6 Mar 2015

Star Wards Submission to RCPsych Commission on Acute Adult Psychiatric Care

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 The Royal College of Psychiatrists have set up a Commission “to review the provision of inpatient psychiatric care for adults in England, Wales and Northern Ireland has been set-up in response to concerns about whether there are sufficient acute inpatient psychiatric beds and alternatives to admission available for patients and service users.” More information about the Commission can be found at www.CAAPC.info.

 

Here’s Star Wards’ Commission submission! We’d love to hear what you think of it all.

 

Questions

 

Q1.

In your opinion, what is the value and purpose of inpatient mental health care for adults?

 

We are interested in hearing your views on the importance, worth, or usefulness of inpatient care.
Please explain your answer (word limit 500 words).

 

Inpatient care should be regarded as an essential, valuable component of an overall mental health service. We reject the commonly used description of it being ‘a last resort’ – totally negative, and negating the positive experiences and recovery that has increasingly become the norm.

 

Specifically, being an inpatient provides the opportunity for:

  • An escape from the situation that triggered the mental health crisis
  • 24/7 support and multi-disciplinary help – from nurses, healthcare assistants, psychologists, OTs, physios, dietitians… (And from psychiatrists, sometimes.) This cannot be overstated. CRHTs and the equivalent rarely do more than pop in once or twice a day, which is absolutely not an equivalent service!! While crisis houses also provide this, they cannot create the extra security of a potentially locked environment, which is very much what I need when an inpatient. Not only does this keep me from wandering off and killing myself, the fact I know I can’t kill myself when an inpatient immediately reduces the suicidal compulsions.
  • Learning or fine-tuning recovery skills.
  • Mutual support. This is undoubtedly one of the most beneficial but least commented on aspects of being an inpatient. Most patients spend much more time in the company of other patients rather than staff and the sharing of everything from empathy, recovery tips, hope for the future, snacks, fags etc are hugely beneficial. (Of course for many patients, including me, some patients can also be a source of anxiety and irritation. It’s not easy being locked up with a random group of strangers who are also going through very dark times.)
  • Medication review. Arguably, in the past this seems to have been a primary reason for and focus of an admission. Wards are now seeing medication as only one of many therapeutic interventions.

At a time when people are being unnecessarily sectioned and/or sent hundreds of miles from home, it feels a bit over-optimistic to include the following. But we strongly believe that there is an important ‘respite’ function for an admission. This might be a respite from managing our illness alone, which is an exhausting and often profoundly dispiriting, relentless experience. And/or a break from having to cope with daily life – not having to worry (so much) about emails, meals, bills etc. For people who have carers, it can be a massive relief for their carers not to have to worry about whether we’re safe, eating, washing etc.

Please explain your answer and give as much detail as possible.

 

 

Q2.

Please can you provide an example of:

 

  • good’ inpatient care
  • good’ alternatives to inpatient care?

 

Please explain your answer, and give as much detail as possible about what made the care ‘good’. Please also tell us where and when this example is from (e.g. Manchester, 2012).

 

Good inpatient care (500 WORD LIMIT)

 

It’s near impossible for us to restrict examples of good inpatient care to 500 words, when we have over 1,000 examples of great inpatient care on Wardipedia! The first issue is that favourite CQC question – what does good look like? For us it has these features:

 

  • talking therapies play as substantial a role as medication
  • patients are supported in enhancing their management of their symptoms and treatment
  • there is a strong culture of patient mutual support, with the potential for this extending once they’ve left hospital
  • a full programme of daily activities doesn’t just eliminate boredom but actively contributes to accelerating patients’ recovery
  • patients retain and build on their community ties
  • thoughtful and constructive patient engagement being the most effective way of increasing safety on wards

 

Harrison House in Grimsby exemplifies great practice across the board.  What differentiates Harrison House includes:

  • A genuine, unswerving focus on what’s best for patients rather than for ‘the system’.
  • Flexibility! For example, if a patient with Borderline Personality Disorder is having a bad day, they invite them back for a cup of tea and a chat. I have BPD and know that at least one admission would have been avoided had I been able to do this. BPD crises are overwhelming at the time, but often are resolved in a few hours. By the time I’ve spent 8+ hours being admitted, I can no longer admit that perhaps I’m calm and stable enough to go home.
  • A combined inpatient and crisis/home treatment team. This is so valuable and we hope the Commission will take a serious look at this model, described in a bit more detail below.
  • Energy, creativity, a highly unusual to embrace change and a staff team who love their work and are able to have fun with patients as well as all the heavy-duty stuff.

Here’s a (somewhat random) bunch of our favourite examples of great inpatient care:

 

Holiday at Home 005

  • Welcome bags made by patients with thoughtful & practical contents eg card, toiletries
  • Podcast and music studio
  • Leaving art materials and books lying temptingly around rather than neatly ‘put away’
  • Providing library cards and encouraged to use local library
  • Partnership with Rethink – ex service users mentoring patients to support them when they leave.
  • Internet access – becoming universal.
  • Link with local football club to raise awareness, and arrange reciprocal visits and tours.
  • Cafes – permanent or pop-up
  • Moving exercise bike where cyclist can see TV
  • Come Dine With Me evenings
  • Holiday at Home (bringing beach to Birmingham hospital, Highcroft)
  • Big circus skills box, spontaneous paper plate Frisbee, using giant gym balls as improvised space hoppers!
  • Video box for patient feedback
  • Patient ‘Jobs Board’
  • Eco Therapist
  • Body image therapist
  • Patients access the local dogs home for volunteer work and also to pet the animals.
  • Staff eat with clients
  • Ward newsletter
  • No noticeboards as these were felt to give too institutionalised a sense. Leaflets etc are on display on sideboard.
  • Music in unit reception area.

 

 

Q3.

Giving as much detail as possible, please can you:

 

  • provide an example of ‘poor’ inpatient care
  • explain how that poor inpatient care could be improved?

Please explain your answer, and give as much detail as possible about what made the care
‘poor’. Please also tell us where and when this example is from (e.g. Cardiff, 2014).

 

Poor inpatient care (500 WORD LIMIT)

 

Obviously having wards properly funded, and there being sufficient beds nationally and locally as well as robust non-hospital services would also help prevent poor inpatient care. In the meantime, the following need addressing.

 

Whereas on ‘general’ (ie non-mental health) ward staff deliver the treatment, on mental health wards staff are the primary treatment. So when things go wrong, it is usually connected with a member of staff getting things wrong. Most Inquiries and Commissions go off on a whole big thing blaming frontline staff, which is lazy, unfair and unhelpful. The reality is that, as the Cavendish Commission described with exceptional clarity and accuracy, most ward staff are great. And when they behave in a not great way, what needs looking at is the training, support and appreciation they get. They work terrible hours, for crap pay, in circumstances that most people (including the blinkered critics) wouldn’t be able to cope with for a week let alone year after demanding year.

 

One aspect of poor inpatient care we’d like to highlight is the role of consultant psychiatrists, the professionals who  are paid the most but appear to patients and many frontline staff to contribute the least and to produce the most obstacles to constructive change. We cover this in Wardipedia in two features – firstly on the ritual humiliation of ward rounds about which Dr Hugh Griffiths, when National Director of Mental Health, wrote : “It is anathema to me that some practice exists where there is an expectation that service users will attend a ward round, usually being interviewed in a meeting with many staff present. Most service users I speak to hate it.” http://www.wardipedia.org/1-consultant-appointments-2/ And ward life would be so much better, and relationships between psychiatrists, patients and staff vastly improved, if there were just one consultant per ward rather than up to 8. With so many consultants, ward rounds become an almost continuous process through the week, preventing therapeutic work from taking place. http://www.wardipedia.org/2-mono-consultants/.

 

In addition to replacing ward rounds with consultant appointments and having one consultant per ward, the following are, in our opinion, the things that make the most difference to patients, staff and visitors.

  1. Staff being appreciated – not in some subliminal way, nor by awards ceremonies (which leave 1% of staff ecstatic and everyone else deflated), but by leaders (for example) being present on wards and thanking staff in an authentic way.
  2. Staff being supported, trusted and equipped. By far the best description of how to achieve this is contained in Henry Stewart’s book The Happiness Manifesto, the ideas in which are starting to be introduced into hospitals. (Fred Lee’s If Disney Ran Your Hospital is also excellent.)
  3. Staff having reflective practice as an integral part of their working life, including a minimum of an hour a month of facilitated reflective practice with other colleagues.

 

Tantalisingly, these three things would require no extra funding, just a change in leadership practices.

 


 

Q4.

Giving as much detail as possible, please can you:

 

  • provide an example of a ‘poor’ alternative to inpatient care
  • explain how that poor alternative to inpatient care could be improved?

 

Please explain your answer, and give as much detail as possible about what made the care
‘poor’. Please also tell us where and when this example is from (e.g. Belfast, 2013).

 

Poor alternative to inpatient care (500 WORD LIMIT)

 

All the experiences I’ve had of being supported at home in a crisis have been pathetic. Two staff turn up – I’m tiny and docile and one caring, skilful person would be ideal, two is wasteful. They stay a few minutes, ask a few nervous questions and leave. There’s no therapeutic input, no relationship-building, nothing at all really other than a ticked box.

 

What would help would be (and it does feel slightly ridiculous even suggesting these things in the current financial mess but here goes:)

 

  1. The option of having up to 24/7 support at home, rather than an hour or so a day max.
  2. Not being restricted to staying in the house – perhaps some CRHT staff already go out and have a cup of coffee with a patient, or accompany them to an appointment that the patient is worried about (benefits, housing, work…)
  3. Staff with a broader range of skills including in creative therapies. Some teams do have peer supporters, which I’d have really appreciated when in meltdown.
  4. Being able to speak to somebody 24/7, as one can when in hospital. A quick chat with a reassuring, skilled professional can be crucial to getting through the next minute/hour/day.

 

Again it’s really worth looking at Harrison House’s integrated inpatient/home team. The benefits include:

 

  • Having staff on duty in the wards 24/7 means patients at home can ring and speak to someone they may already have been supported by at home or in hospital, resolving many crises promptly.
  • There is much more flexibility between home and hospital eg staff are willing and able to accompany a patient if they need to pop home.
  • Much better decisions are made about admissions, based on a sound knowledge of the person, a trusting relationship etc.
  • It’s a more varied, fulfilling role for staff. (Which in turn leads to staff being more motivated and energised.)

 

 

Q5. In your opinion, what would be the best way of measuring ‘good quality’ care on an inpatient ward, or in an alternative to inpatient care?

 

In other words, what should we measure?  And how should we measure it?

 

(500 WORD LIMIT)

 

Wardipedia is evidence-based (unless an activity or approach is so innovative that there isn’t yet the evidence base for it), created by a service user and a member of ward staff and is a comprehensive collection of the issues that are important to patients.  We feel all wards should be measured against these 77 issues:

 

 

 

 

 

 

 

 

Imagination

                                                                                                

  1. Consultant appointments
  2. One ward, one consultant
  3. Therapeutic liaison co-ordinator
  4. Ladder of priorities
  5. Relational security
  6. Animals
  7. Mentalising
  8. Community meetings
  9. Engagement is the thing
  10. Creative communicating
  11. Peer supporters

                                                                                                

                                                                                                

Mindfulness                                                                      

  1. Mindfulness
  2.   Bingo and jigsaws
  3. Multi-sensory
  4. Sanctuaries
  5. Spirituality
  6. Musical
  7. Landscape painting
  8. Gardening
  9. Outdoor activities
  10. Art
  11. Smoking

                                                                                                

Activities

                                                                                              

  1. Media
  2. Wii
  3. Jobs
  4. Ward newsletter
  5. Books.
  6. Funnyness
  7. Food presentation
  8. Indoor sports
  9. Dance
  10. Football
  11. Men’s stuff

       

Generosity                                                                         

                                                                                              

  1. Appreciative culture
  2.  Bring yourself to work day
  3. Role flexibility
  4.   Arriving and leaving
  5. Birthdays
  6. Cafe
  7. Senior managers
  8. Shopping
  9. Charities
  10. Going green
  11.  Gay patients

 

 

Involvement, influence, information                    

                                                                                                

  1. Patient involvement
  2. Patients’ views
  3. Minority languages
  4. Advance statements
  5. Graduated self-medicating
  6. Electronic access
  7. Personalising bedrooms
  8. Physical health
  9.    Bank staff
  10. Handovers
  11. Brain   

 

 

Neighbours                                                                        

                                                                                                

  1. Mealtimes made special
  2. Friends, relatives and carers
  3. Internet
  4. Social media
  5. Website
  6.  Kids visiting
  7. Help with housing
  8. Volunteering
  9. Help with money
  10. Pointless National Days
  11. Good news

 

Empathy                                                                              

 

  1. Ward culture of empathy.
  2. Talking therapies.
  3. Therapeutic ward design.
  4. Comfort objects.
  5. Housekeeping heroes.
  6. Complementary therapies.
  7. Addiction support.
  8. Samaritans train staff.
  9. Reflective practice groups.
  10. Good night.
  11. Happy.

 

 

(Pointless National Days aren’t essential to celebrate!! But the best wards throw themselves energetically into big national events like the Olympics, Red Nose Day etc.)

 

Best ways to measure these? Firstly to find out what is regularly taking place and then to ask patients and staff their views on how helpful these features of ward life are.

 

 


 

Q6.

In your experience, do inpatient wards and alternatives to inpatient care services work well for all patients/service users?  Or are there some groups (such as adults from some BME communities or other adult groups) that inpatient and crisis services do not work well for?  Please give as much detail as possible.

 

 

(500 WORD LIMIT)

 

The issues facing patients from BME communities are well-documented and you’ll have submissions from people and organisations far more experienced than we are. There are, however, some great examples of meeting the needs of people from BME communities in Wardipedia including #10 Creative Communicating, #16 Spirituality and  #47 minority languages

 

Again, the enormous challenges of providing a therapeutic, gentle environment for people with dementia is better covered by more specialist organisations. We’d like to focus on the unenviable experiences of patients with learning disabilities on wards other than those specifically for learning disabled patients. Learning disabled patients are extremely vulnerable on ‘mainstream’ wards because of their communication difficulties, their usually highly protected and limited life experiences and a very common desire to please or go along with other people. Our view is that:

 

  • Mainstream wards are completely inappropriate for people with learning disabilities
  • While these continue to be provided, there must be specialised LD input – from CLDT, MHLD nurse, Intensive Support Team etc.
  • The role of families and (social care) support staff are usually very important and carers must be involved and supported. The Triangle of Care provides an excellent framework.
  • Reasonable adjustments are not an optional extra. Their compulsory nature needs to be enforced!! Default position must always be that patients have the option of additional support, accessible resources and activities etc.

 

Among our recommendations for caring effectively for learning disabled patients are:

  • Review of ward (and hospital, Trust etc) arrangements for LD patients, especially how the CLDT supports patients. (eg using Greenlight toolkit)
  • Staff training
  • Extra 1:1 support for people – ideally from LD nurses. (Or hospitals can pay for person’s current support staff to work on ward.)
  • Specialist staff input eg mental health/LD nurses, Intensive Support Team members etc
  • Flexibility re: visiting arrangements
  • Support for carers (probably via CLDT)
  • Adapted routines – eg ward rounds
  • Accessible activities and resources/equipment
  • Advocacy
  • Accessible information
  • LD Liaison nurse – for consultation, direct involvement with LD patients, staff training. Important for the LD nurse to spend as much time as possible on wards: advising, training, role-modelling

 

 

 

Q7.

We are keen to hear about any examples of good practice, service evaluations, research reports, data-sets, or other information that would help the Commission in its work.

 

Please take the opportunity below to let us know where we could obtain this information, including any contact details of the organisation/person that it can be obtained from.

 

 

(500 WORD LIMIT)

 

Our websites are bursting with exactly this sort of information! The main ones in relation to the Commission are

 

www.starwards.org.uk

www.wardipedia.org

 

We have websites for two of our specific initiatives:

 

www.wardstars.org – Ward Stars is a professional development and validation scheme for healthcare assistants, which is starting to be enthusiastically adopted by Trusts such as Merseycare and Navigo.

 

www.brief-encounters.org – Star Wards co-created Brief Encounters with Dr Joy Bray, the mental health liaison nurse at Addenbrookes Hospital. It’s designed to help staff in ‘general’ (ie not mental health) wards who are caring for patients in emotional crisis. It seems that it is also being consulted by mental health ward staff.

 

 

The person with the most encyclopaedic knowledge of inpatient care (globally!) is Prof Len Bowers who we’re sure you’ll be consulting.

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