CQC’s latest report, Monitoring the Mental Health Act in 2018/2019, develops the idea that human rights should have a place at the heart of mental healthcare. Freedom, Equality, Dignity and Autonomy (FREDA) are put forward as agreed human rights principles. It would be hard to argue that this should not be the case.
However, the real challenge put down by CQC is for organisations to show how they apply these principles. They do not just cover abuse in care on mental health wards, they embrace a right to information, supporting patients to be heard, building skills for life in the community and above all helping patients make the decisions that want to make.
So it is fair to expect that inspections will focus on such issues. The report gives clues as to what inspectors will be checking in particular:
- Board level engagement. Care providers should ensure that they can demonstrate that the Board manages human rights positively. A Mental Health Act steering group is a suggested example of how an organisation can implement and oversee how human rights and equality issues are policed.
- Improved access and outcomes for people from BME service users, with a focus on providing care that reduces the likelihood of detention.
- Explanations about positive and managed risk-taking. In particular for informal patients so that they understand the obligations of staff to protect them while respecting their right to leave the ward such that a risk assessment can be shown to have been undertaken if the patient does choose to leave.
- Encouraging appropriate involvement of carers. Patient records should demonstrate that this is built into care planning and implementation.
- Advance Decision-making. Providers should devise mechanisms which store and check advance decision documentation.
- Individualised risk assessment. Providers should expect care plans to be checked to demonstrate regular updates of risk assessments in response to changes in circumstances. The key here will be to have systems in place which enable such responses.
- Regular reviews of aftercare planning. While this is enshrined in the CPA process, inspectors want to see evidence of reviews responding to events or patient wishes.
- Avoidance of blanket rules and restrictions. As well as being able to demonstrate a continued reduction in restrictive practices, providers will need to show how any restrictions are, if possible, agreed, personalised and reviewed.
- Reduction in segregation. Providers should arrange segregation on the back of expert-led assessments and reviews, using external advice as required. Segregation should be accompanied by demonstrable steps to help patients build the skills or tolerance for being around other people.
- Managing overruns on s.136 suites. Providers should not only be able to show that they have contingency plans in place to deal with patients who reach the 24 hour threshold on s.136 suites, but also what steps can be taken to monitor their efficiency. So if a Trust uses a swing-bed system it should be able to show that it has reviewed how well it works
- Information about medication for community patients. Inspectors are likely to ask how providers ensure that patients understand that medication cannot be imposed under a CTO. This will not just be about giving leaflets, but also about ensuring that the patient has read and understood the leaflet, or chosen to ignore it.
This list is unlikely to be comprehensive, and there are many areas of mental healthcare which engage human rights ranging from detention through to contact with visitors. The key is to be able to show systems and practices which take them into account, which facilitate a balancing exercise such that, for example, a patient’s right to confidentiality is respected because of his particular situation, where for another similar patient his need for protection from unlawful detention is upheld by information given to third parties. The personal circumstances of the individual patients will be the critical feature.