclusion Unit (SEU) 2004 report Mental Health and Social Exclusion
showed that many people with mental health problems experience exclusion.
Frequently, they do not have equal access to a wide range of opportunities
in society, including paid employment and volunteering, housing, lifelong
learning, financial services, access to civil rights and social participation. This
exclusion may be compounded by other issues, such as gender or race. However
improving opportunities for people with mental health problems will enhance
recovery, bring hope to relatives and ultimately reduce dependence on the
State as people make a positive contribution to society, improve their social
networks, pay taxes and make less use of hospital and community services.
Since the SEU 2004 report was published the case for action has been
strengthened by further policy statements, including Improving the life
chances of disabled people (2005), the Disability Discrimination Act (2005)
and the 2006 White Paper Our health, our care, our say.
The SEU report included a 27-point action plan which is being coordinated by
the National Social Inclusion Programme (NSIP), a cross government team that
works nationally and regionally and has made significant progress. One of the
action points focuses on the need to develop a workforce that is fully competent
to deliver inclusive opportunities to people using mental health services.
The First Annual Report (2005) of the NSIP summarises the situation as follows:
Part of their contribution has been to provide a link into each professions
college, group or network, including the Royal College of Nursing and the
Mental Health Nurses Association, the College of Occupational Therapists,
the Royal College of Psychiatrists, the British Psychological Society, the Social
Care Institute for Excellence and the General Social Care Council. This reflects
the importance of promoting inclusive practice in the current workforce, and
to influence the training programmes for undergraduates, so that the future
workforce values and practices within a socially inclusive framework too.
Also key to this process is that the professional groups have been involved in
the national work underway to progress New Ways of Working-for Everyone
(Published by the National Workforce Programme in April 2007) to influence
the direction of the workforce of the future.
To develop the initial work each representative convened a reference group
from interested and expert members of their profession. Through a process
of consultation with these reference groups this initial work has evolved into
a set of social inclusion capabilities with both an organisational and individual
approach, with ideas of how they may enhance practice and add value to
service development and delivery.
Limitations
Inclusion work is subject to the following limiting factors:
The extent to which the wider community adopts inclusive values. This will
vary from one organisation or group to another and be influenced by the
resources, history and culture of that community as well as by its relationship
with the local mental health service, and should take account of other
excluded communities and groups, such as refugees and travellers. This
guidance focuses upon what mental health services can do, although much
of what they can do will be done in collaboration with community partners
and some responsibility for the success of inclusive endeavours will remain
within the community itself. A critical element will be socially inclusive
practices that promote and help to establish community cohesion.
4
Everyones job
The following framework shows quotations from The 10 Essential Shared
Capabilities that are particularly relevant to social inclusion followed by
the Capabilities of an Inclusive Organisation and the Capabilities of an
Inclusive Practitioner.
Every staff member will have duties in relation to the Capabilities of an Inclusive
Organisation as everyone is a contributor to the organisational culture and
goals. Most staff will have direct or indirect duties in relation to the Capabilities
of an Inclusive Practitioner, for example, through working directly with users
and carers, or supervising staff, or making organisational arrangements to
support delivery. Those who have greater seniority will increase the proportion
of organisational responsibility in their job role.
To try and give meaning to this work in relation to the actual delivery of
services the individual capabilities are mapped to the core KSF dimensions, and
the Healthcare Commissions core and developmental standards described in
Standards for Better Health.
This guidance describes a framework for mental health service communities
to work towards adopting. It is aimed at all professional and non-aligned staff
working across the full age range children, adults and older people, and so
reinforces the principle that the capabilities are for the whole of the mental
health workforce. It is hoped that everyone within and beyond mental health
services will rise to the challenge. One of the most significant challenges for
individuals is how they continue to develop their own emotional intelligence
and resilience when encountering a range of complex situations and relationship
dynamics that occur in dealing with people who have mental health issues,
for example working with those who have been subject to violence and abuse.
This is combined with working across organisational boundaries and systems
in a variety of different situations.
>
Guidance from their professional body about the match of seniority and
responsibility in relation to inclusion activities.
>
Aligning their personal values and ability to act ethically and with integrity.
>
This can provide the basis for a framework for practice. For coherent
and comprehensive change, socially inclusive practices should be part of the
contracting and commissioning arrangements at an individual, team and
organisation level. These should be considered in light of the local arrangements
between mental health and community organisations, between functional teams
within the mental health service, and between individual staff.
8
The framework has been assembled for professional and organisational groups
to use as a range of options for local selection and approval. People who use
services need an opportunity to contribute their insights. The voluntary and
community sector will have much to contribute alongside their colleagues in
statutory services.
Many of the organisational and individual capabilities described in this
framework are relevant to other groups at risk of exclusion, such as people
with learning or physical disabilities, older people, families at risk and black
and minority ethnic groups. Staff involved in these services or in cross-cutting
reviews may wish to utilise this work too.
Design job roles, task and job descriptions and select staff.
Supervise and appraise staff, and review supervision and appraisal frameworks.
Create and audit Care Plans (e.g. whether plans include inclusion goals).
In conjunction with the CCTA, undertake a skills audit, gap analysis and
in-service training and teambuilding programme for individuals and
staff teams.
Define support competence levels for each team, role and grade of staff
(perhaps through the Knowledge and Skills Framework).
Recognise, endorse and celebrate good practice at a national and local level.
Build a shared vision for the future of the organisation and its community.
Professional bodies
1 Adopt these capabilities as applicable to the whole of the mental
health workforce.
10
Show how their code of ethics and professional practice links with the
inclusion capabilities.
Commissioners
1 Specify what local services are commissioned (to include both inclusion
capabilities and inclusion outcomes).
2
Practitioners
1 Ensure socially inclusive interventions are built into personal and
team objectives.
2
Highlight good and emerging practice both within and beyond the team,
service and organisation.
11
ESC1 Working in
partnership
Develop and maintain constructive working relationships
with lay people and wider community networks.
We take community networks to include informal friendship
networks and formal community organisations that provide
access to valued roles in the community Job Centre Plus,
colleges, community associations and the voluntary sector etc.
This includes but reaches beyond mental health services and
other helping agencies. The terms networks, organisations
and agencies are used interchangeably.
Standards for better care
12
>
>
>
>
>
>
>
>
>
13
14
Service improvement
Everybody has a role in supporting the implementation of
new ways of working and implementing policies as well as
improving services.
Developing and sustaining partnerships will foster a culture
of mutual support and development ensuring resources for
service improvement are used creatively and the spectrum
of opportunities maximised.
Quality
Effective team working is an important aspect of
maintaining high quality practice. As a member of the
community network team, this relies on, amongst other
things, individuals presenting a positive impression of
their service, recognising, respecting and promoting the
different roles and diversity of services and raising quality
issues with partners.
15
>
>
>
>
>
16
>
>
>
>
Psychology
In Nottinghamshire Healthcare
NHS Trust, Bob Diamond
has been using his expertise
in Community Psychology to
arrange training on social
inclusion and support the
development of Community
Mental Health Teams through
monthly group supervision.
These discussions utilise
written summary information
on themes such as recovery,
inclusion and the Essential
Shared Capabilities to prompt
reflection on case studies
brought by group members.
For example, a recent
discussion explored how
a Care Coordinator might
work with a service user
who consistently rejected all
attempts to be included in
mainstream settings, preferring
instead to maintain his identity
as a mental health service
user and his social network
formed within the service.
Contact: Bob.diamond
@nottshc.nhs.uk
(continued overleaf)
17
Psychology (continued)
Service improvement
Applying, understanding and learning of diversity issues
by adapting ones own practice, and making constructive
suggestions as to how services can be changed to better
respect diversity, will inevitably lead to service improvement.
Quality
Contributing to a system which encourages participation
by all and relies on individuals assuming responsibility for
delivering high quality in all areas of practice.
ESC10 participate in
professional development
and reflective practice.
6
18
>
>
>
>
>
19
>
>
20
>
>
>
>
>
>
>
>
>
21
Service improvement
Practitioners have an individual and collective responsibility
to modernise service delivery.
Inspiring and working collectively with others will enable
strategy and direction to be taken forward into service
improvements.
Quality
Individuals will need to ensure they are clear about their
role in relation to the individual and in relation to others
involved in the individuals care, including those within the
individuals wider social network.
22
ESC4 Challenging
inequality
Recognise and understand the devastating effect that social
inequality and exclusion can have on the recovery process that
makes it difficult for service users to achieve their potential or
take their rightful place in society.
Challenge and address the causes and effects of stigma,
discrimination, inequality and exclusion upon service users,
carers and mental health services.
Create, develop and maintain valued social roles for people
in the communities they come from.
Capabilities of an inclusive organisation/service
> Recognise the processes and explanations within services
that may disempower and harm users and compensate
with empowering approaches. Service users gain a sense of
power and agency, including the opportunity to influence
the mental health organisation (by sitting on Local
Implementation Teams and other planning groups).
>
>
>
>
23
>
Create structures that support user involvement in decisionmaking, user-run services, and user directed care (such as
individualised funding).
>
>
>
>
24
>
>
>
>
>
Nursing
@leicspart.nhs.uk
(continued overleaf)
25
Nursing (continued)
Service improvement
The individual practitioner must assume personal
responsibility for improving service delivery, supporting
others effectively, as current practice is challenged and
changed, and should also proactively work with others to
overcome problems and tensions which might arise.
Quality
Practitioners will need to be sufficiently skilled in order to
manage or challenge quality issues which have resulted in
the service user experiencing stigmatisation, discrimination
or exclusion.
participate in mainstream
community settings.
ESC8 job roles clearly include
26
>
>
>
27
>
>
28
>
>
>
>
>
>
>
Service improvement
Acquiring a broad knowledge base of the range of
opportunities available in the community promotes choice
and empowerment for the service users. It is also the
responsibility of the practitioner to avail themselves to
colleagues, sharing information in order that all service
users accessing the service are fully appraised of available
opportunities and are not limited to an individuals
knowledge of local resources.
Quality
If the service user is to feel empowered and a qualitative
experience realised, individual practitioners will need to fully
engage with a service user on their journey of recovery,
appreciating the individuals strengths and aspirations
and will need to create/facilitate opportunities which
promote choice.
29
>
>
>
>
30
>
Social work
@devonptnrs.nhs.uk
(continued overleaf)
31
Capabilities for inclusive practice ESC6 Identifying peoples needs and strengths
Service improvement
There is an ever increasing body of literature which
addresses and promotes the recovery framework and
social inclusion. Individual practitioners will need to make
constructive suggestions, as a result of acquired and applied
learning in these areas and gathering feedback from those
using mental health services, in order that good practice
from elsewhere can lead to local service improvements
and developments.
Quality
Lack of involvement and shared decision making with
users of services leads to poor quality service delivery.
This essential shared capability demands that individual
practitioners not only work collaboratively with the service
user, rather that they equip the person to feel confident
in directing and defining their own care.
outcomes.
ESC10 promote social
32
>
Governance, D5a, D6
Patient focus, D8, D9a/b, D10
Accessible and responsive
care, C17, D11a/b/c
>
33
Capabilities for inclusive practice ESC7 Providing service user centred care
>
>
>
>
34
Service improvement
The greater the engagement of the practitioner with
community partners, especially those who do not
specifically provide services for mental health users, the
more successful promotion of inclusion and the broader
the spectrum of choice for the service user.
Quality
All practitioners must ensure rigorous evaluation of goals
and outcomes of the individuals care plan.
Individual practitioners will need the skills and be given
the support to identify ineffective quality systems
and approaches.
35
>
36
>
>
>
>
Psychiatry
@icc.wkent.mht.nhs.uk
This simple, everyday story
illustrates a number of inclusion
capabilities:
ESC1 Building on informal and
37
Service improvement
A systemic approach to the evaluation of services including
working collaboratively (such as participation on Steering
Groups, attendance at partnership meetings, working
closely with other agencies etc) will facilitate greater
cohesive service improvement.
Individuals must enable and encourage others to
understand and appreciate the influences of best practice
on the service and why improvements are made.
Quality
Individual practitioners will contribute to improving
quality of service provision by increasing their knowledge
and application of evidence-based interventions and
values-based practice.
38
>
Safety, C1a, D1
Governance, D6, D7
Care environment and
amenities, D12a/b
>
Capabilities for inclusive practice ESC9 Promoting safety and positive risk taking
Service improvement
As an effective team member, one must enable and
encourage others to alter their practice, to share achievements
(thus creating a work culture of optimism and hope) and
to challenge tradition.
Changing practice successfully relies heavily on working
increasingly closely with service users and the public.
Quality
It is important that the individual practitioner works
within the limits of their own competence and levels of
responsibility and accountability, referring issues beyond
these limits and consulting with other relevant people to
ensure opportunities are maximised safely for service users.
As an effective team member one can support and enable
others to problem solve and address issues.
40
ESC10 Personal
development and learning
Keeping up-to-date with changes in practice and participating
in life-long learning, personal and professional development
for ones self and colleagues through supervision, appraisal
and reflective practice.
In order to meet this capability practitioners will need a
personal/professional development plan that takes account
of their hopes and aspirations that is reviewed annually.
Capabilities of an inclusive organisation/service
> Support staff via work/life balance, mentoring and a
positive, encouraging culture to learn and solve problems
using imagination and creativity.
>
>
>
>
>
41
Occupational therapy
>
>
>
(continued opposite)
42
Service improvement
The experience of the service user will greatly improve if
they receive an individually tailored package of care. In
turn, being able to review and learn from the process will
improve the delivery of the broader service sharing with
colleagues can further enhance their practice.
Quality
Engaging with service users and their communities lends
itself to systems working, assists the bridging of gaps
between mental health and non mental health services
and facilitates a seamless approach.
@nelmht.nhs.uk
As a single project, Thinkarts
demonstrates the following
inclusion capabilities:
ESC5 promote opportunities
43
References
Material from other publications has been substantially re-ordered and
extended in this document, so references are not individually cited in the
body of the table, but sources are acknowledged here.
Bates, P. (ed) (2002) Working for Inclusion: Making social inclusion a reality for
people with severe mental health problems London: The Sainsbury Centre for
Mental Health
Department of Health (2007) Standards for Better Health London: DH
Department of Health (2007) Creating Capable Teams Approach (CCTA) London: DH
Department of Health (2007) New Ways of Working for Everyone London: DH
Department of Health (2006) Our health, our care, our say. London: DH
Department of Health (2004) NHS Knowledge and Skills Framework London: DH
Department of Health (2001) Mental Health Policy Implementation Guide
Department of Work and Pensions, Department of Health, Department for
Education and Skills and Office of the Deputy Prime Minister (2005) Improving
the life chances of disabled people London: Strategy Unit
Disability Discrimination Act 2005
Hope, R. (2004) The 10 Essential Shared Capabilities A framework for the
whole of the Mental Health Workforce London: Department of Health
National Social Inclusion Programme (2005) First Annual Report
National Social Inclusion Programme (2006) Second Annual Report
National Mental Health Partnership November (2006) Promoting gender equality
and womens mental health
Ridgway, P. and Press, A. subsequently edited for use in England by Allott, P.
and Higginson, P. (2004) Assessing the recovery-commitment of your mental
health service: A users guide for the Developing Recovery Enhancing Environments
Measure (DREEM) UK Version 1
Ritchie, P., Jones, C. and Broderick, L. (2003) Ways to Work Edinburgh, SHS Ltd
Social Exclusion Unit (2004) Mental Health and Social Exclusion London: Office
of the Deputy Prime Minister
VISION AND
PROGRESS
SOCIAL INCLUSION AND MENTAL HEALTH
2009
No challenge to exclusion can succeed without the full involvement of people with mental
health problems
A co-productive approach, working with people with experience of mental health problems, is essential at every level
of development and delivery.
A sense of personal identity, aside from ill health or disability, supports recovery
and inclusion
People with mental health problems are more than just a diagnosis and have valuable contributions to make,
not just needs to be met. Services should support people to access the opportunities available within the many
communities to which they belong and to make valued contributions as active citizens.
CONTENTS
FOREWORD
EXECUTIVE SUMMARY
INTRODUCTION
12
CHAPTER 2 EMPLOYMENT
17
20
CHAPTER 4 HOUSING
23
26
32
38
ANNEX A
40
ANNEX B
41
ANNEX C
ACKNOWLEDGEMENTS
FOREWORD
THIS REPORT SETS OUT THE WORK OF THE NATIONAL SOCIAL INCLUSION PROGRAMME
(NSIP) AT THE NATIONAL INSTITUTE FOR MENTAL HEALTH IN ENGLAND, FROM THE
INCEPTION OF THE PROGRAMME IN 2004 TO DATE.
NSIP has worked to implement and influence policy but with people at the centre. It has been
enormously fortunate in recruiting the willing and active participation of so many people with
passion, commitment, experience and skills from so many places and sectors over time.
Though simple in aim, thanks to the variety of systems through which we work and the richness
of the people for whom we work, inclusion is diverse in nature. In going about this work, it has
been important to resist reductionism; to reduce the complexity of individuals or the
interdependent nature of communities to a single element or objective, as part of the change
process, may achieve simplicity but it also risks an underestimation of the complexity of human
life. Our starting point was to recognise this and from it, build broad consensus of purpose. We
have tried to think and act outside the box, acknowledging the many accounts of people who
use mental health services that tell us the clinical or professional box is precisely the problem.
These narratives have continued to guide action on social inclusion throughout the programme.
We express thanks to everyone who, over the past four years, has helped us to advance our
goals. Though not surprised, we have been constantly impressed with the way people from
highly diverse backgrounds have so readily brought wide ranging experience from multiple
communities to bear, during the course of this work.
If that was our starting point, we must acknowledge that there is no finishing point. The challenge
is continuing to effect cultural change, through the transformation of thinking and services across
complex organisational boundaries. Whole person approaches demand whole system responses.
This is neither simple, nor short-term. Having been well informed by the many examples of strong
values-based practice that are incorporated in this report, we hope that we have made a good
start. We need to make sure that these often inspirational approaches are positioned to inspire
others. Locally and regionally this is an agenda that needs to be led for the long haul, ensuring
that progress is sustained and shared through innovation in learning and evidence in practice.
As an issue of social justice, inclusion in mental health remains a moral imperative. Though this is
work in progress for the wider inclusion community, the people who individually and collectively
have contributed to our work have set a compass for its achievement.
David Morris
Programme Director
EXECUTIVE SUMMARY
THE NATIONAL SOCIAL INCLUSION PROGRAMME
HAS ALWAYS SOUGHT TO ENSURE THAT THE SOCIAL
INCLUSION AGENDA FOR PEOPLE WITH MENTAL
HEALTH PROBLEMS TAKES ACCOUNT OF THE MANY
AREAS OF LIFE ON WHICH EXCLUSION IMPACTS.
2
In 2004, the Social Exclusion Units report set out what
needed to be done to address mental health and social
exclusion. This Vision and Progress report takes stock of
the progress we have made and addresses new and
future challenges in seven key areas.
COMMUNITY ENGAGEMENT
Social inclusion is not just about having access to
mainstream services but about active participation
in the community, as employees, students, volunteers,
teachers, carers, parents, advisors and residents.
We have:
Encouraged day services to be ambitious, to act not
just as a window on to mainstream communities but
as a bridge, whilst still providing a place for people to
feel safe and be mutually supportive.
Helped increase the number of people using
Direct Payments in lieu of mental health services,
resulting in more people now having greater choice
and control over the way in which they receive
services and support.
Highlighted the importance of adult mental health
services recognising peoples parenting roles and that
young people can be carers too. Joint working across
childrens and adults mental health services has
helped build the impetus to support joined-up
thinking and approaches at a national level.
Established the Communities of Influence
programme which enables Foundation Trusts
to engage and lead their governors and members
to build the community capacity needed to
strengthen socially inclusive outcomes for people
using their services.
EMPLOYMENT
Welfare systems can act as an enabler or be a barrier
to inclusion, and stress, depression and anxiety are the
cause of more lost working days than any other
work-related illness. Workplaces and employers should
support good mental health by providing an
accommodating environment and showing a positive
and enabling attitude. We have:
Helped to increase employment opportunities for
people with mental health problems. This includes
the publication of commissioning guidance on
vocational rehabilitation and feeding in to Reaching
Out: An Action Plan on Social Exclusion which
led to the establishing of nine Regional Employment
Teams (RETs).
3
Worked with Department of Health, Department for
Work and Pensions and Cabinet Office colleagues on
delivery plans for the Public Service Agreement (PSA)
16 and its implementation.
Increased support for employers, such as:
establishing and hosting of the Employer Engagement
Network; ensuring that the RET initiative increases
organisational capacity at a regional level to deliver
current strategies and support stakeholders.
HOUSING
Housing is central to providing a stable base from which
people can seek and make the most of socially inclusive
opportunities. We have:
Established the Housing Reference Group which
provides advice, and shares and coordinates
information on new policy developments.
Worked with the Department of Health, Communities
and Local Government and the Cabinet Office on the
development and implementation of the new Public
Service Agreement (PSA) 16.
INTRODUCTION
HAVING BEEN A SERVICE USER FOR 18 YEARS
I HAVE BEEN SOCIALLY EXCLUDED FROM SO MUCH
BY THE MERE FACT THAT I HAVE A MENTAL
ILLNESS. WHILST MANY OF THESE EXCLUSIONS
REMAIN, I HAVE BEEN EMPOWERED TO TRY
TO ENSURE THAT FURTHER EXCLUSIONS ARE NOT
PLACED UPON PEOPLE LIKE ME. 1
4
Vision and Progress: Social Inclusion and Mental Health
sets out the achievements of the National Social Inclusion
Programme (NSIP) since the 2004 Mental Health and
Social Exclusion report by the Social Exclusion Unit
(SEU).2 It recognises the commitment and hard work of the
team (past and present), its Expert Advisors and
Reference Group, as well as all those partner organisations
who have contributed to these achievements.
This report reviews the last four years in light of our
activity at national, regional and local level. It highlights
the progress that has been made across the statutory
and non-statutory sectors and highlights the additional
value of work beyond our formal remit; work that has
sought to reach out to non-traditional services and
partners to champion the social inclusion agenda in
sometimes unfamiliar areas.
It also provides an assessment of the remaining and
continuing challenges that need to be addressed for
improved outcomes for people with mental health
problems. This is based on feedback from national and
regional social inclusion leads across mental health
and health services, local authorities and regional bodies,
as well as information gathered through an analysis
of progress and gaps with provider organisations at a
local level.
This report is intended to be a further resource for
policy makers, regional agencies and services to ensure
that this important work is sustained and developed in
the future.
5
discrimination (and responsible for action points 1 4 in
the SEU report) by working in partnership on aspects of
the employment agenda, having co-terminus locations
and shared expert advice.
In 2006, the Cabinet Office invited NSIP to contribute to
the development of the Social Exclusion Action Plan 3
which led to our overseeing the creation of dedicated
regional employment teams (RETs) to provide further
support for the implementation of good practice on the
employment of people with severe mental health problems.
The programme has also worked with the Cabinet Office
in developing and implementing the Public Service
Agreement (PSA) 16 on employment and settled
accommodation outcomes for people with severe and
enduring mental health problems, supporting action to
ensure that the PSA drives change at local level.
CHAPTER 1
COMMUNITY ENGAGEMENT
VISION
People need to engage with the wide range of communities
that they rely on for their incomes, social support, selfexpression and sense of continuity; these include communities
of place (neighbourhoods), common interest, and the major
life domains such as employment, education and housing.
For this to be successful, services and opportunities
need to be accessible, well organised, stable and secure.
Our vision is that:
Everyone is supported to access the opportunities available
7
PROGRESS SINCE 2004
This chapter sets out the progress that has been made
in implementing and developing policies to reduce
disadvantage in the areas detailed below. It also set out
how the process of removing the barriers that inhibit
people with mental health problems from achieving a
stable base in life has been developed.
DAY SERVICES
Day services have played a valuable role for many people
with mental health problems. They provide a place
to go, people to see and something to do. However,
they have often not been successful at reaching a wide
range of people or enabling them to move on and
access resources beyond mental health services.
Many services, which have historically provided both
segregated activities and a safe social environment, are
now focused much more on supporting people to
engage with their local community and the resources
and activities within it. This means that the term day
services has become somewhat misleading as activities
may take place in the evenings as well as during the day,
and are often very different in nature from those that
people expect a day service to offer. Indeed many day
services have re-named themselves as community
support or community resource services in recognition
of their changed role.
NSIP has led the work on modernisation of day services
with the publication, in February 2006,5 of
commissioning guidance on day services for people with
mental health problems. It sets out the components that
a modernised day service could incorporate and
explained how commissioners could work towards them.
This guidance was linked to the Department of Health
publication Supporting Women into the Mainstream. 6
Eighteen months later a review of services 7 was carried
out to provide a snapshot of progress against the criteria
in the commissioning guidance. The review identified
where improvement had been made, highlighted
common issues and the approaches to addressing them
and provided examples of good practice.
Having more things in my life has given me the reason
to be more independent. 8
So far, the modernisation agenda has been primarily
focused on resources for providers and commissioners.
In response, NSIP produced How will my newly
redesigned day service help me? 9 a booklet specifically
for people using day services that are facing changes to
how they are run.
blueSCI
blueSCI, Trafford, is an arts and cultural centre that
addresses segregation by opening its doors to a range
of mainstream organisations and the general public.
Alongside blueSCIs reception sits a well-equipped
internet caf, which is open to everyone in the
local community to use. By arrangement, anyone can
also use the professionally equipped music studio
downstairs. The inclusive approach at blueSCI
extends to mainstream local organisations as well,
with several partners including Jobcentre Plus,
Trafford College and a local housing association.
In addition to this, a wide range of community
organisations regularly run sessions within the building.
www.bluesci.org.uk
However, challenges within the modernisation agenda
remain. Anxiety about change is common amongst
people who use services but it is also felt by day services
staff themselves and provider organisations. It can
sometimes be difficult for services to develop a more
appropriate balance of provision that involves both peer
support and support to engage with wider communities.
This is particularly challenging if commissioners and
providers are not assisted to achieve this goal. Many
have felt isolated and value contact with others who
have shared some of their experiences and from whom
they can learn.
9
roles as citizens) we developed and now maintain the
national mental health and personalisation group. NSIPs
employment, housing and personalisation policy leads
have worked with In Control as part of the broader
discussion on how best to achieve integration of work on
personalisation with that of inclusion.
Additionally, NSIP has played an important role in
reviewing the exclusion criteria for Direct Payments,
including those that relate to certain sections
under the Mental Health Act. This issue has recently
been consulted upon and the findings are due to be
published in 2009.
However, some challenges remain. The roll out of
Individual Budgets should take account of the lessons
learned from the implementation of Direct Payments for
people with mental health problems, otherwise the risk
is that their low take up will be repeated and people with
mental health problems will be further excluded.
The personalisation agenda should work to ensure
that support is available to enable people with mental
health problems to exercise more choice and experience
greater dignity.
PARENTS IN HOSPITAL
This review of contact arrangements between parents
in mental health settings and their children identifies
the need to improve visiting arrangements
and facilities, and the support offered to parents.
The findings draw on data from Mental Health Act
Commission visits, hospital staff and importantly,
parents and children themselves.
www.barnardos.org.uk
NSIP also contributed to the Cabinet Offices crossgovernment Families at Risk Review,20 which found that
families often do not get the most effective support when
they need it most and that when parents face a number
of difficulties in their own lives, such as mental health
problems, the impact for both themselves and for their
children can be severe and enduring.
You want your mum when shes ill, especially when
youre just a kid. 21
The experience of the Action 16 partnership shows us
that involving children, young people and their parents
who tell it like it is is crucial to understanding the needs
of families, identifying service improvement issues and
motivating and raising awareness amongst providers and
policy makers. The challenge to services is fundamentally
one of listening actively to the stories and experiences of
all family members including children and young people.
TRANSPORT
Without appropriate and accessible transport people
with mental health problems are at risk of being further
excluded from a range of community opportunities.
The early implementation phase of the SEU report 22 has
seen mental health included within the 2004 Department
for Transports Technical Guidance on Accessibility
Planning in Local Transport Plans. In response, Local
Transport Authorities (LTAs) included accessibility
strategies within their Local Transport Plans in March
2006. Regionally, good practice has been identified in
the West Midlands by the CENTRO authority area
(Birmingham, Solihull, Coventry, Walsall, Wolverhampton,
Sandwell and Dudley).
A review of concessionary travel has also been
undertaken by the Department for Transport resulting in
the Concessionary Bus Travel Act 2007 23 and
accompanying guidance.24 However, further work needs
to be carried out in relation to the review to ensure
greater consistency in embedding the eligibility criteria
CIVIC PARTICIPATION
Civic participation is key to enabling people to engage
within their own community. With Communities and
Local Government (and previously the Home Office)
identifying community engagement as a priority, it has
been essential to ensure that the policy development
process represents the needs of people who are on the
margins of active citizenship. NSIP worked with these
departments, the (then) Disability Rights Commission
and organisations such as RADAR to ensure the
inclusion of people otherwise excluded because of
discrimination from civic opportunities. As a result,
Together We Can, the government strategy on
community engagement now addresses the risk of
people with mental health problems being excluded from
local civic structures. NSIP has continued to influence
the preparatory processes behind the forthcoming
Community Empowerment Bill.
Following identification by the SEU of certain institutional
areas of civic participation from which people with
mental health problems were being systematically
excluded, such as jury service and school governance,
NSIP has worked with relevant agencies to pursue the
removal of constitutional barriers. This includes
contributing to the development of a consultation on jury
service eligibility criteria (publication expected 2009).
We have also seen the revision of school governance
regulations which clarify the disqualification criteria on
10
11
The project, running initially until April 2009, consists of
an action learning set, followed by a series of trustbased development activities to identify and share
innovative practice, tailored to each site. A final national
conference in April will review what has been achieved
and showcase how social inclusion and community
engagement plans are to be embedded into the Trusts
corporate goals.
CHAPTER 2
12
EMPLOYMENT
VISION
Everybody should be helped to be the best they can and those
who want, and are able, to work should receive the right support
to achieve their employment aspirations. Our vision is that:
Employers are supported to feel confident in recruiting
13
PROGRESS SINCE 2004
Work helped me to piece my life back together again. 28
Most people with mental health problems want to work 29
and with the right support, many more would be able to
achieve their employment aspirations. There is strong
evidence 30 to suggest that a job or another form of
occupation is highly effective in improving wellbeing
and social inclusion.
COMMISSIONING GUIDANCE
In response to the SEU report,31 NSIP has published
commissioning guidance on vocational services for
people with severe mental health problems.32 It highlights
how important being in work is in both maintaining good
mental health and promoting the recovery and wellbeing
of those who have experienced mental health problems.
The guidance provides a framework on how to
commission evidence-based vocational services and
highlights tools for monitoring the effectiveness of such
services. It also includes methods that successfully
address the employment needs of people with severe
mental health problems, one of which is the Individual
Placement and Support (IPS) model.
CHAPTER 2 EMPLOYMENT
aspect of this effort has entailed working with localities to
improve employment outcomes with a particular focus
on supporting the mental health employment target in
PSA 16. To date, this has been effectively achieved;
improved practice being promoted by more effective
joined-up working between partners.
RETs have also supported local authorities to do more to
advance employment opportunities for people with
mental health problems with a particular emphasis on
those districts that have adopted National Indicator 150.
Activities undertaken by the regional partnerships
include:
Working strategically within partnerships to raise
awareness of the need to deliver holistic services.
Building capacity in health systems to deliver
increased employment opportunities.
Supporting and promoting activity that allows
individuals to increase capacity for obtaining and
retaining employment, such as the development of
structured volunteering arrangements.
Working to reduce stigma and discrimination,
especially in the workplace setting, such as
supporting the expansion of Mindful Employer 39 and
Shifts Line Managers web resource.40
Promoting activity aimed at maintaining a mentally
healthy workforce. This includes supporting the
increase in people being trained on Mental Health
First Aid 41 and supporting the expansion of
recommended frameworks such as the Health and
Safety Executive Stress Management standards.42
In addition to exploring links between national policies
and regional and local actions to overcome barriers, the
RETs have also looked at how best to influence existing
and developing policies and strategies, such as the City
Strategy Initiative,43 the roll out of Pathways to Work and
Increasing Access to Psychological Therapies.44
EMPLOYERS
A successful return to work following an episode of
mental illness is possible, but it has to be managed well
long-term recovery is not an accident. Good employers
will take return to work practice seriously and
encourage a staged and supportive even protected
return to work. Part-time work, for a time can be a
wonderful investment for long-term good health. 45
In addition to our high level strategic work on
employment, we have also been working closely to
14
support employers and raise awareness and
understanding of mental health in the workplace by
developing and delivering, for example, a training
package for trade union representatives. We have
established an Employer Engagement Network to share
thinking and best practice on how to support employers
in the employment and retention of people with mental
health problems. The network has a membership of
more than 60 organisations including a range of
government departments, practitioners and academics.
One output has been that of hosted workshops on key
and developing policy issues such as how best to adapt
and make the Access to Work programme more flexible
to help many more people with a mental health problem
to remain at work.
ROYAL MAIL
The Royal Mail is the UKs second largest employer
after the NHS. NSIP is working in partnership with
Royal Mail to promote the employment opportunities
of people with mental health problems, to support
health-promoting initiatives within the workplace and
in challenging discrimination.
TRAINING
Ensuring that frontline staff are appropriately trained is
fundamental to improving employment opportunities for
people with mental health problems. NSIP has worked
with a wide range of stakeholders to develop a mental
health awareness training package for trade union
representatives. The training package was piloted during
2007/08, and was followed by the delivery of training
events across several regions. The training has been
embraced by a wide range of unions, including Unite,
Public and Commercial Services (PCS), Prospect and
Unison and has been delivered to more than
100 representatives.
NSIP has also met with Jobcentre Plus on how to
improve the quality of their customer service and
15
employment support that people with mental health
problems receive. This led to us working with Jobcentre
Plus training experts to develop a training module on
mental health and employment awareness, which has
now been formally adopted. We are also working to
finalise a training product for engaging and working with
employers on mental health problems.
BENEFITS DOWN-RATING
In 2004, building on a lengthy existing campaign by
Derbyshire Patients Council and Mind, we worked
with ministers and senior officials to highlight issues
concerning the impact of benefit down-rating for
people with long-term hospital stays. This resulted in
the end of down-rating, securing improvements in
the lives of 21,000 people, to the value of 60 million.
REMAINING CHALLENGES
Over the last few years there has been an increasing
amount of health, employment and wider support
available to employers and people with disabilities, but
despite an overall improvement in the disability
CHAPTER 2 EMPLOYMENT
The need to deliver holistic support is even more critical
in the current economic downturn when the number of
people experiencing poor mental health is likely to
increase and when more people may become at risk of
long-term unemployment. The challenge will be to
demonstrate how the national mental health and
employment strategy will help change attitudes,
assist the development of an evidence base and
promote the creation of a comprehensive range of
mainstream and specialised information and support
which assists access to, and retention of, good
employment opportunities.
16
28 Department of Health, 2006, Action on Stigma: promoting mental health, ending
discrimination at work.
29 Within the Patient Survey (Healthcare Commission, 2005), 52% of respondents said
they had not received any help with finding work but would have liked it.
30 W Anthony, A Howell and KS Danley, Vocational Rehabilitation of the Psychiatrically
Disabled in M Mirabi (ed.), The Chronically Mentally ill: Research and Services,
(Jamaica/New York, Spectrum Publications, 1084); G Shepherd, The Value of Work
in the 1980s, Psychiatric Bulletin, 13 (1989): 231233.
31 Social Exclusion Unit, op. cit., 2004.
32 Department of Health/NSIP, 2006, Vocational services for people with severe
mental health problems: Commissioning guidance.
33 NSIP, 2008, Finding and Keeping Work.
www.socialinclusion.org.uk/publications/Toward_a_MH_employment_strategy_
revsied_after%20repairs.pdf
34 The national indicators are the means of measuring national priorities that have
been agreed by government.
35 Dame Carol Black, 2008, Review of the health of Britains working age population.
Working for a healthier tomorrow.
36 For the announcement of the development of the national mental health and
employment strategy see:
www.dwp.gov.uk/mediacentre/pressreleases/2007/nov/drc057-271107.asp
37 Cabinet Office, op. cit., 2006.
38 Action 23 reads Building on current guidance and legislation, the Government will
develop dedicated regional teams to provide further support for the implementation
of good practice around employment of those with severe mental health problems.
39 The Mindful Employer initiative is aimed at increasing awareness of mental
health at work and providing support for businesses in recruiting and retaining staff.
See website www.mindfulemployer.net/
40 See Shifts line managers web resource site: www.shift.org.uk/employers/
41 www.mentalhealthfirstaid.csip.org.uk/
42 See the Health and Safety Executive stress website: www.hse.gov.uk/stress/index.htm
43 See Department for Work and Pensions announcement:
www.dwp.gov.uk/welfarereform/cities_strategy.asp
44 For information on Increasing Access to Psychological Therapies see:
www.iapt.nhs.uk/
45 Department of Health, op. cit., 2006
CHAPTER 3
17
VISION
People with mental health problems, by accessing learning and
skills provision, should be able to lead active and fulfilling lives
as part of their communities and in employment, in a way that
sustains mental wellbeing. Our vision is that:
Learners with mental health problems have equal access
PARTNERSHIP PROGRAMME
A Partnership Programme between NSIP, the National
Institute of Adult Continuing Education (NIACE) and the
18
19
FAST TRACK SCHEME
In Portsmouth, the PCTs Early Intervention Team
secured funding from the LSC and developed a
partnership with local colleges for a fast track
scheme for clients into Further Education with some
excellent outcomes, such as Back on Track, a
project tailored to meet the vocational needs of young
people with mental health problems.
COLLABORATIVE WORKING
We have undertaken a range of projects, including the Is
it for me? initiative, which is described in more detail in
chapter 1. We have also encouraged better collaborative
working between Early Intervention in Psychosis Services
and Child and Adolescent Mental Health Services to
ensure that young people experiencing mental health
problems are supported to remain in education, training
and employment.
All of the work we carry out at national and regional
level is informed by a co-productive process of sustained
dialogue between policy makers, practitioners
and learners. Through the dissemination of information
and the sharing of good practice, policy informs
practice but the voice of the practitioner and the learner
clearly informs policy across government and sectors.
REMAINING CHALLENGES
The continued drive within the Further Education
system towards targets on the number of learners
achieving qualifications of level 2 and above has led to
a loss of the non-accredited and lower level courses in
the sector that have often been the first step into
learning for many people with mental health
problems. Funding for adult education has also been
increasingly directed towards work-based learning,
yet low take up of these opportunities by people with
mental health problems continues to be problematic.
The end of the LSC in 2010 as the primary funder of this
programme of work and the establishment of two new
agencies to take its place presents many challenges in
ensuring the continuation of the work of the Partnership
Programme.
CHAPTER 4
20
HOUSING
VISION
Stable and appropriate housing is important if people with
mental health problems are to work and take part in
community life. Being able to live independently is equally
important to creating a socially inclusive community.
Our vision is that:
People with mental health problems have a place to live that
reduced.
Commissioning of services meet peoples needs in a holistic
21
PROGRESS SINCE 2004
We need our independence and we want support only
when we need it, but we still want to be safe and secure. 52
Since the SEU report,53 NSIP has coordinated
implementation of the action points on rent arrears
management to reduce non-payment and evictions,
leading to the publication of Improving the effectiveness
of rent arrears management,54 and local authority
allocations schemes which resulted in Implementing and
Developing Choice Based Lettings: A guide to key issues.55
Following on from these, we produced mental healthspecific briefing documents for housing, health and
social care staff on rent arrears management 56 and
Choice Based Lettings 57 to encourage better joint
working between services and increase support for
people with mental health problems to improve their
housing situation. This has helped prevent evictions and
improve opportunities to achieve independent living.
NSIP has also coordinated the SEU reports actions on
homelessness. This includes the revision of the Code of
Guidance for local authorities which set out revised
definitions of those in priority need of housing.58 We also
worked with the NIMHE/CSIP regional development
centres on a series of events to engage staff and people
using local homelessness services in the research
process to inform the development of Getting Through:
Access to mental health services for people who are
homeless or living in temporary or insecure
accommodation: A good practice guide.59
To help drive progress forward, NSIP has brought
together key government departments, housing
agencies and stakeholders into a national Housing
Reference Group. The groups role has shifted on from
advising on the production of guidance documents to
becoming a flexible resource, consulting and
disseminating information on new policy and emerging
practice. As a result, we have been able to respond
rapidly to and advise on any new housing and mental
health developments or initiatives.
NSIP is committed to ensuring that people with mental
health problems using housing services are listened to
when developing local and national policy. For example,
we have coordinated a series of consultation events,
working on behalf of, and across health policy areas to
gather the views of the wide range of people using
services funded by the Supporting People programme,
including people with mental health problems, and to
feed them into the development of the Supporting
People national strategy.60
CHAPTER 4 HOUSING
also on wider social inclusion issues. We have since
worked with the Cabinet Office, Communities and Local
Government and the Department of Health to secure
agreement on the approach to PSA implementation and
continue to provide high level input to the regional roll
out. This has been done by raising awareness and
securing engagement with regional Government Offices
and the Cabinet Office. The NSIP Reference Group
(consisting of people with mental health problems and
carers) has also made an invaluable contribution to the
PSA development and delivery process. Chapter 6
explains the role of the Reference Group in more detail.
REMAINING CHALLENGES
Although considerable progress has been made, we
have identified a number of potential challenges that will
need to be addressed. The SEU report called for
mainstreaming of mental health awareness training for
all housing staff but this has still not been achieved.
We would recommend that all new and existing staff
receive mental health awareness training to enable them
to respond to people in a supportive and flexible way.
Improved communications are often needed between
those working in housing and mental health services to
help support people with severe and enduring mental
health problems with independent living. However, PSA
16 should raise awareness of the need for cooperation
and local performance framework structures, especially
the Joint Strategic Needs Assessment, to identify unmet
need and less effective coordination of services.
Both the PSA and the CPA guidance stress the need for
effective and proactive work with those in secondary
care who are, or who become, homeless. Yet there is
also work to be done on how to meet the mental health
needs of homeless people who are not in contact with
secondary mental health care. Here, new approaches
may be needed, and Practice-Based Commissioning via
primary care could be equally or more suitable.
Greater pooling of resources at a local level will help
make sure that services respond flexibly to the needs of
their local communities and the development of shared
local priorities. However the removal of the ring fence
for the Supporting People grant presents risks to
local services and commissioning, such as resulting in
funding being diverted away from providing much
needed supported housing for people with mental
health problems.
22
and Communities Agency and the Tenant Services
Authority could bring a risk of the loss of the
commitment to housing for the most at risk groups.
Certain challenges remain which may act as barriers to
the inclusion of people with mental health problems in
mainstream communities. For example most people with
mental health problems live in their own homes, but
those with higher support needs may still be
inappropriately living in residential care. Similarly, a lack of
suitable move-on accommodation can result in extended
stays in hospital. Also people with mental health
problems report that they are likely to be allocated less
desirable properties and neighbourhoods, than the
general population.
With greater local accountability for all services, including
social housing, it is important that people with mental
health problems and carers, and mental health services
engage in these local debates on the housing that
people need.
CHAPTER 5
23
VISION
Arts, cultural engagement and community participation are
fundamental to the development of socially inclusive society.
People with mental health problems should have access to the
same diverse range of arts and cultural activity as others in
the places where they live. Our vision is that:
The role that arts and culture play in improving wellbeing, health
24
25
NSIP has carried out a review of regional and local arts in
health programmes in order to develop and build
regionally focused networks. These bring together NSIP
social inclusion leads, service improvement leads, arts
practitioners, voluntary and community arts
organisations, academic institutions and arts council
regional leads and links these to a pan-European
network of arts, inclusion and wellbeing in practice.
REMAINING CHALLENGES
There is a risk that arts and culture activity is not given
enough attention within a landscape of public service
agreements and local area agreements. Projects are
often funded for time-limited periods, which can make
evaluation and continuity difficult.
CHAPTER 6
26
LEADERSHIP AND
WORKFORCE
DEVELOPMENT
VISION
Strong leadership and a skilled, effective workforce are both
essential in setting the direction that makes a positive
difference to the lives of people with mental health problems.
Our vision is that:
Commissioning for socially inclusive outcomes drives the
service delivery.
Social Inclusion is an integral part of professional
27
PROGRESS SINCE 2004
ii
COMMISSIONING NETWORK
NSIP has contributed to a number of regional initiatives
aimed at supporting commissioners. In response to
demand from mental health commissioners, and
particularly those with joint commissioning
responsibilities, we established a commissioning
network for social inclusion in early 2008. As well as the
network meetings with workshops held in London and
the East Midlands, a considerable amount of activity is
self-generated by commissioners, who share ideas and
requests with each other. There have been continued
close links with the day services programme and
network members have requested the production of
broader socially inclusive outcomes guidance for
commissioners and providers,72 adapted from the day
services framework.73 This network is ready for
development and will need to find a new host in 2009.
NSIP has supported the embedding of inclusive
outcomes into World Class Commissioning which
needs to be delivered within a social as well as clinical
framework, and which will be a key driver for delivery
organisations. If commissioning is to add years to life
and life to years 74 then socially inclusive outcomes will
need to be pivotal in shaping this agenda. Whilst the
statutory responsibility for implementing the social
inclusion agenda lies with local authorities and
PCTs, it has often been mental health services that
have championed action, with many appointing social
inclusion leads and staff. Partnerships between
all the local players, including third sector organisations,
are essential.
29
ACADEMIC AFFILIATES
The Collaborative Academic Network is a co-designed
learning network, led and coordinated by the
University of Central Lancashire (UCLan). Its members
work together to advance practical and relevant
commissioned research and developmental work on
social inclusion in mental health and to facilitate the
spread of inclusive learning into practice and evidence.
The networks key tasks are to:
Collaborate to clarify a set of metrics that can be used
by commissioners and regulators to assess the
effectiveness of mental health social inclusion work at
a local level.
Develop a community of practitioners and researchers
who actively link research into practice and vice versa,
in order to enhance social inclusion in mental health.
Develop and disseminate evidence-based practice to
inform every level of the mental health system.
Many members of the Academic Network were formerly
part of NSIPs earlier Research and Evidence Coalition.
This coordinated and supported a range of research
initiatives on inclusion and mental health, some of which
attracted significant funding and profile both nationally
and internationally.75 For more information please see
Annex A.
In 2007/08, NSIP produced a data report for each of the
regional employment teams (RETs). The reports drew on
existing national data sources, as far as possible
breaking down data to a local level and exploring trends
over a three-year period (20052007) in relation to
employment, benefits and education issues for people
with severe mental health problems. The reports
provided each team with information and analysis they
could use as a starting point in discussions with service
providers, commissioners and other partners to inform
the targeting of their interventions. Background
information was included on the data sources, including
commentary on the data quality and any limitations of
the data sets.
Ongoing challenges in relation to this work are:
Variations between data sources in their definition and
classification of mental health problems, in the
populations they cover and the frequency of data
collection.
The extent to which national data can be reliably
disaggregated to provide locally relevant information.
PROFESSIONAL NETWORKS
Workforces need to have the right professional and
leadership skills if they are to reflect the emerging
demands of delivering socially inclusive practice. NSIP
has supported putting strategic and professional level
structures in place to ensure that appropriate
development takes place and that frontline workers get
the right support at the right time.
The SEU report 76 referenced the barrier to inclusion
constituted by low expectations and negative
assumptions by frontline staff about the capabilities of
people with mental health problems. In order to challenge
these perceptions and improve the experience of people
using services, NSIP commissioned the identification of
socially inclusive ways of working, using the framework of
the The 10 Essential Shared Capabilities (ESCs) 77 to
allow staff to reflect on their practice.
The Royal College of Nursing (RCN), the College of
Occupational Therapists (COT), the British Psychological
Society (BPS), the Royal College of Psychiatrists (RCP)
and the Social Care Institute for Excellence (SCIE) fielded
representatives to a working group which led to the
publication of the Capabilities for Inclusive Practice.78
This provided a mapping of individual capabilities to the
Knowledge and Skills Framework 79 and organisational
capabilities as described by the Healthcare Commission
in Standards for Better Health.80 The professional
bodies have continued to show strong commitment to
the social inclusion agenda. Good practice examples
include:
Publication by the BPS of Socially Inclusive
Practice 81 and supporting the secondment of a
clinical psychologist into the NSIP team. The BPS has
also established a Social Inclusion Steering Group
with work streams on Children and Families,
Offenders in prison and Return to work.
A two-year secondment of an occupational therapist
into NSIP, funded by the COT, and publication of a
mental health strategy document Recovering
Ordinary Lives 82 influenced by the NSIP agenda. Also
a joint publication of Work Matters,83 a guide to
STAFF DEVELOPMENT
In order to make the capabilities clearly applicable in the
workplace for staff, NSIP commissioned the development
of two measurement tools. The first 84 measures staff
capabilities and was developed by South Essex
Partnership NHS Foundation Trust, and the second,
developed by people using the services of 2gether NHS
Foundation Trust, is a user and carer-led evaluation tool
(due for publication spring 2009) that assesses socially
inclusive practice within organisations and Local
Implementation Teams.
COMMUNITIES OF INFLUENCE
In engaging trusts across England in the Communities
of Influence project we are linked directly to 14 largescale organisations and their workforces. While the
project focuses on members and governors being key to
engaging with their local communities, the Trusts have
also identified their staff as being an important
community to work with. Communities of Influence is
described in more detail in Chapter 1.
It is of vital importance that corporate values and actions
reflect inclusion at strategic and operational levels.
While many mental health and care trusts include social
inclusion in their organisational vision and values,
regular revisiting of how this is done needs to take place
at corporate, service and team levels to ensure that
organisations are meeting their objectives.
31
the clinical aspects of mental health and too little on
wider outcomes. Integrating commissioning for social
inclusion into World Class Commissioning,88 with
inclusion outcomes identified as driving service delivery
needs to remain a priority.
CHAPTER 7
32
SOCIALLY INCLUSIVE
PRACTICE:
THE CAPABLE ORGANISATION AND TRANSFERABILITY
OF OUR WORK
VISION
Mental health services support both individuals and
community organisations.
Community organisations are flexible enough to allow people
33
Whilst NSIPs work has focused on the specific
experiences of people with mental health problems,
this work should not be entirely separated from the
circumstances of other people who experience
exclusion. This chapter considers the potential for
applying lessons learned in the mental health sphere to
other efforts to combat social exclusion.
COMMUNITY ORGANISATIONS
NSIP has made significant progress because it has
ensured action to coordinate strategic and national
intervention with local activities. For example, the Castle
Museum, in Nottingham has had a long standing
association with mental health services and their local
work has been enhanced by involvement with the Open
to All national programme of mental health training for
museum staff commissioned by NSIP (see Chapter 5).
Similarly, the 15-year history of links between the mental
health service and a large Further Education college has
been strengthened by the national network of education
regional project officers formed through our partnership
with NIACE.
Our strategic and national interventions have created a
supportive climate for local service delivery in several
areas of community life including employment,
education, the arts and community development. These
interventions have blended obligation (such as
information to employers about their duties under the
Disability Discrimination Act) with good practice
examples of what is possible, for example the
awareness-raising activities targeted by NIACE at local
Further Education providers; and the formation of
learning communities, such as the NSIP Affiliates
Network.
It is also worth noting that while we have worked with
large, networked, regulated and centrally funded
34
35
Resources (people, skills and time) to scan the horizon
across a wide range of policy areas and respond to
issues that might hinder or advance the inclusion
agenda for people with mental health problems. These
resources can be scarce at local level.
Strategic alliances with mainstream community
organisations to create dialogue, workable solutions
and convincing cases for change.
A long-term approach that combines both insistence
that change is not delayed with the recognition that
policy, funding priorities and inspection criteria are not
changed overnight.
STEPPING STONES
A multi-agency programme, launched in 2008,
enables Swindons key public sector employers to
maximise their disability equality initiatives by working
together and directly linking to local supported
employment agencies. Between them these agencies
support hundreds of highly motivated disabled people
who are actively seeking employment or work
experience opportunities. The initiative is led by
Swindon Borough Council and now encompasses
Capita, Swindon PCT, Great Western Hospitals NHS
Foundation Trust and Wiltshire Police.
CONCLUSION
I was in such a hopeless place I ended up in secondary
mental health services. Then I took back control of me
and have managed to travel quite a distance down my
recovery path. I have a life again. 91
This report has detailed the work that has taken an
essentially panoramic view of what was to be done. It
has been rich in content and participative in process.
We, the NSIP team, have been fortunate in having the
opportunity to undertake work that is challenging and
satisfying in equal measure and which could lay
foundations or set a compass point. We hope to have
made the most of the opportunity, building on the
previous effort of others to make at least some progress
in the wide range of areas at which we have looked,
taking the brief to do so from the equally broad remit of
the SEU report.92 Thanks to external partnerships of
great goodwill and the immense collaborative commitment
of so many friends and colleagues, this progress, in a
once new, now well-established area of policy, has been
cost effective and is progress of which we are proud.
The still central role of services and their expectations for
people with mental health problems has determined
something of the focus of our work. There is a major
challenge in how the role of services is to be transformed
in the future. The fundamental importance, and value, of
engaged communities will need to be affirmed ever more
widely. Work on inclusion needs to look critically at the
ways in which services become part of, and accountable
to communities themselves.
We need to see the changes of the last four years
embedded in the activity of the next. This will require
36
37
ANNEXES
38
NEXT STEPS
This work is critical to developing and measuring the
impact of social inclusion policy implementation. The
research network has supported the development of
effective research approaches to inclusion and the move
towards evaluating progress in key areas.
There is a need to continue to grow an effective and
practical evidence base for inclusion. Academic/practice
partnerships will be key to this. Through UCLan, NSIP
has established an academic network involving some ten
universities and is linked to international academic
settings to develop this work. Led by UCLan from a new
organisation within the International School for
Community, Rights and Inclusion, the network will seek
to drive the research agenda in practical ways,
collaborating on bids and working to support local
evaluation and knowledge transfer.
A strategic network for social care leads in trusts has
been established in partnership with SCIE and a
commissioning network has been created to develop
socially inclusive outcomes. Specific work is being
undertaken in the Eastern region with the regional
development centre and Strategic Health Authority to
support local PCTs with outcomes development.
Equally, it will be important to work in the other domains
of community life where there are still major barriers to
39
social participation. We will seek to challenge those
barriers and in the process help reduce the
discrimination that they cause. We will do this by
optimising shared learning and innovation; building
further the evidence base for inclusion in practical ways;
working with our partners in support of real change at all
levels in services and beyond; and taking particular
account of new regional and local organisations and the
opportunities that they represent.
The key priorities for the coming year include:
Identifying a range of stakeholders and expanding
membership of the group, particularly focusing on the
engagement of researchers with experience of people
with mental health problems in the process.
Developing communication and dissemination
systems, including links with service providers and the
academic community, as a means of sharing relevant
evidence and research findings more widely.
Coordinating research activity and facilitating
communities of interest around specific topics and
issues.
Exploring opportunities for collaboration to
secure funding for research to strengthen the
evidence base. Also for influencing existing research
streams to ensure a focus on social inclusion issues
and outcomes.
www.socialinclusion.org.uk/home/index.php
www.socialinclusion.org.uk/publications/
2009
40
Direct_Payments_web.pdf
2008
www.socialinclusion.org.uk/publications/Direct_Payments_SU_
Guide.pdf
www.socialinclusion.org.uk/publications/DayServicesLeaflet.pdf
www.socialinclusion.org.uk/publications/Toward_a_MH_emplo
www.socialinclusion.org.uk/publications/NSIP_CBL_briefing.pdf
yment_strategy_revsied_after%20repairs.pdf
2005
Direct Payments in mental health: What are they
being used for?
kc.csip.org.uk/upload/Examples%20of%20DP.pdf
www.socialinclusion.org.uk/publications/
www.socialinclusion.org.uk/publications/ReallyUsefulBook.pdf
NSIP_AnnualReport_FIN.pdf
2007
www.socialinclusion.org.uk/publications/DSdoccover1.pdf
2006
National Social Inclusion Programme Second
Annual Report
www.socialinclusion.org.uk/publications/NSIP_AR2006.pdf
Work%20Matters%20Booklet%20for%20CD.pdf
www.socialinclusion.org.uk/publications/Rentarrearsbriefing.pdf
www.socialinclusion.org.uk/publications/MHSIArts.pdf
DOH_Vocational_web.pdf
www.socialinclusion.org.uk/publications/Gthroughguide.pdf
www.socialinclusion.org.uk/publications/Day_Services_web.pdf
Action_on_Mental_Health%20Fact_Sheets.pdf
www.socialinclusion.org.uk/publications/
ANNEX C ACKNOWLEDGEMENTS
CURRENT TEAM MEMBERS (INCLUDING SECONDEES
AND PART-TIME CONTRIBUTORS)
EXPERT ADVISORS
Malcolm Barrett
Local Liaison and User Development
Sona Peskin
Peter Bates
Development Consultant
Rosemary Wilson
Victoria Betton
Trust Development Associate
Diane Hackney
Fran Singer
REFERENCE GROUP
Les Aqil
Alex Burner
Service User Involvement Lead
Susan Ambury
Marco Carrera
Programme Coordinator
Randall Chan
David Clarke
Regional Employment Team Coordinator
Penny Connorton
Fabian Davis
Associate Director
Kaaren Cruse
Claire Etches
Social Exclusion Lead
Lorraine Looker
Gerry Bennison
Bev Chipp
David Cooke
John Holmes
Tony Martin
Dave Gardner
Commissioning Associate
Naomi Hankinson
Assistant Director
Fiona Hill
PA to David Morris
Kathryn James
Assistant Director Learning and Skills
Robin Johnson
Housing Lead
Neil Lowther
Assistant Director Employment
David Morris
Programme Director
Robin Murray Neill
Personalisation Lead
Marian Naidoo
Arts Lead
Steve Onyett
Leadership Associate
Zoe Robinson
Business and Communications Director
Stafford Scott
Communities of Influence Manager
Ben Taylor
Day Services Lead
Micheal Osbourne
Lizzie Walker
Robert Walker
Mike Walsh
41
ANNEX C ACKNOWLEDGEMENTS
CSIP
Paddy Cooney
CSIP Executive Lead
NIMHE
Peter Horn
NIMHE Executive Lead
42
design: www.gilldavies.co.uk
www.socialinclusion.org.uk
Outcomes Framework
for
Mental Health Services
A. INTRODUCTION
What this Framework is for
This framework is focused on adults of working age with mental health problems.
It is a development of the outcomes framework for day services published in
2007 as part of the work of the National Social Inclusion Programme (NSIP) on
day services modernisation and the programmes wider work on the life domains
in which exclusion occurs. It sets out some suggested outcomes for inclusion as
a resource to commissioners and providers looking to advance inclusion practice
through locally established outcomes for monitoring and evaluating service
effectiveness.
Many health and social care services are being refocused to promote social
inclusion, including the role of work and gaining skills, in line with current policy
and legislation. Changing the way services are delivered will improve lives and
help achieve a range of objectives, including those laid out in the following policy
documents and guidance:
There is more than one way of utilising this framework and its use will be locally
determined. Possible approaches include:
1. Counting the number or proportion of service users who have achieved each
outcome indicator through the support of a service in a given timeframe (e.g.
quarterly, six monthly, annually) giving easily comparable data, and to
supplement this with a small number of case examples (e.g. two for each
outcome area), giving a more detailed sense of the work undertaken and change
achieved.
2. Creating a table which, for each indicator, measures a baseline, people
supported to achieve that outcome indicator and people supported to sustain that
change or activity.
3. Discussing the categories and indicators with people using services as part of
a needs assessment or support planning process. People using the service may
want to add indicators that feel particularly relevant to them.
It is important to recognise that there is some necessary variation in the design of
mental health services across the country and that various frameworks of
outcome objectives will already be in place (see below). Expectations of services
with regard to outcome monitoring may differ according to their design and the
indicators that are monitored should be selected according to the aims and
purpose of the service. For example, an employment service may major on
most, if not all of the employment related indicators, but have fewer or no
indicators relating to independent living.
Methods for monitoring outcomes and the selection of tools to support this are
also a matter of local choice. Section D contains a list of possible tools that could
be used to support outcome measurement. It also highlights possible sources of
supporting evidence in demonstrating that the outcomes have been achieved.
However, in recognition that some commissioners and providers would like an
outcome measurement tool which links directly to this framework, a simple
measurement tool is currently in development to accompany the framework and
will be available on www.socialinclusion.org.uk by spring 2009.
Links to National and Regional Outcome Indicators
Commissioners and providers will be aware of a range of regional and national
outcome indicators against which they are expected to report and against which
targets may be set. The outcomes in this framework are designed to incorporate
information which contributes to this reporting, but some indicators may need
to be adjusted to fit with the expectations in a particular region or locality.
Information relating to the new NHS contracting arrangements, HealthCare
Commission Standards and PSA targets can be found in Appendix 2.
B.
Important
It is suggested that services using this framework should only record outcomes
against the indicators when the service has been involved in successfully
supporting an individual to make the relevant change in their lives. Therefore an
outcome for beginning voluntary work in a mainstream organisation should only
be recorded when the service user has begun the work, rather than when they
receive the support.
It should not be assumed that every indicator is appropriate to every individual as
a measure of social inclusion. For example, an individual may have a high level
of educational attainment and so would find this indicator irrelevant. Conversely,
an individual may have low educational attainment but would prefer a vocational
route to employment. Indicators should only be used where they relate to a
personal goal set by an individual in discussion with their support/key worker or
care co-ordinator.
Services should only record outcomes against the indicators when the outcome
is, at least in part, attributable to the interventions or support of that service, and
not when it was achieved independent of and coincidental to the service being
provided.
Some of the indicators include value judgments (e.g. positive new relationships).
This is necessary to capture significant positive outcomes without inadvertently
capturing negative outcomes. It is important that there is self-definition in
deciding whether these indicators have been met (i.e. it is the service user who
makes the value judgment).
Community Participation
Intended Outcomes
Increased number of
people with mental
health problems
volunteering in
mainstream settings
Increased number of
Social Networks
Intended Outcomes
Increased number of
people with mental
health problems
maintaining social
and caring roles
Employment
Intended Outcomes
Increased number of
people with mental
health problems
preparing for
employment by
Increased number of
people with mental
health problems
accessing education
and training
opportunities
Increased number of
people with mental
health problems
attaining
qualifications
Physical Health
Intended Outcomes
Improved physical
health for people
with mental health
problems
Increased number of
people with mental
health problems
taking regular
exercise
Mental Wellbeing
Intended Outcomes
Improved quality of
life, confidence and
self-esteem for
people with mental
health problems
Increased ability to
manage own mental
distress for people
with mental health
problems
Independent Living
Intended Outcomes
Increased number of
people with mental
health problems
living in independent
accommodation
Increased number of
people with mental
health problems
receiving
appropriate benefits/
financial advice
Increased number of
people with mental
health problems
controlling their own
support
Increased number of
people with mental
health problems in
receipt of direct
payments or
individual budgets
10
C.
These Indicators refer not to outcomes for the individual, but to outcomes for
mental health and related services. They can be used to help identify service
gaps and improvements required.
Service User Satisfaction
NOTE: Achievement against these indicators can be measured using a service
user questionnaire incorporating questions directly relating to the indicators
Intended Outcomes
Key Outcome Indicators
Increased levels of
Proportion of service users expressing that the
satisfaction of
service helps them engage with their local
service users with
community
the delivery and
Proportion of service users expressing that the
outcomes of the
service enables them to achieve their personal
service
goals
Additional Outcome Indicators
Increased proportion Proportion of service users expressing that the
of service users
service helps them manage their mental health
reporting that they
needs
have achieved their
Proportion of service users expressing that the
goals
support they receive is responsive to their needs
Proportion of service users expressing that the
support they receive assisted them to achieve their
life goals
Proportion of service users expressing that the
support they receive meets their cultural needs
11
services and/or
activities
Diversity
Intended Outcomes
Equality of access to
day services for all
people with mental
health problems
Services which
specifically meet the
needs of underrepresented groups
12
D. OUTCOME MEASUREMENT
Approaches to Outcome Measurement
Some of the most commonly used approaches to data collection are:
Questionnaires
Interviews
Observation
Record Keeping
Case note review
It is often helpful to incorporate more than one of these approaches and sources
of assessment into an outcomes monitoring system in order to achieve as
complete and accurate a picture as possible of the outcomes that have been
achieved.
The Recovery Star is also a key working tool and can be used to undertake a
needs assessment, to support planning as well as for outcome measurement. It
is designed to support individuals in understanding where they are in terms of
recovery and the progress they are making, providing both the client and worker
a shared language for discussion mental health and wellbeing.
13
Relationships
Addictive behaviour
Responsibilities
Identity and self-esteem
Trust and hope
The Recovery Star helps to identify any difficulties people using service are
experiencing in each of these areas and how far they are towards addressing
them and moving on.
You can find out more about the Recovery Star on the Mental Health Providers
Forum website: http://www.mhpf.org.uk/recoveryStarApproach.asp
As with the Recovery Star (and Inclusion Web), this is primarily a tool to promote
individual planning, but data can be aggregated as a means of monitoring
changes in a population over time.
The Outcomes Star and associated materials and guidance are available to
download through a Creative Commons Licence from
www.homelessoutcomes.org.uk
14
15
E. REFERENCES
A Prospectus for Arts and Health (DH & ACE, 2007)
Advanced Evaluation and Monitoring (Training Pack) CES, 2006
Guidance Paper 3: Key Terms and Definitions, CES, 2004,
www.ces-vol.org.uk
Capabilities for Inclusive Practice (DH, 2007)
CES/BLF, 2004, Your Project and Its Outcomes
Supporting Women into the Mainstream (DH), 2006b,
Commissioning Women-only Community Day Services
Day Services Outcomes Framework (NSIP, 2007)
Delivering Race Equality in Mental Health Care (DH, 2005)
Developing a Framework for Vocational Rehabilitation (DWP,2004)
Direct payments for people with mental health problems: A guide to action (DH,
2006)
Ending child poverty: everybody's business (DCFS & DWP, 2008)
From Segregation to Inclusion: Commissioning Guidance on Day Services for
People with Mental Health Problems (DH), 2006a,
Health, work and wellbeing caring for our future (DWP, DH, HSE, 2005)
High Quality Health for All (DH, 2008)
Independence, wellbeing and choice (DH, 2005)
In work, better off; next steps to full employment (DWP, 2007)
Mental Health and Social Exclusion (Office of the Deputy Prime Minister, 2004)
Mental Health Social Inclusion and Arts: Developing the Evidence Base (DH),
2007,
Our health, our care, our say: a new direction for community services (DH, 2006)
National Action Plan on Social Inclusion 2006- 2008 Working together (2006)
National Suicide Prevention Strategy for England (DH, 2002)
No one written off, reforming welfare to reward responsibility - Welfare Reform
Green Paper (2008)
Putting People First: A shared vision & commitment to the transformation of Adult
Social Care (DH, Dec 2007)
Reaching Out: An action plan on Social Exclusion Report (Sep 2006)
Ready for Work: full employment in our generation (DWP, 2007)
Ready for Work, Skilled for work (DIUS & DWP, 2008)
Refocusing the Care Programme Approach (Mar 2008)
Report of the Review of the Arts and Health Working Group (DH, 2007)
Supporting Women into the Mainstream (DH/NIMHE, 2006)
Tackling Health Inequalities, A Programme for Action (DH, 2003)
Vocational services for people with severe mental health problems:
Commissioning guidance (DH & DWP, 2006)
Working for a Healthier Tomorrow (DH & DWP, 2008)
Working Neighbourhoods Fund (DCLG & DWP, 2007)
16
F. ACKNOWLEDGEMENTS
This framework was produced by the National Social Inclusion Programme.
Many thanks to all those who developed and contributed to the development of
this document and its predecessor - the Mental Health Day Services Outcome
Indicators Framework, and in particular:
The 5 organisations who piloted the Day Services Framework during 2008
and fed back on their experiences:
Bromley Mind
Community Restart at Lancashire Care NHS Trust
Huntingdon Recovery and Partnership Team at Cambridgeshire
and Peterborough Mental Health Partnership Trust
Quest Day Opportunities at Staffordshire Council
Richmond Fellowship in Wigan
Plus the 22 mental health commissioners who commented on the
framework.
17
G. APPENDICES
Appendix 1
Definitions (Adapted from the Charities Evaluation Service)
Aims Describes the changes you are trying to achieve
Quantitative Measures Those where you count numbers of things that happen,
such as the number of people who found jobs following some computer training
(CES/BLF, 2004)
Qualitative Measures Those where you assess peoples views and
experiences, such as how safe older people feel going out at night (CES/BLF,
2004).
Outcomes The changes, benefits, learning or other effects that actually occur as
a result of your activities.
Outcome Indicators The things you can use to assess whether the expected
outcome is occurring. They assess progress towards meeting aims. They are a
type of performance indicator and can be qualitative or quantitative.
Objectives Describes the mechanism/process and planned activities by which
you are going to achieve your aims
Outputs The activities, services and products provided by an organisation.
Output Indicators The things you can use to assess whether you have achieved
your outputs. They assess progress towards meeting objectives and are a type of
performance indicator.
18
Appendix 2
NHS Contracting Arrangements
A new NHS standard contract, covering agreements between PCTs and
providers for the delivery of NHS funded services for mental health, will be
implemented from April 2009.
The outcome indicators framework can be used by commissioners to support
development of each of the three key sections of the contract as appropriate
the mandatory elements (centrally set), mandatory elements to be defined by
local agreement, and the additional elements to be defined by local agreement.
Visit www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091451
for more information.
Regulation of national standards and targets
The Care Quality Commission will come into force in April 2009, and take over
the functions of the Healthcare Commission, the Commission for Social Care
Inspection (CSCI) and the Mental Health Act Commission (MHAC). Its remit will
cover both health and social care services.
The existing inspection bodies are responsibly for providing assurance that NHS
Trusts and adult social care services in England are meeting essential standards
of quality and safety for everyone.
This is currently undertaken by the through a variety of methods including the
Annual Health Check (HCC), national reviews (HCC & CSCI) and staff and
patient surveys. Assessment of services in relation social inclusion domains can
be found within each of these elements. For example, the community patient
survey asks specific questions relating to employment, support groups and
benefits advice.
The outcomes framework can be used to generate evidence for commissioners
and providers that they are meeting relevant national standards.
Summary of key PSA Targets which the refocusing of mental health
services can contribute to:
PSA 8
PSA 15
PSA 16
19
PSA 17
PSA 18
PSA 19
PSA 21
20
Occupational therapy focuses on the nature, balance, pattern and context of occupations and activities in the dayto-day lives of individuals, family groups and communities. It is concerned with the meaning and purpose people
place on occupations and activities, and with the impact of illness, disability and social or economic deprivation on
their ability to carry them out. Occupational therapy uses the knowledge that the relationship between occupation
and health is reciprocal individuals experiencing health problems will likely see it impact on their abilities and
occupational performance, whereas positive occupational experience and success undertaking activities carries
health benefits and promotes recovery, thus helping people successfully resume ordinary lifestyles despite
extraordinary circumstance.
The main aim of occupational therapy is to maintain, restore, or create a match, beneficial to the individual,
between the:
-
The desired outcome of occupational therapy intervention is that the person achieves a satisfying performance,
and balance of occupations, in the areas of self care, productivity and leisure, that will support recovery, health,
wellbeing and social participation (Creek 2003).
To achieve this, the therapist looks with the service user at her/his range and balance of occupations, and
together they identify problems, deficits, and strengths. The therapist then narrows her/his focus of
attention and works on the specific activities, tasks or skills that will best utilise the individuals assets,
remediate deficits, and enable the person to enact her/his occupations more effectively. Where this is not
possible, the therapist will adapt the desired activity so the individual is able to carry it out, or help make
changes to their clients physical, cultural, institutional or social environments to facilitate occupational
performance. The therapist then shifts the focus outwards again, to see what effect the action has had on
the persons overall pattern of occupations. This shift of perspective happens many times during the period
of contact between occupational therapist and service user (Creek 2003).
Where teams have access to occupational therapy, it is likely to be a limited resource. This can mean
the occupational therapist becomes overwhelmed with demand for in-put or conversely, due to
unfamiliarity with what can be provided, or belief that the resource cannot be accessed, colleagues
may rarely make specific demands for occupational investigation (be it through consultation; full
assessment; short or longer term intervention, or any combination of these things) . Discussion with
occupational therapists, managers and team leaders is developing consensus on what constitutes a
priority for occupational therapy input, The following summary is to assist teams identify when a
person might benefit from occupational assessment or intervention.
There are three overriding conditions identified as necessary components for occupational therapy to
progress appropriately:
x
that the individual can articulate some level of dissatisfaction regarding the balance,
range and meaningfulness of their day-to-day activities, and/or their level of ability in
performing occupations; or in circumstances where the service user does not have insight
or capacity to express such dissatisfaction, the carer/family member may themselves do
so;
Page 1
June 2009
Refs: Creek J (2003) Defining occupational therapy as a complex intervention College of Occupational Therapists, London
nd
Wilcock A (2006) An occupational perspective of health (2 edition) Slack New Jersey, USA
that the person with capacity to consent, does consent to the occupational therapy
intervention; where the person does not have capacity, the therapist is required to
observe for signs of implied consent and act accordingly;
The following represents key indicators suggesting a consultation with an occupational therapist be
sought, an assessment offered if appropriate, and where indicated, interventions provided. This
flow represents the order of priority given to the indicators of need:
Occupational assessment should be considered where there is:
Urgent need for person to maintain dignified independence in daily
living skills, or increase level of safe functioning
For example: Where mental illness or cognitive impairment severely impacts
on independent living skills; level of support has changed/will imminently
change; carers unable to continue with level of input; environmental change
necessitates increased independence
And/or
In addition to direct input with individuals working to meet identified occupational goals, the occupational
therapist will prioritise working as part of the team contributing expertise on the following issues:
x
Developing teams insights into identifying and addressing occupational risk (Wilcock 2002),
working so that the relationship between health and occupation is more fully understood and
made use of.
We hope the above is helpful in highlighting when to explore occupational performance in more detail, and
welcome discussion of service users potential needs following consideration of the above factors.
Page 2
June 2009
Refs: Creek J (2003) Defining occupational therapy as a complex intervention College of Occupational Therapists, London
nd
Wilcock A (2006) An occupational perspective of health (2 edition) Slack New Jersey, USA
Welcome
Dosulepin
The NICE review has highlighted again
the risks of prescribing Dosulepin
(Dothiepin). A recent outcome of an
SUI and the annual suicide audit has
highlighted that there are still patients
who are being prescribed Dosulepin. It
is the recommendation of the SUI and
the audit that all patients who are
currently prescribed Dosulepin should
be reviewed.
Escitalopram and Duloxetine
The NICE committee examined the
benefits of prescribing Escitalopram
and Duloxetine.
For Escitalopram they concluded that
the evidence showed only a small
advantage over other antidepressants
and this was not considered clinically
important. There was a small economic
advantage over three other
antidepressants but this was
considered by the committee to have
limitations and was insufficient to make
a specific recommendation.
The NICE committee found that
Duloxetine was no more clinically
effective than other antidepressants,
the economic evidence was
contradictory and therefore no
recommendation could be made.
Agomelatine (Valdoxan)
The NICE committee did not review
Agomelatine as part of the guideline
review although a technical appraisal
may be released at a future date. The
Scottish Medicines Consortium have
not accepted the use of Agomelatine in
Scotland on the basis of insufficient
robust economic evidence.
Management of Discontinuation
Symptoms with Antidepressant
Treatment
Swapping Antidepressants
Advice on swapping antidepressants is
available on the Pharmacy intranet page