Priority issues and ideas for improving mental health wards
There is outstanding, truly therapeutic, world-leading, creative, empathetic, often fun, empowering work happening on many mental health wards. But there is also terrible variation in quality, even within one hospital. The great thing is that what’s seen as perhaps the darkest part of NHS is actually the most easily transformable even in the recession.
Our Wardifesto is largely based on Wardipedia – an online compendium of great practice on mental health wards, along with hundreds of ward and patient examples and the evidence base for truly therapeutic care. There is information about Star Wards at the end of this paper.
This is the key to therapeutic inpatient care. Staff need to feel appreciated and cared for in order to be able to behave in an appreciative and caring way towards patients and visitors. A straightforward and powerful boost to wards would be for political parties, the government, the DH and others to be explicitly appreciative of inpatient staff. Hospital visits, special thank you events, warm mentions in policy and other papers – this would have a very positive impact on inpatient staff and on the reputation of mental health wards. And, crucially, on patients feeling appreciated, cared about and able to make therapeutic progress.
2. Renaissance Project
While it would cost billions to transform acute/general hospitals or community mental health services, a major and sustainable transformation of mental health wards would be relatively inexpensive to achieve. Unlike general hospitals where staff mainly ‘deliver’ the treatment, on mental health wards staff mainly are the treatment. And there are already staff in place so the primary task is to enable each member of staff to deploy every single skill and quality they have. The other big shift that needs to happen is with power-sharing – from ward staff to patients and patients’ caring circles, from managers to frontline staff and, crucially, from psychiatrists to everyone. Therapeutic Communities provide a much healthier model of care.
There also must be a psychotherapy revolution with a range of talking and creative therapies becoming as integral to inpatient care as medication is – this is the one element that is costly, but nevertheless must improve from the current very low base. IAPT (Improving Access to Psychological Therapies) must be extended to wards.
Star Wards has shown how much change is possible with very modest funding – we’ve had between 1 and 2 members of staff running the project. But we have been limited by our size and funding, especially in our ability to galvanise the wards that are struggling the most. Ideally, in addition to the ward development work that could be achieved, there needs to be a moratorium of bed cuts and an ending to the extravagant insanity of spending millions to send patients, including children, hundreds of miles from home to private sector hospitals.
We know unequivocally that wards can be transformed with no extra resources simply by increasing staff confidence, morale and motivation. By far the most important aspect of patients’ experiences is how nice staff are to them, and all the therapeutic changes that are then possible through effective ‘therapeutic alliance’. The biggest change that can be realistically achieved without it costing Trusts anything additional is for managers to be (much!) more appreciative of staff.
Most of the ideas we collect and promote are small, incremental and no-cost or very low-cost. The vast majority of what the Guardian referred to as our “polite suggestions” require no training for staff (although it is always welcome!) Same team, same patients, same (woefully inadequate) resources. But a very different way for patients and staff to feel and behave.
There are huge benefits (and no financial costs) to abolishing ward rounds and only having one consultant for each ward. The combination of up to 8 consultants and ward rounds means that a ridiculous amount of staff time is sucked into the ritual humiliation that are ward rounds and everything else grinds to a halt, apart from patient boredom and frustration. The block is, of course, that psychiatrists are used to doing things in certain ways. http://www.wardipedia.org/1-consultant-appointments-2/
Ward rounds are daunting, distorting and draining
A women’s secure unit in the north introduced a bunny rabbit – and rates of self-harming fell by 50%. Self-harming is a very fraught issue on wards – staff find it very distressing and the response to an episode is often to place the patient on 1:1 staffing, which is very expensive and greatly disliked by patients.
The benefits to inpatients of having contact with animals go way beyond reducing self-harm. There is a huge evidence base for the therapeutic benefits of pets, including:
- easing loneliness
- reducing stress
- promoting social interaction
- encouraging exercise and playfulness
- providing unconditional love and affection
The Care Quality Commission and the Department of Health have confirmed that pets are indeed allowed on wards but there is a big gulf of awareness and practice, with local health and safety teams egregiously inflicting irrelevant and anti-therapeutic risk criteria from general hospital wards. Enthusiastic backing of pets on wards, along with a tiny amount of money to facilitate this, would make a huge difference to patients and also staff and visitors.
5. Healthcare Assistants
HCAs (or nursing assistants) are the staff who have the most contact with patients, yet an alarming lack of training – often a day or two, mainly focusing on wrestling agitated patients to the ground. The Cavendish Report was an excellent account of the personal qualities and professional skills of HCAs and the Department of Health have agreed to introduce a Certificate of (Fundamental) Care. This is crucial to establishing a consistently expert and confident clinical team and needs to be energetically supported and developed. (Star Wards has created Ward Stars, a professional development and validation scheme for HCAs, requiring no off-ward time or costs, being enthusiastically introduced by Merseycare and other Trusts.)
Because mental health ward staff are the primary treatment for inpatients, their morale and ability to engage warmly and skilfully with patients is the single most important factor in creating truly therapeutic admissions.
There has to be a strong, motivating, effective leadership framework in the NHS. Something where all staff and managers can say: “This is what leadership means for us – staff feeling appreciated, supported, trusted, equipped….” We’re a long way from that at the moment. By far the best leadership model we’ve come across is from Henry Stewart and his Happy Manifesto, which is very much about:
- appointing for attitude and training for skills
- having recruited good staff, they then need to be enabled to use all their skills, through feeling confident, motivated, trusted and equipped
- leaders’ main role is to provide the culture and opportunities for each member of staff to flourish
7. Care Quality Commission
The ‘new’ CQC is excellent – energetically seeking and incorporating views of patients and relatives and starting to increase the amount of sharing of great practice. They are the one organisation which has a detailed knowledge of what is working well on wards but currently waste most of this rich information. Most of Star Wards’ work consists of excavating great practice and promoting this across all wards and this has proved really effective. CQC need to be encouraged (or made!) to systematically collect and share in an accessible and motivating way the thousands of examples of great practice which other wards could adopt. (Other regulators do much more to promote great practice.)
8. National network of mental health inpatient experts
This is very unsexy but exceptionally important. Mental health inpatient care is highly complex, risky, expensive and not yet consistently therapeutic. There was an excellent national and regional network (run by NIMHE and then CSIP) but shockingly it was axed. There is now no forum or network or structure for mental health inpatient experts to share challenges, developments, innovations, research findings etc. This is a very dangerous and wasteful gap and would cost very very little to rectify.