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The Royal College of Psychiatrists Improving the lives of people with mental illness

Northern Ireland CPD Blog

Reflecting on Confidentiality and Communicating with Families or Carers

Dr May McCann (Central Carers' Forum member & Chair of CAUSE)

31 January 2018

It was interesting to attend the recent ‘Working towards Improvement’ RQIA and RCPsych workshop; the final presentation motivated me to explore a little the current environment in relation to ‘confidentiality’ and reflect on its College history.

 

It was a privilege to hear the dignified, measured ‘personal perspective’, of Hamish Elvidge (pictured third from right below) recounting the health service’s ‘tick-box’ risk assessment, devoid of family involvement, that preceded his son Matthew taking his own life. ‘And they didn’t look into Matthew’s eyes…’ The response of the family, on the other hand, has been impressive.  ‘As is so common, we (the family) were not fully aware of the depth of his depression and how to help.  We therefore do as much as we can to help others who are, or may be, in a similar situation, by increasing the awareness of depression and other mental health issues and, we hope, preventing other young people from taking their own lives.

 

RQIA College 2018

 

 

 

 

 

 

Hamish Elvidge (pictured third from right ) 

 

 

 

 

In 2010 they established, covering all running costs, the Matthew Elvidge Trust, funded by events organised by supporters - they are currently Fleet M&S charity of the year. In a five-year period, the trust raised over £300,000, supporting selected projects and activities including bereavement support.  It works in partnership with related charities and sits on government advisory bodies in the Departments of Health and Education.  In 2014, the National Suicide Prevention Strategy Advisory Group, of which Mr Elvidge is a member, developed the ‘Consensus Statement’ (Information Sharing and Suicide Prevention: Consensus Statement, 2014), which makes it clear that the duty of confidentiality is no justification for not listening to the views of family members and friends, who may offer insight into the individual’s state of mind. It is about allowing for greater disclosure to families at times of risk and has been signed up to by the Department and Professional bodies. The document is, for good reason, somewhat legalistic in tone, devoid of the human touch which is the ‘touchstone’ of effective practice. In his presentation, Hamish Elvidge suggested a different way of communicating the consent question….a conversation…...

 

One way is to say “Do we have your consent to share information with a family member, friend or colleague?” The chances are that the answer will be, “No.” Or you could say, “In our experience, it is always much better to involve a family member, friend or colleague whom you trust in your treatment and recovery, and we know the triangle of care is likely to result in a greater chance of successful recovery. This will result in you recovering much quicker. Would you like us to make contact with someone and would you like us to do this with you now?

 

Concern about the increasing suicide rate is a driver in the current iteration of the consent discussion, which includes an awareness that families should be viewed as potential partners in suicide prevention. Some examples are: ‘Sharing Information to save lives’ (the title of Hamish Elvidge’s presentation), Simon Wessely’s Blog, ‘Confidentiality In The Context Of Suicide Prevention’ (2016), ‘Breaching patient confidentiality sometimes necessary to prevent suicide, say eminent psychiatrists’, a press statement from the International Congress (2017). 

 

I was glad to see the latter reference the ‘Carers and Confidentiality’ booklet, part of a raft of excellent materials, including leaflets and a training resource, emanating from the 2004, ‘Partners in Care’ campaign, (RCPsych and Princess Royal Trust for Carers). The then ex-President, Mike Shooter, was significantly involved, as were some great women from the Carers’ Forum. Confidentiality, a number one issue for carers then as now, was part of the section on Communication, one aspect of ‘working together to make a real difference’. There was no specific suicide focus.  I’ve used Partners in Care materials as teaching aids in many contexts, including MRCPsych and, with permission, the confidentiality booklet and another Partners in Care leaflet are available on the CAUSE website.

 

‘Carers and Confidentiality’ provides a useful explanation, for carers, of the ethical and legal issues faced by professionals in relation to consent - a list of barriers to sharing information and examples of good practice.  These include discussing confidentiality with patients at an early stage when they are not acutely unwell, encouraging patients to understand the benefits of sharing appropriate information with carers, recording discussions/views on confidentiality in patient’s notes to allow for continuity, revisiting the issue, encouraging the use of advanced directives. It reminds professionals that even when the patient continues to withhold consent, carers should be given sufficient knowledge to enable them to provide effective care, the opportunity to discuss any difficulties they are experiencing in their caring role, help to try and resolve these and general information about mental illness and about emotional and practical support for carers.  None of this involves a breach in confidentiality.

 

Despite the tragic reasons behind the current interest in confidentiality, it is important that the issue is now aired so publicly. However, already the House of Commons Health Committee is concerned at the lack of movement on ‘the Consensus Statement’ after three years.  There is commitment from the College to take it forward, hence, I suppose, among other things, the selection of guest speaker at the recent RQIA/RCPsych workshop.  But it is concerning to reflect on how long it is since the Partners in Care campaign which, at the time, gained widespread interest ‘with requests from all over the UK, the USA, Canada and Australia.

 

If communication with families/carers remains a problem, it is difficult to see how our forthcoming Mental Capacity Act will work as intended.  The rights of the ‘nearest relative’ will be gone, which, regarding the role of ‘applicant for assessment’, could be very detrimental to family/friend relationships. Carers, as well as professionals, face problems with information sharing. While they can be the first to notice worrying changes, their contacting professionals can be interpreted as a breach of trust and confidentiality.  In the new Act there are more positive potential roles for ‘carer’ involvement - in supporting decision making, in determining best interest, as possible ‘nominated person’ - and, if one has not been appointed, ‘carer’ is first on the default list, preceding specified family roles. I look forward to participating in the College’s forthcoming event on Mental Capacity legislation in the Waterfront in March.

 

Next month I attend my first session at the newly structured Carers’ Forum in London. In preparation, I need to write a brief report on the last meeting of the Special Committee on Human Rights (SCHR), to which I was recently appointed. It is strange to be sitting on a Committee with people whose work so informed discussions during the Bamford Review - Genervra Richardson and George Szmukler, who is Chair. As requested, I prepared a brief paper on the background to our Mental Capacity legislation. Discussion of the review of mental health legislation was obviously on the agenda and we have just finished responding to the draft position paper on the human rights case for significant reform of the Mental Health Act which George Szmukler is preparing. It should be available very soon.

 

Promoting Positive Practice in Capacity Assessment

Dr Liz Dawson

23 November 2017 

The Law Society of Northern Ireland's Inaugural Elder Law Conference 2017

The inaugural Elder Law conference was held at Law Society House in Belfast on the 17 November 2017. 

 

Organised by the Law Society of Northern Ireland, in association with Step NI and Age NI, this is the first time a conference has brought together representatives from the RCPsych NI Psychiatry of Old Age Faculty and legal professionals working in Northern Ireland. 

 

This important conference was extremely timely given that the Mental Capacity Act (NI) 2016 has recently been awarded Royal Assent, paving the way for implementation by 2020 if all goes to plan. 

 

The conference attended by legal and psychiatric professionals provided the opportunity to have a realistic look at the groundbreaking new legislation whilst also addressing some of the potential challenges ahead for both professions.

 

From discussion, it soon became clear that both legal professionals and psychiatrists have their clients or service user’s best interests in mind when undertaking assessments relating to capacity. 

 

The underlining message from the conference was the need for a joined up approach between the legal and medical professions to develop a culture of co-operation and shared learning.

This will undoubtedly assist with improving communication and promote good medico-legal practice for service users and clients with mental illness and capacity issues.

 

Those attending the conference had an opportunity to hear from a number of key speakers including,

 

  • Ian Huddleston (President of the Law Society Northern Ireland);
  • Linda Johnston (Solicitor representing STEP NI);
  • Doctor Julian Sheather, (Specialist Advisor Ethics and Human Rights, BMA); and
  • Doctor Barbara English (Consultant in Psychiatry of Old Age and Clinical Lead for Psychiatry in the BHSCT). 
  • Eddie Lynch (Commissioner for Older People in NI) was also present on the discussion panel.

All of the speakers provided an excellent insight into the psychiatric and legal challenges of capacity assessment, and the Commissioner for Older People, Eddie Lynch, alarmingly emphasised the growth of recorded financial abuse cases among older people in NI. 

Recent statistics show that 1 in 5 older people have been subject to some form of financial abuse over the past 12 months in the province, which is a sobering figure.

Dr Barbara English

 

Doctor English also provided some excellent advice on examples of good (and bad!) capacity assessments, with an emphasis on the provision of clear legal instruction regarding medical advice required.  She also highlighted the importance of obtaining adequate background psychiatric and medical history, and also relevant social history as all the above factors may have a bearing on capacity.

 

From the legal perspective, there was also some excellent advice relating to avoidance of duress and undue influence during capacity assessment.  The importance of concise medical record keeping was emphasised, for example by recording observations as to where and when a service user is assessed, and also noting the quality of interaction between the service user and any associates present during the interview process.

 

The Conference was very well received by both the psychiatry and legal professionals in attendance and it is anticipated that the conference will provide a foundation on which to further develop and build  relationships between both professions in the coming years. 

 

Finally the Law Society of Northern Ireland have established an Elder Law Group of legal professionals and they have been working to identify opportunities to build and further develop relationship with other professionals including colleagues from the Psychiatry of Old Age arena.  If interested please email info@lawsoc-ni.org

 

Rising Mortality Among UK Addicts - the NI Experience

Dr Billy Gregg

12   June 2017

The Royal College of Psychiatrists  hosted  a Public Mental  Health Conference Rising Mortality among UK addicts at  their headquarters in Prescott Street London  on Monday  22 May  2017 at  which representatives from all of   four UK  countries presented their regional data on deaths attributable to  substance  use.

 

Professor Colin Drummond highlighted at the meeting and subsequently in the BMJ that changes to the commissioning of alcohol and drug services in England had resulted in a serious loss of expertise, resources, and training posts within the NHS.  There is some emerging evidence that service providers for addiction services outside the NHS may be struggling to meet the needs of more complex patients.

 

In 2015 drug related deaths across the UK were the highest ever recorded, with most deaths being primarily linked to opiods or cocaine use, often used in combination with other drugs including alcohol.    During 2015 there were 258 recorded drug related deaths plus deaths due to drug misuse across Northern Ireland (NI).   

 

There was a significant rise in alcohol related deaths in 2015 (310) in NI, approaching the relative death rates in Scotland and substantially higher than the rates in England or Wales.   

Around 2,300 people die from smoking related illnesses in NI each year. 

 

Deaths from alcohol or drug use are commoner in males and in areas of social deprivation across the UK.

 

Some of the increase in drug related deaths has been linked to the failing health of an ageing cohort of UK drug users.  Other possible explanations include a shift towards more risky drug use, the use of more potent opiods drugs, such as fentanyl or the use of new psychoactive substances or lack of access to high quality addiction treatment services.   Suicide may also be a factor.

 

The most recent Confidential Inquiry into Homicides and Suicides (2016) reported that NI had the highest rates of suicide in the UK.  It also noted that “over half the patients who died by suicide had a history of alcohol or drug misuse. There were national differences, with alcohol misuse a more common antecedent of suicide in Scotland and Northern Ireland.   This inquiry also found that opiods were the most likely drugs to be used in fatal self-poisoning.

 

Northern Ireland has the highest relative prescription rates in the UK for most opiods as well as for pregabalin and gabapentin and this is contributing to our particularly striking levels of prescription drug misuse.  Pregabalin misuse is now a serious problem and has been linked to deaths in individuals, particularly in those who are also using opiods or other sedatives.

 

Key Points

1. Drug and alcohol services need to be adequately funded to provide a comprehensive range of services across statutory, voluntary and community sectors to meet the needs of service users, some of whom are getting older and who have complex comorbidities.

 

2. More care is required when prescribing opiods and gabapentenoids and particularly those with a history of substance use or mental health disorders.  These drugs should be prescribed in limited amounts and the benefits and risks of prescribing these medications should be kept under review.   Prescribing high dose opiods for chronic non-cancer pain (pain lasting more than 3 months) is not supported by the current evidence. 

 

3.  Mental  health, Addiction Service and Primary  Care Services need to  develop integrated care pathways which  ensure the physical  and mental  health  disorders in individuals who  misuse alcohol  or drugs   are being addressed.  

 

For more information please contact Dr Billy Gregg, Consultant in Addiction Psychiatry. billy.gregg@northerntrust.hscni.net

 

 

 

 

 

 

 

 

 

 

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Welcome to our local academic blog. If you would like to contribute to this blog, please email Nora.McNairney@rcpsych.ac.uk

 

Dr Barbara English and Group 1 informal

Dr English with presenters at Law Society's Conference on Elder Law

Speakers at Elder Law Event

L-R: Linda Johnston, Dr Julian Sheather, Ian Huddleston, Eddie Lynch, Dr Barbara English