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

Chair's Blog

March 2018

Guest Blogger Dr David Bell reflects on the National Confidential Inquiry into Suicide and Homicide (NCISH) Meeting at Stormont Pavilion on 12 March 2018 following his attendance at same on behalf of Dr Gerry Lynch; Guest Blogger Dr Keira Walsh reflects on the Spring Conference at Belfast Waterfront Hall on 22 March 2018 which took the Mental Capacity Act (Northern Ireland) 2016 as its focus.

Professor Louis Appleby, Prof Nav Kapur and Cathryn Rodway (NCISH) joined local cross-sector clinical colleagues alongside representatives from RCPsychNI, HSCT regions, DoH and PHA in a meeting to share expertise on safety of Mental Health Care in Northern Ireland by contributing from a UK wide perspective.

They began by presenting summary findings from the most recent NCISH report (2017) highlighting NI figures in comparison to UK data. In particular it was reflected that NI continues to display the highest UK rate of suicide which persists despite recent falls in England, Scotland and Wales. The proportionate areas of greatest difference are the peak rates in younger people, rising steadily from teenage years, in comparison to early middle age in other regions.  Another key difference relates to the higher rates of associated alcohol and drug misuse observed locally. Recent trends include a rise in self-poisoning deaths, especially opiate based and risk to specific groups such as sole carers. Inpatient suicides remain uncommon, predominantly during permitted leave, and post-discharge remains a time of heightened risk (peak day 4). 

 

Topics for debate during subsequent discussion included the value of personalised risk management over generic assessment tools, recognising that lower rates in those deemed high risk may reflect high quality care responses. Addressing apparently ‘lower risk’ categories as a key opportunity to reduce patient suicides requires focus on the ‘health of the organisation’ by building safety into the care system itself and supporting areas of weakness.  Recent interest in the ‘Zero Suicide’ campaign was discussed in a balanced manner which recognised the need for caution in message delivery (aspiration verses target) alongside the positive aspects of raising public and political awareness. The variable quality of SAI reporting was commented upon with tendency to become process focussed at the expense of losing sight of true understanding and service delivery models were also considered with respect to the functionalisation of services which service user feedback suggests may be perceived as disrupting continuity of care.

 

The recent fall in Scottish rates was touched upon with respect to their whole system approach of developing regional and localised initiatives combined with strengthening dual diagnosis services and supported by political buy-in. The opportunity to similarly improve by broadening ownership in NI was noted.

 

Gerard Collins (DoH) then provided a presentation on the Protect Life 2 strategy draft which is awaiting ministerial clearance and executive approval having gone through consultation process. Despite this delay approval has been given for prospective procurement to proceed in order to expedite its introduction. Key aims for this strategy are to reduce the suicide rate in NI by 10% by 2022 and to target at least 75% associated financial investment to deprived areas. Sitting alongside the Programme for Government Mental Health and Wellbeing and ‘Making Life Better’ agendas which encompass social determinant factors the strategy sets out 14 objectives which align with NCISH recommendations. Action points to date include multi-sector community training, streamlining of governance, structured support for bereaved families and development of a specialist Trauma service. Enhancing local community capacity to prevent and respond as well as increasing accessibility to de-escalation services are priorities. Protect Life representatives in each HSCT will link in with local services and communities.

 

This meeting proved to be a productive collaboration of idea sharing which demonstrated clear evidence of a joint commitment to reduce suicide rates in Northern Ireland supported by our contribution to, and feedback from, the NCISH. In an upcoming change RQIA will now take over the initial stages of data collection before feeding into the national system.  Prof Appleby reflected on the strong data collection and research base present and expressed his encouragement for local clinicians to contact his team with additional suggestions on how to maximise the partnership with NCISH to achieve greater understanding. 

 

The take-home message emphasised the fundamental importance of developing safer systems of working and recognised that the relatively high rate in NI holds a significant potential for impacting change with the right interventions. With Protect Life 2 now on the horizon we have a further opportunity to initiate this change across an array of individual, systems and societal levels through collaborative working and a shared aspiration to improve.   

 

The NCISH continue to promote awareness of safer mental health care via their annual publications, social media presence and audit tool kit which is available for download. Current and future projects include an examination of risk assessment tools, mapping of UK substance misuse services and detailed focus on suicide in middle age.  Find out more about the NCISH.

 

Authored by Dr David Bell
ST6 GAP/Medical Psychotherapy

 

Belfast Waterfront

 

 

 

 

 

 

Dr Gerry Lynch welcomed and introduced a day of thought provoking presentations from a variety of experts and professionals. College President Professor Wendy Burn chaired the morning session which began with an informative journey through the history of the development of the MCA (NI) 2016 from Professor Roy McClelland. This generated good discussion from the audience and provided a platform for the day’s content.

 

This was followed up by an entertaining talk from Dr Tony Zigmond who joined us from England. He highlighted the issue of unwise but capacitous decision making, how uneasy we feel about this as a specialty and how the MCA (NI) 2016 impacts on this. The general feeling from him was that NI is leading the way in the UK in terms of capacity legislation and enabling autonomy.

 

Dr Julian Sheather (BMA) recommenced proceedings after coffee emphasising the ethical issues involved in the new legislation. He addressed some specific concerns from the audience.

 

A very helpful simplified outline of the draft code of practice was provided by Taryn McKeen from the DOH. This was made relatable by providing various scenarios about what constitutes deprivation of liberty and how the new legislation should be utilised in practice.

 

The conversation and debate continued among the audience during lunch and we returned for the afternoon session chaired by Dr Gavin Davidson.

 

We heard an eloquent story of recovery within services from Catherin Harper BL and her positive views on what the MCA (NI) 2016 could mean for service user/patient experience.

 

The latter portion of the day was dedicated to clinical scenarios about the use of the legalisation in daily practice across multiple specialities within psychiatry. This involved general opinions from some specialities and the challenges the are expecting to face. It was helpful to hear from the panel about how to manage certain scenarios. A lot of conversation and debate was generated during this portion of the day but as there were several different scenarios the time for discussion was limited.

 

As a whole the seminar was successful, and it was interesting to be able to hear from the speakers about how the new legislation may work in practice. We were provided with a lot of thinking points and topics to be considered over the coming months.

 

Authored by Dr Keira Walsh
LAT4, General Adult Psychiatry

 

February 2018

Gerry etc

It’s been another busy month! The attached report reflects the high level of activity and engagement of College members in very many different areas. Very many thanks, as always, to all those who put in so much time and effort to promote the voice of the College and the profession. 

The trip to Westminster was a very valuable opportunity for me to raise the  problems faced by mental health services in a collaborative way and I would like to express my thanks to the Mental Health Foundation and Action Mental Health for organising the event. The fact that most of the Northern Ireland MPs were there, despite all the other pressing political problems that were facing them, indicates to me that there is a real intention on the part of our elected representatives to work to improve mental health and the services for the mentally ill here. The meeting in Dublin with our colleagues in the College of Psychiatrists of Ireland clarified that the problems we face are not unique to us.

Gerry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This month, we have the President’s lecture (the first time it’s been held outside London) and the Spring Conference (focusing on the Mental Capacity Act (NI) 2016) to look forward to. Please keep an eye on the College website and support all the events as much as you can.  Any comments, thoughts or suggestions are very welcome.  I’d especially be interested in your thoughts on the scenarios concerning the Mental Capacity Act (NI) 2016. Our input as a profession into the Code of Practice and the accompanying scenarios will be vital if the Act is to work effectively.

Looking ahead, details of our Masterclass programme will be issued shortly, but at this stage please save the dates of 20 & 21 September - our PIPSIG colleagues are compiling a programme that will be of interest to all. Trainees are encouraged to submit their preliminary entries by 22 June 2018  for the Thomas Freeman Award and our Research, Audit and QI Presentation Day, and also please note that entries for the 2018 RCPsych Awards close on 31 March 2018.

 

Gerry

January 2018

Guest Blogger Dr May McCann (Central Carers' Forum member and Chair of CAUSE) reflects on "Confidentiality and Communicating with Families or Carers" following her attendance at the joint RCPsych in NI & RQIA event at Belfast Castle on 19 January

 

RCPsychNI and RQIA

 

It was interesting to attend the recent ‘Working towards Improvement’ RQIA and RCPsych workshop during January (despite the falling snow!); 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.

 

Joint event with RQIA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

 

Authored by Dr May McCann

 

 

 

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Dr Gerry Lynch

 

Dr Gerry Lynch, Chair RCPsychNI

President's Lecture,

21 March, 

Riddel Hall, Belfast

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Spring Conference on MCA (NI) 2016, 22 March,

Belfast Waterfront

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