1. health and fitness
2. disorders
3. mental disorder
4. depression

Depression Pathway
LCFT localised Map pathway
June 2009
Instructions:
Instructions:
Throughout this pathway if you click on
the Bookmarks tab to the left of the
screen and then click on the various
documents you will find additional
information to explain the steps in the
process
People may enter the pathway at
different steps, depending on severity
and previous history. Within the steps,
there are choices for people about the
type of treatment that suits them best. It
is a needs led process; people may
move directly to the appropriate level
and move between levels, to suit their
needs.
Presentation of Depression in
Primary Care Box 1
Screening
e
Nic 6
pg
Box 2
KEY
Step 1
Assessment
Box 3
Step 2
Patient Education
Box 4
Step 3
Step 5
Where mild depression
persists after other
interventions or is
associated with
psychosocial and medical
problems, or if a patient
has a history of moderate
or severe depression and
presents with mild
depression. Consider
move to Step 3 moderate
to severe depression
Box 6
Possible treatment
options
Box 7
Watchful Waiting
Box 8
e
c
i
N 7
pg
Signposting
Box 15
Sleep & Anxiety
Management
Box 16
Exercise
Box 17
e
Nic 7
pg
Guided self help
Box 18
e
Nic 7
pg
e
Nic 7
pg
Further assessment
after 2 weeks
Box 9
Improving
Box 10
Consider another
Step 2 Option
Box 14
Discharge
Box 13
Treatment of Moderate
Depression
Box 21
Treatment of Severe
Depression
Box 22
Social
Interventions
Box 20
Consider referral/joint
working with Specialist
Mental Health Services Box
24
Treatment options
(consider patient choice)
Box 23
e
Nic 8pg 0
1
Anti depressant medication
(in moderate depression offer anti
depressant medication routinely before
psychological interventions
Box 25
Psychological
Interventions also
consider MBCT
(mindfulness based
cognitive therapy)
Box 19
e
Nic 7
pg
Throughout the Step 2 process, use
clinicaljudgement and patient choice to decide
the number of Step 2 options to try before
considering a move to Step 3. Consider a move
to Step 3 if:
Two interventions have been tried at Step 2 with
no improvement
One intervenetion has been tried with no
improvement and there are employment/
accommodation issues or physical health is at
risk
Completely improved
Box 12
Further assessment
after 2 weeks
Box 11
Consider move to
Step 3
Moderate or
Severe
Depression
Throughout the pathway continued to consider:
Risk review and management as indicated by the needs identified
Safeguarding Children and Protecting Vulnerable Adults
Support Needs of Carers and family
Socially Inclusive Practice
Consider identifying occupational need
Treatment of mild
depression
Box 5
Step 4
e
Nic 11
pg
Combination of Antidepressant medication and
individual CBT
(in severe depression a combination should be
considered as it is more cost effective than other
treatments on their own)
Box 26
Treatment of depression by mental health specialists Box 27
Referral received at single point of access Box 28
Allocation of care co-ordinator Box 29 See ECPA Policy bookmark
Full Assessment Box 30
e
Nic 12
pg
Severly depressed and at risk of self harm or suicide Box 31
Depression.vsd
No
Box 32
Discuss diagnosis and treatment options with the
patient with a view to gaining agreement about the
treatment plan Box 35
Yes
Box 33
Straight to Step 5
Box 34
e
Nic 13
pg
Psychotic
Depression
Box 36
e
Nic 12
pg
Treatment Resistent
Depression
Box 37
Inpatient Care via Crisis/Home
Treatment Teams
Box 40
e
Nic 14
pg
e
Nic 13
pg
Recurrent
Depression
Box 38
Atypical
Depression
Box 39
e
Nic 13
pg
If individual refuses treatment
consider assessment under
Mental Health Act
Box 41
1
Pathway Principles
We will work in partnership with service users and their carers to support them in
remaining as well as possible and in maintaining and improving their health and quality of
life. Our services will focus on mental wellbeing as well as mental ill health.
People with mental health problems have the same rights as other citizens. In particular,
they have the right to be consulted and actively involved in the planning of their care,
regardless of their level of disability.
The service will, at all times, treat individuals with dignity and respect. This involves:
x
Being sensitive to issues of age, gender, race, disability and sexual orientation.
x
Respecting the rights of the individual and separate rights of carers and addressing
these rights separately, or together with, the cared for person.
x
Promoting wellbeing through inclusion and independence
x
Developing opportunity through learning and providing information.
x
Working in partnership with service users and their carers
x
Offering treatment and care with hope and optimism.
x
Taking time to build supportive and empathic relationships
The stepped care model.
In line with NICE Guidelines, this pathway is presented within a stepped care framework
that aims to match the needs of individual people with depression to the most appropriate
services, depending on the characteristics of their illness and their personal and social
circumstances.
Each step represents increased complexity of intervention, with higher steps assuming
interventions in previous steps remain relevant.
People enter the clinical pathway at different steps, depending on severity and previous
history. Within steps, there are choices for people about the type of treatment that suits
them best. It is a needs led process; people may move directly to the appropriate level
and move between levels, to suit their needs.
Step 1: Recognition in primary care and general hospital settings
Step 2: Treatment of mild depression in primary care
Step 3: Treatment of moderate to severe depression in primary care
Step 4: Treatment of depression by mental health specialists
Step 5: Inpatient treatment for depression
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Page 1 of 3
Things to take into consideration when using this map.
This map should provide a useful reference for professionals in the diagnosis and
treatment of depression. However, these guidelines do not override the individual
responsibility of health professionals to make decisions appropriate to the circumstances
of the individual patient, in consultation with the patient and, if appropriate, their carers or
independent mental health advocate.
Depression in Children
These guidelines do not address the assessment or treatment of children/young people
under the age of 18 with depression.
Older Adults
These guidelines can be used with older adults, with specific differences in assessment
and treatment being taken into account.
Bipolar Disorder
Also known as Manic Depression, Bipolar Disorder is an illness that affects mood,
causing a person to switch between feeling very low (depression) and very high (mania).
Treatment of Bipolar Disorder is not covered by these guidelines. Check for history of
hypomania in all adults presenting with depression.
Co-morbidities
Psychiatric and other co-morbidities (e.g. physical illness) need to be taken into
consideration when following these guidelines. When symptoms of depression are
accompanied by symptoms of anxiety, the first priority should usually be to treat the
depression. Consideration needs to be given to depression as a possible side effect of
current medication.
Competency Level
Consideration must be given to the level of competency required to deliver effective care.
Capacity to Consent
The capacity of the person to consent to treatment should be assessed each time a
change is being considered. An individual is presumed to have the capacity to make an
admission and/or treatment decision unless s/he, on the balance of probabilities, is
unable to:
• Understand and believe the main elements of their treatment plan; and/or
• Retain such information for long enough to make a judgment about it; and/or
• Weigh such information in the balance; and/or
• Take and communicate an informed choice regarding it.
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Page 2 of 3
Early Detection and Recognition of Depression
x
x
x
x
x
x
x
x
x
x
The socially isolated
Those with ongoing relationship problems
Past history of depression
Family history of depression
Anticipated or actual adverse events
Concurrent physical illness (particularly chronic conditions)
Women up to 12 months post childbirth (Ten percent of new mothers are
likely to develop a depressive illness)
Drug and alcohol misusers
Care home residents
Men aged over 75 years
Presentations of Depression
x
x
x
x
x
Vague physical symptoms – tiredness, aches and pains, poor sleep, weight or
appetite change, poor concentration
Repeated consultation for minor physical symptoms
Patient whose symptom severity/disability is out of proportion to its causes
Social dysfunction – drug/alcohol use, relationship failure, anger, aggression,
frequent absence from work
Bonding difficulties
Suicide Risk
x
x
Suicide risk is not solely dependent upon a diagnosis of depression. For
example, amongst young people experiencing their first onset of untreated
psychosis 20 to 30% are a danger to themselves or others, including suicide
attempts
The possibility that the person is at risk of suicide should be fully assessed in
the presence of known high risk factors
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Depression Pathway
Guidance Notes
Box 1
Presentation
Individual presents in a primary care location for example, GP surgery etc
Box 2
Screening
NICE guidance recommends primary care routinely screens certain high risk groups
x Patients with significant physical illness
x Patients with other mental health problems, such as dementia
x Patients suffering major life events, eg. Childbirth, long-term/recent unemployment and
bereavement
x Patients with a history of relationship difficulties and physical, sexual or emotional abuse
Screening questions:
During the last month have you been bothered by feeling down, depressed or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing
things?
Box 3
3a Assessment and categorization
If screening identifies a possible depression, a more comprehensive assessment must be
conducted. The assessment should involve standardized measures of:
x Severity of depression; mild, moderate or severe
x Risk: patients with depression should always be asked directly about suicidal thoughts and
intent
x Other relevant psychosocial factors:
o Previous mental health problems including treatment and outcome
o If history of hypomania see NICE Guidelines for Bipolar/Affective Disorder
o Family history of mental health problems
o Associated disability (ask how the patient is when s/he is well
o Availability of social support
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o Social problems (family disputes, financial, employment)
o Alcohol and drug use
x Ruling out of other causes (testing of thyroid function)
x Checking for Seasonal Affective Disorder (clear seasonal pattern).
3b Assessment
This may be most appropriately done by the GP but could be completed by a variety of
appropriately trained health professionals, eg Health Visitor
3c Factors
Assessment must take into account that depression can present differently in different groups:
eg young/old men/women, ethnic groups etc.
Older Adults:
x Older adults are more likely to report altered sleep, loss of appetite, agitation and somatic
complaints. They are less likely to express low mood and suicidal intent
x Depression may appear as dementia due to poor nutrition or other physical condition
x Key symptoms for older adults might include complaints that memory is poor, and somatic
complaints
x Associated symptoms for older adults might include negative and nihilistic thoughts,
withdrawal and disengagement
3d Key Symptoms
x
x
x
Persistent sadness or low mood
Loss of interests or pleasure
Fatigue or low energy
At least one of these, most days, most of the time for at least 2 weeks
3d Associated Symptoms
x
x
x
x
x
x
x
Disturbed sleep
Poor concentration or indecisiveness
Low self-confidence
Poor or increased appetite
Suicidal thoughts or acts
Agitation or slowing of movements
Guilt or self-blame
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Box 4
Patient Education
There is a need for discussion with the patient about diagnosis and treatment options, with a
view to gaining agreement about the treatment plan. This will involve:
x Consideration of the person’s capacity to consent
x Feedback to patient on the outcome of the assessment
x Providing patient information leaflets and other sources of information (eg. NHS Direct
website, Patient Advice and Liaison Service, NICE Patient Information Leaflet, Beyond Blue
website)
x Discussing treatment options
x Give patient information on who to contact if they have questions or concerns
x Consideration of any advance directives/statements or other expression of patient choice
x Provide information on recovery statistics
Box 5
Mild depression
x
Has four symptoms including at least one key symptom
Box 6
No further information.
Box 7
Possible treatment options – mild depression
x
x
Consider patient choice and availability
Arrange follow up to monitor progress (telephone follow-up reduces workload and can
almost double remission)
If post natal consider health visitor support
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Box 8
Watchful waiting
x
x
For individuals who do not want to have an intervention
The health professional thinks the individual will recover without an intervention
Box 9
Further assessment after 2 weeks
Box14
No additional information
Box 15
Signposting
Help the individual to find appropriate local or national statutory or voluntary organizations,
depending on cause of depression and contributing factors
Box 16
Sleep and Anxiety Management
x
x
Look at lifestyle habits not conducive to sleep
Refer to NICE Guidelines for anxiety managment
Box 17
Exercise:
Advise patients of all ages with mild depression of the benefits of following a structured and
supervised exercise programme. Effective duration of such programmes is up to 3 sessions per
week of moderate duration (45 minutes to 1 hour) for between 10 to 12 weeks.
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Box 18
Guided Self Help
For patients with mild depression, consider a guided self-help programme that consists of the
provision of appropriate written materials and limited support over 6 to 9 weeks, including follow
up, from a professional who typically introduces the self-help programme and reviews progress
and outcome.
Box 19
Psychological Interventions:
x
x
x
x
In mild and moderate depression, consider psychological treatment specifically focused on
depression (problem-solving therapy, brief CBT and counseling) of 6 to 8 sessions over 10 to
12 weeks
Offer the same range of treatments to older people as to younger people
In psychological interventions, therapist competence and therapeutic alliance have significant
bearing on the outcome of intervention
Where significant co-morbidity exists, consider extending treatment duration or focusing
specifically on co-morbid problems
Box 20
Social Interventions:
Social Services, Citizen Advice Bureau, Housing, Community work etc
Box 21
Moderate Depression:
Has 5-6 symptoms including at least 1 key symptom
Box 22
Severe Depression:
Has over 7 symptoms including at least 1 key symptom
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Box 23
Possible Treatment Options:
x
Consider patient choice
Box 24
Consider referral and joint working with specialist mental health services if:
x
x
x
x
High risk of suicide or self-harm, or
Significant degree of functional impairment
Presence of significant physical or psychiatric co-morbidity
Medical history suggests referral to secondary care as the most appropriate step
Box 25
Antidepressant medication
x In moderate depression offer anti depressant medication to all patients routinely before
psychological interventions. Refer to NICE Guidance, Page 8-10)
Box 26
Combination of anti depressant medication and individual CBT
x When individual presents initially with severe depression, a combination should be
considered as it is more cost effective than either treatment alone, (NICE Guidance, page
11)
Box 30
Step 4: Treatment by depression by mental health specialists including crisis teams
x Assess patients with depression referred to specialist care, including their symptom profile
and suicide risk and, where appropriate, previous treatment history. Where the depression
is chronic or recurrent, assess psychosocial stressors, personality factors and significant
relationship difficulties as well
x Consider re-introducing any previous treatments that were inadequately delivered to
adhered to
x Crisis resolution teams should be used as a means of managing crises for patients who
have severe depression and are assessed as presenting significant risk
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x Medication in specialist services should be initiated under the supervision of a consultant
psychiatrist
Full Assessment
x
x
x
x
Symptom profile
Suicide risk
Consider social factors
Consider carer needs
Box 32-34
No additional information
Box 35
Discuss diagnosis and treatment options with patient, with a view to gaining agreement about
the treatment plan. This will involve:
x
x
x
x
x
Feedback to patient on the outcome of the assessment
Provide patient information leaflets and other sources of info (eg NHS Direct website)
Discussing treatment options
Give patient information on who to contact if they have questions or concerns
Consider any advance directives/statements or other expression of patient choice
Box 36
Special considerations
Psychotic depressions
x
For patients with psychotic depression, consider augmentation of the current treatment plan
with antipsychotic medication
Box 37
Treatment-resistant depression:
x
For all people whose depression is treatment resistant, consider the combination of
antidepressant medication with individual CBT of 16-20 sessions over 6 to 9 months
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x
For patients with treatment-resistant moderate depression who have relapsed while taking, or
after finishing, a course of antidepressants, consider the combination of antidepressant
medication with CBT
x
Consider a trial of lithium augmentation for patients whose depression has failed to respond
to several antidepressants and who are prepared to tolerate the burdens associated with its
use
x
Before initiating lithium augmentation carry out an ECG
x
If venlafaxine has not been used before, it may be considered for patients whose depression
has failed to respond to two adequate trials of alternative antidepressants. The dose can be
increased up to BNF limits if required, provided patients can tolerate the side effects. See
step 3 for prescribing advice
x
Consider augmenting an antidepressant with another antidepressant (there is evidence for
benefits of adding mianserin or mirtazapine to SSRIs)
x
When augmenting one antidepressant with another, monitor carefully (particularly for the
symptoms of serotonin syndrome), and explain the importance of this to the patient
x
When augmenting an antidepressant with mianserin be aware of the risk of agranulocytosis,
particularly in older adults
x
Re-evaluate the adequacy of previous treatments and consider seeking a second opinion if
considering using combinations of antidepressants other than mianserin or mirtazapine with
SSRIs. Document the content of any discussion in the notes
x
Consider phenelzine for patients who have failed to respond to alternative antidepressants
and who are prepared to tolerate the side effects and dietary restrictions associated with its
use. Consider its toxicity in overdose when prescribing for patients at high-risk of suicide
x
Augmentation of an antidepressant with carbamazepine, lamotrigrine, buspirone, pindolol,
valproate or thyroid supplementation is not recommended in the routine management of
treatment-resistant depression
x
Consider referring patients who have failed to respond to various strategies for augmentation
and combination treatments to a clinician with a specialist interest in treating depression
x
Dosulepin should not be used routinely because the evidence supporting its tolerability
relative to other antidepressants is outweighed by the increased cardiac risk and its toxicity in
overdose
x
There is insufficient evidence to recommend augmentation of antidepressants with
benzodiazepines
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Box 38
Recurrent depression and relapse prevention
Pharmacological treatments
x
Continue antidepressants for 2 years for people who have had two or more depressive
episodes in the recent past and who have experienced significant functional impairment
during the episodes
x
Re-evaluate patients on maintenance treatment, taking into account age, comorbid
conditions and other risk factors in the decision to continue the treatment beyond 2 years
x
Maintain the antidepressant dose used for relapse prevention at the level at which acute
treatment was effective
x
Patients who have had multiple episodes of depression, and who have had a good response
to treatment with an antidepressant and lithium augmentation, should remain on the
combination for at least 6 months
x
When patients are taking an antidepressant with lithium augmentation, if one drug is to be
discontinued, this should be lithium in preference to the antidepressant
Box 39
Atypical depression
x
Consider prescribing phenelzine for women whose depression has atypical features, and
who have not responded to, or who cannot tolerate, an SSRI. Consider its toxicity in
overdose when prescribing for patients at high risk of suicide
x
All patients receiving phenelzine require careful monitoring (including taking blood pressure)
and advice on interactions with other medicines and foodstuffs, and should have their
attention drawn to the product information leaflet
Box 40
Step 5: Inpatient treatment for depression
Inpatient care
Inpatient treatment should be considered for people with depression where the patient is as
significant risk of suicide or self-harm
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Crisis resolution teams should be considered for patients with depression who might benefit from
an early discharge from hospital after a period of inpatient care
Box 41
See Adult Admission/Discharge Pathway
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Issue date: December 2004, with amendments April 2007
Quick reference guide (amended)
Depression: management of
depression in primary and
secondary care
Amendment of recommendations concerning venlafaxine: April 2007
On 31 May 2006 the MHRA issued revised prescribing advice for venlafaxine*. This
amendment brings the guideline into line with the new advice but does not cover other
areas where new evidence may be available. NICE expects to make a decision on a full update
later in 2007.
The revised sections are marked in italics on pages 8, 9,10 and 12 of this quick reference
guide.
*See
www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&useSecondary=true&ssDocName=CON2023843&ssTargetNodeId=389
Clinical Guideline 23 (amended)
Developed by the National Collaborating Centre for Mental Health
Contents
Contents
Which NICE guideline?
3
The stepped care model
3
Key priorities for implementation
4
General principles of care – all steps
5
Step 1:
Recognition of depression in primary care and general hospital settings
6
Step 2:
Treatment of mild depression in primary care
7
Treatment of moderate to severe depression in primary care
8
Step 3:
Step 4:
Step 5:
Special patient characteristics
Limited response to initial treatment in moderate and severe depression
Chronic depression
Enhanced care in primary care
9
10
11
11
Treatment of depression by mental health specialists
12
Treatment-resistant depression
Recurrent depression and relapse prevention
Special considerations
12
13
13
Inpatient treatment for depression
14
Inpatient care
Electroconvulsive therapy
14
14
Grading of the recommendations
15
Implementation
15
Further information
Back cover
This guidance is written in the following context:
This guidance represents the view of the Institute, which was arrived at after careful consideration of the evidence
available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement.
The guidance does not, however, override the individual responsibility of healthcare professionals to make decisions
appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
National Institute for
Health and Clinical Excellence
MidCity Place
71 High Holborn
London
WC1V 6NA
ISBN: 1-84629-402-9
Published by the National Institute for Health and Clinical Excellence
April 2007
Artwork by LIMA Graphics Ltd, Frimley, Surrey
Printed by Abba Litho Sales Limited, London
www.nice.org.uk
© National Institute for Health and Clinical Excellence, April 2007. All rights reserved. This material may be freely reproduced for educational
and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express
written permission of the Institute.
2
NICE Guideline: quick reference guide – depression (amended)
Which NICE guideline?
Which NICE guideline?
What are the patient’s symptoms?
Low mood or loss of interest, usually accompanied
by one or more of the following: low energy,
changes in appetite, weight or sleep pattern, poor
concentration, feelings of guilt or worthlessness
and suicidal ideas?
Yes
Enter depression
guideline
(this guideline)
No
Apprehension, cued panic, spontaneous panic
attacks, irritability, poor sleeping, avoidance,
poor concentration?
Yes
Enter NICE clinical guideline on anxiety (www.nice.org.uk/CG022)
The stepped care model
The recommendations in this guideline are presented within a stepped care framework that aims
to match the needs of people with depression to the most appropriate services, depending on the
characteristics of their illness and their personal and social circumstances. Each step represents
increased complexity of intervention, with higher steps assuming interventions in previous steps.
Step 1: Recognition in primary care and general hospital settings
Step 2: Treatment of mild depression in primary care
Step 3: Treatment of moderate to severe depression in primary care
Step 4: Treatment of depression by mental health specialists
Step 5: Inpatient treatment for depression
Who is responsible for care?
Step 5:
Step 4:
Step 3:
Step 2:
Step 1:
Inpatient care,
crisis teams
What is the focus?
What do they do?
Risk to life,
severe self-neglect
Medication, combined
treatments, ECT
Mental health
specialists, including
crisis teams
Treatment-resistant,
recurrent, atypical and
psychotic depression, and
those at significant risk
Medication, complex
psychological interventions,
combined treatments
Primary care team,
primary care mental
health worker
Moderate or severe
depression
Medication, psychological
interventions, social support
Primary care team,
primary care mental
health worker
Mild depression
GP, practice nurse
Recognition
Watchful waiting, guided self-help,
computerised CBT, exercise, brief
psychological interventions
Assessment
NICE Guideline: quick reference guide – depression (amended)
3
Key priorities for implementation
Key priorities for implementation
Screening in primary care and general hospital settings
• Screening should be undertaken in primary care and general hospital settings for depression in
high-risk groups – for example, those with a past history of depression, significant physical
illnesses causing disability, or other mental health problems such as dementia.
Watchful waiting
• For patients with mild depression who do not want an intervention or who, in the opinion
of the healthcare professional, may recover with no intervention, a further assessment should
be arranged, normally within 2 weeks (‘watchful waiting’).
Antidepressants in mild depression
• Antidepressants are not recommended for the initial treatment of mild depression, because the
risk–benefit ratio is poor.
Guided self-help
• For patients with mild depression, healthcare professionals should consider recommending a
guided self-help programme based on cognitive behavioural therapy (CBT).
Short-term psychological treatment
• In both mild and moderate depression, psychological treatment specifically focused on
depression (such as problem-solving therapy, brief CBT and counselling) of 6 to 8 sessions
over 10 to 12 weeks should be considered.
Prescription of an SSRI
• When an antidepressant is to be prescribed in routine care, it should be a selective serotonin
reuptake inhibitor (SSRI), because SSRIs are as effective as tricyclic antidepressants and are less
likely to be discontinued because of side effects.
Tolerance and craving, and discontinuation/withdrawal symptoms
• All patients prescribed antidepressants should be informed that, although the drugs are not
associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on
stopping, missing doses or, occasionally, on reducing the dose of the drug. These symptoms are
usually mild and self-limiting but can occasionally be severe, particularly if the drug is stopped
abruptly.
Initial presentation of severe depression
• When patients present initially with severe depression, a combination of antidepressants and
individual CBT should be considered as the combination is more cost-effective than either
treatment on its own.
Maintenance treatment with antidepressants
• Patients who have had two or more depressive episodes in the recent past, and who have
experienced significant functional impairment during the episodes, should be advised to
continue antidepressants for 2 years.
Combined treatment for treatment-resistant depression
• For patients whose depression is treatment resistant, the combination of antidepressant
medication with CBT should be considered.
CBT for recurrent depression
• CBT should be considered for patients with recurrent depression who have relapsed despite
antidepressant treatment, or who express a preference for psychological interventions.
4
NICE Guideline: quick reference guide – depression (amended)
General principles of care – all steps
General principles of care – all steps
Depression and anxiety
• In comorbid depression and anxiety, treat the depression as a priority. GPP
Patient preference
• Consider patient preference and the experience and outcome of previous treatment(s) when
deciding on treatment. GPP
Information
• Give patients and carers appropriate information on the nature, course and treatment of
depression, including the use and likely side effects of medication. GPP
• Inform patients, families and carers about self-help and support groups, and encourage them
to participate where appropriate. GPP
• Keep use of clinical language to a minimum and, where possible, provide interventions in a
language understood by the patient. GPP
Consent
• Ensure that a patient can give meaningful and properly informed consent, especially when he or
she has a more severe depression or is subject to the Mental Health Act. GPP
Management of care
• Where management is shared between primary and secondary care, establish a clear agreement
between all professionals on the responsibility for monitoring and treatment; this should be
shared with the patient and, where appropriate, with families and carers. GPP
• Consider advance directives, especially for people who have recurrent severe or psychotic
depressions, and for those who have been treated under the Mental Health Act. GPP
NICE Guideline: quick reference guide – depression (amended)
5
Step 1: Recognition of depression in primary care and general hospital settings
General principles of care
Assessment
• Consider the psychological, social and physical characteristics of the patient and the quality of
interpersonal relationships. Assess impact on: GPP
– depression
– choice of treatment
– monitoring.
• Consider alternatives when discussing treatment options. Factors influencing choice include past
or family history of depression, response to previous interventions, and the presence of associated
problems in social or interpersonal relationships. GPP
• In older patients, consider their physical health, their living conditions, and their social
situation. GPP
Risk
• Always ask patients with depression directly about suicidal ideas and intent, and advise patients
and carers to be vigilant for changes in mood, negativity and hopelessness, and suicidal intent,
particularly during high-risk periods such as during initiation of and changes to medication and
increased personal stress. Advise patients and carers to contact the appropriate healthcare
practitioner if concerned. GPP
• Assess whether patients with suicidal ideas have adequate social support and are aware
of appropriate sources of help, and advise them to seek appropriate help if the situation
deteriorates. GPP
• Where a patient presents considerable immediate risk to self or others, consider urgent referral to
a specialist mental health service. GPP
• Make contact with patients with depression who do not attend follow-up. C
Step 1: Recognition of depression in primary care and
general hospital settings
• In
–
–
–
primary care and general hospital settings, screen patients with: C
a past history of depression
significant physical illnesses causing disability
other mental health problems, such as dementia.
• Bear in mind the potential physical causes of depression and the possibility that depression can be
caused by medication. C
• Use two screening questions, such as: B
– “During the last month, have you often been bothered by feeling down, depressed or hopeless?”
and
– “During the last month, have you often been bothered by having little interest or pleasure in
doing things?”
6
NICE Guideline: quick reference guide – depression (amended)
Step 2: Treatment of mild depression in primary care
Step 2: Treatment of mild depression in primary care
Watchful waiting
• In mild depression, if the patient does not want treatment or may recover with no intervention,
arrange further assessment – normally within 2 weeks. C
Sleep and anxiety management
• Consider advice on sleep hygiene and anxiety management. C
Exercise
• Advise patients of all ages with mild depression of the benefits of following a structured and
supervised exercise programme. Effective duration of such programmes is up to 3 sessions per
week of moderate duration (45 minutes to 1 hour) for between 10 and 12 weeks. C
Guided self-help
• For patients with mild depression, consider a guided self-help programme that consists of the
provision of appropriate written materials and limited support over 6 to 9 weeks, including follow up,
from a professional who typically introduces the self-help programme and reviews progress and
outcome. C
Computerised cognitive behavioural therapy
• Computerised CBT should be considered for the treatment of mild depression. GPP
Psychological interventions
• In mild and moderate depression, consider psychological treatment specifically focused on depression
(problem-solving therapy, brief CBT and counselling) of 6 to 8 sessions over 10 to 12 weeks. B
• Offer the same range of treatments to older people as to younger people. C
• In psychological interventions, therapist competence and therapeutic alliance have significant bearing
on the outcome of intervention. C
• Where significant comorbidity exists, consider extending treatment duration or focusing specifically
on comorbid problems. C
Antidepressants
• Antidepressants are not recommended for the initial treatment of mild depression, because the
risk–benefit ratio is poor. C
• Where mild depression persists after other interventions, or is associated with psychosocial and
medical problems, consider use of an antidepressant. C
• If a patient with a history of moderate or severe depression presents with mild depression, consider
use of an antidepressant (see Step 3 on pages 8 to 11). C
Review in mild depression
• Consider contacting all patients with mild depression who do not attend follow-up appointments. C
NICE Guideline: quick reference guide – depression (amended)
7
Step 3: Treatment of moderate to severe depression in primary care
Step 3: Treatment of moderate to severe depression in
primary care
Starting treatment
• In moderate depression, offer antidepressant medication to all patients routinely, before
psychological interventions. B
• Discuss the patient’s fears of addiction or other concerns about medication. For example, explain that
craving and tolerance do not occur. GPP
• When starting treatment, tell patients about: C
– the risk of discontinuation/withdrawal symptoms
– potential side effects.
• Inform patients about the delay in onset of effect, the time course of treatment and the need to take
medication as prescribed. Make available written information appropriate to the patient’s needs. GPP
Monitoring risk
• See patients who are considered to be at increased risk of suicide or who are younger than 30 years
old 1 week after starting treatment. Monitor frequently until the risk is no longer significant. C
• If there is a high risk of suicide, prescribe a limited quantity of antidepressants. C
• If there is a high risk of suicide consider additional support such as more frequent contacts with
primary care staff, or telephone contacts. C
• Monitor for signs of akathisia, suicidal ideas, and increased anxiety and agitation, particularly in the
early stages of treatment with an SSRI. C
• Advise patients of the risk of these symptoms, and that they should seek help promptly if these are at
all distressing. C
• If a patient develops marked and/or prolonged akathisia or agitation while taking an antidepressant,
review the use of the drug. C
Continuing treatment
• See patients who are not considered to be at increased risk of suicide 2 weeks after starting
treatment and regularly thereafter – for example, every 2–4 weeks in the first 3 months –
reducing the frequency if response is good. C
• For patients with a moderate or severe depressive episode, continue antidepressants for at least
6 months after remission. A
• Once a patient has taken antidepressants for 6 months after remission, review the need for continued
antidepressant treatment. This review may include consideration of the number of previous episodes,
presence of residual symptoms, and concurrent psychosocial difficulties. C
Choice of antidepressants
• For routine care, use an SSRI because they are as effective as tricyclic antidepressants and less likely to
be discontinued because of side effects. A
• Consider using a generic form of SSRI. Fluoxetine or citalopram, for example, would be reasonable
choices because they are generally associated with fewer discontinuation/withdrawal symptoms. C
• Treatments such as dosulepin, phenelzine, combined antidepressants, and lithium augmentation
of antidepressants should be routinely initiated only by specialist mental healthcare professionals
(including General Practitioners with a Special Interest in Mental Health). C
• Consider toxicity in overdose in patients at significant risk of suicide. Note that the highest risk is
with tricyclic antidepressants (with the exception of lofepramine) but that venlafaxine is also more
dangerous than other equally effective drugs recommended for routine use in primary care. C
• Be aware of clinically significant interactions with concomitant drugs (particularly when prescribing
fluoxetine, fluvoxamine, paroxetine, tricyclic antidepressants or venlafaxine). Consider consulting
appendix 1 of the British National Formulary. C
8
NICE Guideline: quick reference guide – depression (amended)
Step 3: Treatment of moderate to severe depression in primary care continued
• If increased agitation develops early in treatment with an SSRI, provide appropriate information
and, if the patient prefers, either change to a different antidepressant or consider a brief period
of concomitant treatment with a benzodiazepine followed by a clinical review within 2 weeks. C
• St John’s wort may be of benefit in mild or moderate depression, but its use should not be prescribed
or advised because of uncertainty about appropriate doses, variation in the nature of preparations,
and potential serious interactions with other drugs. C
• Tell patients taking St John’s wort about the different potencies of the preparations available and
the uncertainty that arises from this, and about the interactions of St John’s wort with other drugs
(including oral contraceptives, anticoagulants and anticonvulsants). C
Pharmacological treatment of atypical depression
• Treat patients with features of atypical depression with an SSRI. C
• If there is no response to an SSRI and there is significant functional impairment, consider referral to a
mental health specialist. GPP
Stopping or reducing antidepressants
• Inform patients about the possibility of discontinuation/withdrawal symptoms on stopping or missing
doses or reducing the dose. These symptoms are usually mild and self-limiting but can occasionally be
severe, particularly if the drug is stopped abruptly. C
• Advise patients to take their drugs as prescribed, particularly drugs with a shorter half-life (such as
paroxetine and venlafaxine). C
• Reduce doses gradually over a 4-week period; some people may require longer periods, and
fluoxetine can usually be stopped over a shorter period. C
• For mild discontinuation/withdrawal symptoms, reassure the patient and monitor symptoms. C
• For severe symptoms, consider reintroducing the original antidepressant at the effective dose (or
another antidepressant with a longer half-life from the same class) and reduce gradually while
monitoring symptoms. C
• Ask patients to seek advice from their medical practitioner if they experience significant
discontinuation/withdrawal symptoms. GPP
Special patient characteristics
Gender
• Note that women have a poorer toleration of imipramine. B
Age
• For older adults with depression, give antidepressant treatment at an age-appropriate dose for a
minimum of 6 weeks before considering that it is ineffective. If there is a partial response within this
period, treatment should be continued for a further 6 weeks. C
• When prescribing antidepressants for older adults, consider:
– the increased risk of drug interactions GPP
– careful monitoring of side effects, particularly with tricyclic antidepressants. C
Patients with dementia
• Treat depression in people with dementia in the same way as depression in other older adults. C
Patients with cardiovascular disease
• When initiating antidepressant treatment in patients with recent myocardial infarction or unstable
angina, sertraline is the treatment of choice and has the best evidence base. B
• Perform an ECG and measure blood pressure before prescribing a tricyclic antidepressant for a
depressed patient at significant risk of cardiovascular disease. GPP
• Do not prescribe venlafaxine or a tricyclic antidepressant (except lofepramine) for patients with a
high risk of serious cardiac arrhythmias or recent myocardial infarction. C
NICE Guideline: quick reference guide – depression (amended)
9
Step 3: Treatment of moderate to severe depression in primary care continued
Limited response to initial treatment in moderate and severe
depression
Pharmacological approaches
• When a patient fails to respond to the first antidepressant prescribed, check that the drug has been
taken regularly and at the prescribed dose. GPP
• If response to a standard dose of an antidepressant is inadequate, and there are no significant side
effects, consider a gradual increase in dose in line with the schedule suggested by the Summary of
Product Characteristics. C
• Consider switching to another antidepressant if there has been no response after a month. If there
has been a partial response, a decision to switch can be postponed until 6 weeks. C
• If an antidepressant has not been effective or is poorly tolerated and, after considering a range of
other treatment options, the decision is made to offer a further course of antidepressants, then
switch to another single antidepressant. C
• Choices for a second antidepressant include a different SSRI or mirtazapine; alternatives include
moclobemide, reboxetine and lofepramine. Consider other tricyclic antidepressants (except dosulepin)
and venlafaxine, especially for more severe depression. B (See notes below about switching.)
• When switching from one antidepressant to another, be aware of the need for gradual and modest
incremental increases of dose, of interactions between antidepressants, and the risk of serotonin
syndrome when combinations of serotonergic antidepressants are prescribed. Features include
confusion, delirium, shivering, sweating, changes in blood pressure, and myoclonus. C
Special considerations when switching to mirtazapine, moclobemide or reboxetine
• If switching to mirtazapine, be aware that it can cause sedation and weight gain. A
• If switching to moclobemide, be aware of the need to wash out previously prescribed
antidepressants. A
• If switching to reboxetine, be aware of its relative lack of data on side effects, and monitor carefully. B
Special considerations when switching to a new tricyclic antidepressant
• Consider their poorer tolerability compared with other equally effective antidepressants, and the
increased risk of cardiotoxicity and toxicity in overdose. B
• Start on a low dose and, if there is a clear clinical response, maintain on that dose with careful
monitoring. C
• Gradually increase dose if there is lack of efficacy and no major side effects. GPP
• Lofepramine is a reasonable choice because of its relative lack of cardiotoxicity. C
Special considerations when switching to venlafaxine
• Before prescribing:
– take into account the increased likelihood of patients stopping treatment because of side effects,
and its higher cost, compared with equally effective SSRIs B
– ensure pre-existing hypertension is controlled in line with the current NICE guideline
(www.nice.org.uk/CG034). C
• Do not prescribe for patients with uncontrolled hypertension. C
• Venlafaxine should only be prescribed at 300 mg per day or more under the supervision or advice of a
specialist mental health medical practitioner. C
• Monitoring:
– measure blood pressure at initiation and regularly during treatment (particularly during dosage
titration); reduce the dose or consider discontinuation if there is a sustained increase in blood
pressure. C
– check for signs and symptoms of cardiac dysfunction, particularly in people with known
cardiovascular disease, and take appropriate action as necessary. C
10
NICE Guideline: quick reference guide – depression (amended)
Step 3: Treatment of moderate to severe depression in primary care continued
Psychological treatments
• CBT is the psychological treatment of choice. Consider interpersonal psychotherapy (IPT) if the patient
expresses a preference for it or if you think the patient may benefit from it. B
• CBT and IPT should be delivered by a healthcare professional competent in their use – treatment
typically consists of 16 to 20 sessions over 6 to 9 months. B
• Consider CBT (or IPT) for patients with moderate or severe depression who do not take or refuse
antidepressant treatment. B
• For patients who have not made an adequate response to other treatments for depression (for
example, antidepressants and brief psychological interventions), consider giving a course of CBT
of 16 to 20 sessions over 6 to 9 months. C
• Consider CBT for patients with severe depression for whom avoiding the side effects often associated
with antidepressants is a clinical priority or personal preference. B
• For patients with severe depression, consider providing 2 sessions of CBT per week for the first month
of treatment. C
• Where patients have responded to a course of individual CBT or IPT, consider offering follow-up
sessions – typically 2 to 4 sessions over 12 months. C
Initial presentation of severe depression
• When patients present initially with severe depression, a combination of antidepressants and
individual CBT should be considered as it is more cost-effective than either treatment on its own. B
Couple-focused therapy
• Consider couple-focused therapy for people with depression who have a regular partner and who
have not benefited from a brief individual intervention. An adequate course is 15 to 20 sessions over
5 to 6 months. B
Chronic depression
• In chronic depression, offer a combination of individual CBT and antidepressant medication. A
• For men with chronic depression who have not responded to an SSRI, consider a tricyclic
antidepressant, as men tolerate the side effects of tricyclic antidepressants reasonably well. C
• Consider offering befriending (by trained volunteers offering weekly meetings for 2 to 6 months)
as an adjunct to pharmacological or psychological treatments to people with chronic depression. C
• Consider a rehabilitation programme for patients who are unemployed, or have been disengaged
from social activities over a longer term. C
Enhanced care in primary care
• For all patients, consider telephone support from the primary care team, informed by clear treatment
protocols, particularly for monitoring antidepressant medication regimes. B
• Primary care organisations should consider establishing multi-faceted care programmes, which
integrate through clearly specified protocols the delivery and monitoring of appropriate psychological
and pharmacological interventions for the care of people with depression. C
NICE Guideline: quick reference guide – depression (amended)
11
Step 4: Treatment of depression by mental health specialists including crisis teams
Step 4: Treatment of depression by mental health
specialists including crisis teams
• Assess patients with depression referred to specialist care, including their symptom profile and suicide
risk and, where appropriate, previous treatment history. Where the depression is chronic or recurrent,
assess psychosocial stressors, personality factors and significant relationship difficulties as well. GPP
• Consider re-introducing any previous treatments that were inadequately delivered or adhered to. GPP
• Crisis resolution teams should be used as a means of managing crises for patients who have severe
depression and are assessed as presenting significant risk. C
• Medication in specialist services should be initiated under the supervision of a consultant
psychiatrist. GPP
Treatment-resistant depression
• For all people whose depression is treatment resistant, consider the combination of antidepressant
medication with individual CBT of 16 to 20 sessions over 6 to 9 months. B
• For patients with treatment-resistant moderate depression who have relapsed while taking, or
after finishing, a course of antidepressants, consider the combination of antidepressant medication
with CBT. B
• Consider a trial of lithium augmentation for patients whose depression has failed to respond to
B
several antidepressants and who are prepared to tolerate the burdens associated with its use. ●
• Before initiating lithium augmentation carry out an ECG. ●
C
• If venlafaxine has not been used before, it may be considered for patients whose depression has
failed to respond to two adequate trials of alternative antidepressants. The dose can be increased up
to BNF limits if required, provided patients can tolerate the side effects. C See Step 3 (page 10) for
prescribing advice.
• Consider augmenting an antidepressant with another antidepressant (there is evidence for benefits
of adding mianserin or mirtazapine to SSRIs). C
• When augmenting one antidepressant with another, monitor carefully (particularly for the symptoms
of serotonin syndrome), and explain the importance of this to the patient. GPP
• When augmenting an antidepressant with mianserin be aware of the risk of agranulocytosis,
particularly in older adults. C
• Re-evaluate the adequacy of previous treatments and consider seeking a second opinion if
considering using combinations of antidepressants other than mianserin or mirtazapine with SSRIs.
Document the content of any discussion in the notes. C
• Consider phenelzine for patients who have failed to respond to alternative antidepressants and who
are prepared to tolerate the side effects and dietary restrictions associated with its use. Consider its
toxicity in overdose when prescribing for patients at high-risk of suicide. C
• Augmentation of an antidepressant with carbamazepine, lamotrigrine, buspirone, pindolol, valproate
or thyroid supplementation is not recommended in the routine management of treatment-resistant
depression. B
• Consider referring patients who have failed to respond to various strategies for augmentation and
combination treatments to a clinician with a specialist interest in treating depression. GPP
• Dosulepin should not be used routinely because the evidence supporting its tolerability relative to
other antidepressants is outweighed by the increased cardiac risk and its toxicity in overdose. C
• There is insufficient evidence to recommend augmentation of antidepressants with
benzodiazepines. C
12
NICE Guideline: quick reference guide – depression (amended)
Step 4: Treatment of depression by mental health specialists including crisis teams continued
Recurrent depression and relapse prevention
Pharmacological treatments
• Continue antidepressants for 2 years for people who have had two or more depressive episodes in the
recent past and who have experienced significant functional impairment during the episodes. B
• Re-evaluate patients on maintenance treatment, taking into account age, comorbid conditions and
other risk factors in the decision to continue the treatment beyond 2 years. GPP
• Maintain the antidepressant dose used for relapse prevention at the level at which acute treatment
was effective. C
• Patients who have had multiple episodes of depression, and who have had a good response to
treatment with an antidepressant and lithium augmentation, should remain on the combination for
at least 6 months. B
• When patients are taking an antidepressant with lithium augmentation, if one drug is to be
discontinued, this should be lithium in preference to the antidepressant. C
Psychological treatments
• CBT should be considered for:
– patients with recurrent depression, who have relapsed despite antidepressant treatment, or who
express a preference for psychological interventions ●
C
– patients with a history of relapse and poor or limited response to other interventions ●
B
– patients who have responded to another intervention but are unable or unwilling to continue
with that intervention, and are assessed as being at significant risk of relapse ●
B
B
• Mindfulness-based CBT should be considered for patients with recurrent depression. ●
Special considerations
Psychotic depression
• For patients with psychotic depression, consider augmentation of the current treatment plan with
antipsychotic medication. C
Atypical depression
• Consider prescribing phenelzine for women whose depression has atypical features, and who have
not responded to, or who cannot tolerate, an SSRI. Consider its toxicity in overdose when prescribing
for patients at high risk of suicide. C
• All patients receiving phenelzine require careful monitoring (including taking blood pressure) and
advice on interactions with other medicines and foodstuffs, and should have their attention drawn to
the product information leaflet. C
NICE Guideline: quick reference guide – depression (amended)
13
Step 5: Inpatient treatment for depression
Step 5: Inpatient treatment for depression
Inpatient care
• Inpatient treatment should be considered for people with depression where the patient is at
significant risk of suicide or self-harm. C
• Crisis resolution teams should be considered for patients with depression who might benefit from
an early discharge from hospital after a period of inpatient care. C
Electroconvulsive therapy
• Electroconvulsive therapy (ECT) should only be used to achieve rapid and short-term improvement of
severe symptoms after an adequate trial of other treatments has proven ineffective, and/or when the
condition is considered to be potentially life-threatening, in a severe depressive illness. N
• When considering ECT, review risks and potential benefits to the individual, including: the risks
associated with the anaesthetic; current comorbidities; anticipated adverse events, particularly
cognitive impairment; and the risks of not having treatment. N
• Particular care is needed when considering ECT treatment during pregnancy, in older people, and in
children and young people, because the risks may be increased. N
• Valid consent should be obtained in all cases where the individual has the ability to grant or refuse
consent. The decision to use ECT should be made jointly by the individual and the clinician(s)
responsible for treatment, on the basis of an informed discussion. This discussion should be enabled
by the provision of full and appropriate information about the general risks associated with ECT and
about the risks and potential benefits specific to that individual. N
• Advance directives should be taken fully into account and the individual’s advocate and/or carer
should be consulted. N
• Clinical status should be assessed after each ECT session and treatment should be stopped when
a response has been achieved, or sooner if there is evidence of adverse effects. Cognitive function
should be monitored on an ongoing basis, and at a minimum at the end of each course
of treatment. N
• A repeat course of ECT should be considered under the circumstances indicated above only for
individuals who have severe depressive illness, and who have previously responded well to ECT. N
• In patients who are experiencing an acute episode but have not previously responded, a repeat
trial of ECT should be undertaken only after all other options have been considered and following
discussion of the risks and benefits with the individual and/or where appropriate their carer/
advocate. N
• As the longer-term benefits and risks of ECT have not been clearly established, it is not recommended
as a maintenance therapy in depressive illness. N
14
NICE Guideline: quick reference guide – depression (amended)
Implementation/Grading of the recommendations
Grading of the recommendations
This guidance is evidence based and the recommendations are graded as follows.
A
Based on level I evidence (meta-analysis of randomised controlled trials [RCTs] or at least
one RCT)
B
Based on level II or level III evidence (well-conducted clinical studies but no RCTs) or
extrapolated from level I evidence
C
Based on level IV evidence (expert committee reports or opinions and/or clinical experience
of respected authorities)
GPP
Recommended good practice based on clinical experience of the Guideline Development
Group
N
Evidence from NICE technology appraisal guidance
For further information, see the NICE guideline (www.nice.org.uk/CG023NICEguideline) or the
full guideline (www.nice.org.uk/CG023fullguideline)
Implementation
and includes a template that local communities
can use (www.nice.org.uk/CG023costtemplate).
Local health communities should review
their existing practice in the treatment and
management of depression against this
guideline. The review should consider
the resources required to implement the
recommendations set out in the NICE guideline
(www.nice.org.uk/CG023NICEguideline), the
people and processes involved and the timeline
over which full implementation is envisaged.
It is in the interests of patients that the
implementation timeline is as rapid as possible.
Relevant local clinical guidelines, care pathways
and protocols should be reviewed in light of this
guidance and revised accordingly.
Information on the cost impact of this guideline
in England is available on the NICE website
The implementation of this guideline will
build on the National Service Frameworks for
Mental Health in England and Wales and should
form part of the service development plans for
each local health community in England and
Wales. The National Service Frameworks are
available for England from
http://www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/
DH_4009598, and for Wales from
www.wales.nhs.uk/sites/home.cfm?orgid=438
Suggested audit criteria are listed in Appendix D
of the NICE guideline. These can be used as the
basis for local clinical audit, at the discretion of
those in practice.
NICE Guideline: quick reference guide – depression (amended)
15
Further information
Distribution
The distribution list for this quick reference guide is
available from www.nice.org.uk/CG023distributionlist
NICE guideline
The NICE guideline, ‘Depression: management
of depression in primary and secondary
care’, is available from the NICE website
(www.nice.org.uk/CG023NICEguideline).
The NICE guideline contains the following
sections: Key priorities for implementation;
1 Guidance; 2 Notes on the scope of the guidance;
3 Implementation in the NHS; 4 Key research
recommendations; 5 Other versions of this guideline;
6 Related NICE guidance; 7 Review date. It also
gives details of the grading scheme for the evidence
and recommendations, the Guideline Development
Group, the Guideline Review Panel and technical
detail on the criteria for audit.
Information for the public
NICE has produced a version of this guidance
for people with depression, their advocates and
carers, and the public. The information is available,
in English and Welsh, from the NICE website
(www.nice.org.uk/CG023publicinfo). Printed
versions are also available – see below for
ordering information.
Full guideline
The full guideline includes the evidence on which
the recommendations are based, in addition to the
information in the NICE guideline. It is published by
the National Collaborating Centre for Mental Health.
It is available from www.bps.org.uk/publications,
from www.nice.org.uk/CG023fullguideline and on
the website of the National Library for Health
(www.library.nhs.uk).
Related NICE guidance
For information about NICE guidance that has
been issued or is in development, see the website
(www.nice.org.uk).
Antenatal and postnatal mental health.
NICE clinical guideline 45 (2007). Available from:
www.nice.org.uk/CG045
Hypertension: management of hypertension in
adults in primary care. NICE clinical guideline 34
(2006). Available from: www.nice.org.uk/CG034
Depression in children and young people:
identification and management in primary, secondary
and community care. NICE clinical guideline 28 (2006).
Available from: www.nice.org.uk/CG028
Anxiety: management of generalised anxiety
disorder and panic disorder (with or without
agoraphobia) in adults in primary, secondary and
community care. NICE clinical guideline 22
(amended 2007). Available from:
www.nice.org.uk/CG022
Guidance on the use of computerised cognitive
behavioural therapy for anxiety and depression.
NICE technology appraisal guidance 51 (2002).
Available from: www.nice.org.uk/TA051
Guidance on the use of electroconvulsive therapy.
NICE technology appraisal guidance 59 (2003).
Available from: www.nice.org.uk/TA059
Review date
NICE expects to make a decision on a full update of
this guideline later in 2007.
Ordering information
Copies of this quick reference guide can be obtained from the NICE
website at www.nice.org.uk/CG023quickrefguide or from the NHS
Response Line by telephoning 0870 1555 455 and quoting reference
number N1237. Information for the public is also available from the NICE
website or from the NHS Response Line (quote reference number N1238).
N1237 1P 35k Apr 07 (ABA)
National Institute for
Health and Clinical Excellence
MidCity Place
71 High Holborn
London
WC1V 6NA
www.nice.org.uk
Effective Care Co-Ordination Policy - CPA Policy
EFFECTIVE CARE CO-ORDINATION POLICY
POLICY NO
DATE RATIFIED
NEXT REVIEW DATE
CL 012
AUGUST 2008
AUGUST 2011
POLICY STATEMENT/KEY OBJECTIVES:
To ensure a consistent and thorough approach to the application of the Care
Programme
Approach across Lancashire
ACCOUNTABLE DIRECTOR: Director of Nursing
POLICY AUTHOR: Lancashire Multi Agency Effective Care Co-ordination Sub
Group
x
x
x
x
Date of Issue: AUGUST 2008
1 of 28
KEY POLICY ISSUES
Care Programme Approach
Effective Care Co-Ordination
Integration of CPA/Care
Management
Application of the Policy across
all service areas
Effective Care Co-Ordination Policy - CPA Policy
CONTENTS
PAGE NO.
1.
Definitions And Principles
3
2.
Scope Of The Policy
5
3.
Assessment
6
4.
Allocation of Co-Ordinator
6
5.
Principles Of Care Planning
10
6.
7 Day Follow Up
12
7.
Caring about Carers (National Service Framework Six, Carers Act)
12
8.
Review
13
9.
Discharge and Re-accessing Specialist Mental Health Services
15
10.
Section 117 After Care
15
11.
Rejection, Refusal, Non Compliance and Missing Person
16
12.
Service Users who lose touch with or go missing from Services
16
13.
Transition Protocols
17
14.
Care Co-ordination within the Criminal Justice System
18
15.
Meeting The Needs of Children
22
16.
CPA and Confidentiality
23
17.
Training
24
18.
Audit
24
20.
References
25
Appendix 1
Appendix 2
Appendix 3
Date of Issue: AUGUST 2008
26
27
28
2 of 28
Effective Care Co-Ordination Policy - CPA Policy
1.
DEFINITION AND PRINCIPLES
“REFOCUSING THE CARE PROGRAMME APPROACH” (CPA)
1.1
This document reflects the ongoing partnership between the Lancashire Care
NHS Trust, the Primary Care Trusts and Blackburn with Darwen, Blackpool and
Lancashire Social Services. All these agencies are committed to working
together to improve the delivery of Mental Health Services within the CPA
framework and the scope of this policy. Service Users, Carers and other
organisations delivering Mental Health Services, have also participated in the
process of developing this Policy.
1.2
The aim of this policy is to promote an optimistic and positive approach to all
people who use mental health services. “The vast majority have real prospects
of recovery – if they are supported by appropriate services, driven by the right
values and attitudes” (The Journey of Recovery, Department of Health). It also
incorporates the guidance issued by the Department of Health on refocusing
the Care Programme Approach. From October 2008 the term Care Programme
Approach will describe the approach used in Secondary mental health care to
assess, plan, review and coordinate the range of treatment, care and support
needs for people in contact with secondary mental health services who have
complex needs and who are most at risk.
1.3
There are four main principles in delivering the CPA:
x The person for whom the Care Programme is being developed must be
central to the process as far as possible, involved and informed at all stages.
x A needs and strengths led, rather than Service led approach should be
adopted.
x The foundation of the Care Programme Approach is good multi-professional
and interagency working and co-ordination of care in respect of people with a
Mental Health disorder.
x Carers needs will be assessed and a Care Plan agreed to meet their needs
where this is appropriate. This enables them to continue to contribute to the
service user’s care.
1.4
There are five main elements to the Care Co-ordination process:
x Systematic arrangements for assessing Health and Social Care Needs
x An agreed Care Plan (including a contingency plan identifying who will
provide support in the absence of the Care Coordinator and a Crisis Plan for
Individuals on an enhanced CPA).
x The appointment of a Care Co-ordinator.
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x Monitoring of the Service Users progress
x Regular review and where appropriate discharge from Services.
1.5
The new guidance does not make any fundamental changes to the values and
Principles that underpin the Care programme approach. These are
described in detail in the new guidance (see appendix 1) The new guidance
builds on existing policy and follows a national consultation.
The full document can be accessed at
www.nihme.csip.uk/our-work/reviewing-the-care-programme-appraoch-cpa-.html
The link also provides access to a range of best practice guidance.
1.6
The principles and values outlined above are underpinned by a number of
Standards. All practitioners, teams and services must strive to meet these
standards, which are outlined below:
x
One assessment and care plan will follow the service user through the whole range
of care settings.
x
The care plan must incorporate a full risk assessment and management plan
supported by crisis and contingency plan
x
The assessment will consider issues relating to housing, employment and Social
inclusion
x
All service users will have a HONOS (or Honos 65+ or HONOSCA if appropriate)
assessment completed at least annually
x
All service users will be provided with a Credit/Business Card which provides
information about their care coordinators contact number and details a number
they will contact in case of emergency
x
The care plan must provide evidence of service user involvement i.e. it is signed,
the service user has a copy and there is a record that this has taken place
x
A carer’s assessment should be offered to all carers, and where indicated a plan of
support should be in place. The clinical record must record the date of assessment,
the carer’s need for support and how this support will be provided. This must be
reviewed on a regularly basis. Again this is recorded in the clinical record.
x
The service users status is reviewed at every Care Programme Approach review
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2.
SCOPE OF THE POLICY
2.1
This Policy will apply for all Service Users in contact with Specialist Mental
Health Services who are subject to the Care Programme Approach. However,
the application will differ across service networks. It is important to consider the
relationship with the Single Assessment Process (SAP) in Older Adult Services
and the very specific needs of CAMHS. Local procedures will be in place where
required. Service users treated by the Primary Care Mental Health Teams or
steps 2 and 3 are not subject to formal CPA.
Whilst Individuals are free to refuse services, (unless subject to certain sections
of the MHA 1983) they cannot refuse to be part of the CPA, as this is a locally
and nationally agreed process by which Mental Health Services are delivered.
2.2
For Service Users who are in contact with Drug/Alcohol Services or Learning
Disability Services, where there are no co-existing mental health needs
requiring Specialist Services, the CPA will not apply. Should Clients of these
services develop severe mental health problems and become involved with
Specialist Mental Health Services the CPA will apply as per Policy. In these
cases the Care Co-ordinator should ordinarily be a member of the Specialist
Mental Health Service and the case will need to be managed jointly.
2.3
From October 2008 the term CPA will no longer apply to those individuals who
have contact with one professional or agency providing mental health services.
2.4
From October 2008 service users with a severe mental health problem and the
following characteristics will be subject to the Care Programme Approach. (this
is taken directly from the national guidance)
x
Severe mental disorder (including personality disorder) with a high degree of
clinical complexity.
x
Current or potential risk(s) including: Suicide, self harm, harm to others
(including history of offending), Relapse history requiring urgent response,
Self neglect/non concordance with treatment plan, Vulnerable adult with
safeguarding issues
x
Current or significant history of severe distress/instability or disengagement.
x
Presence of non-physical co-morbidity e.g. Substance /alcohol/prescription
drug misuse, learning disability.
x
Multiple service provision from different agencies, including: housing,
physical care, employment, criminal justice, voluntary agencies.
x
Currently/recently detained under the Mental Health Act or referred to
crisis/home treatment team
x
Significant reliance on carer(s) or has own significant caring responsibilities
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x
Experiencing disadvantage or difficulty as a result of: parenting
responsibilities,
physical
health
problems/disability,
unsettled
accommodation/housing issues, employment issues when mentally ill,
significant impairment of function due to mental illness, ethnicity (e.g.
immigration status, race/cultural issues, language difficulties, religious
practices, sexuality or gender issues)
Appendix 2 provides further guidance on how to differentiate between
service users on the Care programme Approach and service users who are
not.
3.
ASSESSMENT
Assessment of Health and Social Care Needs
3.1
Assessment of need is pivotal to the whole CPA process. Systematic
arrangements for assessing Health and Social Needs of people accepted into
specialist Mental Health Services must be in place.
3.2
This assessment, inclusive of risk assessment will be the initial process in
formulating the service user’s needs and be carried out by a suitably qualified
mental health professional. Specialist assessments will support and enhance
this initial assessment.
The assessment process must include an Assessment of Risk and the
development of a Risk Management Plan where risk factors are identified.
Further guidance is provided in the trust policy on clinical risk management.
4.
ALLOCATION OF CARE CO-ORDINATOR:
4.1
The role of the Care Co-ordinator is essential in the delivery of well-coordinated
and high quality Mental Health Services. The joint agencies within Lancashire
have agreed that the Care Co-ordinator function can only be carried out by a
Mental Health Practitioner who is identified by both Health and Social Service
organisations as being employed for that purpose. The Care Co-ordinator will
also be a person whose practice is regulated by a regulatory professional body
or professional codes of conduct (NSF).
4.2
Professionals who can be CPA Care Co-ordinators
Only STR Workers who are Team Leaders can be Care Co-ordinators
-
Community Mental Health Nurses
Mental Health Social Workers
Consultant Psychiatrists
Staff Grade Doctors
Psychologists
Occupational Therapists
Psychotherapists
Counsellors
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4.3
Support, Time and recovery workers (Team Leaders only)
The responsibilities of the Care Co-ordinator are as follows:
1.
To co-ordinate the Assessment of Need and to ensure that where
necessary, an assessment of the Carer’s needs is undertaken.
2.
To remain in touch when a Service User is admitted to hospital and
actively participating in the process of assessment, care planning, review
and discharge.
3.
To develop with the Service User, Carers (usually with Service User’s
consent) and others involved in the service users care (where
necessary), an agreed Care Plan that addresses the Service User’s
Health and Social Care Needs, including the management of any
associated risks.
4.
To offer the service user a direct payment as an alternative to any Social
Services, other than residential care, which would otherwise be
commissioned as part of the care package. To assist in the planning, and
then monitoring, the delivery of the agreed Care Package, record
decisions made about it and ensure that it is reviewed in accordance with
this Policy.
5.
To develop, where appropriate, a Contingency Plan (as part of the Care
Plan), which provides the Service User and any Informal Carers with a
contact number and a named representative to contact in the event of the
Care Co-ordinator’s absence or if part of the care plan breaks down or is
not available. This will need to incorporate information relating to the
provision of Out of Hour’s Services e.g. Crisis Resolution and Home
Treatment.
6.
To ensure that the care process is documented on eCPA.
7.
To co-ordinate and participate in regular formal reviews of the Service
User’s Care Plan and to convene where necessary, urgent reviews or
mobilise Emergency Services.
8.
To provide a consistent point of contact for the Service Network (where
applicable), the Service User and informal Carers and to monitor that all
relevant caring agencies are contributing as agreed to the Service User’s
Care Plan.
9.
Wherever feasible to discuss with the service user, in advance any
change of the Care Co-ordinator.
10.
To inform other members of the Team, the Service User’s family (where
applicable), their GP and any relevant others such as a Probation Officer,
if the Service User is found to be missing.
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11.
To use their professional skills collaboratively, assisting the Service User
and maintaining regular contact with them. This should include, where
appropriate, consultation with Carers.
12.
To provide support and care in a positive, non-discriminatory manner,
which is acceptable to the Service User.
13.
To ensure the Service User is registered with a GP and then to work in
close contact with the Primary Care Team and other involved
professionals informing other members of the Team of changes in the
Service User’s circumstances. If the Care Co-ordinator is unable to
register the Service User with a GP, the reasons should be fully
documented and discussed with the Multi-Disciplinary Team. Further
action may then be necessary.
14.
To ensure that the Service User has regular physical health checks and
the process is clearly documented in the record.
15.
Ensuring information is provided regarding medication and other aspects
of treatment.
16
To actively offer Advocacy Services to the Service User.
17
To be aware of resources available and provide information or refer as
appropriate.
18
Access updates in CPA training to ensure up-to-date knowledge of the
process.
Allocation of role
4.4
The role of the Care Co-ordinator in respect of an Individual Service User will
already be agreed at the earliest opportunity. Before accepting the role of Care
Co-ordinator the Practitioner should be aware of the Service Users
presentation, their needs and their risk potential.
4.5
All Service Users must be allocated a Care Co-Coordinator and if disputes arise
this must be resolved quickly and safely through the Local Team Management
arrangements. If this fails to occur the matter must be referred to the Service
manager. In the event of an ongoing dispute the Service Manager will make a
decision over the allocation of Care Co-Coordinator and this will be binding.
4.6
The Service User has a right to request a change of Care Co-ordinator and
there should be flexibility to enable the Service User to exercise choice.
Requests for a change of Care Co-ordinator should be discussed at an
arranged CPA Review Meeting. Any change of Care Coordinator should be
kept to a minimum. Should a change occur it is the responsibility of the Care
Co-coordinator to ensure that a thorough handover takes place.
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4.7
All members of the Care Team must be aware of whom the Care Cocoordinator is, and where they can be contacted and this must be stated in the
Care Plan.
4.8
Team Mangers need to ensure, and be able to demonstrate, that Staff in Care
Co-ordination roles are maintaining caseloads of suitable sizes dependant on
the needs of Individuals on caseload. Where workload issues are problematic
this must be brought to the attention of the Service Manager and/or Assistant
Network Director and if serious risks are identified then the Network Director
must be informed.
4.9
The views and wishes of the Service User and their Carers must also be given
due consideration with attention to gender, culture and language. If their wishes
or preferences still cannot be fulfilled then clear reasons why must be
documented and given in writing to the Line Manager.
Case transfer / Fostering Cases, Short & Long Term Absence / Reallocation
4.10
It is the responsibility of the Line Manager to ensure that any absence is
communicated to the Service User and where necessary temporary allocation,
alternative appointments or arrangements must be made depending on need.
4.11
Where complete reallocation of a Care Co-ordinator’s caseload is required, for
example when they terminate their employment or move to a different position,
the Line Manager and Care Co-ordinator should, when possible, meet for
Caseload Management, to discuss how best to manage the situation.
4.12
No Service User will be left in the position of having no identifiable Care Coordinator, and where possible a formal hand over involving the Service User
and, where appropriate the Carer, should take place.
4.13
It is the responsibility of the Line Manager and the Care Co-ordinator to ensure
that changes in Care Co-ordinator are recorded and passed onto the relevant
CPA Manager / Co-ordinator / Lead Officer.
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PRINCIPLES OF CARE PLANNING
5.1
The Care Co-ordinator should engage the Service User and/or their Carer(s) in
the Care Planning process by prompting the inclusion of Service User goals and
actions. Access to Advocacy Services should be included on the Care Plan as
well as an opportunity for the Service User to record their agreement or
disagreement with the plan.
5.2
The Care Plan should be formulated by the professional acting in the role of
Care Co-ordinator and detail the interventions of the Care Coordinator and of
other professionals engaging in the plan (as agreed with the Service User). The
Service User and, where appropriate his/her Care Coordinator, should be
involved in writing their Care Plan, and if this is not possible this must be clearly
documented.
5.3
The Service User must receive full information on the CPA process and a copy
of the agreed Care Plan.
5.4
Service users on CPA will have a Care Plan which includes:
x Arrangements for Mental Health Care including medication.
x An assessment of the nature of any risk posed and the plans for managing
this risk.
x A Crisis Plan, which should include who the Service User is most responsive
to; how to make contact with that person; and previous strategies that have
been successful in engaging the Service User. This information must be in a
separate section of the Care Plan that should be easily accessible out of
normal office hours.
x Explicit contingency arrangements so that the Service User or their Carer can
contact Specialist Services.
x Arrangements for physical health care
x Action needed to secure accommodation, appropriate to the Service User’s
needs.
x Arrangements to provide domestic support.
x Action needed for employment, education or training or another occupation.
x Arrangements needed for adequate income.
x Action to provide for cultural and faith need.
x Arrangements to promote independence and sustain social contact, including
therapeutic leisure activity.
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x The date of the next planned review.
5.5
The written Care Plan should be drawn up by the named Care Co-ordinator,
with the involvement of the Service User, and the Carer (where appropriate).
5.6
In all cases (with some possible exceptions due to risk factors) copies of the
Care Plan including Risk Management Plans and Crisis and Contingency Plans
should be given to the following people (in addition to the Service User) after
discussion with the Service User:
x
x
x
Each professional involved in the Care Plan
The Service User’s General Practitioner
The Carer (where appropriate)
Discharge Care Plans
5.7
Discharge Planning should ideally begin at the commencement of
the Service Users stay in hospital.
5.8
If the MDT has identified the need for follow-up, then a Care Co-ordinator
should be identified as early as possible within the admission process.
5.9
The responsibility for organising the final discharge meeting and ensuring that
all key personnel are aware of the date and time of the meeting, is the
responsibility of the Care Co-ordinator in liaison with the ward.
5.10
The final Care Plan will have developed over the period of the individuals stay
in hospital. The responsibility for formulating the Care Plan will now have
shifted to the Care Co-ordinator.
5.11
The final discharge Care Plan will be written by the Care Co-ordinator, who will
have ensured that the Service User and Carers are fully conversant with the
aftercare arrangements.
5.12
The Care Co-ordinator is also responsible for ensuring that all the required
information is contained within the Care Plan, including arrangements for 7-day
follow up. (or 48hour follow up when appropriate)
5.13
Particular attention will be made to the Care Plans of those Service Users at
risk of suicide and, where indicated, will include more intensive provision for the
first three months after discharge from hospital (or intervention at home).
5.14
All Service Users, upon discharge from In Patient care, should be provided
with a copy of their written Care Plan.
5.15
These arrangements should be detailed in the Discharge Care Plan. The MDT
must review plan within one month of discharge.
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5.16
The discharge of Service Users from other NHS or independent facilities must
be In accordance with the process described above. The Principles and
Procedures associated with the CPA apply equally to those Service Users
treated outside the area or in the Independent sector.
5.17
Where a service user is not subject to CPA the professional involved will be
responsible for coordinating care. Formal designated paperwork for CPA will
not be required. However, a statement of care agreed with the service user
must be recorded. This will be clearly documented in the clinical record. This
documentation constitutes the care plan. This process must never be used
where more than one professional and/or agency is involved. All essential
information will be recorded on eCPA and there must be evidence of
assessment (including risk assessment), intervention and review. In Older
Adult Services those Service Users not subject to CPA will be managed by
SAP. In primary care separate arrangements are also in place. Both these
procedures are supported by separate procedural guidance.
5.18
The eCPA system is used in all cases for our Service Users regardless of
whether they are subject to CPA.
6.
7 DAY FOLLOW UP
7-Day follow up visits are an important intervention aimed at supporting Users
and Carer’s and promoting recovery, social inclusion and suicide prevention.
All Service Users on the care programme approach, discharged from an Acute
Psychiatric Inpatient Unit (including periods of Home Leave) must be followed
up through face-to-face contact with a Community Mental Health professional
within 7 days of discharge. (or 48 hours when appropriate)
Where Service Users are discharged to another district (i.e. from one trust to
another) the 7-day follow up becomes the responsibility of the mental health
provider in that area. However, it is important that the new provider is involved
in the planning of discharge.
If 7 Day follow up does not take place the reason why must be clearly
documented in the client record
7.
CARING ABOUT CARERS (NSF STANDARD 6), CARERS (RECOGNITION
AND SERVICES) ACT 1995
7.1
The Carers (Recognition and Services) Act 1995 places a duty on Local
Authorities to assess the ability of any persons caring for vulnerable Service
Users. Authorities are required to provide services to Carers if the assessment
indicates that the Carer’s efforts should be supplemented by Social Service
provision. In order that Local Services should meet Standard 6 of the NSF, Care
Co-ordinators and other Staff in contact with Service Users must offer Carers an
assessment of their caring needs.
The Care Co-ordinator should ensure that:
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x Carers are informed of their rights to an assessment under the Carers
(Recognition and Services) Act 1995, complying with Standard 6 of the NSF.
x Each Carer’s needs are assessed as appropriate.
x Carers receive easy to understand information about both the help available
to them and the services provided.
x A written Care Plan is completed as appropriate and agreed with the Carer,
covering their caring, physical and Mental Health Needs, and also
educational and welfare needs for Young Carers.
x The Care Plan is reviewed annually or earlier if appropriate.
Service Users who are also Carer’s are entitled to a Carer’s assessment, in
addition to an assessment of their own Health and Social Care needs.
Who should undertake the assessment?
7.2
The NSF indicates that local arrangements should be made to ensure that the
Service User and Carer’s Care Plans are considered together. The Care Coordinator also has an essential role in informing the Service User and their
Carer of the Carer's right to request an assessment and also to ensure coordination of the Service User’s and their Carer’s Assessment Plans.
7.3
In most cases the Care Co-ordinator is likely to be working with both the Service
User and the Carer and will therefore be the most appropriate person to
undertake the Carer Assessment and draw up the Carer’s Care Plan.
7.4
However, in some situations, especially when there is a conflict of interest or
opinion between the Carer and the Service User, it may be more appropriate for
another Mental Health Worker to assess the needs of the Carer.
7.5
On completion (or receipt) of the Carer's Assessment it is the responsibility of
the Care Co-ordinator to complete the Carer's Care Plan and arrange Services
and support outlined in the plan.
8.
REVIEW
8.1
Review and evaluation of the effectiveness of the Care Plan should take place
with the Care Co-ordinator as part of the Multi-Disciplinary Team (MDT), in
collaboration with the Service User and those others identified in the Care
Planning arrangements.
8.2
The Care Co-ordinator is responsible for ensuring reviews take place. (For In
Patient Services where a Care Co-ordinator has not yet been identified this
responsibility will fall to the Primary/Named Nurse.)
8.3
An assessment of risk will be repeated at each formal CPA Review.
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8.4
The timing or frequency of reviews should take place in response to the Service
User’s needs and in negotiation with the Service User and their Carers, the
MDT, GP and other relevant parties in keeping with protocols and standards. As
a minimum requirement each Service User must be reviewed at least once in
every twelve month period. Separate arrangements exist for Service Users on
supervised community treatment orders.
8.5
Review and evaluation of the service user’s care plan should be ongoing. The
regularity of reviews will depend on the needs of the individual but should
always take into account care management requirements and the care team
should agree which issues will trigger emergency reviews (e.g. non
compliance). Review of risk is an ongoing process carried out on each and
every contact with the service user. In all circumstances, the date of the next
CPA review must be set and recorded at each review meeting, with the
knowledge and agreement of the Service User and the Care Team. This date
must include the time, day, month and the year.
8.6
Reviews should be pre-planned and confirmed with all interested parties.
Anyone involved in the delivery of care to the Service User, including the
Service User and their GP, should be invited to attend or contribute. If any
member of the Care Team cannot attend the review meeting, it is their
responsibility to ensure that any significant/relevant information regarding the
Service User should be communicated for the purposes of the review.
8.7
The purpose of the review is to consider the progress the Service User has
made and how they have responded to the services provided, to consider ways
in which their needs may have changed and, therefore, the extent to which the
Care Plan requires amending.
8.8
Priority should be given to the review of the Risk Management Plan, identifying
those aspects that have been successful, those that have not and any
alternative strategies.
8.9
All aspects of the Service User’s Care should be reviewed simultaneously
including the Service User’s statutory status.
8.10
A member of the Care Team, the Service User or Carer, can call an early
review at any time via the Care Co-ordinator. The Care Team must consider
calls for an early review and, if this is not considered appropriate, then reasons
why must be given and documented.
A Review should be arranged when: significant adverse events occur, they are
requested by service user / carer, risk increases, inpatient admission, prior to
discharge, breakdown of current care plan, before services are changed
through withdrawal, reduction, transfer or transition.
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9.
DISCHARGE
SERVICES
AND
RE-ACCESSING
SPECIALIST
MENTAL
HEALTH
9.1
When a Service User is discharged from Specialist Mental Health Services,
they should be provided with written information that explains how they can
readily access Mental Health Services if their situation deteriorates.
9.2
For those Service Users who have previously been significantly disabled by
their mental health problem, and/or have had a diagnosis of severe and
enduring mental illness, clear Discharge Plans which inform how to reengage
with services in the event of signs of relapse/ deterioration must be in place.
9.3
Crisis and Contingency Plans must be as robust as possible and inform the GP,
the Primary Health Care Team, the Carers and the Service User how to reaccess Mental Health Services. These must be written, communicated and
understood before discharge can take place.
10.
SECTION 117 AFTERCARE
10.1
Section 117 of the Mental Health Act 1983, places a statutory duty on
authorities to provide aftercare services of certain detained Service Users.
10.2 Section 117 aftercare only applies to those detained under Section 3, 37 and
transfer orders made under Section 45A, 47 and 48.
10.3
Given that the principles of CPA and after-care are the same, Section 117
needs should be incorporated into the CPA care plan. Therefore Section 117
care planning should be incorporated into the CPA review process. Section 117
runs in parallel and is complementary to the Care Programme Approach.
10.4
The duty to provide aftercare lasts until both authorities are satisfied that the
Service User is no longer in need of such Services.
10.5
When it is felt that the service user is no longer in need of Section 117
aftercare, the signature of both agencies, even where only one agency is
involved, is required. In all cases a Social Worker should consult with their
Team Manager before signing to agree that Section 117 aftercare is no longer
appropriate. The Social Worker will then complete the Section 117 discharge
form.
10.6
The Service User can refuse to accept the offer of aftercare services. Under
these circumstances the Care Coordinator should continue to attempt to
persuade the service user to accept the service until it is agreed at a formal
CPA review meeting that this is no longer appropriate.
10.7
The Service User should be identified as being subject to Section 117 by
completing the relevant details on the relevant form.
10.8
Supervised community treatment orders. (See policy on SCTO)
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11.
REJECTION, REFUSAL, NON-COMPLIANCE AND MISSING PERSON
11.1
It is the responsibility of each worker to ensure that his or her part of the Care
Package is carried out. However, in some cases relationships between the
Service User and the worker can break down and jeopardise the Care Plan. In
this case the responsibility falls to the Care Co-ordinator to find out why the
service user no longer wishes to co-operate with the plan so that the situation
can be redressed to the satisfaction of all involved.
11.2
Service Users who meet the criteria for the CPA and have a history of severe
and enduring mental illness must not be discharged solely on the grounds they
are uncooperative. All possible efforts should be made by the Care Coordinator to stay in touch with the Service User and work at developing a
relationship that will enable increased care in the long term. The Care Plan
should acknowledge the MDT’s difficulty in attaining engagement with the
Service User. This acknowledgement must be communicated with all those
involved in that Service User’s care and documented.
11.3
If there is a serious risk of suicide, self-neglect or harm to others through the
Service User’s refusal, then compulsory admission and treatment under the
Mental Health Act should be considered. This would necessitate MultiDisciplinary consultation and the subsequent arrangement of a joint assessment
visit with the GP, ASW and Consultant Psychiatrist.
11.4
When working with Service Users who have a history of rejection, refusal or
non-compliance, a thorough risk management strategy should be in place that
considers the range of actions that should be taken at times of greatest
concern.
11.5
Decision to discharge must be agreed by the Multi-Disciplinary Team through a
formal CPA Review meeting. Service Users must not be discharged following
failure to keep a fixed number of appointments.
12.
SERVICE USES WHO LOSE TOUCH WITH OR GO MISSING
FROM SERVICES
12.1
If a Service User fails to attend for an appointment or is not at home for a prearranged visit, consideration should be given to the Service User’s previous
reliability with respect to such arrangements. If contact cannot be reestablished, the Care Co-ordinator should be informed and the appropriate
action taken. This may include contacting a third party such as relatives, the
GP, support agencies or the police.
12.2
For those Service Users with a history of a loss of contact, trigger factors should
be identified and action should be documented within the risk management
strategies recorded on the Care Plan in relation to relapse. This would ensure
that all professionals involved would respond in the same way without periods
of time elapsing without action.
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12.3
A CPA Review meeting should be called as soon as the Service User loses
contact with services to share information and determine action.
12.4
It will be necessary to take into account the Service User’s current mental state,
previous history; potential and actual risk to self or others and the other
available support networks, in order to plan intervention.
12.5
Where a Service User seems to disappear from Services there is a duty of care
to make all reasonable efforts to locate them to negotiate arrangements for their
care and treatment. Actions to achieve this should be clearly recorded.
12.6
The Care Co-ordinator should contact any Carers, other members of the Care
Team, relatives and known associates to try to locate the Service User and to
offer support and monitor their wellbeing. Use of the National Tracking Service
may assist in checking their location via GP registration.
12.7
Where there are dependent children within the household of a Service User
with mental health needs, special consideration should be given to the
implications this may have for those children. Children’s welfare is a paramount
consideration for all professionals. Where there are issues of concern, the
Trust’s Public Health Advisor for Children and Families and the relevant Child
Care Services from the transferring and receiving district should be involved in
the planning arrangements for the transfer, so that children’s needs may be
properly identified and managed.
12.8
Where a child is on the Child Protection Register and is moving to another
Local Authority area, it is imperative that a speedy exchange of information is
carried out between districts. The Trust’s Public Health Advisor for Children
and Families must be informed in order to liaise with the appropriate Lead Child
Protection Health Professional within that area. There will be a transfer Child
Protection Conference held which Staff transferring care must attend. Staff
must at all times follow the relevant Trust and Local Authority Protection
Procedures.
13.
TRANSITION PROTOCOLS
13.1
Periods of transition in the care process represent a time of increased risk. For
this reason a number of transition protocols are in place to support the delay of
effective and efficient clinical services. These protocols must be read in
conjunction with this policy and all operate in accordance with the framework
provided by the CPA. The transition protocols are as follows: x Protocol for the transit of Clients from Child & Adolescent Mental Health
Services.
x Protocol for the transition of Clients between Adult & Older Adult Mental
Health Services.
x Protocol for the transition of Clients between HM Prison (Lancashire
Locality) and Mental Health Services (Lancashire).
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x Protocol for good practice in the transfer of Service Users care between
districts.
14.
CARE CO-ORDINATION WITHIN THE CRIMINAL JUSTICE SYSTEM
MAPPA
14.1
The link between mental illness and offending is noteworthy, however it is
complex. There are distinct differences in offending patterns between men and
women, which clearly affect their care and treatment needs under the CPA.
14.2
A significant number of individuals within the Criminal Justice System will
require the support of the Mental Health System at some point in their lives and
not necessarily just when in prison. For some people with mental health
problems, their first contact with Mental Health Services will come through the
Criminal Justice System. The CPA applies to these people regardless of the
setting. Where Service Users are the shared responsibility of Mental Health
and Criminal Justice Systems, close liaison and effective communication over
care arrangements, including ongoing Risk Assessment and Management are
essential.
14.3
Where a Service User is not in formal contact with the criminal justice system,
but is assessed as being a potential risk to others, careful liaison with the Police
to manage any immediate risks is necessary. In this context it is important to
note that the common law duty of confidence requires that, in the absence of a
statutory requirement to share information provided in confidence, such
information should only be shared with the informed consent of the Individual.
However, this duty is not absolute and can be over-ridden if the holder of the
information can justify disclosure as being in the public interest (including a risk
to public safety). The Caldicott Principles and Data Protection Act 1998 should
be adhered to at all times.
Further guidance on the operation of the common law is included in the DH
publication HSG (96) 18 The Protection and Use of Patient Information.
Decisions to disclose information against the wishes of an individual should be
fully documented and the public interest justification clearly stated.
Service Users considered as High Risk to Others
14.4
Some Service Users of mental health services will also have co-existing risk
issues, which may or may not be diagnostically related. Service Users who
present a significant risk to the public and have previous convictions for
assaultative, abusive or threatening behaviour may also be subject to MAPPA
protocols and procedures. Mental Health Services have a responsibility to
participate fully within the MAPPA framework to ensure protection of the public.
Most high risk mentally disordered offenders will be registered as Level 2
MAPPA cases, unless a multi-agency decision, particularly the police and
probation consider the case as highly dangerous requiring very close
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monitoring and special arrangement where an Individual may be recorded as
MAPPA 3.
14.5
However, there are also a number of Service Users who appear to present a
considerable risk to others, family, staff and the public, but who do not have
recent, relevant or significant previous convictions, which precludes them from
registration and monitoring under the MAPPA framework; i.e. Level 1. This
means that the responsibility for Care Delivery and monitoring lies with Mental
Health Services, specifically the RMO and Care Co-ordinator. For further
information regarding MAPPA Framework i.e. levels 1, 2 and 3 refer to the
Criminal Justice Act 2002.
Multi-disciplinary, Cross Agency CPA Reviews Incorporating Risk
Assessment/Management
14.6
CPA Reviews encourage attendance of all Staff involved in the care of the
Individual Service User, in addition to the User and the Carer. However, it is
difficult for partnership agencies to prioritise CPA Reviews when they do not
fully understand the CPA process are not formally invited by letter and if
reviews do not take account of the individual agencies remit and Service
objectives.
14.7
In order to develop effective risk management plans for Mental Health Service
Users it may be beneficial to invite the police, probation and other agencies e.g.
Child Protection Social Workers. Clearly, these Staff will not necessarily have a
direct interest or involvement in the review of the Mental Health Care Plan.
Therefore, it would be advantageous to hold a CPA Review, which directly
focuses on Risk Management – a CPA/Risk Review.
Multi-Disciplinary Risk Review
14.8
To be arranged by the Care Co-ordinator or RMO when a person presents a
significant risk to self or others and the current Care Plan has become
ineffective and/or the person presents such a high level of risk and complexity
that it appears impossible to construct a care/risk plan within current resources.
14.9
A multi-agency Risk/CPA Review should be arranged to discuss the elevation
of risk/breakdown of the care plan in order to amend intervention to ensure
safety of the Service User, Carer, Staff and the Public.
14.10 The Care Co-ordinator will formally invite all relevant parties involved with the
Service User and Carer, if appropriate. NB. Due to the level and nature of the
risk presented by the Individual Service User, it may be necessary to hold
professionals’ only meeting (or have a closed section of the meeting). Where
possible, efforts should be made to provide feedback to the service user and
carer. The Care Co-ordinator in discussion with the Multi-Disciplinary Mental
Health Team should determine who needs to attend the Risk Review:
14.11 Examples of possible invitees include the local Community Affairs Inspector (or
nominated deputy) to represent the police, the local Senior Probation Officer (or
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nominated deputy) if a current or previous probation Service Client, the Criminal
Justice Liaison Worker and a representative of the Forensic Community Mental
Health Team, if possible.
14.12 Summaries of the Risk Assessment and current Risk Management Plan should
be distributed with the invitation letter to allow attendees to be appraised of the
specific areas of concern, prior to the meeting.
14.13 The Mental Health Team should ensure:
x
x
x
x
x
x
x
The development of a standard letter of invitation for partnership agencies
that succinctly explains the importance of the Risk Review Meeting. This
letter should include a confidentiality clause outlining the highly confidential
nature of content and minutes of the meeting. It may also be necessary to
have a ‘restricted, not for disclosure’ section in the minutes, which contains
highly confidential information such as surveillance information from the
police, 3rd party names who may be at risk etc.
Minutes of the meeting should be circulated only to invited participants, and
other necessary professionals as agreed at the meeting.
The minutes should be stored in the 3rd party section of the medical case
notes
Sufficient advance notice to maximise attendance, unless the meeting is
urgent/emergency
An appropriate venue to host the meeting
The Risk Review Meeting commences on time
A formal style of meeting – Chair and Minute Taker
14.14 The chairperson should:
x
x
x
x
x
x
x
x
Be a Senior Practitioner/Manager who is not directly involved in the care of
the Service User.
Formally introduce the purpose of the meeting i.e. to review the
current/previous risk profile, relevant historical factors, level and context of
risk and areas where the current Care/Risk Plan is ineffective.
Reiterate the confidentiality clause for all participants
Ensure that all attendees are able to contribute to the discussion about risk
features and areas of concern from their individual professional/agency
perspective.
Progress the meeting to establish possible cross agency communication
and strategies to manage identified risks.
Conclude the meeting to summarise specific risks, management strategies,
Individuals responsible for intervention, contingency arrangements and
timescales for review.
Attendees should formally sign as acceptance of the Risk Management Plan
determined by the meeting, prior to leaving. Any contentious views should
be noted with the signature.
Minutes and the Risk Management Plan should be circulated promptly to all
attendees as appropriate.
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14.15 The above structure is designed to focus CPA meetings on the multi-faceted
management of Individual Service Users who may present significant risks to
themselves or others and require the construction of a robust risk management
plan owned by representatives of relevant agencies.
Service Users not registered under the CPA
14.16 A&E and Criminal Justice Liaison Teams for example; may encounter Service
Users who appear to display significant risk features, but are not registered
under the CPA. The above system is applicable for such Individuals and the
Team Leader/Manager should determine who is most appropriately placed to
take on the co-ordination role to arrange the Risk Review.
Prison Based Health Care
14.17 Prison based Health Care staff and NHS Mental Health Services share
responsibility for ensuring appropriate liaison on the care of mentally disordered
prisoners. It is particularly important that effective links are made to ensure
sound discharge planning when prisoners are released from prison.
14.18 If a Service User is being held on remand or has received a sentence shorter
than twelve months, the Care Co-ordinator must ensure that they maintain
contact with the Service User and review the care and treatment they receive
when they enter the prison system, thus ensuring the continuity of the care.
14.19 As soon as the Care Co-ordinator is made aware that a Service User has been
detained or entered the prison system early communication of his or her
involvement must take place. This communication will be followed up by a fax
message (number to be made available to each Line Manager). The name of
the Health Care Staff member with whom communication has taken place must
also be recorded.
14.20 The Care Co-ordinator will discuss the arrangements for an early CPA review
with those involved including the identified Mental Health in reach team or
prison based Health Care Staff where possible. Particular emphasis should be
made to risk assessment and management.
14.21 Following review, a Care Plan should be agreed with the service user (and if
appropriate, their carers and others involved in their care) prior to release from
prison with contingencies in the event of early release.
14.22 In particular the Care Co-ordinator needs to make sure that they are, wherever
possible, aware of the Service User’s prison establishment and location and
likely release date, so that appropriate planned care can be implemented when
they are released.
Discharging Service Users who enter the Prison System
14.23 If a Service User has been sentenced and is likely to be detained in prison for
longer than twelve months the existing Care Co-ordinator in most cases is
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unlikely to be the person ‘best placed’ to ensure care is co-ordinated effectively.
Therefore, clear arrangements for discharge from local Specialist Mental Health
Services must be in place.
14.24 The arrangements for discharge from local Mental Health Services are best
delivered through a formal review meeting. Ideally all those involved should be
present (the review can take place in the prison setting if deemed the most
appropriate place).
14.25 At the review a Care Co-ordinator or equivalent will be identified and the
arrangements for re-accessing Mental Health Services once the sentence has
passed must also be in place (within a care plan).
Other Service Users In Contact with the Criminal Justice System
14.26 The principles outlined above should also be applied to other Service Users
who may be in contact with the Criminal Justice System. For example,
Individuals who are subject to probation orders or where regular communication
with the Police may occur through the MAPPA arrangements. In such cases it
is important that
effective links are made in order to facilitate effective care
planning and robust risk assessment management.
.
15.
MEETING THE NEEDS OF CHILDREN
15.1
Specific Policies and Procedures must be in place within the Community Mental
Health Services in particular, and the rest of Mental Health Services for those
Service Users who have dependent children and/or children who are
identified as being in need or where there are Child Protection concerns. It
is important that reference is made to the Adult Mental health and Child
Protection guidance and Multi-Agency protocol
15.2
The relevant Child Protection Procedures must be followed where there are
concerns for the welfare/safety of children and young people.
Service Users who may pose a risk to Children and Young People
15.3
During the assessment and provision of care, it may become known that the
Service User may pose a risk or potential risk to children/young people or
adults. The protection of children and vulnerable adults is paramount and
integral to the provision of any Healthcare Service.
15.4
The Care Co-ordinator and all Staff providing care must be made aware of any
disclosures made and Police Public Protection Unit notified as well as
Children’s Social Care, in line with LSCB procedures. Staff must identify if
Multi-agency Public Protection Arrangements (MAPPA) have been put into
place.
15.5
In a ward environment staff must consider any young person currently being
cared on the same ward who must be protected from disturbed and/or
dangerous situations and arrangements should be sought to find alternative
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accommodation providing a safe environment away from known offenders or
those who pose a risk to children/young people.
15.6
Information regarding the arrangements for identification of child protection
issues, referral and assessment arrangements, co-ordination of follow up of
assessment outcomes are contained in Lancashire Care Trust’s policy for
Safeguarding Children and the relevant Local Authority Policy documents.
16.
CPA AND CONFIDENTIALITY
16.1
The implementation of CPA does not affect the service user’s right to
confidentiality in any way. All information relating to service users remains
confidential within the usual exceptions.
16.2
In order to deliver appropriate care for those Service Users, it is vital that those
involved have ready access to the information necessary for the safe, sound
and supportive implementation of the care package. However, it is also
important that Service Users and their Carers can trust that personal
information will be kept confidential and that their privacy will be respected.
16.3
All Staff have an obligation to safeguard the confidentiality of personal
information. This is to comply with the law, contracts of employment and in
many cases, professional codes of conduct. All staff should be made aware
that breaches of confidentiality could be a matter for disciplinary action and
provides grounds for complaint against them.
16.4
It is neither practicable nor necessary to seek a service user’s specific consent
every time information needs to be passed on for the particular purpose of
delivering care and treatment for the Service User. This is contingent on the
service user having been fully informed of the uses to which information about
them may be divulged.
16.5
Clarity about the purposes to which personal information is to be divulged is
essential and only the minimum identifiable information necessary to satisfy that
purpose should be made available. Access to personal information should be
on a strict need to know basis.
16.6
It is the responsibility of the Care Co-ordinator to seek out and relay the
relevant information to other agents who have a legitimate need to know. This
is particularly important in circumstances where there may be family and child
welfare issues, probation, or housing, health and social issues involving other
agencies.
16.7
There may be other circumstances in which the disclosure of information is
required by statute or court order, or the absence of consent can be justified in
the public interest.
16.8
Specific consent is required prior to personal information being transferred for
purposes other than those defined in this policy, unless there are exceptional
circumstances as outlined above. Where Service Users are unable to give
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consent to their information being shared, the decision should be made on the
Service User’s behalf by those responsible for providing care, taking into
account the views of the Service User and Carers with the Service User’s best
interest being paramount.
17
TRAINING
17.1
Training and development is an essential requirement for the successful
delivery of Mental Health Services within Lancashire. The development and
delivery of training to support CPA is part of the Trust’s/Local Authorities
training plan. This training will focus on the key principles underlying the care
process, i.e. assessment, core planning and intervention. All training and
monitoring for this policy will be undertaken in line with the requirements set out
in the Statutory / Mandatory Training Policy.
17.2
All recording and mandatory training will be undertaken in line with the
requirements sent out in the Statutory Training Policy
18.
AUDIT
18.1
“Audit and monitoring are essential components of successful implementation
of CPA” (ECC paragraph 72).
18.2
All Staff and their Managers have crucial roles in respect of providing audit
information for Service Users on their caseload, they must be aware that
completion of the audit is mandatory.
18.3
The responsibility for auditing the ‘quality’ of care plans lies with each
departmental manager in line with the NSF. Utilising supervision mechanisms
together with other audit initiatives, they will ensure that standards for Care
Planning are met. The CPA leads will support these processes.
18.4
Evidence of CPA audit activity must be built into the activity of both Clinical
Governance and Best Value as part of both each organisations drive towards
continuous improvement. Also evidence of any required actions stemming out
of these audits must be made available when required.
18.5
Audit will be on an annual basis and will be based on the standards outlined in
this policy
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REFERENCES
DEPARMENT OF HEALTH: The National Service Framework (1999). L46/01 16575
com 30k 1P Sep 1999
THE MENTAL HEALTH ACT (1983)
DEPARTMENT OF HEALTH: Effective Care Co-ordination in Mental Health Services Modernising the Care Programme Approach, NHSE (1999).
DEPARTMENT OF HEALTH: The Care Programme Approach (1991). (Joint Health &
Social Services Circular HC (90) 23/LASSL (90) 11)
DEPARTMENT OF HEALTH (2007) Best practice in managing risk
DEPARTMENT OF HEALTH (2008) Refocusing the Care programme Approach
SOCIAL SERVICES INSPECTORATE: Still Building Bridges (1999) C1 (1999).
‘An Audit Pack for the Monitoring of the Care Programme Approach (2001)
The CPA Handbook – The CPA Association (2001)
NATIONAL HEALTH SERVICE EXECUTIVE: Audit Pack for Monitoring the CPA,
(HSG (96) 6).
NATIONAL CONFIDENTIAL ENQUIRY INTO SUICIDE AND HOMICIDE BY PEOPLE
WITH MENTAL ILLNESS (1999)
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Appendix 1
Statement of Values and Principles
Table 1
The approach to individuals’ care and support puts them at the centre and promotes
social inclusion and recovery. It is respectful – building confidence in individuals with
an understanding of their strengths, goals and aspirations as well as their needs and
difficulties. It recognizes the individual as a person first and patient/service user
second.
Care assessment and planning views a person ‘in the round’ seeing and supporting
them in their individual diverse roles and the needs they have, including: family;
parenting; relationships; housing; employment; leisure; education; creativity;
spirituality; self-management and self-nurture; with the aim of optimising mental and
physical health and well-being.
Self-care is promoted and supported wherever possible. Action is taken to encourage
independence and self-determination to help people maintain control over their own
support and care.
Carers form a vital part of the support required to aid a person’s recovery. Their own
needs should also be recognized and supported.
Services should be organised and delivered in ways that promote and co-ordinate
helpful and purposeful mental health practice based on fulfilling therapeutic
relationships and partnerships between the people involved. These relationships
involve shared listening, communicating, understanding, clarification, and organization
of diverse opinion to deliver valued, appropriate, equitable and co-coordinated care.
The quality of the relationship between service user and the care-coordinator is one of
the most important determinants of success.
Care planning is underpinned by long-term engagement, requiring trust, team work
and
commitment. It is the daily work of mental health services and supporting partner
agencies, not just the planned occasions where people meet for reviews.
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Appendix 2
Table 2
Service users needing (new) CPA
Other service users
An individual’s characteristics
Complex needs; multi-agency input;
higher risk.
See detailed definition in Table 1.
More straightforward needs; one agency
or no problems with access to other
agencies/support; lower risk.
What the service users should expect
Support from CPA care co-ordinator
(trained, part of job description, coordination support recognised as
significant part of caseload)
Support from professional(s) as part of
clinical/practitioner role. Lead
professional identified. Service user selfdirected care, with support.
A comprehensive multi-disciplinary, multi- A full assessment of need for clinical
agency assessment covering the full
care and treatment, including risk
range of needs and risks.
assessment.
An assessment of social care needs
against FACS eligibility criteria (plus
Direct Payments)
An assessment of social care needs
against FACS eligibility criteria (plus
Direct Payments)
Comprehensive formal written care plan;
including risk and
safety/contingency/crisis plan.
Clear understanding of how care and
treatment will be carried out, by whom,
and when (can be a clinician’s letter)
On-going review, formal multidisciplinary, multi-agency review at least
once a year but likely to be needed more
regularly.
On-going review as required.
At review, consideration of on-going need On-going consideration of need for
for (new) CPA support.
move to (new) CPA if risk or
circumstances change.
Increased need for advocacy support.
Self-directed care, with some support if
necessary.
Carers identified and informed of rights to
own assessment.
Carers identified and informed of rights
of own assessment.
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Appendix 3
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Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
POLICY AND PROCEDURE FOR
SAFEGUARDING AND
PROTECTING VULNERABLE ADULTS
POLICY NO
DATE RATIFIED
NEXT REVIEW DATE
CL 022
Feb 2009
Feb 2012
POLICY STATEMENT/KEY OBJECTIVES:
The Trust has policy and procedures in place for all Lancashire Care NHS Foundation
Trust Staff to promote the welfare of vulnerable adults and ensure their safety and
protection.
ACCOUNTABLE DIRECTOR: Director of Nursing
POLICY AUTHOR: Public Health Advisor Children and Families Named Nurse Child
Protection
Date of issue – March 2009
1
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Executive Summary
Subject
Safeguarding and protecting
procedures
Applicable to
All employees of Lancashire Care NHS Foundation
Trust
Key Policy Issues
To ensure all staff have an awareness of their roles
and responsibilities
To provide clarity of referral processes where there
are concerns for an adult in need of support or
protection
General vulnerable adult procedure if abuse is
suspected
Date Issued
Dates Policy reviewed
Next review due date
Policy written by
February 2009
February 2009
January 2012
Public Health Advisor Children and Families/
named Nurse Child Protection / LCFT
Safeguarding Practitioner
Executive Directors
Senior Management Team
Safeguarding Committee
Safeguarding Committee
Director of Nursing
Consultation
Policy reviewed by:
Lead responsible for policy
Monitoring arrangements
Approved by
Authorised by
Signature
Related procedural documents
Date of issue – March 2009
Vulnerable
Adult
The Public Health Advisor Children and Families/
named Nurse Child Protection will be responsible
for monitoring this procedure and will provide
assurance to Safeguarding Committee and EMT
Governance via quarterly and annual reports the
Risk Management Annual Report
Safeguarding Committee
Senior Management Team Policy & Governance
Patrick Sullivan
Director of Nursing
Procedure for the reporting and management of
incidents including the management of serious
untoward incidents
No Secrets in Lancashire: A Joint Strategy to
Protect Vulnerable Adults From Abuse
Blackpool Vulnerable Adults Committee, Code of
Practice and Procedures and
Blackburn with Darwen Adult Protection Policy
and Procedures
2
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Contents
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
12.0
13.0
14.0
15.0
16.0
17.0
18.0
19.0
20.0
21.0
Page
Summary
Introduction
Standards
Definitions
Scope
Principles
Duties
Confidentiality
Capacity and consent
Concerns Regarding Poor Practice “Whistle blowing”
Record Keeping
Concerns about Abuse from staff
Concerns regarding Abuse from one Vulnerable Adult to Another
Abuse/concern within the Home Environment
Training
Support for staff
Monitoring
Equality and Diversity Impact Assessment
Review
Other associated Policies and Procedure
References
References
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Date of issue – March 2009
Procedure for Safeguarding and Protecting
Vulnerable Adults
Blackburn with Darwen Flowchart for Reporting
Lancashire Flowchart for Reporting
Blackpool Flowchart for Reporting
Female Body Map
Male Body Map
4
4
4
5
7
7
7
10
10
10
11
11
11
11
11
11
12
13
13
13
13
15
27
28
29
30
31
3
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
1.0
Summary
The Department of Health’s No Secrets document (DoH, 2000) provides guidance that
requires all agencies to have arrangements in place to effectively safeguard, protect and
respond to known or suspected abuse of vulnerable adults. Lancashire Care Foundation
Trust (LCFT) Policy and Procedures have been developed in line with current evidence and
follows the principles outlined in the following Local Authority Procedures:
x
x
x
No Secrets in Lancashire: A Joint Strategy to Protect Vulnerable Adults From
Abuse
Blackpool Vulnerable Adults Committee, Code of Practice and Procedures and
Blackburn with Darwen Adult Protection Policy and Procedures
This document be should read in conjunction with the appropriate mentioned
documents, depending on the residence of the vulnerable adults.
The abuse of vulnerable adults constitutes a clear infringement of their rights and freedoms
as citizens.
2.0
Introduction
This policy aims to promote the protection of vulnerable adults, who are at risk of all forms
of abuse, and ensure that they receive a safe, sound and supportive service, through the
process of identifying, investigating, managing and preventing such abuse.
3.0
Standards
LCFT Safeguarding Adult practice reflects the standards within the national framework for
Safeguarding adults October 2005 - Produced in Oct 2005 by the Association of Directors
of Social Service (ADSS)
x
Accountability for and ownership of ‘Safeguarding Adults’ work is recognised by
each partner organisation’s executive body
x
Each partner agency has a clear, well-publicised policy of Zero-Tolerance of abuse
within the organisation
x
Each partner agency has a set of internal guidelines, consistent with the local multiagency ‘Safeguarding Adults’ policy and procedures, which sets out the
responsibilities of all workers to operate within it
x
The Trust will work in partnership with the local authority and other agencies as
needed, where Adult Safeguarding incidents are identified
Date of issue – March 2009
4
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
x
The safeguarding procedures are accessible to all adults covered by the policy.
“Safeguarding adults is the responsibility of all agencies and cannot exist in
isolation. It must be effectively linked to other initiatives, as part of a network of
measures aimed at enabling all citizens to live lives that are free from violence,
harassment, humiliation and degradation.” (ADSS Framework)
x
As a service we are committed to promoting equality of opportunity to all members
of our community. It is every adult’s right to live in safety and to be free from abuse
or fear of abuse from others. It is every adult’s right to live an independent life
based on ‘self-determination’ and personal choice. An independent life style may
involve risk for vulnerable adults. LCFT respects this choice and will support them
in making such decisions.
It is the responsibility of all the agencies and
professionals to actively work together to help prevent abuse of vulnerable adults.
This will be achieved by raising awareness, empowering people to make their own
decisions and putting safeguards in place
x
To ensure all adult protection incidents are recorded, reported and investigated in
line with Trust serious untoward incident and risk management arrangements
x
Manage the risks associated with Adult Safeguarding in line with the Trust Adult
Safeguarding procedure in Appendix 1.
A CRIMINAL INVESTIGATION BY THE
OVER ALL OTHER LINES OF ENQUIRY.
ALL LINES OF ENQUIRY. AN INTERNAL
CONDUCTED WHERE LCFT STAFF ARE
ABUSE.
4.0
POLICE WILL TAKE PRIORITY
LCFT WILL COOPERATE WITH
INVESTIGATION WILL STILL BE
ALLEGED PERPERTRATORS OF
Definitions
Safeguarding adults is defined for the purpose of this policy and its procedure as:
x
x
x
protecting adults from harm or maltreatment
preventing impairment of health
ensuring that adults live in circumstances consistent with the provision of
safe and effective care
Adult at risk is a person aged 18 or over and who may already be in receipt or in need of
community care services by reason of mental or other disabilities, age or illness. This
person may be unable to take care of him or herself, or unable to safeguard themselves
against significant harm or exploitation.
The concept of significant harm introduced in the Children Act can be applied to the
consideration of harm to vulnerable adults. This suggests that:
Date of issue – March 2009
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Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Harm should be taken to include not only ill treatment (including sexual abuse and forms
of ill treatment which are not physical) but also the impairment of or an avoidable
deterioration in physical or mental health, and the impairment of physical, intellectual,
emotional, social or behavioural development.
Emotional harm can be caused by a vulnerable adult being exposed to domestic violence
or being aware of domestic violence within the home.
Neglect is the persistent failure to meet an adult’s basic physical and / or psychological
needs, likely to result in the serious harm to that persons health and welfare. The
consequences of neglect can have a life long impact.
Safeguarding adults encompasses all aspects of adult protection.
Abuse is a violation of an individual’s human and civil rights by other person or persons.
Abuse may consist of single or repeated acts. It may be physical, verbal or psychological, it
may be an act of neglect or an omission to act, or it may occur when a vulnerable person is
persuaded to enter into a financial or sexual transaction to which he or she has not
consented, or is unable to consent to. Abuse can occur in any relationship and may result in
significant harm, or exploitation of the person subjected to it.
Abuse may take one or more of the following forms:
x
x
x
x
x
x
x
x
Physical abuse, including hitting, slapping, pushing, kicking, misuse of medication,
restraint, or inappropriate sanctions
Sexual abuse, including rape and sexual assault or sexual acts to which the adult has
not consented, could not consent to, or was pressured into consenting
Psychological abuse, including emotional abuse, threats of harm or abandonment,
deprivation of contact, humiliation, blaming, controlling, intimidation, coercion,
harassment, verbal abuse, isolation or withdrawal from services or supportive networks
Financial or material abuse, including theft, fraud, exploitation, pressure in
connection with wills, property or inheritance or financial transactions, or the misuse or
misappropriation of property, possessions or benefits
Neglect and acts of omission, including ignoring medical or physical care needs,
failure to provide access to appropriate health, social care or educational services, the
withholding of the necessities of life, such as medication, adequate nutrition and
heating
Discriminatory abuse, including racist, sexist, that based on a person’s disability, and
other forms of harassment, slurs or similar treatment
Domestic abuse is any incident of threatening behaviour, violence abuse
(psychological, physical, sexual, financial or emotional) between adults who are or
have been intimate partners or family members, regardless of gender or sexuality. It is a
pattern of abusive and controlling behaviour by which the perpetrator seeks to exert
power over the victim
Institutional abuse can include any of the above and poor or unsatisfactory
professional practice, or pervasive ill treatment or gross misconduct. It is abuse or
mistreatment by a regime as well as by individuals, within any setting where care is
provided
Date of issue – March 2009
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Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
x
5.0
Bullying behaviour is a form of abuse, defined as ‘the unjustified display of verbal or
physical aggression on the part of one individual or group towards another’
Scope
This policy must be followed by all staff employed and independently contracted by
Lancashire Care Foundation Trust (LCFT). This policy is supplementary to and not a
replacement for individual Local Safeguarding Adult multi agency policy and procedure
and must be read in conjunction with them.
x
This policy applies to all vulnerable adults 18 years or over
x
This policy is to be followed irrespective of the setting in which abuse is either
suspected or alleged. This will ensure that the need of the vulnerable adult remains the
focus of all interventions and actions and that staff will also be supported and protected.
6.0
Principles
In the provision of services to all Trust service users, the Trust has a commitment to deliver
these services in a non-discriminatory manner.
No assumption can or should be made that people with mental health problems, those in
receipt of substance misuse services or those with a learning disability constitute a risk to
children simply by virtue of their difficulties.
Vulnerable adults have the right to be protected from harm and to receive services when
their health or welfare is at risk. All interventions should enable an adult "who is or may be
eligible for Community care services" to retain independence, well being and choice and to
access their human right to live a life that is free from abuse and neglect (No Secrets).
Protection will be provided to those who do not have the mental capacity to access it
themselves in line with:
Human Rights Act 1988,
Mental Capacity Act 2005
Mental Health Act 2007 & Mental Capacity Act Amendments – Deprivation of Liberty
Standards
Domestic Violence Crime and Victims Act 2004
7.0
Duties
7.1
Chief Executive
The Chief Executive as the Accountable Officer has overall responsibility for ensuring the
implementation of effective Safeguarding Adult arrangements and meets all statutory
requirements. Executive responsibility is delegated to the Director of Nursing.
Date of issue – March 2009
7
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
7.2
Director of Nursing
x The Director of Nursing is the executive lead for LCFT and reports directly to the Chief
Executive on related issues and is a representative on the local authority safeguarding
boards.
x
The Director of Nursing also has responsibility for ensuring the Trust as a partner
agency meets the standards for good practice embodied in “No Secrets” D.H. 2000 and
the ADSS National Framework and ensures that local arrangements and protocols are
in place to support compliance with local authority multi agency adult protection policy
and procedure.
x
Providing assurance to the Trust Board of compliance with this procedure via the
Governance report
7.3
Deputy Director of Nursing
Line manages the LCFT Safeguarding Team and sits on local authority safeguarding
boards.
7.4
Public Health Advisor Children and Families/Named Nurse Child Protection
and the Safeguarding Practitioner general responsibilities include:
x Liaison and links with local authority Safeguarding Adult leads
x Ensuring that the Safeguarding of Adults and Children are linked and considered
together
x Development of safeguarding practice
x Provision of safeguarding advice and support
x Identification of safeguarding/vulnerable adult training needs and facilitate access to
appropriate
training
x Facilitating advice on legal matters in conjunction with the Trust’s legal advisors
x Close liaison with the management structures within LCFT and other agencies to
address both strategic and operational issues relating to the safeguarding adult agenda
x Providing assurance to the Safeguarding Committee of compliance with this procedure
x Developing an action plan to address issues of non compliance with this procedure
7.5
Network Directors are responsible for:
x Ensuring policy implementation in their service area
x Ensuring staff receive proper supervision in relation to safeguarding incidents in line
with the Trust’s Supervision Policy
x Ensuring that Adults Safeguarding issues are a standing item in all service meetings
x Ensuring that local arrangements and protocols are in place that supports compliance
with the local multi-agency Adult Protection Policies and that they are adhered to by all
managers and their staff
x Ensuring that all serious Adult Safeguarding Incidents are managed in line with the
trust incident reporting procedures
x Ensuring and monitor that all staff in their area are appropriately skilled and have up to
date knowledge of Safeguarding procedures through their KSF and PDP outline
Date of issue – March 2009
8
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
7.6
Service Managers, Modern Matrons, Professional Leads, Senior Nurses and
Managers are responsible for:
x Ensuring staff receive proper supervision in relation to safeguarding incidents in line
with the Trust’s Supervision Policy
x Ensuring all adult protection alerts are reported in line with local authority multi agency
safeguarding adult policy and procedures
x Responding to instances of suspected or actual adult abuse in a clinical proactive way
to ensure the protection and safeguarding vulnerable adults
x Coordinating investigations, chair adult protection strategy meetings and ongoing
investigations in line with local authority multi agency safeguarding adult policy and
procedures
x Ensuring that all Team Leaders and Ward Mangers are aware of local authority multi
agency safeguarding adult policy and procedures through their KSF and PDP outline
7.7
Team Leaders and Ward Managers are responsible for:
x Ensuring that staff are aware of local authority multi agency safeguarding adult policy
and procedures through their KSF and PDP outline
x Ensuring that all staff are aware of the process for raising an adult protection alert
x Ensuring that staff have access to the Trust Intranet Safeguarding and Protecting adult
page
x Ensuring staff receive proper supervision in relation to safeguarding incidents in line
with the Trust’s Supervision Policy
x Providing support for staff involved in any incident relating to vulnerable adults
x Ensuring staff receive training as highlighted in the trust’s Training Needs Analysis
7.8
Safeguarding Champions These are identified practitioners in teams who liaise
and work closely with the Safeguarding Team and they are responsible for:
x Appraising existing care plans to ensure safeguarding issues are included and that they
are sensitive to the current needs of the child and family
x Clarifying roles and responsibilities of staff in line with LCFT and LSCB procedures
x Establishing that practice is compliant with national and local safeguarding policies,
procedures and guidance
x Providing appropriate supervision and support, to enable safe and effective practice
x Promoting professional development, identifying with the practitioner, gaps in
knowledge and skills and directing staff into appropriate training
x Ensuring that there is close communication with the Safeguarding Team/line managers,
regarding safeguarding and protecting issues arising from practice
7.9
All Staff are responsible for:
x Protecting and safeguarding vulnerable adults.
x Understanding and implement the Trust Safeguarding and Protecting Vulnerable Adult
Policy and Procedures
x Familiarising themselves with the risk factors and signs/symptoms of abuse, and to be
aware of the action to be taken should such an incident present itself
x Attending training as required by the Trust’s Training Needs Analysis
7. 10
Trust Board is responsible for:
Date of issue – March 2009
9
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Receiving assurances that this policy is being implemented, also EMT Governance in
respect of receiving assurance from the safeguarding committee and providing assurance to
the Trust Board
7.11 EMT Governance
EMT Governance is responsible for:
x Receiving assurance of compliance with this procedure from the Safeguarding
Committee
x Providing assurance to the Trust Board of compliance with tis procedure via the
Director of Nursing’s Governance Report
7.12 LCFT Safeguarding Committee is responsible for:
x To oversee the development, implementation and monitoring of systems, processes and
policies to ensure Children, Young People and Vulnerable Adults are safeguarded
whilst accessing services provided by LCFT
x To approve performance processes and agree strategic direction for Safeguarding
within LCFT
x To monitor implementation of current legislation and policy in relation to Safeguarding
Children and Vulnerable Adults
x To agree quality standards, audit priorities/tools and support a training strategy for
Safeguarding Children, Young People and Vulnerable Adults
x Reporting to the Trust Board and will provide assurances that Safeguarding Children,
Young People and Vulnerable Adults procedures are implemented according to the
committee structure in the Risk Management Standard the Safeguarding Committee
reports to EMT Governance
8.0
Confidentiality
Information regarding Safeguarding of Adults must be handled in line with the Trust’s
Policy for the lifecycle management of records. All staff and practitioners must protect all
confidential information concerning patients and clients obtained in the course of
professional practice and abide by their professional codes of conduct
9.0
Capacity and Consent
All capacity and consent issues will be handled in line with the Mental Health Capacity
Act 2005 and the Mental Health Act of 2008
10.0 Concerns Regarding Poor Practice “Whistle Blowing”
If a criminal offence is alleged or suspected, police in the Police Public Protection Unit
must be contacted for advice or to report directly.
Date of issue – March 2009
10
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
11.0
Record Keeping
Record keeping will be handled in line with the Trust’s Record Keeping Policy. Further
guidance helpful to record keeping for Safeguarding incidents is included in the procedure.
12.0
Concerns about Abuse from Staff
Inappropriate behaviour by a staff member towards any patients will not be tolerated and
will be dealt with in line with the Trust’s Disciplinary Procedure.
13.0 Concerns Regarding Abuse from One Vulnerable Adult to Another
Inappropriate behaviour between patients will not be tolerated and will be stopped
immediately and handled in line with the Trust’s procedure.
14.0 Abuse/Concern Within the Home Environment
Any issues or concerns regarding abuse within the home environment will be dealt with
swiftly and in line with he Trust’s procedure in Appendix 1.
15.0 Training
Staff will be trained in line with the Trust’s Training Needs Analysis See statutory and
mandatory training procedure.
Attendance and non attendance will be monitored in accordance with the statutory and
mandatory training procedure.
Expertise and knowledge levels of staff will be monitored in line with KSF and PDP
outlines. Links to further training are available via the Trust’s Safeguarding and Protecting
Adult intranet site.
16.0 Support For Staff
x
All managers have a duty to respond and take appropriate action, to provide support for
staff and implement strategies to manage subsequent actions and care strategies to
manage subsequent actions and care in line with LCFT Procedure for Supporting Staff
following Traumatic/Stressful Incidents, Complaints or Claims.
x Occupational Health is available for counselling and staff can either self refer or be
referred by their manager.
Further support please is available via LCFT Safeguarding Team
Date of issue – March 2009
11
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
17.0
Monitoring
The process for monitoring the effectiveness of these procedures and of the safeguarding
arrangements for children within the Trust will be by the Trust Safeguarding Committee.
An Annual Report from the Safeguarding Committee will be submitted to the Executive
Management Team (EMT) Governance who will feedback to the Trust Board each year.
The Trust Board has overall accountability for ensuring these procedures are in place.
The Trust’s Safeguarding and Protecting Adults procedures and compliance will be
monitored through a number of means, which are outlined in the following table.
Standard
Duties
Timeframe/
Format
Annually in
report to the
Board
Review of reported
safeguarding incidents to
establish themes and trends
Quarterly in
reports to the
Board
Training as per Trust’s
Training Needs Analysis
Annually in
report to the
Board
Local Safeguarding
arrangements are being
followed
Quarterly in
reports to the
Board
Date of issue – March 2009
How
Whom
Review of a sample of
EMT and Safeguarding
Committee minutes,
Local Authority training
records and LCFT Oracle
Learning Management
system (OLM), work
plans, objectives
Quarterly reports,
reported incidents and
SUI’s regarding concerns
about an adult’s safety,
reviewed.
Attendance records
Quarterly training reports
Public Health
Advisor
Children/Families
Review of Incident
reports, minutes
Safeguarding Committee
meetings, Safeguarding
Champions meetings.
LASB meetings and
subgroups
LCFT Safeguarding
Annual Report,
programme of audit.
Public Health
Advisor
Children/Families
Public Health
Advisor
Children/Families/
Training and
development
Manager
Public Health
Advisor
Children/Families
LCFT
Safeguarding
Committee
12
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Supporting Staff
Annually in
report to the
Board
Specific audit activity of
Safeguarding practice,
findings and direct action
will be monitored by
LCFT Safeguarding
Committee.
Safeguarding Team
Advice records
Safeguarding Champions
meeting minutes.
Public Health
Advisor
Children/Families
LCFT
Safeguarding
Committee
Public Health Advisor Children/Families is responsible for proving assurance of
compliance with this procedure to the Safeguarding Committee. The Safeguarding
Committee will provide assurance to EMT Governance of compliance with this procedure
via quarterly and annual reports. An action plan to address issues of non compliance with
this procedure will be developed and monitored by the Safeguarding Committee
18.0
Equality and Diversity Impact Assessment
See appendix 7
19.0
Review
This procedure will be reviewed every 3 years or earlier if there is a change in NHS or DH
Guidance.
20.0
x
x
x
x
Procedure for the reporting and management of incidents including the management of
serious untoward incidents
No Secrets in Lancashire: A Joint Strategy to Protect Vulnerable Adults From Abuse
Blackpool Vulnerable Adults Committee, Code of Practice and Procedures and
Blackburn with Darwen Adult Protection Policy and Procedures
21.0
x
Other Associated Polices and Procedures
References
Blackburn with Darwen Inter Agency Policy and Procedures For the Protection of
Vulnerable Adults From Abuse (April 2004)
Blackpool Borough Council & Social Services, Blackpool Vulnerable Adults Committee
(2004), Code of Practice and Procedure
Date of issue – March 2009
13
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Lancashire Social Services (2001) No Secrets in Lancashire: A Joint Strategy to Protect
Vulnerable Adults from Abuse, Lancashire Social Services
Department of Health (2000) No Secrets: Guidance on Developing and Implementing
Multi-Agency Policies and Procedures to Protect Vulnerable Adults From Abuse,
Department of Health, London
Department of Health (November 2003), Confidentiality, NHS Code of Practice,
Department of Health, London
Lord Chancellor’s Department, 1999), Making Decision, London
Safeguarding Adults National Framework of Standards for Good Practice and Outcomes in
Adult Protection Work Oct 2005 ADSS
Date of issue – March 2009
14
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Appendix 1
PROCEDURE FOR
SAFEGUARDING AND
PROTECTING VULNERABLE ADULTS
STATEMENT/KEY OBJECTIVES:
The Trust has procedures in place to support LCFT policy 022
to promote the welfare of vulnerable adults and ensure their safety and protection.
ACCOUNTABLE DIRECTOR: Director of Nursing
AUTHOR: Public Health Advisor Children and Families/Named Nurse Child Protection
Date of issue – March 2009
15
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Contents
Page
1.0
2.0
3.0
17
18
4.0
5.0
6.0
7.0
8.0
9.0
10.0
11.0
Introduction
Capacity & Consent
Local Arrangements and Procedure for Risk where Abuse is
Recognised or Suspected
The Alert
The Investigation
Strategy/Discussion Meetings
Case Conference/Safeguarding Planning Meeting
Action/Safeguarding Plans
Case Monitoring and Review
Record Keeping
Abuse/Concern from one Adult to another
18
21
23
23
24
24
24
25
25
References
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Date of issue – March 2009
Blackburn with Darwen Flowchart for Reporting
Lancashire Flowchart for Reporting
Blackpool Flowchart for Reporting
Female Body Map
Male Body Map
27
28
29
30
31
16
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
1.0
Introduction
This document covers the procedures and actions to be taken when an allegation of abuse is
made. In line with LCFT Safeguarding and Protecting Adults Policy CL022, LCFT is
required to maintain procedures for ensuring instances of adult abuse are reported and
investigated. These procedures are in place to support compliance with local authority
multi agency adult protection policy and procedure.
These procedures should not be read in isolation but used in conjunction with the LA
Safeguarding and Protecting Adult Procedures. Across the geographical area covered by
LCFT, these are:
x
x
x
No Secrets in Lancashire: A Joint Strategy to Protect Vulnerable Adults From
Abuse,
Blackpool Vulnerable Adults Committee, Code of Practice and Procedures
Blackburn with Darwen Adult Protection Policy and Procedures
The Local Authority are the lead agency co-ordinating the response to adult abuse
allegations. They have an important responsibility to work closely with other agencies and
organisations including health.
When a situation is discovered in which a vulnerable adult reports, or is thought to be at
risk of abuse, then agencies will act quickly in a co-ordinated manner to address issues and
concerns. LCFT recognises the potential for people to be discriminated against on the basis
of race, culture, gender, age, disability or sexual orientation, and is committed to working
with vulnerable adults in a positive manner that values people as individuals.
The first priority of staff should be to ensure the safety and protection of the vulnerable
adult. Service users should be made aware of the limitations of and exceptions to
confidentiality in relation to adult protection, and that information will be shared if they or
others are at significant risk. They should be assured that they will be treated in a fair and
equitable manner.
Those who have a role in working with adults identified as vulnerable who may be
parents/carers must consider any risks to children within the home, family or who they may
have caring responsibility for. Where there may be risks identified that impact on a
child/young persons welfare, staff must ensure that appropriate referrals are made to
Children’s Integrated Services (CIS) or partner agencies, in line with LCFT and Local
Safeguarding Children Board Procedures.(Refer to LCFT Procedures for Safeguarding and
Protecting Children CP001) .
All mental health/substance misuse services including forensic services have a role to play
in assessing the risk posed by adult perpetrators, and in the provision of treatment services
for perpetrators.
Date of issue – March 2009
17
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
2.0 Capacity and Consent
2.1
One of the overriding principles in safeguarding adults is capacity and consent.
Whenever possible every effort must be made to obtain the consent of an adult to report
abuse taking into consideration the definitions of the Mental Capacity Act 2005. This is
underpinned by the principle that every adult has the right to make his /her own decisions,
and must be assumed to have capacity to do so unless it is proved otherwise. However
when there is a duty of care and the adult does not have the capacity to protect him/ herself
the matter must be discussed with a senior manager and Multi Disciplinary Team (MDT) or
Safeguarding Team on how best to proceed.
2.2
Any patient affected by abuse, who has capacity, should be consulted as to whether
or not they wish action to be taken in relation to their own situation. However, their
response will be viewed in the context of the need for any intervention in order to protect
other service users and / or staff from harm or risk of harm. If the individual does not wish
to report the abuse a discussion must take place with the MDT, Service/Team Manager or
Modern Matron as to the appropriate course of action to safeguard other service users and
staff or in the public interest.
2.3
Anything done for or on behalf or people without capacity must be in their best
interests.
3.0 Local Arrangements and Procedure for Risk Where Abuse is
Recognised or Suspected
3.1
An overview of local procedures for Lancashire, Blackburn with Darwen and
Blackpool are set out in appendix 2, 3 & 4. There are links and detailed guides of Local
Authority procedures on LCFT Safeguarding and Protecting Adult intranet site and the
Local Authority internet. The procedures are good practice and contain advice to be
followed at each stage of the adult protection process.
3.2
Clinical staff must undertake assessments of risk using LCFT Safety Profile , as
part of assessment and review processes in line with LCFT Clinical Risk Management
Policy (CL028). Risk Assessment is important. Staff must be aware of situations, which
could place people at particular risk. These may include: x The need for close personal assistance e.g. with bodily functions
x Situations where one person is heavily dependent on another
x Where a person has communication difficulties
x Where a vulnerable person lives in the vicinity of, knows or has contact with a
known abuser
x Where a person is living in, and may be isolated within, an environment which is
unsupportive, inappropriate, hostile or dangerous
x Where there is a change of lifestyle for whatever reason
Date of issue – March 2009
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Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
3.2.1 Both actual and potential risks should be considered together with interventions
aiming to reduce risk to the vulnerable person. Staff must establish the current risk to the
individual, staff and/or other people including children.
3.2.2 The vulnerable person could be the carer. Consider too that the challenging
behaviour of a vulnerable adult could lead to acts of abuse towards their carer, who is also
vulnerable within the definitions of "No Secrets".
3.3
Where there is concern that a crime has taken place the Service Manager must
ensure that the local multi agency policy and procedures are followed and the incident
reported to the police as appropriate. The Director of Nursing, Network Director and
Associate Director must be contacted and notified that the police have been contacted.
3.4
x
x
x
Actions to be taken when abuse is suspected:
When a member of staff has a cause for concern that a vulnerable adult is suffering
or at risk of suffering significant harm through abuse, the following procedures
must be implemented immediately
All staff must ensure that all concerns are discussed with their manager and
identified within the client’s care plan
Investigation of all allegations should be undertaken by managers and staff in line
with: a) LCFT Incident Reporting Procedures
b) LCFT Standing Operating Procedures For The Notification of Serious
Untoward Incidents
and Resulting Review and Enquires HS 001A
c) In accordance with Local Authority Procedural Frameworks
When allegations meet the criteria for referral laid down within local authority procedures
staff must inform Adult Social Services of concerns or allegations to initiate a multi agency
adult protection investigation
3.5
Other relevant policies and procedures that may need to be accessed as a result of
the incident are for example the LCFT:
x
x
x
x
x
Disciplinary Procedure HR 014
Complaints Policy and Procedure RM 001
Whistle Blowing Policy HR 007
Preventing Bullying and Harassment at Work HR 006
Being Open Procedure HR 010(1)
3.6
The Trust has a duty of care to all its patients and a clear mandate to intervene
whenever care provided does not meet expected standards. If the abuse of a patient is
suspected by staff working within the Trust, staff are required to raise an adult protection
alert with their line manager, following the locally agreed multi agency Adult Protection
Procedures. However, there will be a presumption that other patients might also be at risk
or be likely to be affected.
3.6.1 Adult protection issues can also be identified through other LCFT Trusts structures
and must be raised where identified through:
Date of issue – March 2009
19
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
x
x
x
Analysis of the incident reporting system
Accumulation of complaints about individuals or service areas
Feedback from service users and carers about individuals and services
3.6.2 All staff have a duty to raise concerns with their line manager through the above
processes if they are made aware of adult protection issues. The line managers should raise
this concern in the first place with the Network Director who will agree the level of
investigation in line with local and Trust policy and procedures.
3.7
Concern about Abuse by Staff.
3.7.1 If an allegation involves inappropriate behaviour by another staff member,
regardless of the agency they work for, you must inform your line manager or another
member of your service’s senior management team immediately.
3.7.2 In the event of a complaint/allegation against a manager within the Trust, you must
inform the manager’s line manager (i.e. a person senior to the individual).
3.7.3 Where the perpetrator of the abuse is a member of staff, immediately following the
alert the Manager should seek guidance from Human Resources, to take the most
appropriate course of action, which may include suspending the person from duty whilst
the Adult Protection investigation takes place. Staff must be supported and offered regular
supervision throughout the investigative process.
3.8
The first priority should always be to ensure the safety and protection of the
vulnerable adult. Medical attention or diagnosis should be sought according to the patient’s
clinical need and in accordance with this policy. This should be sought without delay from
either the patient/client’s GP or hospital staff as required in consultation with the Social
Services Department and the Police.
Where the alleged perpetrator is a member of staff, managers should ensure the employee
has no subsequent contact with service users.
3.9
Where medical attention is necessary the examining doctor must be made aware of
any suspicions of abuse. The doctor may be required to provide a report of findings and
opinion for use in any subsequent legal or disciplinary proceedings.
3.9.1
x
x
x
When to seek Medical Attention
Injury to the genital/rectal area. This may indicate sexual abuse and both Social
Services Department/ Police should be notified immediately so that arrangements
can be made for appropriate medical attention and examination
Injuries which are life threatening
Injuries where the patient/client appears to be in great pain.
N.B. Inform and support the patient/client on the appropriate actions and medical attention
required
Date of issue – March 2009
20
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
3.10 If a vulnerable adult makes a disclosure, focus on what the person is saying. Do not
make comment other than to be sympathetic and reassuring. Do however allow the person
to speak freely and remember to make an accurate written record of the content of the
disclosure as soon as possible. Do not however attempt to interview the patient/client or
suggest words/phrases to describe what has occurred.
3.11 In cases of actual abuse the protection and preservation of evidence is critical to the
investigative process. Failure to secure evidence may result in a failed investigation and
lack of prosecution of an offender. Early reporting is therefore essential. Forensic
examinations in cases of suspected sexual abuse will be conducted by designated police
surgeons in accordance with local protocols as arranged by the police and subject of
appropriate consent. Either the patient/client’s GP or hospital staff as necessary will
conduct examinations of suspected physical abuse.
3.12 When complaints about alleged abuse suggest that a criminal offence may have
been committed the Police must be informed immediately. Early referral or consultation
with the police will enable them to establish whether a criminal act has been committed.
Referral can be made either by the professional involved, the line manager or social
services. Referral of physical and sexual abuse should be to the local Public Protection
Unit (PPU).
A CRIMINAL INVESTIGATION BY THE POLICE TAKES PRIORITY OVER
ALL OTHER LINES OF ENQUIRY.
4.0
Alert
Alerting is the first stage in the safeguarding adult process. It is the responsibility of any
member of staff if they suspect abuse of an adult is likely or has taken place. It is a formal
process to raise a concern.
4.1
Staff must seek advice from the MDT, line manager as appropriate providing this
does not cause significant delay in referral.
4.2
Staff must arrange for emergency medical attention if required. For IMMEDIATE
medical treatment dial 999 for an ambulance.
4.3
Members of staff must, with immediate effect, inform an appropriate team or line
manager. Where appropriate, with the adults consent, you as an individual officer, or you're
team or line manager will make the Alert to the appropriate Adult Social Care Services or
the Emergency Duty Team (out of hours) including weekends and bank holidays.
Contact details :
Lancashire
0845-053-0028
www.lancashire.gov.uk/safeguardingadults
Date of issue – March 2009
21
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Blackburn with Darwen
01254 587547
www.blackburn.gov.uk/server.php?show=ConWebDoc.15125
Blackpool
01253 477592
EDT 01253 477600
www.blackpool.gov.uk/Services/M-R/ProtectionofVulnerableAdults
4.4
Alerters, (with their line manager) must complete an on line Alert form within 24
hours of making the alert. Links to all local authority Safeguarding Adult internet sites are
above and on LCFT Safeguarding and Protecting Intranet site.
4.5
Staff must inform their line manager, service user’s GP and other relevant members
of Primary Health Care Team.
4.6
The purpose of an adult protection investigation is to establish:
x
x
If the person is a vulnerable adult as defined within local Authority Policy and
Procedure
If abuse is likely to have taken place
The risk factors
To inform the vulnerable adult and carer of concerns
To gather views from the vulnerable adult and carer concerning the allegation of
abuse and what has happened
To make preliminary assessment of the mental capacity of the vulnerable adult
x
x
To gather background information
To establish what support is available
x
x
x
x
4.7
All those involved in the provision of care within LCFT are committed to providing
follow-up support to all service users who continue to require health needs.
4.8
Where English is not the first language of the adult concerned, and communication
is necessary for the purpose of safeguarding and promoting the adult’s welfare, the use of
an interpreter must be considered. If the use of an interpreter is dispensed with, the reason
for doing so must be recorded in the records.
4.9
Advice must be sought from staff’s line manager or named social worker prior to
discussion with families and carers, however they should be informed of the incident
immediately, if it is agreed safe to do so. The partner/relative/carer of the alleged abused
person should only be informed if it is felt that such information will not place the
individual in increased danger, nor will it prejudice the investigation or in rare cases,
prompt a suicide.
4.10 It is important that service users are aware of procedures at all times, and that they
are enabled to express their own fears/concerns/points of view.
Date of issue – March 2009
22
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
4.11 The alert will be communicated and forwarded to the locality Adult Social Care
Team Manager who will identify an investigating officer to gather information, consider
any immediate actions and have initial discussions with the alerter and partner agencies.
4.12 It is the decision of the investigating officer as to whether a referral to Safeguarding
Adult Procedures is made.
4.13 If it is suspected that a child/young person (under 18) may be at risk of harm then a
referral must be made in line with LSCB and LCFT Safeguarding and Protecting Children
Procedures.
5.0
The Investigation
The object of a preliminary investigation is:
x To establish relevant facts
x Assess the needs of the vulnerable adult for protection, support and redress; and
make decisions with regard to what follow-up action should be taken with regard to
the perpetrator, and the service or its management, if they have been culpable,
ineffective or negligent.
x Establish any criminal offences e.g. assault (physical or psychological), sexual
assault and rape, theft, fraud (or any other form of financial exploitation), and
certain forms of discrimination whether on racial or gender grounds.
6.0
Strategy Discussion/Meetings
The primary aim of the meeting is to discuss in a multi-disciplinary setting any information
which has come to light as a result of a referral, complaint, assessment, any other
information pertinent to the investigation or safeguarding arrangements, or any other
intervention, and amounts to an allegation of or suspicion of the abuse of a vulnerable
adult.
6.1
The Professionals attending the meeting will consider what, if any, response should
be provided by their respective agencies in the light of the reported/suspected abuse and
agree how any further actions, enquiries or investigations should be handled and by whom.
6.2
The Professionals/Strategy meetings will:
x
x
x
x
x
x
Establish facts
Establish if the incident amounts to a criminal act and warrants a criminal
investigation
Deal with any immediate risk(s)
Gather further information
Assess needs and what actions need to be undertaken to prevent the risk of further
abuse of the patient/vulnerable adult or others who might be vulnerable
Decide on what action is to be taken in respect of the alleged abuser
Date of issue – March 2009
23
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
x
x
x
x
x
7.0
Establish what internal investigative procedure will need to take place
Be managed in line with Trust policy e.g. staff suspension, transfer of patient,
internal investigation
Keep relevant others informed
Refer to all relevant organisational policies
Implement an interim safeguarding plan
Case Conference/ Safeguarding Planning Meeting
This is required to review the outcomes of the investigation, draw conclusions and develop
a Safeguarding Plan (please refer to Local Authority Safeguarding Adult Policy and
Procedures).
LCFT must attend as requested and provide a written report of their service involvement,
care, interventions and findings of their own investigation.
8.0
Action/Safeguarding Plans
Local procedures and protocols will make clear the agency responsibility for co-ordinating
the multi agency response to an adult protection concern, and all agencies retain their
statutory responsibilities.
8.1
Agencies assigned to undertake specific tasks within the agreed action/safeguarding
plan remain responsible for ensuring these are completed.
8.2
Any unachievable actions agreed within the action/safeguarding plan should be
communicated to the chair of the Professionals/Strategy meeting as a matter of urgency.
9.0
Case Monitoring and Review
Monitoring is vital where vulnerability remains and is an important part of risk
management. LCFT staff must continue to work with a vulnerable adult if their service is
required. Anyone monitoring an abusive situation can ask Social Services to reconvene a
review strategy meeting to discuss escalating or new concerns.
9.1
Safeguarding review meetings will be held in line with Local Authority
Safeguarding Adult Policy and Procedures to review the safeguarding plan, risk, and ensure
agreed actions have been implemented.
9.2
LCFT staff must ensure that CPA, care and discharge plans consider and
incorporate safeguarding adult alerts, investigations and safeguarding plans.
Date of issue – March 2009
24
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
10.0 Record Keeping
LCFT staff must maintain records in line with the Trust Policy for Professional Clinical
Record Keeping (CL 027). This policy describes the expected clinical record keeping
practice (either electronic or paper based) building on professional requirements.
10.1 Records are an essential source of evidence for investigations and inquiries, and
may also be required to be disclosed in court/legal proceedings.
10.2
x
x
x
x
x
x
x
x
x
x
x
x
When recording Safeguarding concerns or incidents staff must note, in particular:
Sign and date the report
Note the time of day, date and location of the incident
Describe how the disclosure came about
Describe what happened and any injuries or consequences for the victim
Where appropriate, use a body map to indicate where there are cuts or bruises
(appendix 4 & 5) and keep the information as concise and factual as possible,
including your description of any injuries seen
All telephone conversations must be recorded
If it is appropriate to include an opinion or third party information, ensure this is
made clear
Record the words used by the vulnerable person in making the allegation
Establish who are the key people in the alleged abused adult’s life, e.g. family,
neighbours, children, and grandchildren
If the individual has parent/caring responsibility for children/young people
Is the current investigation for physical, sexual, emotional or financial abuse or for
neglect
Is there any form of physical evidence available, e.g. soiled or bloodstained clothing
11.0 Abuse/Concern regarding Abuse by one Vulnerable Adult to
another
Members of staff who have reason to think that a vulnerable adult has been abused by
another vulnerable adult within LCFT or another establishment should inform their
manager/person in charge of the establishment as soon as possible and follow the
appropriate procedures. This principle must also be put into practice when visiting another
establishment; e.g. day service, group homes, nursing homes, schools etc.
12.0 References
x
Blackburn with Darwen Inter Agency Policy and Procedures for the Protection of Vulnerable
Adults from Abuse (April 2004)
Blackpool Borough Council & Social Services, Blackpool Vulnerable Adults Committee
(2004), Code of Practice and Procedure
Date of issue – March 2009
25
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Lancashire Social Services (2001) No Secrets in Lancashire: A Joint Strategy to Protect
Vulnerable Adults from Abuse, Lancashire Social Services
Department of Health (2000) No Secrets: Guidance on Developing and Implementing
Multi-Agency Policies and Procedures to Protect Vulnerable Adults from Abuse,
Department of Health, London
Department of Health (November 2003), Confidentiality, NHS Code of Practice,
Department of Health, London
Lord Chancellor’s Department (1999), Making Decision, London
Safeguarding Adults National Framework of Standards For Good Practice and Outcomes in
Adult Protection Work Oct 2005 ADSS
Date of issue – March 2009
26
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Blackburn with Darwen
Appendix 2
Flowchart for Investigation Process An Alert May Come From
Outside social services e.g. member
of the public, professional worker
or volunteer from another
agency/organisation
Within social services e.g. service
user is already known; it is an open
case
Referral is taken by
Customer Liaison Officer Customer Liaison Officer
(Form SA2 completed)
(Form SA2 completed)
Responsible Manager is identified
Strategy meeting is convened (either on the telephone or in a
formal meeting) within 24 hours of receiving the referral
Decision to commence an abuse investigation or not. If
proceeding, two investigating officers will be identified
Investigation starts
within 24 hours of the strategy meeting
Case Conference is convened
within 15 working days from the strategy meeting
Minutes and Protection Plan to be circulated
within 10 working days of conference
Review Case Conference
within 3 months (depending on level of risk)
Responsible Manager completes Form SA3
Date of issue – March 2009
27
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Lancashire Safeguarding Adults – Partner Agencies
Procedures for Recording & Reporting Abuse
Appendix 3
Do you have any concerns or think
someone is being abused?
Is the person at risk in any
immediate
danger of further abuse?
YES
NO
In an emergency dial 999
Do not ask questions
Respond Sensitively
Do not ask questions
Write down any disclosure/incident information you
have as soon as possible, sign and date it
Is your manager a potential suspect or you think is
in any way implicated in the suspected abuse?
YES
Contact a more Senior Manager within the
organisation, in authority, immediately,
who will begin the process of investigation
by ensuring the safety of the adult at risk
securing evidence and HR issues
NO
Report to your manager or
responsible person, who will begin
the process of investigation by
ensuring the safety of the adult at risk
securing evidence and HR issues
Report an alert: How to report any concerns or suspected incidents of abuse by
making an alert to The Safeguarding Adults, Adult Social Care dedicated
telephone number: 0845 053 0028 Alternatively, visit the Safeguarding Adults
web page and complete an on-line Partner Alert Form at:
www.lancashire.gov.uk/safeguardingadults
Date of issue – March 2009
28
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
Appendix 4
Blackpool Flowchart for Investigation of Safeguarding Adult Concerns
Alert :Refer to Social Services Direct tel (01253) 477592
Referral
Decision
Strategy Formulation
Assessment & Investigation
Assessment/Investigation Outcome
Post Assessment /investigation action
Review
Social Services - Who To Refer To
Situation
Refer to
The exact circumstances of
the person are unknown
Refer to Social Services Direct tel (01253) 477592
Email: [email protected]
Person is receiving a social
care service but social worker
and team commissioning
service is not known
Person is receiving a social
care service and social worker
and team commissioning
service is known
Refer to Social Services Direct tel (01253) 477592
Email: [email protected]
Out of Hours – Between 5 pm
and 9 am Mon - Fri &
weekend
Safeguarding Children contact
Date of issue – March 2009
Refer to Team Manager of Team involved – if not contactable directly the
refer immediately to Social Services Direct tel (01253) 477592
Email: [email protected]
Emergency Duty Team Tel 01253 477600
Office Hours 01253 477668 Out of hours 01253 477600
29
APPENDIX 5
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
FEMALE
BODY MAP
SKIN MAP
Date of Issue: March 2009
30 of 33
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
APPENDIX 6
SKIN MAP
adult male
Date of Issue: March 2009
31 of 33
Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
APPENDIX 7
LANCASHIRE CARE NHS FOUNDATION TRUST
INITIAL EQUALITY IMPACT ASSESSMENT
Department/Function
Safeguarding Adults
Person responsible
Bridget Welch – Public Health Advisor Children
and Family
Contact details
01772 645790
Name of policy/procedure/service
to be assessed
Policy and Procedure for safeguarding and
protecting adults
Date of assessment
4 February 2009
Is this a new or existing
policy/procedure/service?
Existing
1. Briefly describe the aims,
objectives and purpose of the
policy/procedure/service?
Ensure arrangements are in place to effectively
safeguard, protect and respond to known or
suspected abuse of vulnerable adults.
2. Who is intended to benefit?
Service users and staff
3. What outcomes are wanted?
Ensure adult service users are safeguarded
effectively
4. Who are the main stakeholders? To be completed in full impact assessment in
March 09
5. Who is responsible for
implementation?
Date of Issue: March 2009
Public Health Advisor Children and Families
Named Nurse Child Protection
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Policy and Procedure for Safeguarding and Protecting Vulnerable Adults
6. Are there concerns that
there could be differential
impact on the following
groups and what existing
evidence do you have for
this?
Race/ethnicity
Full impact assessment to be completed
March 2009
Full impact assessment to be completed
March 2009
Gender
Full impact assessment to be completed
March 2009
Disability
Full impact assessment to be completed
March 2009
Religion/belief
Full impact assessment to be completed
March 2009
Sexual orientation
Full impact assessment to be completed
March 2009
Age
Full impact assessment to be completed
March 2009
7. Could any differential
impact identified above be
potentially adverse?
8. Can any adverse impact
be justified on the grounds
of promoting equality of
opportunity?
9. Have you consulted with
those who are likely to be
affected?
10. Should the
policy/procedure/service
proceed to full impact
assessment?
Full impact assessment to be completed
March 2009
Full impact assessment to be completed
March 2009
Full impact assessment to be completed
March 2009
Full impact assessment to be completed
March 2009
I understand the impact assessment of this policy/procedure/service is a statutory
obligation and take responsibility for the completion of this process.
Names of assessors: Bridget Welch, Public Health Advisor Children & Family
Date of assessment: 5 February 2009
Date of next review: 3yrs January 2012
Date of Issue: March 2009
33 of 33
Safeguarding and Protecting Children Procedures
SAFEGUARDING AND PROTECTING
CHILDREN PROCEDURES
PROCEDURE NO
DATE RATIFIED
NEXT REVIEW DATE
CP 001
February 2009
February 2011
PROCEDURES STATEMENT/KEY OBJECTIVES:
The Trust has procedures in place to ensure the safety and protection of all children and
Young People under the guiding principles within the Children Act 1989, statutory guidance
on making arrangements to safeguard and promote the welfare of children under section 11 of
the Children Act 2004.
and Working Together to Safeguard Children 2006.
ACCOUNTABLE DIRECTOR: Director of Nursing
POLICY AUTHOR:
Date of Issue: March 2009
Public Health Advisor Children and Families/
named Nurse Child Protection LCFT Safeguarding
Practitioner
1
Safeguarding and Protecting Children Procedures
Executive Summary
Subject
Safeguarding and protecting children procedures
Applicable to
All employees of Lancashire Care NHS Foundation
Trust
Key Policy Issues
To ensure all staff have an awareness of their roles
and responsibilities
To provide clarity of referral processes to Social
Services where there are concerns for a child and
family in need of support or protection.
General procedure if abuse is suspected.
Guidelines for Child Protection meetings and report
writing.
February 2009
February 2009
January 2011
Public Health Advisor Children and Families/
named Nurse Child Protection / LCFT
Safeguarding Practitioner
Date Issued
Dates Policy reviewed
Next review due date
Policy written by
Consultation
Policy reviewed by:
Lead responsible for policy
Monitoring arrangements
Approved by
Authorised by
Signature
Related procedural documents
Date of Issue: March 2009
Executive Directors
Senior Management Team
Safeguarding Committee
Safeguarding Committee
Director of Nursing
The Public Health Advisor Children and Families/
named Nurse Child Protection will be responsible
for monitoring this procedure and will provide
assurance to Safeguarding Committee and EMT
Governance via quarterly and annual reports the
Risk Management Annual Report
Safeguarding Committee
Policy & Governance EMT
Patrick Sullivan
Director of Nursing
Working Together to Safeguard Children 2006,
Local Safeguarding Board Procedures, CP002
Policy for Safeguarding Young People Admitted to
Adult Wards, CP003 Policy on Children Visiting
Wards and Other Clinical Areas Within Lancashire
Care Trust Premises
2
Safeguarding and Protecting Children Procedures
CONTENTS
PAGE NO
1. Summary
4
2. Introduction
4
3. Definitions
5
4. Rationale
6
5. Scope
7
6. Principles
7
7. Duties
8
8. Confidentiality
13
9. Local Arrangements/Procedures
13
10. Disclosure of Abuse
17
11. Actions to be Taken in Specific Circumstances
18
12. Child Protection Conference/Meetings
21
13. Record Keeping
23
14. Profession Conflict, Concerns or Complaints
23
15. Incomplete/Confliction Details & Missing Families
24
16. Child of School Age Not Registered with School
25
17. Effective Care Co-ordination
25
18. Service Users Admitted under MH Act with Carers
Responsibility for Child
26
19. Home Leave and Pre Discharge Planning
26
20. Children Visiting Adult Wards
26
21. Responsibility for Looked After Children
27
22. Private Fostering
27
Date of Issue: March 2009
3
Safeguarding and Protecting Children Procedures
23. Requests for Information
28
24. Statements for Legal Proceedings
28
25. Attendance at Court
29
26. Incident Reporting
29
27. Child Death Overview Panel
29
28. Serious Case Reviews
29
29. Aggression Violence and Intimidation
30
30. Professional Development
31
31. Support
31
32. Training
31
33. Implementation & Compliance
32
34. Monitoring the Effectiveness
32
Appendix 1
Appendix 2
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Appendix 8
Appendix 9
Appendix 10
Appendix 11
34
37
38
40
43
45
46
47
48
49
51
Date of Issue: March 2009
4
Safeguarding and Protecting Children Procedures
1.0 Summary
The purpose of these safeguarding children procedures is to enable the Trust to:
x
x
x
Provide a structured approach for all healthcare staff with regard to arrangements for
safeguarding children. Working Together to Safeguard Children – A guide to interagency working to safeguard and promote the welfare of children (2006), sets out how
organisations and individuals should work together to safeguard and promote the
welfare of children.
Provide a mechanism that will allow audit of Child Protection compliance with
Section 11 of the Children Act (2004), national standards e.g. National Service
Framework (DfES 2004), Every Child Matters, (DOH 2003).
Provide necessary interventions for the child and family, an understanding of multidisciplinary partnerships and the systems that may be utilised to safeguard children.
2.0 Introduction
2.1 Lancashire Care Trust (LCFT) staff have a duty of care to safeguard and protect children
at risk of harm and neglect from the subsequent negative outcomes and enable all children to
reach their full potential. Every child has the right to be protected from potential significant
harm.
2.2 LCFT also takes into account the standards within the National Service Framework for
Children, young people and maternity services and reflects the requirements of Statutory
guidance on making arrangements to safeguard and promote the welfare of children under
section 11 of the Children Act 2004.
Section 11 of the Children Act 2004 states that NHS Trusts ‘must make arrangements for
ensuring that its functions are discharged having regard to the need to safeguard and promote
the welfare of children’.
The Children Act 1989 places specific duties on agencies to co-operate in the interests of
vulnerable children. The Children Act 1989 introduced the concept of significant harm as the
threshold that justifies compulsory intervention in family life in the best interest of the
children. Decisions about significant harm are complex.
2.3 The Department of Health (DOH) guidance listed below is issued under Section 7 of the
1970 Local Services Act, which means it is secondary legislation and therefore must be
complied with unless local circumstances indicate exceptional reasons, which could justify a
variation. It advises further involvement of Health Professionals by collaborating and
working together with Social Services.
These procedures are based on:
x The principles of the Children Act 1989 and 2004
x The UN Convention on the Rights of the Child
x The Human Rights Act 1998
x The Data Protection Act 1999
x The Adoption and Children Act 2002
x Local Safeguarding Children’s Boards guidance and procedures
Date of Issue: March 2009
5
Safeguarding and Protecting Children Procedures
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Department of Health guidance on Working Together to Safeguard Children
2006
The Framework for the Assessment of Children in Need and their Families
2000
Safeguarding Children Involved in Prostitution 2002
What to do if you are worried a child is being abused 2003-12-16 The Laming
Report 2003
Statutory guidance on making arrangements to safeguard and promote the
welfare of children under section 11 of the Children Act 2004.
National service Framework for Children Young People and Maternity
Services 2004
Every Child Matters DOH 2004
2.4 These procedures apply to all children up to their 18th birthday, whether the children are
service users of the Trust in their own right, or children cared for by adults who are receiving
services from the Trust.
Children of Service users may be providing an active caring role and this must be considered
in assessing and providing interventions through Care Programme Approach Policy.
2.5 Staff working with adults with carers responsibilities for children are now clearly viewed
as part of the ‘children’s workforce’ in terms of safeguarding. Local Safeguarding Children
Boards have been given statutory powers to ensure that agencies comply with this statutory
guidance
2.6 Each case should be informed by careful assessment of the child’s circumstances and
discussions between the statutory agencies and with the child and family. Where the question
of whether harm suffered by a child is significant, their health or development shall be
compared with that which could reasonably be expected of a similar child.
3.0 Definitions
3.1 Safeguarding and promoting the welfare of children is defined for the purpose of these
procedures as:
ƒ
ƒ
ƒ
ƒ
protecting children from harm or maltreatment;
preventing impairment of children’s health or development;
ensuring that children are growing up in circumstances consistent with the
provision of safe and effective care; and
undertaking that role so as to enable those children to have optimum life
chances and enter adulthood successfully.
3.2 Harm is defined by the Children Act 1989 as:
ƒ III treatment (including sexual abuse and physical abuse)
ƒ Impairment of health (physical or mental) or development
ƒ (physical, intellectual, emotional, social or behavioural) as
ƒ compared to a similar child
ƒ Harm suffered by seeing or hearing ill treatment of another
particularly in the home
Date of Issue: March 2009
6
Safeguarding and Protecting Children Procedures
The Adoption and Children Act 2002 broadens the definition of significant
harm to include the emotional harm suffered by those children who witness
domestic violence or are aware of domestic violence within the home
3.3 Neglect is the persistent failure to meet a child’s basic physical and / or psychological
needs, likely to result in the serious impairment of the child’s health or development. The
consequences of neglect can have a life long impact.
3.4 Safeguarding children and young people encompasses all aspects of child welfare an child
protection.
These procedures are intended to be followed by all staff employed and independently
contracted by Lancashire Care Trust (LCFT).
This policy is supplementary to and not a replacement for individual Local Safeguarding
Children Board procedures and must be read in conjunction with them. (Links to all the
LSCB procedures here)
It is not a replacement for one to one consultation, discussion, support or supervision with the
LCFT Safeguarding Team (Appendix 9)
4.0 Rationale (why)
These procedures outline LCFT safeguarding children’s arrangements and implementation of
Local Safeguarding Children’s Board policy and procedures.
4.1 The purpose of these procedures is to ensure a structured and systematic approach to child
protection across the organisation. To provide a mechanism that will demonstrate compliance
with the Children Acts 1989 and 2004 and national standards for safeguarding and protecting
children.
The Children Act 1989 and 2004 places a statutory duty on Health Professionals to help
Social Services with their enquires so long as it is compatible with their own statutory duties
or other duties and obligations.
4.2 “Every Child Matters” (2004) states that all children deserve to achieve their full
potential. The Outcomes Framework sets out the 5 areas that are key to achieving children’s
well-being:
ƒ
ƒ
ƒ
ƒ
ƒ
Be healthy;
Stay safe;
Enjoy and achieve;
Make a positive contribution; and
Achieve economic well-being
4.3 The Common Assessment Framework (CAF) promotes more integrated multi-agency
working, where information is shared and service planning and delivery is coordinated, and
provided at an early stage to ensure the child meets the 5 outcomes from Every Child Matters
(see 2.1).
4.4 Information Sharing promotes multi-disciplinary and multi-agency working at an early
stage in order to identify and provide services to children in need of additional support before
their needs escalate.
Date of Issue: March 2009
7
Safeguarding and Protecting Children Procedures
4.5 Adult mental health services, including those providing general adult and community,
forensic, psychotherapy, alcohol and substance misuse and learning disability services, have a
responsibility in safeguarding children when they become aware of or identify a child at risk
of harm. This may be as a result of service’s direct work with those who may be mentally ill,
a parent, a parent-to-be, or a non-related abuser, or in response to a request for the
assessment of an adult perceived to represent a potential or actual risk to a child or
young person.
5.0 Scope (Who, Where & When)
5.1 This policy applies to all children from unborn to 18 years of age (Section 105 Children
Act 1989) (and up to 25yrs of age where there is a continuing duty of public care) whether
the children are service users of the Trust in their own right or children cared for by adults
who are receiving services from the trust.
5.2 Children under 1 year of age are most at risk of abuse. It is therefore imperative that the
welfare of unborn children of service users who are pregnant is considered including the risk
from domestic abuse.
5.3 Every member of staff has an individual responsibility for the protection and safeguarding
of children. All levels of staff and management must understand and implement the Trust
Safeguarding and Protecting Children Procedures and the national guidance “What to do if
you’re worried about a child” (DOH 2003).
5.4 These procedures are to be followed by all staff working for LCFT. Staff seconded to
LCFT are also required to follow these procedures.
5.5 Any student/trainee should be aware and adhere to these procedures.
6.0 Principles
6.1 In the provision of services to all Trust service users, the Trust has a commitment to
deliver these services in a non-discriminatory manner.
6.2 No assumption can or should be made that people with mental health problems, those in
receipt of substance misuse services or those with a learning disability constitute a risk to
children simply by virtue of their difficulties.
6.3 Children’s needs are best met when parents are supported, but the needs of the child
remain paramount.
6.4 The Children Act 1989 established an unambiguous principle the ‘Paramountcy Principle’
that states that the welfare of the child is paramount.
6.5 Children have the right to be protected from harm and to receive services when their
health or development is at risk.
Date of Issue: March 2009
8
Safeguarding and Protecting Children Procedures
6.6 Service users should be made aware of the limitations of, and exceptions to
confidentiality in relation to child protection.
7.0 Duties
7.1 Each NHS Trust has to have a named Doctor and Nurse with appropriate Child Protection
expertise, to take a lead on Child Protection matters.
These roles and responsibilities are in line with Working Together to Safeguard Children
2006 They will take the professional lead within the Trust on safeguarding matters.
7.2 Chief Executive
The Chief Executive as the Accountable Officer has overall responsibility for ensuring the
implementation of an effective Safeguarding and Protecting Children Policy and Procedure
and meeting all statutory requirements. The Chief Executive delegates executive
responsibility to the Director of Nursing
7.3 Director of Nursing
The post holder is the lead director and holds the executive lead for the safeguarding and
protecting children’s agenda within LCFT and reports directly to the Chief Executive on
related issues. The post holder is a member of Lancashire Safeguarding Children’s Board.
The Director of Nursing is responsible for providing assurance to the Trust Board of
compliance with this procedure
7.4 Deputy Director of Nursing
The post holder directly line manages the LCFT Safeguarding Team and reports to the
Director Nursing.
7.5 Public Health Advisor Children and Families/Named Nurse Child Protection and
Safeguarding Practitioner
Their general responsibilities include:
ƒ Liaison and links with Designated Nurses and local Safeguarding Children’s
Boards
ƒ Development of safeguarding practice
ƒ Provision of safeguarding advice and support
ƒ Identification of safeguarding training needs and the co-ordination/provision
of appropriate training
ƒ Participation in single and multi-agency safeguarding training.
ƒ Initiating and facilitating the monitoring and audit of safeguarding practice
ƒ Facilitating advice on legal matters in conjunction with the Trust legal
advisors
ƒ Facilitating the provision of child protection clinical supervision to
practitioners as appropriate
ƒ The management of internal child protection/ safeguarding reviews relating to
child protection practice and contribute to multi-agency serious case reviews
when a child has died or been seriously injured and abuse or neglect is known
or suspected to be a factor
ƒ Close liaison with the management structures within LCFT and other agencies
to address both strategic and operational issues relating to the safeguarding
agenda
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ƒ
Close liaison with LCFT Safeguarding Teams in the PCT’s and acute Trusts,
to address and implement local and national responsibilities and practice
7.6 Medical Director
The post holder is the executive lead for the medical profession and liaises directly with the
Chief Executive and Director Nursing.
7.7 Named Doctor (see appendix 9)
The Named Doctor liaises with the Medical Director and LCFT Safeguarding Team.
The named Doctor is responsible for:
ƒ Taking the lead in supporting medical staff in relation to their safeguarding
responsibilities
ƒ Carrying the usual professional accountability to their professional body.
ƒ Providing expertise, advice and consultancy to the LCFT Safeguarding Team
ƒ Professional child protection supervision
ƒ Facilitation of training
ƒ Contributing to the serious case review and analysis of critical child protection
incidents
ƒ Linking with the Designated Doctors who work in partnership with
commissioners and providers
7.8 Modern Matrons, Professional Leads, Senior Nurses and Managers
must provide effective leadership and ensure that: ƒ They maintain their knowledge and expertise and are therefore able to offer
staff advice and support on issues relating to the agenda
ƒ All staff within their area of responsibility are aware of, respond to instances
of suspected or actual child abuse and have contact details for the safeguarding
and protecting lead professionals within their organisation
ƒ Clinical practice takes a proactive approach to protecting and safeguarding
children
ƒ Staff within their areas of responsibility access training, which provides
information regarding, known indicators and predictors of abuse, and an
awareness of the Local Safeguarding Board procedures and protocols for
safeguarding children
ƒ Utilise resources appropriately to provide caseload cover where there are areas
of concern regarding a child’s welfare
ƒ All staff are trained in line with the Trust Training Needs Analysis
NB Doctors, Professional Leads, Senior Nurses or Managers may recognise limits to
their own experience/knowledge in relation to safeguarding and protecting children and
should seek advice from the Trust’s Safeguarding Team
7.9 The roles, responsibilities and accountabilities of all Mental Health/ substance
misuse staff
7.9.1 Initial Contacts
Front line staff in any part of the Trust who come into contact with children or their
families must ensure that basic information about the child is routinely recorded at
each new contact .Both the children’s needs and patients who are parents/carers
needs must be considered using the Care Programme Approach.
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The needs of these children in terms of parenting capacity, family and environment and
child’s developmental needs must be considered and documented.
7.9.2 Requests for information regarding children in the families staff care for, must be
handled sensitively, in the context of the need to complete a holistic assessment to best
identify any risks, stressors and meet the needs of the service user in terms of appropriate
advice and support.
7.9.3 Those who have a role in working with these parents/carers must ensure that both the
expertise of adult mental health workers and childcare workers is used to inform any
assessment regarding the welfare of the children
7.9.4 All mental health/substance misuse services including forensic services have a role to
play in assessing the risk posed by adult perpetrators, and in the provision of treatment
services for perpetrators.
7.10 Safeguarding Champions
These are identified practitioners in teams who liaise and work closely with The
Safeguarding Team.
The role of the Safeguarding Champion is to support staff working with child welfare / child
protection issues in a planned, proactive process by: ƒ Appraising existing care plans to ensure safeguarding issues are included and
that they are sensitive to the current needs of the child and family
ƒ Clarifying roles and responsibilities of staff in line with LCFT and LSCB
procedures
ƒ Establishing that practice is compliant with national and local safeguarding
policies, procedures and guidance
ƒ Providing appropriate supervision and support, to enable safe and effective
practice
ƒ Promoting professional development, identifying with the practitioner, gaps in
knowledge and skills and directing staff into appropriate training
ƒ Ensuring that there is close communication with the Safeguarding Team/Line
managers, regarding safeguarding and protecting issues arising from practice
7.11 Trust Board
The Trust Board is responsible for:
x Ensuring robust systems and processes are in place for safeguarding children
x Receiving assurance of compliance with this procedure from EMT
Governance
7.12 EMT Governance
EMT Governance is responsible for:
x Receiving assurance of compliance with this procedure from the Safeguarding
Committee
x Providing assurance to the Trust Board of compliance with tis procedure via
the Director of Nursing’s Governance Report
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7.11 Role of LCFT Safeguarding Committee
ƒ Overseeing the development, implementation and monitoring of systems,
processes and policies to ensure Children, Young People and Vulnerable
Adults are safeguarded whilst accessing services provided by LCFT
ƒ Approving performance process’s and agree strategic direction for
Safeguarding within LCFT
ƒ Monitoring implementation of current legislation and policy in relation to
Safeguarding Children and Vulnerable Adults.
ƒ Approving performance process’s and agree strategic direction for
Safeguarding within LCFT
ƒ Agreeing quality standards, audit priorities/tools and support a training
strategy for Safeguarding Children, Young People and Vulnerable Adults
ƒ Monitoring compliance with this procedure
ƒ Developing and monitoring an action plan to address issues of non compliance
with this procedure
ƒ Providing assurance to EMT Governance of compliance with this procedure
via minutes of meeting and an annual report
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7.12 Organisational/Accountability Structure
Chief Executive
Medical
Director
Director of Nursing
Named Doctor
Designated /
Named
Professionals
within the
PCT’s
(PCT’s have
overarching
responsibility
for
Safeguarding
and Protecting
Children)
Deputy Director Nursing
PHACF/Named Nurse
Child Protection
Safeguarding Practitioner
Managers/Snr Nurses
/Lead Professionals
Safeguarding
Champions
All Lancashire
Care Staff
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8.0 Confidentiality and Information Sharing
All practitioners have a duty to be aware of their responsibilities from the Data Protection Act
1998, the Human Rights Act 1998, the Common Law Duty of confidentiality and Caldicott
principles.
8.1 All staff and practitioners must protect all confidential information concerning patients
and clients obtained in the course of professional practice and abide by their professional
codes of conduct. Disclosures should only be made with consent, where required by the order
of a Court, where justification of disclosure is in the wider public interest or where there is an
issue of child protection (Code of Professional Conduct, (5.3) page 7, Nursing and Midwifery
Council 2002)
All staff and practitioners must make themselves aware of Information Sharing
Protocols both high level and locally in place with partners agencies and organisations.
They must understand the agreements made to the sharing of information and the
acceptable methods in which this may happen.
Best Practice would indicate that any member of staff who has reasonable
belief/concern that a child is:
At risk of Significant Harm or is a Child in Need of Service.
should seek parental consent and or the child’s agreement for referral to Social Services
UNLESS
Seeking agreement to referral, places a child at increased risk of significant harm (see
above). If permission is refused and the concern is of a child protection nature, then a
referral can be made without consent.
9.0 Local Arrangements Procedures
The following procedures illustrate the local arrangements for implementing LSCB policy
and procedure.
9.1 Abuse of a child is caused by inflicting harm or failing to act to prevent harm. Children
may be abused in a family or in an institutional setting, by those known to them or more
rarely a stranger. Children may be physically, sexually, emotionally abused and neglected.
Often a child suffers a combination of the types of abuse.
9.2 If staff have concerns that a child is suffering or, is at risk of suffering abuse or neglect or
has suffered abuse or neglect a telephone referral must be made to Children’s Integrated
Services (CIS) in line with the LSCB procedures within one working day.
9.3 Any staff member who is involved in any case where there is child protection concerns
must follow the flow chart diagram in ‘What to do if you are Worried a Child is Being
Abused’ outlined in Appendix 2 and follow the Local Safeguarding Children Board (LSCB)
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procedures. Local flow charts are available on LCFT Safeguarding and Protecting Children
Intranet page.
9.4 Staff should consult their line manager or the Safeguarding Team unless to do so would
cause undue delay.
On making a referral to Children’s Integrated Services staff must routinely enquire if the
child or family is already known to the department or if the child/children are subject to a
child protection plan.
Staff must always send a copy of referrals made to the LCFT Safeguarding Team
9.5 When making enquires or consulting regarding a child welfare issue either in house or
external to the Trust, practitioners must clearly identify the name, role of the person consulted
with, whether this was in person or by telephone along with the time and date the
consultation took place. This information should be recorded in the service users records.
9.6 Staff must always follow LSCB procedures for a Child Protection referral. Telephone
referrals must be confirmed with a written referral within 2 working days
9.7 Staff must liaise appropriately with universal services involved with the family and
General Practitioner when concerns are identified and child protection referrals are made.
9.8 Where English is not the first language of the child concerned, and communication is
necessary for the purpose of safeguarding and promoting the child’s welfare, the use of an
interpreter who is not a family member must be considered. If the use of an interpreter is
dispensed with, the reason for doing so must be recorded.
9.9 A chronology of significant events must be compiled (see appendix 7 and 8 for guidance
and form template)
9.10 Each Local Safeguarding Children Board(LSCB) have developed their individual levels
along the welfare continuum. Levels of need and risk may change in response to changes in
family circumstances, illness and lifestyles. Staff should be sensitive to those changes and
reassess risk as required. Within Lancashire the following definitions are used:
Most operate within four levels as defined nationally (Levels 1, 2, 3 & 4):
ƒ Level 1 – Children and Young People whose needs are met by universal
services which every child/ family is offered i.e. midwife, health visitor, GP,
school nurse, school
ƒ Level 2 –Children and Young People who are at risk of poor outcomes and
thus in need of extra support from services. This could be provided by a single
agency, but where multiagency working is required then the CAF process
should be initiated
ƒ Level 3 – Children and Young people who meet the threshold for statutory
assessment and a multi agency response is required. (Section 17 of the
Children Act 1989)
ƒ Level 4 – Children and Young People who are in need of protection and
require intensive support. Those at risk of significant harm or who have
suffered significant harm (Section 47 of the Children Act 1989). Other
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agencies have a duty to cooperate (Section 27 of the Children Act) this
includes the sharing of appropriate information
9.10.1 Making a child protection referral (section 47) level 3-4
All staff are directed to follow procedures laid down by Local Safeguarding Children’s Board
(LSCB) and must have access to an electronic version of the LSCB Procedures. The
procedures are updated regularly therefore it is not advised that staff print off a hard copy.
These are available on the Trust intranet or LSCB website.
9.10.2 Referrals should be made by telephone to the local CIS Office. Please see flowcharts
on LCFT Safeguarding and Protecting Children’s Intranet Site
9.10.3 The initial call will be received by a customer care officer who will receive the
preliminary details. The referrer should offer a clear, concise account of concerns about a
child’s welfare, whether there are issues of significant harm and whether these require urgent
action to safeguard the child. The referrer should clearly state whether their concerns are of
an immediate child protection nature or a child in need of support. The referrer should ask to
speak to a duty social worker specifying the referral is of a child protection nature.
9.10.4 All decisions and outcomes/actions must be recorded on the service users file. The
telephone referral must be followed up in writing within 48 hours to CIS using the
appropriate referral form for that area in line with LSCB procedures.
Staff must attach a recent risk assessment to the referral.
A copy must be stored within the service users file and a copy sent to the LCFT
Safeguarding Team.
9.10.5 Staff will receive a reply from CIS within 3 working days regarding the outcome of
the referral. If this is not the case staff should contact CIS to enquire as to the outcomes of
their referral and where there are any concerns contact the LCFT Safeguarding Team
9.10.6 At the end of any referral discussion, the referrer and the CIS must be clear about who
will be taking what action if any. Professionals must record, the discussion and decisions
taken, document the name of the person accepting the referral and date and sign the records.
9.10.7 All cases causing concern must be reviewed and discussed with Line Manager/LCFT
Safeguarding Team /Modern Matron /Safeguarding Champion.
9.10.8 Any concerns relating to a response from CIS or difference in professional opinion as
to the level of risk of harm should be discussed with LCFT Safeguarding Team.
9.10.9 Some Section 47 investigations (Children Act 1989) when a child is considered to
have suffered or be at risk of significant harm are complex. At the outset of complex Section
47 investigations staff may be invited to a strategy discussion meeting. Staff should prioritise
their attendance. If there are resource issues staff should inform their manager. Staff are
obliged to co-operate with Section 47 enquiries (Children Act 1989)
9.11 Emergency situation
Where the child requires IMMEDIATE medical treatment:
x Dial 999 for an ambulance
x Inform CIS by telephone
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x
x
Inform Line Manager / LCFT Safeguarding team
Inform GP and family health visitor
9.12 Referring a child and family for family support (section 17) (level 3 see app 2)
9.13 When a member of staff has concerns about the welfare of a child, a request for other
services may be appropriate when they meet the threshold for statutory assessment and a
multi agency response is required
9.14 Referrals should only be made after discussion and with the consent of the family.
Families must be made aware that a referral constitutes consent for CIS to contact them to
facilitate the provision of services and enables CIS to make enquiries of other agencies.
9.15 To refer a family/child with needs, the appropriate referral form for the area should be
completed and attached completed risk assessment. All relevant information held by the
professional must be included on the form and forwarded to CIS.
All out of hour’s concerns regarding child protection should be referred to the local CIS out
of hour’s duty social work team in line with local procedures .
9.16 Referring a child and family for a Common Assessment Framework (CAF)
level 2
9.16.1 The Common Assessment Framework (CAF) is a key part of delivering frontline
services that are integrated and focused around the needs of children and young people. The
CAF is a standardised approach to conducting an assessment of a child's additional needs and
deciding how those needs should be met.
9.16.2 The CAF promotes more effective, earlier identification of additional needs. It is
intended to provide a simple process for a holistic assessment of a child's needs and strengths,
taking account of the role of parents, carers and environmental factors on their development.
9.16.3 Part of the process will be completion of the CAF form and liaison with local CAF coordinator. Please see LCFT Safeguarding and Protecting Children intranet site for flowcharts
and CAF contact details
9.16.4 Practitioners will be able to agree, with the child and family, about what support is
appropriate. The CAF will also promote co-ordinate service provision.
10.0 Disclosure of abuse – General Procedure
10.1 When commencing any therapeutic work a statement of confidentiality must be used
either written or spoken that describes the parameters of confidentiality. It must be made
clear that absolute confidentiality cannot be guaranteed e.g. if risk identified to themselves or
others including risks to any children.
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If the disclosure comes from:
ƒ A child - reassure and state that you will be informing the appropriate service
to help them. Document the information and refer onto CIS. Inform LCFT
Safeguarding Team and liaise with the family Health Visitor or School Nurse.
ƒ A parent/relative/non-professional - explain that they have a responsibility
to refer to CIS – if they refuse – explain that now you are in receipt of the
information, you have a duty to refer to CIS to protect the child. Document
and refer the information to CIS.
ƒ Another professional – request they make a direct referral following LSCB
procedures. Document and follow up the outcome to ensure the information
has been referred to CIS in line with these procedures.
10.2 When a service user discloses abuse either to themselves or from them, either current or
historic, the practitioner to whom the service user discloses has a duty and responsibility to
ascertain if any other children could be at risk of abuse from the alleged perpetrator and take
action as set out in the Local Safeguarding Children Board procedures and this document.
Advice and support in dealing with such issues is available from LCFT Safeguarding Team.
10.3 Out of hours
If a practitioner identifies a suspected case of child abuse out of office hours, at the weekend
or on a bank holiday, CIS Emergency Duty Team should be contacted on Lancashire 0845
6021043, Blackpool 01253 477600, Blackburn 01254 587547. The police may be contacted
in an emergency situation.
10.4 Guidance for LCFT management team regarding safeguarding issues arising during the
evening, weekends or bank holidays
All managers and directors are referred to the LCFT’s Internal Safeguarding Procedures and
Local Safeguarding Children’s Board Procedures for full guidance on the referral process and
the systems involved when child abuse/death is identified.
10.5 The child’s welfare should remain the central concept in the assessment of whether to
advise the practitioner to refer to the on-duty social work team. If you have a concern that a
child is at risk of significant harm due to actual or perceived child abuse the advice must be
immediate referral to CIS by the person raising the cause for concern. The next day might be
too late for the child.
10.6 Practitioners during home visits may find children “home alone”. In these circumstances
they should be advised to ring the police, stay with or near to the child/ren until the police
arrive and make a safeguarding referral to social services.
10.7 Police interviews with LCFT staff witnesses for child abuse investigations should be
arranged to take place in normal working hours on LCFT premises. In the absence of LCFT
Safeguarding Team, a manager should be present at all police interviews of LCFT Trust staff.
LCFT Safeguarding team take the lead for safeguarding support/issues for Managers in
normal working hours from Monday to Friday inclusive. The on call director will take the
lead out of hours and will notify The Named Nurse For Safeguarding of any untoward
incidents.
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11.0 Actions to be Taken in Specific Circumstances
11.1 Children in whom illness is induced or Fabricated by Parents or Carers - previously
known as Munchausen’s Syndrome by proxy.
Staff must seek advice from LCFT Safeguarding Team if they suspect Fabricated or Induced
Illness is occurring. It is important to note that consent from parent/carer should not be sought
or anything discussed with them that might jeopardise the
course of an investigation as per DOH guidance (2002)– Fabricated or Induced Illness.
If an adult service user has a suspected or confirmed diagnosis of Fabricated and Induced
Illness or similar condition and they have carers responsibility for a child advice must be
taken from LCFT Safeguarding Team
11.2 Sexual Abuse
Any suspicion of sexual abuse should be referred immediately to CIS. Sexual abuse
investigations are jointly investigated by the police and social services. Referral must be
made to the police if sexual abuse is recent to expedite the collection of forensic evidence.
Sited in the grounds of the Royal Preston Hospital is the Sexual Assault and Forensic
Examination Centre. (SAFE Centre).
11.3 In cases of suspected sexual abuse staff must not take for granted that any parent or carer
thought not to be involved would take on a protective role. Collusion can often occur. Staff
must not interview the service user about the disclosure or disclose any information to parents
or carers without the advice from CIS. To do so could jeopardize any legal action and could
put the service user at risk.
Staff must also remain vigilant regarding the issue of the use of the internet in relation to
child pornography. This is child sexual abuse and the practitioner will inform the LCFT
Safeguarding Team. This is a criminal offence and will be referred to the police.
11.4 New offences targeted at those who abuse children through prostitution
The Sexual Offences Act 2003 introduced a number of new offences to deal with those who
abuse and exploit children in this way. They protect children up to the age of 18 and can
attract tough penalties.
They include:
ƒ paying for the sexual services of a child
ƒ causing or inciting child prostitution
ƒ arranging or facilitating child prostitution
ƒ grooming
NB In the case of suspected sexual abuse the police will arrange the medical
examination
In some areas across the county multi agency teams have been established with a
specific remit to recognise and support young people who are victims of sexual
exploitation. Please see Safeguarding intranet site.
11.5 Domestic violence
11.5.1 Children may suffer both directly and indirectly if they live in households where there
is domestic violence. Domestic violence is likely to have a damaging effect on the health and
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development of children, and it is often appropriate for such children to be regarded as
children in need. Children living in families where they are exposed to domestic violence
have been shown to be at risk of behavioural, emotional, physical, cognitive-functioning,
attitude and long-term developmental problems. (Working Together to Safeguard Children
Chapter 11)
11.5.2 Victims of domestic violence are most at risk when they have decided to leave the
abusive relationship. Staff may consequently put themselves at risk when assisting in this
process.
11.5.3 Children who are experiencing domestic violence may benefit from a range of support
and services, and some may need safeguarding from harm. Often, supporting a non-violent
parent is likely to be the most effective way of promoting the child’s welfare.The police and
other agencies have defined powers in criminal and civil law that can be used to help those
who are subject to domestic violence.
11.5.4 MULTI-AGENCY RISK ASSESSMENT CONFERENCES (MARACS)
Maracs are a series of monthly conferences tackling cases of serious domestic abuse.
MARACs involve key agencies meeting to share information and expert knowledge about
high risk domestic abuse cases and drawing up action plans to help victims. In a single
meeting, a domestic violence MARAC combines up to date risk information with a
comprehensive assessment of a victim’s needs and links those directly to the provision of
appropriate services for all those involved in a domestic violence case: victim, children and
perpetrator.
11.5.5 Aims of a MARAC
ƒ To share information to increase the safety, health and well being of victims –
adults and their children
ƒ To determine whether the perpetrator poses a significant risk to any particular
individual or to the general community
ƒ To construct jointly and implement a risk management plan that provides
professional support to all those at risk and that reduces the risk of harm
ƒ To reduce repeat victimisation
ƒ To improve agency accountability; and
ƒ Improve support for staff involved in high-risk DV cases
11.5.6 Representatives attend the meetings from statutory and non statutory partner agencies
.LCFT nominated staff from Substance Misuse Services and Adult Mental Health attend and
contribute to cases and risk assessments involving individuals known to our services.
11.6 Children of drug-misusing parents
Staff must at all times consider, as an integral part of the assessment process ,the impact of a
parent/carer’s substance misuse on children within the household and family. Where there is
cause for concern about complex substance misuse, the ability of the parent or caregiver to
ensure that the child’s needs are being adequately then staff must follow LCFT Protocol for
Children of Drug/Alcohol Misusing parents (CP004) and consider the criteria for referral to
Children’s social care in order to assess the risk to children and young people. If concerns
remain, then a referral to CIS must be made.
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11.7 Child abuse linked to belief in ‘possession’ or ‘witchcraft’, or in other
ways related to spiritual or religious belief. The belief in ‘possession’ and ‘witchcraft’ is
widespread. It is not confined to particular countries, cultures or religions, nor is it confined
to new immigrant communities in this country. The number of known cases of child abuse
linked to accusations of ‘possession’ or ‘witchcraft’ is small, but children involved can suffer
damage to their physical and mental health, capacity to learn, ability to form relationships and
self-esteem. Such abuse generally occurs when a carer views a child as being ‘different’,
attributes this difference to the child being ‘possessed’ or involved in ‘witchcraft’, and
attempts to exorcise him or her. A child could be viewed as ‘different’ for a variety of
reasons, such as disobedience, independence, bedwetting, nightmares, illness or disability.
The attempt to ‘exorcise’ may involve severe beating, burning, starvation, cutting or stabbing,
and/or isolation, and usually occurs in the household where the child lives.
11.7.1 Staff need to be aware of these indicators, be able to identify children at risk of this
type of abuse and intervene to prevent it. They should apply basic safeguarding principles,
including sharing information across agencies, being child-focused at all times and keeping
an open mind when talking to parents and carers.
11.8 Forced Marriages of Children/Young People
Forced marriages of children must, in so far as it is likely to cause significant harm and may
involve non-consensual and/or underage sex, be regarded as a child protection issue.
In cases of suspected or actual ‘forced marriage’ actions should be conducted wholly in
accordance with the agreed Home Office, Foreign & Commonwealth Office and ACPO
guidance for Police, “Dealing With Cases of Forced Marriage” (2002).
LSCB procedures must be followed and advice taken from LCFT Safeguarding Team.
Further information and helplines are available from the Safeguarding and Protecting
Children intranet site.
Staff must never act as a mediator and need to be aware that mediation as a response to
forced marriage can be extremely dangerous. Refusal to go through with a forced marriage
has in the past been linked to so called ‘honour crimes’.
11.9 Sharing of information about circumstances of family stress – domestic abuse, mental
health of a parent, drug and alcohol misuse
11.9.1 Health Professionals should always act in the child’s best interest – the safety and well
being of the child must come first. The welfare of the child is always paramount (Children
Act 1989) and over rides the duty of confidentiality to the adult.
11.9.2 A decision whether to disclose information may be particularly difficult if you think it
may damage the trust between you and your patient or client. Wherever possible you should
explain the problem, seek agreement and explain the reasons if you decide to act against a
parent or child’s wishes. It is often helpful to discuss such concerns with a senior colleague or
the LCFT Safeguarding Team.
11.9.3 Staff must consider is the proposed disclosure in order to protect the welfare of the
child. The amount of confidential information disclosed, and the number of people to whom
it is disclosed, should be no more than is strictly necessary to meet the public interest in
protecting the health and wellbeing of a child. Disclosure must be based on a Need to Know’
Basis
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11.9.4 CIS have a statutory duty to make enquiries and they need the help from other
agencies to do this effectively. When approaching Health Professionals for information,
consent for disclosure of information would normally be sought.
11.9.5 In certain circumstances, disclosure is necessary in the interests of others. Adults who
pose a risk of harm to a child and children, who may be the subject of abuse, are included in
circumstances where information can be released, without the consent of the patient or client.
11.9.6 It is good practice to share information with the Health Visitor/School Nurse if a
service user has care of a child. Good practice would indicate the service users consent is
sought although there may be times that information is shared on a need to know basis to
exclude risk to children /young people.
12.0 Child Protection Conferences/meetings
12.1 Staff must attend all Conferences and Reviews with a written report in the format
detailed in this policy. A copy of all reports must be sent to the LCFT Safeguarding Team.
The content of the report should be shared with the client/child’s parents prior to the
conference if possible. (See Appendix 6 for template report)
12.1.2 Important points to include within the report:
ƒ Clarify what is fact, and what is your professional judgement. Never include
opinion
ƒ Interventions / referrals made and their outcomes
ƒ Identify family strengths and weaknesses
ƒ Analysis of the information presented
12.1.3 The body of the report should include a health profile based on the ‘Assessment
Framework’ (DOH 2000).
The Summary: should include an analysis of the issues of concern including the risk and
protective issues. A conclusion should be reached followed by your professional
recommendations regarding future involvement, service provision and anticipated outcomes.
Evidence that may have informed your professional judgement may be indicated.
Professional opinion should be based on fact and not on assumptions.
12.1.4 Staff invited to attend a Child Protection Conference or a Child Protection review must
prioritise attendance and produce a report as in Appendix 5 following guidance in Appendix
4, Staff must not feel that because they may no longer be involved with the service user they
do not need to attend or produce a report. A decision has been made by children’s social care
that attendance is required in order to obtain relevant information. Staff may hold vital
information to inform the conference decision. If there are resource difficulties this should be
discussed with their line manager who must attend to represent the Trust if the staff member
cannot attend. LCFT Safeguarding Team must be contacted if a member of staff is not
attending in order that the individual situation can be risk assessed.
12.1.5 Whenever possible the Child Protection Conference will reach a unanimous decision
on whether the child’s/children should have a child protection plan.. All practitioners must
make a decision after careful consideration of the evidence presented within the conference.
Date of Issue: March 2009
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Safeguarding and Protecting Children Procedures
If, however, any member disagrees with the conclusion of the conference he/she has a
responsibility to declare his/her dissent and reasons and ensure that dissent has been recorded
by reviewing the Minutes.
The date of the child protection review conference will be arranged.
12.1.6 Following a Child Protection Conference if the child is to have a child protection plan
a Core group will be formed. The procedure, roles and responsibilities for members of the
Core Group are detailed in Local Safeguarding Children Board procedures. Attendance at
Core Groups and subsequent Child Protection Reviews with a written report must be
prioritised.
A date and time for the first core group meeting will be agreed and should be within 7
working days of the conference.
12.1.7 Minutes will be sent to all conference attendees. If you consider the Minutes are not a
true record and corrections are necessary, inform the Child Protection Conference chair in
writing within one week of receipt of the Minutes.
The outcome of the Child Protection Conference must be documented in the appropriate
client records. Child Protection conference Minutes must be filed in the records. Where
electronic records are in use, minutes must be scanned and saved in line within line with
LCFT CL027A A Framework For Professional Clinical Record Keeping Standards and
CL027 Policy For Professional Clinical Record Keeping record keeping policy.
12.1.8 If any health practitioner is concerned that a person who may be attending a case
conference may pose an aggression, intimidation or violence risk to other conference
attendees the chairperson should be made aware, if possible prior to the conference. This will
enable the chairperson in their decision making as to whether the person exhibiting the risk
behaviour should be excluded. In the event of a conference member exhibiting violent or
aggressive behaviour during the conference that person be asked to leave the proceedings by
the chairperson.
12.1.9 Other Child Welfare Meetings
There are times that staff may wish to hold multi agency meetings to discuss and share
concerns and develop actions. These may fall below the threshold for Child Protection
Conferences e.g. Child in Need meetings and strategy meetings. The service user must be
informed of the meeting and outcomes.
12.1.9.1 Where the outcomes of a meeting are ,that it may be suspected a child may be
suffering or likely to suffer significant harm, an immediate referral must be made in line with
these procedures.
12.1.9.2 Attendance at meetings should be prioritised and should involve three basic steps:
ƒ A clear record of the discussion of the meeting should be completed and
circulated to all those present and all those with responsibility for an action
point
ƒ A list of action points should be drawn up, including time scale and person
responsible
ƒ A mechanism for reviewing completion of the agreed action must be specified.
The date upon which the first such review is to take place should be agreed
and documented
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Safeguarding and Protecting Children Procedures
13.0 Record Keeping
13.1 A clear record of conversations must be kept in all cases, recording telephone
conversations, face-to-face contacts, discussions and the outcomes of supervision..
13.2 A chronology of significant events form should be completed for each child about whom
there are welfare concerns as described in Appendix 8
13.3 When the Trust is involved with more than one member of the family each case file
must contain a full account of all relevant safeguarding information e.g dates of 13.4
Safeguarding Case Conferences and outcomes, or any other minutes of meetings held under
LSCB procedures.
13.5 Records must use clear, straightforward language, and should be accurate not only in
fact, but also in differentiating between opinion, judgements and hypothesis. All telephone
conversations should also be recorded.
See LCFT CL027A A Framework For Professional Clinical Record Keeping Standards and
CL027 Policy For Professional Clinical Record Keeping record keeping policy.(Children’s
records are kept for 25 years.)
14.0 Professional conflict, concerns or complaints
14.1 There will be times when there are difficulties between agencies, sometimes
misunderstandings or differing perspectives on the nature of the concerns possibly due to the
adult’s needs being in conflict with the child or young person.
14.2 If difficult situations arise that have been discussed but are not able to be resolved at
practitioner level or within the normal management processes of the organisation then these
concerns can be raised with the LCFT Safeguarding Team who will address it within the
Local Safeguarding Children Board framework, to ensure that good multi-disciplinary
working is maintained.
14.3 Procedure for safeguarding referrals involving staff members
Where allegations of child abuse are made against members of staff the situation requires
sensitive but appropriate management. It is important to remember that the allegation will be
investigated by other agencies.
14.4 In the event that a Safeguarding referral is made involving a member of staff employed
by LCFT, whether or not the alleged offence occurs on Trust premises Local Safeguarding
Children’s Board Procedures will be followed to instigate the investigation.
14.5 The employee’s Line Manager will be advised of the situation immediately by the
employee making the Safeguarding referral, or just receiving information of the referral. The
Safeguarding Team must be made aware who in turn will inform the Director of Nursing of
the investigation.
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Safeguarding and Protecting Children Procedures
14.6 Any employee of LCFT may be in a position of trust in relation to a child, young person
or their family. It is illegal to abuse this position of trust. It is illegal for anyone in a position
of trust to groom or have a sexual relationship with a young person less than 18 yrs of age.
14.7 In line with LSCB Procedures a multi-disciplinary strategy meeting will be convened to
decide on the multi-agency response to the referral.
14.8 The police may also need to conduct criminal investigations. Internal investigations
should not compromise the criminal process. Advice should be sought via the Trusts legal
advisor and Human Resources.
14.9 In order to discharge the duties outlined in ‘Working Together to Safeguard
Children’ 2006, any allegations or concerns about staff members must be reported to Human
Resources
The Local Authority, has an identified person known as the Local Authority Designated
Officer (LADO) who is central to conducting investigations and is required to make
judgements about a person’s ‘suitability to work with children’.
14.10 In all cases of suspected professional abuse coming to the attention of managers the
LCFT Safeguarding Team must be contacted. The LCFT Safeguarding Team will work
collaboratively with the manager, human resources and the LADO ensuring that the
appropriate Local Safeguarding Children Board procedures and LCFT policy/procedures are
adhered to.
15.0 Incomplete or conflicting details and missing families
15.1 As a matter of routine, all practitioners/staff are responsible for making sure that at each
new contact with a client who is a parent/carer basic information is checked/obtained and
recorded on CPA documentation. This must include the child’s name, date of birth, address,
General Practitioner (GP), school and the name of their primary carer. Incomplete details
should give rise to concern. Gaps in the basic information available must be addressed,
trigger further inquiries and be communicated to the relevant authority, agency or
practitioner.
15.2 Staff will give the child’s main carer, information and contact numbers for local GP’s in
their area of residence. If the family cannot register with a local GP because their lists are
full, give the address and contact number for Lancashire and South Cumbria Agency who
will allocate the family a GP.
15.3 When a member of staff has advised a carer to register a child with a GP and given the
above information, it is that staff member’s responsibility to liaise with the health
visitor/school nurse manager (depending on the age of the child) to ensure that a health
visitor/school nurse can follow this up.
15.4 Where a family goes missing, and there are safeguarding /welfare concerns, then LCFT
Safeguarding Team and the key social worker should be informed. The information will then
be cascaded to the appropriate professional groups. If the child/ children have a child
protection plan in place, LCFT Safeguarding Team and key social worker must be informed
immediately as there is a mechanism to alert colleagues in other areas of missing families. If
Date of Issue: March 2009
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Safeguarding and Protecting Children Procedures
a professional is made aware of the whereabouts of a ‘missing family’ LCFT Safeguarding
Team should be informed immediately.
16.0 Child of school age not registered with a school:
ƒ
Inform LCFT and local PCT Safeguarding Team.
17.0 Effective Care Co-ordination ECC
17.1 Effective Care Coordination provides a framework for effective mental health care.
All staff should ensure that safeguarding and promoting the welfare of children and
young people forms an integral part of all stages of care and assessment.
Information about the child/children in families must be recorded at assessment or as soon as
possible and recorded on CPA documentation/client records.
17.2 Staff implementing the ECC process must be mindful of service users /carers
responsibility for children and consider the welfare of children at every stage of the ECC
process utilizing the Framework for Assessment of Children in Need and their Families
outlined in Appendix 4 .( LCFT Effective Care Co-ordination Policy – CPA CL012)
17.3 When conducting visits to a family home where there are welfare concerns about a
child(ren) staff should establish the whereabouts of the child(ren). Staff should be mindful as
to when the child was last seen. This includes siblings within the family group. Where there
is a concern that a child(ren) has not been seen, staff should consult with a Senior Colleague,
Manager, LCFT Safeguarding Team .
18.0 Service Users who are admitted under a Section of the Mental Health
Act 1983 and have carer’s responsibility for a child
18.1 If a service user needs to be sectioned under the Mental Health Act 1983 consideration
must always be given to any carers responsibilities that person has and appropriate measures
put in place regarding the safety and well being of the child. Consideration always needs to
be given to the safety of any children with the Approved Social Worker consulting and
liaising closely with children’s services within the local authority.
18.2 If the service user has a child the safeguarding team at the PCT should be informed so
that they can share the information with key staff. This information may be communicated in
some areas by the paediatric liaison team.
18.3 A children’s social worker may need to be involved in the planning and or
implementation stage of a section. If the service user to be sectioned is the sole carer for the
child and/or there is potential risk to the child, police presence must be considered when the
section is administered in line with Trust policy.
Arrangements between Approved Social Workers, Police and Child Care Social Workers
must be robust.
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Safeguarding and Protecting Children Procedures
19.0 Considering Home Leave and Pre Discharge Planning
19.1 When service users have responsibility for a child and home leave or discharge is being
planned. The needs of children must always be considered. A pre discharge-planning
meeting should be called. If the child is under school age the Health Visitor should be invited
to the pre discharge-planning meeting. Other professionals working with the child and family
should be invited to attend as appropriate e.g. CAMHS, education, school nurse
19.2 If there are welfare concerns, the focus of the meeting should be changed to a Child in
Need Meeting at an appropriate stage when the child’s needs become the focus of discussions
and an appropriate action plan produced.
19.3 Safeguarding children requires information to be brought together from a number of
sources and careful professional judgements to be made on the basis of this information.
Good record keeping is essential.
19.4 Liaison with the PHACF/Named Nurse Safeguarding must be considered and sent a
copy of the minutes of the meeting.
20.0 Children visiting adult psychiatric wards
20.1 Arrangements for children visiting adult psychiatric wards must be undertaken in line
with the Trust policy (CP003).
20.2 A visit by a child or young person should only take place following a decision that such
a visit is in the best interests of the child. Decisions to allow such visits are reviewed
regularly.
21.0 Responsibilities for looked after children
21.1 Where a child/young person who is looked after, then staff must advise and liaise with
the young persons key Social Worker, who is the key professional in respect of
communication, and local Lead Nurse for Children Looked After, employed by thr PCT
21.2 Children who are provided with accommodation by the Social Service Departments are
described as ‘Children Looked After’. This term pertains to children subject to compulsory
care as well as those who are voluntarily accommodated.
Looked after children can be accommodated with family and friends, registered foster carers
and also in residential units.
21.3 Child/young person accommodated /detained over a period of 3 months
In line with the Children Act 1989, the Trust is required to notify the Childrens Integrated
Services when a child is accommodated or there are plans to accommodate for a consecutive
period of at least 3 months duration, and when the child leaves the accommodation. See
Mental Health Act 1983 Code of Practice 31.23 (1999) This notification is the
responsibility of the in patient unit .
Staff must refer to the Trust policy relating to the Admission of Young People to Adult wards
(CP002)
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22.0 Private fostering
22.1 The Children (Private Arrangements for Fostering) Regulations 2005 came into force 1st
July 2005 This has particular implications for inpatient services when a service user makes a
private arrangement with a non-relative to care for their child for 28 days or more (see 28 day
rule below). Also situations could come to the attention of other workers e.g. CAMHS,
CMHTs. The law states that the Local Authority Children’s services must be informed in
order that they can assess the situation.
Where private arrangements are made by a parent, or other with Parental
Responsibility to have their child look after who is:
ƒ
ƒ
ƒ
under 16 years of age
or, if disabled, under 18 years of age
and if these arrangements last for more than 28 days, in total – not necessarily
consecutive (see footnote)
with someone who is not
ƒ a parent
ƒ someone with parental responsibility
ƒ a relative
22.2 A private fostering arrangement differs from a public care fostering arrangement by the
fact that it is not arranged or paid for by the Local Authority.
22.3 Notification
Both the child’s parents and the private foster carers have a duty to notify the Local Authority
of the intention to place the child in private foster care not less than six weeks before and not
more than 13 weeks before the arrangement is intended to start, unless it is made as an
emergency, in which case notification shall not be more than 48 hours after the child has been
placed with the carers. 1
22.4 Local Safeguarding Children Procedures should be followed regarding notification
procedures.
23.0 Requests for information from solicitors, children’s guardians,
children and family reporters or the police
23.1 In order to ensure a standard approach is used, where there are child welfare issues, the
LCFT Safeguarding Team must be contacted. If staff are contacted directly staff must not
disclose any verbal or written information.
1
The calculation is based on the child being resident with the carers for a total of 28 days or more at any one time.
This means if the intention is for the child to stay with the carer for over 28 days but during this period they return to
have a break with their parents for a few days and return to the carers then this remains a private fostering
arrangement.
However if the child stays with carers on a regular basis for respite for a few days, even though over a year this might
accumulate to over 28 days this does not constitute private fostering.
(ref Surrey CC v Battersby 1965 1 AIIER 277.Cited in Hershman & McFarlan
Date of Issue: March 2009
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Safeguarding and Protecting Children Procedures
23.2 Requests must be made via Line Manager or PHACF/Named Nurse for Safeguarding.
Staff member may be accompanied by Line Manager/PHACF/Named Nurse for Safeguarding
if required. Sight of the final report should be requested.
A written request for information is required, a verbal request is not acceptable. Relevant
information may be given either by a prepared written statement or by an interview for the
purpose of preparing a statement. Statements should be discussed with and seen by the LCFT
Safeguarding Team and the Trusts Legal Advisor prior to submission. If taken by interview
the named nurse/line manager or a nominated representative must be present. The statement
should be signed and dated and a copy kept with the records.
23.3 Sharing of information with the Police may be necessary in the child’s best interests as
part of the Trust’s legislative duty to co-operate. Advice must be sought prior to releasing any
information from the Trust Records Manager, LCFT Safeguarding Team, Line Manager, one
of which will accompany staff when being interviewed or giving statements. Statements must
be checked and signed by the practitioner on each page. The Trust record Manager and Line
Manager must be notified of any requests for records.
24.0 Statements for Legal Proceedings where there are child welfare issues
24.1 If a member of staff receives a request for a statement for court where there are child
welfare issues they should contact their manager and the LCFT Safeguarding Team Trust
who will advise and support the staff member.
25.0 Attendance at court as a witness
If a member of staff receives a request, witness summons or is subpoenaed to appear in court
as a witness where there are child welfare issues they should contact their manager and LCFT
Safeguarding Team who will advise and support the staff member.
26.0 Incident reporting
26.1 Serious or untoward incidences must be reported in line with the Trust Serious
Untoward Incident Reporting and Management Procedure (HS001A.) LCFT Safeguarding
Team must be informed of any serious or untoward incidents involving children/young
people unborn to 18 years of age.
27.0 Child Death Overview Panel
27.1 All child deaths whether expected, sudden, accidental or otherwise have to be reported
to the above panel. This panel is part of the LSCB procedures. There is a reporting structure
that should be adhered to.
If a practitioner becomes aware of a child death whether it was sudden or expected they must
contact their manager and LCFT Safeguarding Team who will complete the CDOP
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Safeguarding and Protecting Children Procedures
notification form and forward it to the panel. This applies to children who are not in the area
at the time of death as well as those who die within Lancashire.
27.2 Some of the children reported to the panel will have died as an immediate or longer-term
consequence of abuse or neglect.
The CDOP panel will then decide whether the case meets the criteria for a Serious Case
Review.
28.0 Serious Case Reviews
28.1 These are held when a child dies or receives serious injuries and abuse or neglect are
known or suspected to be a factor in the death and the case gives rise to concerns about interagency working. The decision to carry out a serious case review is taken by the LSCB.
28.2 LSCBs will always consider whether a serious case review should be conducted:
ƒ
where a child sustains a potentially life-threatening injury or serious and
permanent impairment of health and development through abuse or neglect,
ƒ
where there has been subject to particularly serious sexual abuse, or their
parent has been murdered and a homicide review is being initiated,
ƒ
where the child has been killed by a parent with a mental illness,
ƒ
where the case gives rise to concerns about inter-agency working to protect
children from harm.
or
or
or
28.3 The purpose of the serious case review is to:
ƒ
ƒ
ƒ
Establish whether there are lessons to be learned from the case about the way
in which local professionals and agencies work together to safeguard children
Identify clearly what those lessons are, how they will be acted upon, and what
is expected to change as a result and as a consequence
To improve inter-agency working and better safeguarding children
28.4 Immediately it is suspected that a case may become the subject of a serious case review
the LCFT Safeguarding Team will arrange to secure all records.
28.5 Cases not meeting the criteria for a Serious Case Review may be subject to an internal
management review if it is felt that lessons can be learnt regarding multi agency working
(Working Together to Safeguard Children 2006).
28.6 LCFT Safeguarding Team will:
ƒ Ensure all notes and files relating to child/family are secure.
ƒ Liaise with manager and consider the circumstances of the incident death and
decide whether it needs reporting in line with LCFT Serious Incident/Patient
Safety Incident Reporting and Management Procedure HS001
ƒ Compile LCFT chronology of service involvement with all relevant family
members
Date of Issue: March 2009
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Safeguarding and Protecting Children Procedures
ƒ
ƒ
liaise with the the Designated Nurse/Doctor (PCT) who will compile the
composite health chronology and analysis and alert Chief Executives or
nominated representative within the involved health organisations of the need
for review of the case.
Liaise with the Trusts Legal Advisor
28.7 Review report (report from each discipline must be completed within the timescale set
by the LSCB serious case review panel)
Designated Nurse/Doctor, Named Nurse/Doctor for Safeguarding working with Service
Managers/Named Nurses will ensure each discipline carries out the following management
objectives:
ƒ Establish a factual chronology of all actions/interventions taken by
professionals involved with the child/ren family
ƒ Assess whether actions/interventions in the case areas are per Trust
policies/procedures
ƒ Analyse and identify any significant gaps in organisational systems, service
provision and or professional practice
ƒ Recommend appropriate action
29.0 Aggression, violence and intimidation
29.1 Aggression and violence to practitioners may be an indicator that the children may also
be at risk of abuse and is often used by parents to detract from child centeredness.
Practitioners must at all times remain aware and seek advice and support in order to prevent
the risk of professional collusion and dangerousness.
29.2 Practitioners who have concerns regarding adults who may pose a risk to the public must
discuss their concerns with their line manager or the LCFT safeguarding team. An assessment
of risk is central to the protection of children and practitioners. A Multi-Agency public
protection panel referral (MAPPA) may be indicated. This should only be instigated after
consultation with your line manager/LCFT Safeguarding Team who can request the police to
provide information relating to possible risk factors relating to adults when they are
safeguarding issues/concerns or practitioner’s safety is considered to be at risk.
30.0 Safeguarding and protecting children – professional development
30.1 Safeguarding Supervision
Supervision provides a framework for examining a case from different perspectives.
Functioning properly, supervision will facilitate quality, innovative reflective practice in a
safe environment.
30.2 Staff working with complex families or directly with children/young people must
receive safeguarding supervision every three months either on 1:1 basis or group supervision.
Other professionals must receive Safeguarding supervision as necessary or as determined by
their Line Managers or LCFT Safeguarding Team. (See LCFT Clinical Supervision policy).
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Safeguarding and Protecting Children Procedures
31.0 Support for staff
Support in complex cases is available from the safeguarding team. Staff must be offered
immediate support if they have been involved in a serious incident and where relevant a debrief must be offered.
ƒ
A leaflet outlining the meaning of a Serious Untoward Incident is available on
the Risk Management webpage on the intranet.
ƒ
Relevant staff involved in a traumatic / stressful incident will be offered
ongoing appropriate support as required via their managers, occupational
health or an outside agency if necessary.
ƒ
Support will be offered for staff experiencing difficulties associated with an
event throughout the incident investigation, and will continue once the
incident has concluded if necessary. This will also include support as required
via their managers, counselling, occupational health, or an outside agency if
necessary including Child Protection supervision and Clinical supervision.
For further information refer to the Procedure for supporting staff involved in traumatic /
stressful incidents complaints or claims
32.0 Training
In order to protect and safeguard children, all clinical staff need to have a basic awareness of
how to recognise, child in need/child protection issues, how to respond to their findings, and
how to refer to social services if necessary.
Safeguarding Children and Young People: Roles and Competences for Health Care Staff
April 2006 provides a recognised framework for all health care staff to meet the needs of
specific practitioners depending upon their particular role in relation to Safeguarding children
and Young People.
Training Levels
Staff groups will have different training needs to fulfil their duties, depending on their degree
of contact with vulnerable families, parents, children, young people and their level of
responsibility. (Safeguarding Children and Young People: Roles and Competences for Health
Care Staff April 2006) .Training for staff will be provided in accordance with the Trust’s
Training Needs Analysis.
Attendance and non attendance will be monitored in accordance with LCFT statutory and
mandatory training procedure.
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Safeguarding and Protecting Children Procedures
33.0 Implementation/compliance
33.1 Managers at all levels are responsible for ensuring that their staff are trained in the use
of these procedures and that staff are aware of the location of LCFT and LSCB Safeguarding
and protecting Children procedures and that this information is given to all new staff on
induction. They are also responsible for keeping staff up to date about any changes to these
procedures. All Safeguarding and Protecting Children Procedures are available on the Trust
Intranet.
33.2 The process for monitoring the effectiveness of these procedures and of the safeguarding
arrangements for children within the Trust will be by the Trust Safeguarding Committee.
34.0 Monitoring
34.1 The Trust’s Safeguarding and Protecting Children procedures and measures will be
monitored through a number of means, which are outlined in the table below.
Standard
Duties
Review of reported
safeguarding incidents to
establish themes and trends
Training provided to staff in
line with LCFT Safeguarding
Children Strategy
Preparation of an annual
safeguarding action plan that
includes actions arising from
corporate, national and local
safeguarding requirements and
developments
Date of Issue: March 2009
Timeframe/
Format
Annually via
the
Safeguarding
Annual Report
How
Whom
Review of a sample of
minutes of relevant
committees training
records, work plans,
objectives
Quarterly via
Quarterly reports
quarterly
Reported incidents and
reports to EMT SUI’s regarding concerns
Governance
about a child’s safety,
reviewed.
Annually
Training reports
Attendance lists
Training calendar
Training needs regularly
reviewed via evaluation
forms
Annually via
Review of Action Plan
the
Review of copies of
Safeguarding
referrals to Children’s
annual report
Integrated Services and
Annually
CAF activity
33
Public Health
Advisor
Children/Families
Public Health
Advisor
Children/Families
Public Health
Advisor
Children/Families
Public Health
Advisor
Children/Families
Safeguarding and Protecting Children Procedures
Local Safeguarding
arrangements are being
followed
Quarterly via
quarterly
reports to EMT
Governance
Sample Incident reports
relating to safeguarding
issues, minutes of
relevant committees.
LCFT Safeguarding
Action Plan
Annual report,
programme of audit.
Public Health
Advisor
Children/Families
Supporting staff
Annually via
the
Safeguarding
Annual Report
Review of investigation
reports / feedback reports
form staff
Public Health
Advisor
Children/Families
Public Health Advisor Children/Families is responsible for proving assurance of compliance
with this procedure to the Safeguarding Committee. The Safeguarding Committee will
provide assurance to EMT Governance of compliance with this procedure via quarterly and
annual reports. An action plan to address issues of non compliance with this procedure will
be developed and monitored by the Safeguarding Committee.
35.0 Equality and Diversity Impact Assessment
See Appendix 11
36.0 Review
This procedure will be reviewed every 3 years or earlier if there is a change in legislation or
guidance.
37.0 Other Associated Policies and Procedures
38.0
References
References and internet links
x
Safeguarding Children – A Joint Chief Inspectors’ Report
on Arrangements to Safeguard Children. London, Department of Health.
x
Children Act 1989 (1989). London, HMSO.
x
Children Act 2004.London,HMSO. Website
http://www.everychildmatters.gov.uk/
x
Data Protection Act 1998 (1998). London, HMSO.
http://www.opsi.gov.uk/ACTS/acts1998/19980029.htm
x
Date of Issue: March 2009
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Safeguarding and Protecting Children Procedures
x
Working Together to Safeguard Children DOH 2006
x
Responding to Domestic Abuse: A Hand Book for Health Professionals, DH
Department of Health (2005)
x
National Service Framework for Children, Young People and Maternity
Services. London, DOH. DfES (2004).
Website:
x
www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenSe
rvices/ChildenServicesInformation/fs/en.
x
Framework for the Assessment of Children in Need and their Families.
London, The Stationery Office. DOH.DfES(2000).
x
What To Do If You’re Worried A Child Is Being Abused. London,
DOH,DfES Home Office, Department for Culture, Media and Sports, Office
of the Deputy Prime Minister and the Lord Chancellor’s Department (2003).
x
Safeguarding Children in whom illness is Fabricated or Induced (2002);
Department of Health, Home Office, Department for Education and Skills
x
Statutory guidance on making arrangements to safeguard and promote the
welfare of children under section 11 of the Children Act 2004. London,
Department for Education and Skills.HM Prison Service (2004).
Date of Issue: March 2009
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Safeguarding and Protecting Children Procedures
Appendix 1
A GUIDE TO MEETINGS HELD IN RELATION TO PROTECTING
AND SAFEGUARDING CHILDREN
Health professionals working with vulnerable children and their families involved with LCFT
will be invited to attend a variety of multi-agency meetings to share relevant information and
develop plans to safeguard children. These multi-agency meetings are the forum for agreeing
services for vulnerable children and their families and should be held at regular intervals to
review the risks the child is facing and the range of support services provided. Decisions to
commission new services or to withdraw services should be reported to the meetings. These
meetings should be formally recorded and the Minutes distributed to all those involved. All
health staff should record the action plan in the client’s records immediately following any
multi-agency meeting they attend.
Practitioners attending meetings within the safeguarding and protecting children’s agenda
should fully participate in the multi-agency discussions which include constructively
challenging decisions that the professional does not consider to be in the best interest of the
child. Practitioners should be prepared to take responsibility in the management of the
meeting by supporting the chair.
Strategy discussion/meeting
The discussion or meeting takes place when there is reasonable cause to suspect that a child is
suffering or likely to suffer significant harm. It may take place by telephone (within 24 hours
of the initial assessment being completed) or by a meeting of all related professionals within
5 working days.
It is not usual for family members to take part in strategy discussions/meetings. Strategy
meetings are chaired by the team manager, or a senior social worker, from the Social Services
Department. The meeting will decide the intervention felt to be appropriate to an individual
family. The information shared at this time is crucial to the decision on whether a Section 47
enquiry (see 7.0) will be initiated, how the enquiries will be handled, what action is needed to
investigate and how best to protect the child/children. A report with a chronology of
significant events may be required.
Initial Safeguarding Conference
The conference brings together family members, the child where appropriate and
professionals involved with the child and family following the completion of Section 47
enquiries (where a child is considered to be at risk of significant harm). It is chaired by an
independent reviewing officer.
Its purpose is to collate information obtained about the child’s health development and
functioning and the parent’s capacity to ensure the child’s safety and promote his/her
health and development. From this, the conference will decide whether the child is at risk of
Date of Issue: March 2009
36
Safeguarding and Protecting Children Procedures
significant harm in the future and decide what action is needed to safeguard the child and
promote his/her welfare.
A multi-agency decision is made regarding the level of concern and the need to place/not to
place the child/children’s names on the Safeguarding Register and under what category of
abuse. A safeguarding plan is outlined and will usually involve health professionals. All
members of the meeting will be involved in this decision-making and planning process.
All initial safeguarding conferences should be attended. Where the practitioner is on leave, a
colleague should attend on their behalf. A written report is required. This report should be
shared with the family prior to the conference if possible. This is especially necessary if the
family’s first language is not English and a translation via the interpreter service is required.
Core Group Meetings
These are held at monthly intervals in respect of children currently on the Safeguarding
Register. The first core group meetings should be arranged at the end of the initial
safeguarding conference and should be held within 7 working days of that conference. The
core group led by the Children and Family key worker (social services) is responsible for
developing and implementing the safeguarding plan as outlined at the safeguarding
conference. All practitioners involved in core groups should work in line with and therefore
be in receipt of the protection plan.
The relevant health professionals identified at the safeguarding conference should attend. A
written report is not required if the identified health professional is in attendance and can
contribute verbally. If the identified health representative cannot attend, a report must be
prepared and submitted to the key worker prior to the meeting. It is also advised that a
representative for the health professional attends the meeting.
Review Safeguarding Conference
Once a child’s name is placed on the Safeguarding Register, a date for a first review
safeguarding conference is usually set for 3 months time. Subsequent review conferences will
always be planned, unless there has been a change in circumstances, in which case the
conference can be brought forward. Health professionals should attend all Review
Conferences. A written report is required. The report should be shared with the family prior
to the conference if possible.
Transfer in Safeguarding Conference
When a child on the Safeguarding Register moves to another area, the social services
department in the receiving area will convene a safeguarding conference within 14 working
days. The transfer conference will decide whether the registration in the new area will
continue. All practitioners should liaise will their colleagues in the receiving authority and
depending on the distance and/or circumstances, should either attend the conference or
provide a report detailing involvement to date. All liaison conversations should be
documented.
Family Support Meeting
This meeting is convened and chaired by the Named Social Worker following the completion
of the initial assessment. It should be attended by professionals and agencies involved with
the family, an agreed action plan to support the family should be formulated and individual
roles and responsibilities to meet the child’s needs should be agreed. Family members are
invited to the meeting. Further family support meetings should take place approximately
every 2 months to evaluate the support package and monitor the progress of the action plan.
Invited health professionals should attend these important meetings. A written report is not
Date of Issue: March 2009
37
Safeguarding and Protecting Children Procedures
required if the relevant health professional attends the meeting and contributes verbally. If
they are not able to attend, a representative must attend in their place and a report must be
submitted. The agreed action plan must be recorded in the child’s records by the health
representative immediately following the meeting. Staff should also ensure they receive a
copy of the Minutes of family support meetings to complete their records.
Initial Statutory Review (Looked after Children)
The meeting is arranged by the social worker and the review and protection chairperson as
soon as possible after a child is accommodated. All relevant agencies and the family
members are invited. The meeting is to clarify and consider a child’s care plan whilst in the
care of the local authority. Invited practitioners should attend. A concise report on the child’s
health and development, information on how the child has settled in the placement and any
observations on the interaction between the foster carers and child or parents and child should
be presented at the meeting. This report can be written or verbal depending on the individual
circumstances.
Statutory Review (Looked after Children)
A meeting to review the child’s health/education/development and placement and ensure
needs are being met is held one month after the placement. Invited health professionals
should attend. Planned regular reviews are held thereafter or on demand if there is a change
of circumstances. A report as above is required.
Professional Abuse Strategy Meeting
This meeting is chaired by the independent reviewing officer from the Social Services
Department. Its purpose is to clarify whether any further enquiries are required in relation to
the safety and welfare of the children, any police investigation into a possible crime and the
employer’s disciplinary procedures, which may be invoked.
Date of Issue: March 2009
38
Safeguarding and Protecting Children Procedures
Appendix 2
What To Do
If you are worried a Child is Being Abused
PRACTITIONER HAS CONCERNS ABOUT
CHILD'S WELFARE
Practitioner discusses with manager and/or other senior
colleagues as they think appropriate
Still has concerns
Still has concerns
No longer has concerns
No longer has concerns
Practitioner
Practioner refers
refersto
toSocial
Social
Services,
Services,following
following
upupininwriting
within
writing
48 within
hours 48 hours
Social worker and manager
acknowledge receipt of referral
and decide on next course of
action within one working day
Initial assessment required
Concerns about child's
immediate safety
No further child protection
action, although may need to
act to ensure services
provided
Feedback to referrer on next
course of action
No further social services
involvment at this stage,
although other action may be
necessary, eg. onward
referral
Emergency action taken by
Social Services/Police
Every Child Matters What to do if you’re worried a child is
being abused (Dept for Education & skills)
Date of Issue: March 2009
39
Safeguarding and Protecting Children Procedures
Appendix 3
DRAFTING A STATEMENT FOR COURT: A STEP BY STEP GUIDE
Remember the following key points:
1. To write a successful statement you must be very clear about the kind of information, which is required.
You need to ask yourself a number of questions:
a.
b.
c.
d.
e.
Why are you writing the statement?
Who will read the document?
What are the facts?
When is the statement needed?
What guidance have I available?
2. All statements must firstly be prepared in draft form and discussed with your line manager/Child
Protection Nurse Specialist.
3. Legal advice from is available via the Trust Legal Advisor /Named Nurse Safeguarding and should
always be sought in preparation for writing a court report and prior to submission.
4. Think before you write anything down and refer to all your records.
5. Statements must be accurate and written in chronological order.
6. Write down the statement in English, using uncomplicated language. Be clear, comprehensive and
concise in your writing skills. Check your spelling and punctuation are correct.
7. Statements must be factual, that is based on what was said, what was heard, what was observed and
what was done. What was the result of your assessment? Ensure your assessment is within your own
professional limits. What were your concerns? Key events/incidents must be written up in full detail.
8. You may need to include headings and sub-headings to make your statement clearer, particularly if it is
a lengthy document. Dates and times of home visits/other contacts should be recorded with a brief
summary of what happened, what you observed on each occasion and your action plan.
9. Do not forget to record “No access” visits and the action you took following these.
10. Non-contentious entries in nursing records can be summarised by entries in the following style:
‘Between 1.9.92 and 10.10.93, home visits continued and no problems were identified’.
11. Professional opinion and judgement is valued by the court; however they should be clearly
differentiated from fact.
12. Do not include unsubstantiated opinions or assumptions as facts. ‘There is no room for hypothesis or
conjecture’. (Barnes et al, 1989)
13. Try to make the statement as brief and concise as possible.
14. Be truthful.
15. Before signing the statement you should consider the content carefully and make any necessary
amendments.
16. Sign and date the final draft.
Date of Issue: March 2009
40
Safeguarding and Protecting Children Procedures
17. Keep a copy of the statement for your own reference – this is very important.
18. Prior to submission ensure the Trust legal advisor and The Named Nurse For Safeguarding view the
report.
WRITING A STATEMENT FOR COURT: A SUGGESTED FORMAT
To:
Date:
From:
Name:
Designation:
Professional Qualifications:
My experience has been:
Work address:
Work telephone number:
Stages of the Statement
1. Introduction
I first became involved with the family/child (ren) in:
(Statements must be written in chronological order)
2. Main body of statement
The main body of the statement will be a series of dated paragraphs summarising the corresponding entry in
your records.
Give an account of the contacts and events in chronological order from your records.
Each section should have a date as the heading.
Statements must be factual. Opinion should be stated as such.
Each section must include what was observed, heard, your professional assessment and any actions taken.
Signature:
Date of Issue: March 2009
Date:
41
Safeguarding and Protecting Children Procedures
Appendix 4
THE COMMON ASSESSMENT FRAMEWORK
CHILDS DEVELOPMENT NEEDS
Consider each child.
Consider among other issues:
Has the child attended for routine health surveillance and immunisation?
Are there any health problems or developmental delay?
If school age – is the child attending school?
Is there evidence of a stable, affectionate relationship with parent, caregivers and siblings?
Is the social presentation appropriate for age, gender, culture and religion?
Are there any hygiene issues?
Are there appropriate self-care skills
If pregnant Expected Date of Delivery……….
Is antenatal care being accessed?
Date of Issue: March 2009
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Safeguarding and Protecting Children Procedures
Health
Include growth and development as well as physical and mental well-being. Includes whether appropriate
health care has been accessed, i.e. immunisations, appropriate health assessments, hospital/GP/other medical
appointments including dental and optical care. Include centile charts, and Chronology of significant events.
Education
Include all significant issues relating to the child’s cognitive development e.g. opportunities for play and
interaction, attendance at school.
Emotional and Behavioural development
Include the nature and quality of attachment to parents/carers, and the child’s ability to adapt to change, his
response to stress etc.
Identity
Include the child’s sense of himself as a separate and valued person (self-image and self-esteem). Include issues
relating to race, religion, age, gender, sexuality and disability.
Family and Social relationships
Include whether the child has a stable and affectionate relationship with parents, caregivers and siblings and
whether they have age appropriate friends.
Social Presentation
Include whether the child is dressed appropriately for their age, gender, culture and religion and discuss
cleanliness and personal hygiene.
Self-Care Skills
Include whether the child has developed age appropriate self care skills, if not, why not?
DIMENSIONS OF PARENTING CAPACITY
Are the parents/carers capable of meeting the child’s basic needs including requirements for secure,
secure, stable and affectionate relationships?
Are the parents/carers ensuring the child is adequately protected from harm and setting appropriate
boundaries?
Are the parent/carers providing a sufficiently stable family environment?
Basic care
Include whether the child’s basic needs are being met i.e. are they receiving appropriate medical and dental
care? Do they have adequate provision of food, drink, warmth, shelter and appropriate clothing.
Ensuring Safety
Include whether the child is being adequately protected from harm or danger e.g. are hazards and dangers in the
home recognised by parents, is the child protected from ‘unsafe’ adults etc?
Emotional Warmth
Include whether the child’s emotional needs are being met e.g. appropriate physical contact, comfort and
cuddling sufficient to demonstrate warm regard, praise and encouragement.
Stimulation
Include whether the child’s cognitive development and potential is being stimulated through interaction,
communication, talking, play, attending school etc.
Date of Issue: March 2009
43
Safeguarding and Protecting Children Procedures
Guidance and Boundaries
Include whether parents/carers are providing guidance and setting appropriate and consistent boundaries for
their child. Also include, whether parents are demonstrating and modelling appropriate behaviour and control
of emotions and interactions with others.
FAMILY AND ENVIRONMENTAL FACTORS
What are the parental/carers strengths and difficulties?
What roles do the wider family including non-related persons have in the care of the child?
Does the accommodation have basic amenities and facilities appropriate to the age and development of
the child and other resident members? Is there sufficient income to meet the family’s needs?
Is there evidence of integration of isolation?
What community resources are available and used by the family?
Employment
Include who is working in the household and any impact this may have on the child.
Family History and Functioning
Include genetic and psychosocial factors which are impacting on the child. Include any significant changes in
the family/household composition; history of childhood experiences of parents; chronology of significant life
events and their meaning to family members; nature of family functioning, including sibling relationships and
its impact on the child; and parental strengths and difficulties.
Wider family
Include the wider families’ role and importance to the child and parents. Significant non-related persons can be
included here if they have some importance to the child.
Housing
Include whether the child’s living accommodation has basic amenities i.e. water, sanitation, cooking facilities,
adequate sleeping arrangements, hygiene and safety and their impact on the child’s upbringing.
Income
Include whether there is sufficient income to meet the family’s needs, the way available resources are used and
whether there are financial difficulties which affect the child.
Family’s Social Integration
Include the degree of the family’s integration or isolation, their peer groups, friendship and social networks and
what importance is attached to them and how this impacts on the child.
Community Resources
Include what resources are available in the community (e.g. Sure Start, Day Care facilities, shops, leisure
activities, schools, health centres), and how the availability and standard of these resources impact on the
family and the child.
Date of Issue: March 2009
44
Safeguarding and Protecting Children Procedures
Distribution:
1. To case conference / meeting
2. Held on Client Records
3. Named Nurse Child Protection
Appendix 5
REPORT FOR SAFEGUARDING CONFERENCE / MEETING
NAME OF CLIENT: ………………………………………
SURNAME
FORENAME
D.O.B.
DATE……………………….
ADDRESS
CHILDREN
SIBLINGS
MOTHER
FATHER/HUSBAND
CO-HABITEE
HEALTH PROFESSIONAL…………………….. DESIGNATION: …………………………………
BASE……………………………………………………………………………………………………….
GP:………………………………….. SOCIAL WORKER: ……………………………………………
T OTHER AGENCY INVOLVEMENT
DATE OF REGISTRATION: ………DATE OF LAST REVIEW/MEETING: ……………….
DATE OF COMMENCMENT OF CURRENT EPISODE OF CARE: ……………………………
Date of Issue: March 2009
45
Safeguarding and Protecting Children Procedures
REPORT TO CONFERENCE / MEETING
Contact
Dates
Venue
Comments / Outcome / Summary
The Introduction: should include relevant background information including length of time known to the service,
chronology of service involvement a description of the most recent incident, if there has been involvement/assessment of
risk and self-involvement with the child/family.
The use of the Framework for Assessment should be seen as a positive opportunity to identify and respond to any needs
of the children and family identified. It should identify the strengths as well as difficulties. You may only have limited
information under some of the headings e.g. Child’s developmental needs - but when all the information is put together in
the format of the Framework for Assessment at case conference a fuller picture is available to aid the decision making
process.
The body of the report should include a health profile based on the ‘Assessment Framework’ (DOH 2000).
x
Child Development (if known)
x
Parenting Capacity
x
Social and Environmental factors
The Summary: should include an analysis of the issues of concern including the risk and protective issues. A conclusion
should be reached followed by your professional recommendations regarding future involvement, service provision and
anticipated outcomes. Evidence that may have informed your professional judgement may be indicated.
SIGNED ……………………………………… DATE……………………………
SUPERVISOR / TEAM LEADER ……………………………DATE…………………………….
Date of Issue: March 2009
46
APPENDIX 6
Date of Issue: March 2009
If other children’s services are involved:
xDiscuss with the client inviting key staff from other services to
CPA meetings e.g. CAMHS, Health Visitors, children and
families social workers
xDiscuss with the client liaison/communication with those
professionals outside of the CPA process.
Practitioners will consider
xWho is in the family? (include age, gender, full names of
dependant children)
xDoes the child have special needs?
xDoes the client have parental responsibility?
xWhat symptoms and behaviours does the adult exhibit and what
may the impact of these be on children when acute/when chronic?
xWhat other adults are involved in parenting?
xIs the client pregnant?
xIs the family known to children’s services? (CAMHS or Social
Services) If so, what current involvement is there?
xAre there any previous or current concerns and do these relate
specifically to mental illness in the parent?
xDoes the client have insight and willingness to accept support /
services?
xDiscuss with the client the availability of support for their
parenting role from family or other services e.g. health visitor,
CAMHS, Social Services, Parental Mental Health Service.
ASSESSMENT STAGE
47
If you have major concerns about the welfare
and safety of the child/ren:
xDiscuss with manager/supervisor.
xSeek advice from the Trust-named nurse or doctor
in Child Protection if you are not sure.
xRefer to children & families team.
xAgree with children and families team when and
how to inform client that referral has been made.
If you have minor concerns for the child/ren
which are not shared by the adult client, incl.
pregnancy:
xDiscuss with a senior colleague or line manger
and agree plan.
xInformal discussion with Children and Families or
Parental Mental Health Service to decide whether
referral is indicated and level of urgency.
xIf appropriate, discuss again with client.
xIf concerns are shared by others consider referring
without client’s agreement.
xIn most instances, the client should be informed of
the referral even if it is not with their consent.
If you have no concerns for the child/ren:
xRecord
xInclude parental issues in care plan at every review
WHAT TO DO
Ref: Central and North London Mental Health NHS Trust
If the parent is being looked after at home:
xIf the child remains at home, it must be
remembered that the welfare of the child is
paramount.
xEnsure there is ongoing communication between
all professionals and services involved.
xAs part of the discharge planning, ensure
support for the parenting role is included.
xThe safety and welfare of the child should be kept
under constant review, and consideration should be
given to involving specialist childcare services.
If the adult is admitted:
xConsider how the impact on children can be
minimised e.g. agree how contact can be
maintained, what support and information the other
carer and children need; who will explain the
situation to the children and how.
xDiscuss with Children and Families Social
Services as early as possible when it has been
identified that admission may be required.
xEnsure written information on the children and
arrangements for their care is passed to ward staff
and there is ongoing communication between all
professionals and services involved.
xRefer to the Trust policy on children’s visiting to
inpatient areas, if relevant.
xAs part of discharge planning, ensure support for
the parenting role is included.
FOR ADULTS IN CRISIS
Principles:
•Children’s whose parents/carers have severe and/or on-going mental health needs/ substance misuse problems will usually be children in need in their own right. As
part of the assessment Practitioners need to consider how the adult’s illness/problems impacts on their children or those children with whom they have regular contact.
•By law, “the welfare of the child is paramount” – this means that children’s needs always override those of the adult and that the welfare principle enshrined in the
Children Act 1989 takes precedence over the Mental Health Act 1983 in all events.
Practice guidance for mental health/
substance
misuse
practitioner
Safeguarding
and Protecting
Children
Procedures
Welfare of children whose parents/carers have mental health /substance misuse problems
Safeguarding and Protecting Children Procedures
APPENDIX 7
Chronology Of Significant Events
A chronology lists in date order all the major changes and events in family, or a child
or young person's life.
It is seen as a trigger to enable a quick reference to the date and time in the records
where a full entry of events is recorded.
Using a Chronology
A chronology can be a useful way of gaining an overview of events in a family that
impacts on a child or a young person's life.
The chronology should be used by practitioners as an analytical tool to help them to
understand the impact, both immediate and cumulative, of events and changes in
clients lives which affect the child or young person's developmental progress.
The type of changes and events that should be included in a chronology would
include;
x Changes in the family composition, significant events and changes in the
circumstances of the child and family
x Change in address, GP.(School if client of school age)
x Changes in the child or young person's legal status within the family.
x Periods of hospitalisation or other significant medical treatment
and any injuries (accidental or non-accidental), hospital and A&E
attendances.
x History of any offences;
x Self harm, suicide attempts or overdose
x Multi agency meetings attended/ case conferences etc.
x Changes in the family, new births/deaths.
x Post natal depression, clinical assessment and liaison with Health Visitor.
x Non-compliance with health care/treatment/care plans. Missed appointments,
DNA’s.
x Domestic abuse/violence incident.
x Social Incidents, homelessness, housing, financial problems.
The Chronology records all significant events and changes in the life of a service user
with parent/caring responsibility, a child or young person or those who pose a risk to
children and young people.
The Chronology is an analytical tool designed to help understand the impact, both
immediate and cumulative, of events and changes affecting the child/ young person. .
A Chronology can help structure information to inform analysis and decisionmaking.
It should draw on various sources of information.
Date of Issue: March 2009
48
DOB:___________________________
APPENDIX 8
Domestic violence incident reported by Lisa
Core group meeting
Child found wandering streets at 9.00 pm asking for food
Lisa admitted to hospital with suspected drug overdose
following a domestic violence incident
06/8/2002
08/8/2002
17/8/2002
21/08/2002
COMMENTS / ACTION
SIGNATURE
Date of Issue: March 2009
49
N.B. Definition of significant harm: “A compilation of significant events, both acute and long-standing, which interfere with a child’s on-going
development, and interrupt, alter or impair physical or psychological development” or affect parenting capacity
Safeguarding case conference
29/7/2002
Example of recording
OCCURRENCE / EVENT
Bruising noted on John’s face. Safeguarding
Investigation initiated
AGE
14/7/2002
DATE
To include Accident and Emergency attendances, where known, injuries, accidents, self harm, known, GP contacts, complaints, missed appointments,
inappropriate minding, changes of address / school / carer, safety issues.
NAME OF CLIENT__________________________________
CHRONOLOGY OF SIGNIFICANT
Safeguarding and Protecting Children Procedures
Safeguarding and Protecting Children Procedures
APPENDIX 9
Safeguarding Children within LCFT
"Adult mental health services, including general adult and community, forensic,
psychotherapy, alcohol and substance misuse have a responsibility in safeguarding children when they
become aware of or identify a child at risk of harm”.
Working Together to Safeguard Children 2006
All NHS Trusts and NHS Foundation Trusts must identify a named doctor and a named nurse/midwife
for child protection with specific roles and responsibilities for safeguarding children and young people
Within LCFT Named Nurse Child Protection role is undertaken by:
Bridgett Welch
Public Health Advisor Children and Families/Named
Nurse Child Protection
Tel: 01772 64579
Mobile: 07507847567
[email protected]
Olivia Guly
Consultant Psychiatrist
Named Doctor Safeguarding Children
[email protected]
And Safeguarding Team
Bridget Boyle
Safeguarding practitioner
Tel: 01772 645794
Mobile; 07500 020312
[email protected]
Sharon McDonagh
Administrator
Tel:01772 645794
[email protected]
Role and responsibilities include;
x
x
x
x
x
x
x
x
x
statutory role, taking a professional lead on all aspects of the Trust contribution to safeguarding
children
promote good professional practice within the Trust, and provide advice , support and supervision for
staff
provide expertise in local arrangements for safeguarding and promoting the welfare of children
work closely with clinical governance to ensure safeguarding children is integral to the Trust
governance arrangements , monitoring and audit of quality
work closely with LCFT risk department and support staff in risk management issues pertinent to
children and young people
provide skilled professional involvement in child safeguarding processes, in line with LSCB
procedures, and in serious case reviews.
as part of serious case reviews ,review practice and learning
ensure and provide safeguarding training and strategy is in place and is
delivered .
contribute, develop and implement policies and procedures
If you have a concern regarding a child’s welfare don’t hesitate to contact the team
Protecting & Safeguarding Children is Everyone’s Responsibility
Date of Issue: March 2009
50
Tel:
(01995) 607624
Mobile: 07801 398778
Email: [email protected]
51
Alice Marquis-Carr
Named Nurse, Safeguarding and Vulnerable Children’s Team
North Lancashire PCT, Garstang Clinic, Kepple Lane
Garstang, Preston PR3 1PB
Date of Issue: March 2009
Tel:
Mobile: 07788 416457
Email: [email protected]
Tel:
(01253) 651265
Fax: (01253) 651258
Email: [email protected]
Janet Edwards – Named Nurse CP
Blackpool PCT Blackpool Stadium, Seasider’s Way
Blackpool FYI 6JX
Ms Anne Kopcke – Designated/Named Nurse
North Lancashire PCT, Garstang Clinic
Kepple Lane, Garstang,, Preston PR3 1PB
Tel:
(01253) 651262
Mobile: 0781 3108252
Fax: (01253) 651258
Email: [email protected]
Tel:
01772641471
Fax:
Email: [email protected]
Tel:
(01695) 598113
Fax: (01695) 598163
Email: [email protected]
CONTACT DETAILS
Dr Cathie Turner - Lead Nurse Safeguardiing and Vulnerable Children/Designated
Nurse
Blackpool PCT/North Lancashire PCT Blackpool Stadium
Seasider’s WayBlackpool FYI 6JX
Maria Coll
Named Nurse for Safeguarding and Protecting Children (West Lancs )
Central Lancashire PCT, Ormskirk and District Hospital , Wigan Road
Ormskirk L39 2AJ
Liz Thompson, Named Nurse
Central Lancashire PCT, The Willows, Peddar Lane, Preston
NAME
LANCASHIRE SENIOR NURSES SAFEGUARDING GROUP
Safeguarding and Protecting Children Procedures
APPENDIX 10
Tel:
(01254) 263611
Mobile:
Email: [email protected]
Tel:
(01772) 645790
Mobile: 07507847567
Email: [email protected]
Kath Thomson Named Nurse
Blackburn with Darwen PCT, Larkhill Health Centre
Mount Pleasant, Blackburn BB1 5BJ
Bridgett Welch -Named Nurse LCFT
Sceptre Point, Sceptre Way, Walton Summit
Walton Le Dale
Preston
Bridget Boyle ,Safeguarding practitioner.
Sceptre Point, Sceptre Way, Walton Summit
Walton Le Dale
Preston
Date of Issue: March 2009
52
Tel:
(01772) 645794
Mobile: 07500 020312
Email: [email protected]
Tel:
(01254) 263611
Mobile:
Email:
Susan Crorken, Safeguarding Lead Nurse
Blackburn with Darwen PCT, Larkhill Health Centre Mount Pleasant, Blackburn
BB1 5BJ
Turner Road, Nelson, BB9 7DR
Tel:
(01282) 699857
Mobile: 07976 878993
Email: [email protected]
Tel:
(01282) 699857
Mobile: 07976 878984
Email: [email protected]
Tel:
(01995) 607623
Mobile: 07795 445309
Email: [email protected]
East Lancashire PCT, Suite 200 Biz Spaces
Melanie Hartley Named Nurse
Suite 200 Biz Spaces, Turner Road, Nelson, BB9 7DR
Safeguarding Lead Nurse East Lancashire PCT
Janette Abbotts
Named Nurse, Safeguarding and Vulnerable Children’s Team
North Lancashire PCT, Garstang Clinic, Kepple Lane
Garstang,, Preston PR3 1PB
Jane Carwardine
Safeguarding and Protecting Children Procedures
Bridgett Welch
Public Health Advisor Children
and Families/Named Nurse
Child Protection
Bridgett Welch
Public Health Advisor Children
and Families/Named Nurse
Child Protection
March 2009
Lead
person
March 2009
Timescale
N/A
N/A
Costs
Lancashire Care Trust Equality and Diversity Action Plan
Service/ Dept/ Ward ………………Trustwide………………..
Date of Issue: March 2009
53
All completed actions to be fed back to the Equality and Diversity Lead to inform the relevant equality and diversity working group.
To improve monitoring of BME
groups within child protection
referrals made by staff.
Establish a data base. Raise
awareness of EI for all relevant
staff.
To liaise with the Local
Authority’s to establish a
breakdown of children whose
names are placed on the child
protection register, by area,
ethnicity, gender and sexual
orientation.
Action
Appendix 11
Safeguarding and Protecting Children Procedures
Update
from meetings
Safeguarding and Protecting Children Procedures
Appendix 11
LANCASHIRE CARE TRUST
INITIAL EQUALITY IMPACT ASSESSMENT
Department/Function
Trustwide
Person responsible
Public Health Advisor Children and Families/Named Nurse Child
Protection
Contact details
5 Fulwood Park
Caxton Road
Preston
Tel 01772 645790
[email protected]
Name of policy/procedure/service
to be assessed
SAFEGUARDING AND PROTECTING CHILDREN PROCEDURES
CP001
Date of assessment
1/11/07
Is this a new or existing
policy/procedure/service?
Existing reviewed procedures
1. Briefly describe the aims,
objectives and purpose of the
policy/procedure/service?
To ensure all staff have an awareness of their roles and
responsibilities and provide clarity of referral processes to Social
Services where there are concerns for a child and family in need of
support or protection.
The purpose of these procedures is to ensure a structured and
systematic approach to child protection across the organisation. To
provide a mechanism that will demonstrate compliance with the
Children Acts 1989 and 2004 and national standards for safeguarding
and protecting children.
The Children Act 1989 and 2004 places a statutory duty on Health
Professionals to help Social Services with their enquires so long as it
is compatible with their own statutory duties or other duties and
obligations.
2. Who is intended to benefit?
These procedures apply to all children up to their 18th birthday,
whether the children are service users of the Trust in their own right,
or children cared for by service users who are receiving services from
the Trust or children providing an active caring role.
3. What outcomes are wanted?
The Trust has procedures in place to ensure the safety and protection
of all children and Young People under the guiding principles within
the Children Act 1989 , Statutory guidance on making arrangements
to safeguard and promote the welfare of children under section 11 of
the Children Act 2004.and Working Together to Safeguard Children
2006.
Children, young people, parents/carers.
Local Safeguarding children,s Boards.
Childrens Social Care.
4. Who are the main stakeholders?
Date of Issue: March 2009
54
5. Who is responsible for
implementation?
Safeguarding and Protecting Children Procedures
Multi agency health partners , acute services, PCT’s and
Commissioners
Staff and the Organisation.
All LCT staff
Safeguarding Team
Managers , policy holders and clinical leads.
please explain and also include local demographics,
monitoring of E and D (e.g. % of BME communities in East
Lancashire – is this % reflected in recruitment and/or
service use?)
6. Are there concerns that
there could be differential
impact on the following
groups and what existing
evidence do you have for
this?
People from a Black or
minority ethnic
background
No negative equality impact identified the procedures are
underpinned by Child Protection legislation and National Standards.
N
Women or men
Including trans people
People with disabilities or
long term health conditions
N
Y
Where English is not a child or families first language, the
procedures refer to staff ensuring that they receive appropriate
assistance and access to an interpreter..
Where staff are engaging with safeguarding and child protection
procedures as laid out by Local Safeguarding Children’s Boards, the
outline child protection plans agreed will address ethnic/ cultural /
religious considerations – e.g. necessity for an interpreter, avoidance
of appointments with family on significant religious festivals; issues
arising from any disability; the plan should be constructed with the
family in their preferred language and they should receive a written
copy in this language.
Equal consideration for intervention, protection and support will be
given irrespective of gender
The procedures do not make specific reference to children who
appear to have a disability as they apply to all, however these
children are among the most vulnerable in our society, this will be
specifically included in future reviews .
Specific reference is made to Child abuse linked to belief in
‘possession’ or ‘witchcraft’, or in other ways related to spiritual or
religious belief which cannot be justified on religious or cultural
grounds and the fact that is not confined to particular countries,
cultures or religions, nor is it confined to new immigrant
communities in the UK. Specific reference is made to children/
young people and Forced Marriage where young people are coerced
into marrying against their will or their consent. Forced marriage is
an abuse of human rights and a form of domestic and child abuse.
As of autumn 2008 the Forced Marriage Act will come into force.
All children are entitled to the provision and protection provided by
the Children Act.
The rights of all young people in relation to the development of
healthy relationships and sexual health and well being are considered
within Lancashire Sexual Health Policy For Children and Young
People July 2007 .This provides a broad outline of the roles and
responsibilities of everyone who works with young people in relation
to the development of healthy relationships and sexual health and
well being. It provides a framework for multi agency/partnership
working. It is acknowledged that both male and female children and
young people suffer as victims of abuse through sexual exploitation.
People with or without a
religion or beliefs
N
Lesbian, gay ,bisexual or
heterosexual people
N
Older or younger people
N These trust wide wide procedures are explicitly based on the
Date of Issue: March 2009
55
Safeguarding and Protecting Children Procedures
principle that children of all ages who are harmed or abused will
have come from a variety of backgrounds, and in this respect, takes
account of all ‘equality strands’ .The child/ young person’s
circumstances and needs will be addressed with due regard to their
gender, race, ability, culture, religion and sexual orientation.
7. Could any differential
impact identified above be
potentially adverse?
Individual backgrounds , experiences and belief systems could possibly
impact on behaviour . Clinical staff must have access to effective
supervision systems.
Y
The legislation , protection and provisions under the Children Act 1989
and 2004 apply to all children and young people across the country.
8. Can any adverse impact
be justified on the grounds
of promoting equality of
opportunity?
9. Have you consulted with
those who are likely to be
affected?
N
10. Should the
policy/procedure/service
proceed to full impact
assessment?
N No
N No. The procedures are in line with LSCB procedures and a
mandatory requirement for the Trust.
I understand the impact assessment of this policy/procedure/service is a statutory obligation
and take responsibility for the completion of this process.
Names of assessors……Bridgett Welch…………………………
Signature of assessors
……………………………………………………………
Date of assessment…………10/10/08
Date of next review…………………July 2010
…………………………………………………………………………………
Date of Issue: March 2009
56
Capabilities for inclusive practice
In collaboration with
7889
Foreword
The workforce is key to opening up life opportunities for people who
experience social exclusion. In order to make inclusion a reality for people
using mental health services, the National Social Inclusion Programme (NSIP)
has worked with core mental health professionals to develop a set of
capabilities, capturing best practice in order to drive the transformation
of services and promote socially inclusive outcomes.
In producing these capabilities, NSIP have worked closely with the National
Institute for Mental Health in England (NIMHE) National Workforce Programme.
This has provided the necessary engagement of staff organisations and enabled
the work to link in a complementary way with the key workforce development
initiatives already underway. Through this collaboration, there is a need to
ensure that effective and positive change in the lives of those with whom
services work is secured and sustained.
These capabilities for socially inclusive practice are intended to be a resource
for reflection, challenge and practice change. Their purpose is to enable the
range of organisations and practitioners involved in mental health, whether as
commissioners, providers or educators, to make the values of recovery and
inclusion a reality. We hope this framework will support people, who use
services, to realise their aspirations as contributors to their communities,
advancing their choices, independence and participation.
David Morris
Programme Director for the
National Social Inclusion Programme
Roslyn Hope
Programme Director for the
National Workforce Programme
1
Capabilities for inclusive practice
Contents
Foreword
1
Executive Summary
3
Introduction
4
Using this framework
8
Social inclusion capability framework
2
ESC1 Working in partnership
12
ESC2 Respecting diversity
16
ESC3 Practicing ethically
19
ESC4 Challenging inequality
23
ESC5 Promoting recovery
27
ESC6 Identifying people’s needs and strengths
30
ESC7 Providing service user centred care
33
ESC8 Making a difference
36
ESC9 Promoting safety and positive risk taking
39
ESC10 Personal development and learning
41
References
44
Executive summary
The National Social Inclusion Programme (NSIP) has coordinated the delivery
of the action plan in the Social Exclusion Unit report Mental Health and
Social Exclusion (2004). This report showed that many people with mental
health problems experience exclusion and lack equal access to a range of
opportunities in society, including paid employment, volunteering, housing
and education. This is not only unjust but it lowers self esteem and self
confidence. However, improving opportunities for people with mental health
problems will enhance recovery, bring hope to people and their families, and
ultimately reduce dependence as people are enabled to contribute, in multiple
ways, to society and their community.
A key action in making this happen is the development of a workforce capable
of delivering inclusive opportunities to people using mental health services.
Working closely with the National Workforce Programme, NSIP has adapted
and developed The 10 Essential Shared Capabilities (ESC) which remains valid
as a framework for socially inclusive practice.
Consultation on the framework involved a representative from each of the
core professional groups in the mental health workforce – nursing, occupational
therapy, psychiatry, psychology and social work. A reference group including
these professions discussed, reviewed and refined the work, supporting their
evolution as a set of inclusion capabilities. The capabilities which include both
organisational and individual dimensions, contain ideas for the ways in which
they might enhance practice and add value to service development and delivery.
To give the capabilities clear meaning and personal application to the people
delivering services the organisational capabilities are mapped to the core
and developmental standards of the Healthcare Commission as described in
Standards for Better Health (2007), and the individual capabilities are mapped
to the core dimensions of the Knowledge and Skills Framework (KSF) (2004).
Progress in changing practice is best made when people have the opportunity
to engage with issues and to contribute their ideas and energy to the formation
of a local response. These capabilities can be used by Universities and
training bodies, managers and supervisors, training leads, organisational leads,
professional bodies, commissioners and practitioners as a resource in that process.
3
Capabilities for inclusive practice
Introduction
The Social Exclusion Unit (SEU) 2004 report Mental Health and Social Exclusion
showed that many people with mental health problems experience exclusion.
Frequently, they do not have equal access to a wide range of opportunities
in society, including paid employment and volunteering, housing, lifelong
learning, financial services, access to civil rights and social participation. This
exclusion may be compounded by other issues, such as gender or race. However
improving opportunities for people with mental health problems will enhance
recovery, bring hope to relatives and ultimately reduce dependence on the
State as people make a positive contribution to society, improve their social
networks, pay taxes and make less use of hospital and community services.
Since the SEU 2004 report was published the case for action has been
strengthened by further policy statements, including Improving the life
chances of disabled people (2005), the Disability Discrimination Act (2005)
and the 2006 White Paper Our health, our care, our say.
The SEU report included a 27-point action plan which is being coordinated by
the National Social Inclusion Programme (NSIP), a cross government team that
works nationally and regionally and has made significant progress. One of the
action points focuses on the need to develop a workforce that is fully competent
to deliver inclusive opportunities to people using mental health services.
The First Annual Report (2005) of the NSIP summarises the situation as follows:
“NSIP…has worked closely with the National Workforce Programme to ensure
that the development of workforce initiatives are in line with the skills base
requirements of social inclusion practice and management. This is focused on
appropriate adaptation and development of the ‘Ten Essential Shared Capabilities’
as a framework for inclusion. …The work with professional networks will
support its implementation across professional groups by linking it with a new
initiative on inclusion capabilities.”
Together with representation from the National Mental Health Workforce
Programme, the professions; nursing, occupational therapy, psychiatry,
psychology, and social work, which all play a substantial role in mental health
services, have each identified a steering group member to work with NSIP on
developing these capabilities.
4
Part of their contribution has been to provide a link into each profession’s
college, group or network, including the Royal College of Nursing and the
Mental Health Nurses Association, the College of Occupational Therapists,
the Royal College of Psychiatrists, the British Psychological Society, the Social
Care Institute for Excellence and the General Social Care Council. This reflects
the importance of promoting inclusive practice in the current workforce, and
to influence the training programmes for undergraduates, so that the future
workforce values and practices within a socially inclusive framework too.
Also key to this process is that the professional groups have been involved in
the national work underway to progress New Ways of Working-for Everyone
(Published by the National Workforce Programme in April 2007) to influence
the direction of the workforce of the future.
To develop the initial work each representative convened a reference group
from interested and expert members of their profession. Through a process
of consultation with these reference groups this initial work has evolved into
a set of social inclusion capabilities with both an organisational and individual
approach, with ideas of how they may enhance practice and add value to
service development and delivery.
Ten essential shared capabilities
The publication of The 10 Essential Shared Capabilities (ESCs) in 2004
identified common ground across practitioners, service users and carers and
brought coherence to the array of workforce initiatives in mental health. The
ESCs have brought an emphasis on the importance of socially inclusive practice.
Sharing a common set of capabilities creates a shared language and acknowledges
the common set of purposes and practices that lie at the heart of all effective
work in mental health. It facilitates dialogue about the level and mix of
capabilities that compose each role but does not diminish the unique contribution
of each profession, grade or individual; nor does it seek rigid uniformity. The
term ‘capabilities’ is used in this document to refer to values, characteristics
and skills. This is in line with other current initiatives that emphasise that work
in mental health needs to be both evidence-based and value-driven, while
organisational development is stimulated by well-articulated and coherent
values that increasingly drive clearly defined and effective practices.
5
Capabilities for inclusive practice Introduction
Distinctive skills for inclusive practice
This best practice guidance document explores the distinctive skills that explicitly
promote socially inclusive opportunities. In doing so, many of the values and
skills described in the 10 ESCs are taken for granted. For example, all inclusion
work with individuals rests on supporting empowerment, working respectfully
with the person and responding positively to diversity and should be present
in all services, whether or not they are designed to promote social inclusion.
Similarly, there will be a number of features shared by all organisations that
support inclusive opportunities: they will be healthy workplaces that continuously
strive for excellence; they will harness individual creativity, maintain honest
communication and so on. However, these things on their own will not
guarantee an inclusive outcome, as additional skills are needed for that. In
focusing on inclusion, this guidance lists the distinctive, additional elements that
are required, rather than the core skills that one would expect to find in all
mental health services, whether they were aiming to promote inclusion or not.
Limitations
Inclusion work is subject to the following limiting factors:
6
1
The extent to which all staff exercise the Capabilities of an Inclusive
Practitioner and utilise opportunities to promote and deliver socially inclusive
practice. If staff (whatever their profession or non-professional affiliation,
grade or role) adopt inclusive values and practices, then people using services
will have more opportunities. Practicing inclusively is everyone’s job and
some staff may have a particularly strong focus on particular inclusive goals.
2
The extent to which the mental health service as a whole demonstrates
the Capabilities of an Inclusive Organisation. If the service is outwardly
focused and builds links with community organisations beyond the welfare
system, then individual effort to promote inclusion will flourish. Similarly,
if the mental health service values inclusive efforts in its performance
management system, then again individual effort will prosper. While a
healthy organisation might support inclusive opportunities, an unhealthy
organisation can never do so over the long term.
3
The extent to which the wider community adopts inclusive values. This will
vary from one organisation or group to another and be influenced by the
resources, history and culture of that community as well as by its relationship
with the local mental health service, and should take account of other
excluded communities and groups, such as refugees and travellers. This
guidance focuses upon what mental health services can do, although much
of what they can do will be done in collaboration with community partners
and some responsibility for the success of inclusive endeavours will remain
within the community itself. A critical element will be socially inclusive
practices that promote and help to establish community cohesion.
4
It is important to recognise that some practitioners may also experience
exclusion, and so organisations need to have clear systems in place to
identify and address workforce inequalities.
Everyone’s job
The following framework shows quotations from The 10 Essential Shared
Capabilities that are particularly relevant to social inclusion followed by
the Capabilities of an Inclusive Organisation and the Capabilities of an
Inclusive Practitioner.
Every staff member will have duties in relation to the Capabilities of an Inclusive
Organisation as everyone is a contributor to the organisational culture and
goals. Most staff will have direct or indirect duties in relation to the Capabilities
of an Inclusive Practitioner, for example, through working directly with users
and carers, or supervising staff, or making organisational arrangements to
support delivery. Those who have greater seniority will increase the proportion
of organisational responsibility in their job role.
To try and give meaning to this work in relation to the actual delivery of
services the individual capabilities are mapped to the core KSF dimensions, and
the Healthcare Commissions core and developmental standards described in
Standards for Better Health.
This guidance describes a framework for mental health service communities
to work towards adopting. It is aimed at all professional and non-aligned staff
working across the full age range – children, adults and older people, and so
reinforces the principle that the capabilities are for the whole of the mental
health workforce. It is hoped that everyone within and beyond mental health
services will rise to the challenge. One of the most significant challenges for
individuals is how they continue to develop their own emotional intelligence
and resilience when encountering a range of complex situations and relationship
dynamics that occur in dealing with people who have mental health issues,
for example working with those who have been subject to violence and abuse.
This is combined with working across organisational boundaries and systems
in a variety of different situations.
7
Capabilities for inclusive practice
Using this framework
Each of the capabilities describes a dimension that could be marked with
a scale to show specific levels of achievement. Together these dimensions
and performance standards can form an audit framework to assist in the
assessment of local capability and also help to inform commissioning and the
developing of future capacity within community infrastructures. This could
help those responsible for staff to undertake a comprehensive training
needs analysis, which in turn can provide substantive information for staff
training programmes. By enhancing staff capabilities, it is important that the
organisation as part of its overall organisational development programme can
develop and maintain the capabilities of an inclusive service. This framework
describes the capabilities and suggests where and how they might be used.
At present, local arrangements for inclusion support vary from site to site.
For example, a service user might obtain employment support from the local
Jobcentre Plus, a supported employment service, an employment specialist
based in primary care or the mental health trust, or a member of the Community
Team with a lead role in employment support. Managers will need to make
a judgement about who does what based on the local population profile and
the landscape of provision, expertise, interests and workload. The Creating
Capable Teams Approach (CCTA) published by the NIMHE National Workforce
Programme in April 2007 can support this process.
The particular role and activities of an individual worker should be shaped by
a number of factors, including:
>
Their professional training, personal skills and experience.
>
Guidance from their professional body about the match of seniority and
responsibility in relation to inclusion activities.
>
Aligning their personal values and ability to act ethically and with integrity.
>
Managing their own emotions (including emotional resilience) and
developing their social and emotional intelligence.
This can provide the basis for a framework for practice. For coherent
and comprehensive change, socially inclusive practices should be part of the
contracting and commissioning arrangements at an individual, team and
organisation level. These should be considered in light of the local arrangements
between mental health and community organisations, between functional teams
within the mental health service, and between individual staff.
8
The framework has been assembled for professional and organisational groups
to use as a range of options for local selection and approval. People who use
services need an opportunity to contribute their insights. The voluntary and
community sector will have much to contribute alongside their colleagues in
statutory services.
Many of the organisational and individual capabilities described in this
framework are relevant to other groups at risk of exclusion, such as people
with learning or physical disabilities, older people, families at risk and black
and minority ethnic groups. Staff involved in these services or in cross-cutting
reviews may wish to utilise this work too.
Integrating inclusion capabilities into practice
The best progress is made when people have an opportunity to engage with
issues and contribute ideas and energy to the formation of a local response.
Communicating the message of this document may be enhanced by the use
of creative media. This might include video accounts from service users. The
message needs to be in a variety of formats, to communicate to people who
have different learning styles. Case study examples illustrating how organisations
and individuals have taken the suggested actions (shown below) forward
will help to bring the message to life.
These capabilities can be used (alongside other resources) by:
Universities/training bodies
1 Design and/or amend undergraduate and post-graduate training syllabus.
2
Accredit training programmes.
3
Select suitable students, lecturers and practice placements.
4
Train and accredit lecturers and practice supervisors.
5
Use a variety of media (lectures, posters, video) to inform service
users and staff.
Professional and operational managers/supervisors
1 Train supervisory staff.
2
Design job roles, task and job descriptions and select staff.
3
Contribute to assigning worker time and reviewing caseload management.
4
Supervise and appraise staff, and review supervision and appraisal frameworks.
5
Form staff personal development plans.
6
Create and audit Care Plans (e.g. whether plans include inclusion goals).
9
Capabilities for inclusive practice Using this framework
Training and development leads
1 Audit Continuing Professional Development (CPD) records and staff exit
interview records.
2
In conjunction with the CCTA, undertake a skills audit, gap analysis and
in-service training and teambuilding programme for individuals and
staff teams.
3
Define support competence levels for each team, role and grade of staff
(perhaps through the Knowledge and Skills Framework).
Organisational development leads
1 Promote inclusive values and practices (e.g. through the public adoption
of these capabilities by key staff within the service).
2
Identify and sponsor committed leadership for social inclusion at the
frontline and in senior roles.
3
Recognise, endorse and celebrate good practice at a national and local level.
4
Undertake an audit of values, beliefs and priorities that shape
organisational cultures.
Board level leaders
1 Review governance frameworks.
2
Revise the organisation mission and statement of purpose.
3
Build a shared vision for the future of the organisation and its community.
4
Survey current practice and innovation in other partner and potential
partner organisations.
Professional bodies
1 Adopt these capabilities as applicable to the whole of the mental
health workforce.
10
2
Show how their code of ethics and professional practice links with the
inclusion capabilities.
3
Set the research and practice development agenda.
4
Promote and disseminate best practice through professional networks,
conferences and publications.
5
Advise on how expectations and levels of responsibility should vary with
the grade, seniority, experience and work setting of the member.
6
Revise the guidance on CPD issued to members.
Commissioners
1 Specify what local services are commissioned (to include both inclusion
capabilities and inclusion outcomes).
2
Support service users to design user satisfaction feedback systems.
3
Enable service users and carers to be a part of local commissioning processes.
Practitioners
1 Ensure socially inclusive interventions are built into personal and
team objectives.
2
Highlight good and emerging practice both within and beyond the team,
service and organisation.
3
Challenge practice which is not inclusive.
4
Contribute to developing a shared vision of local community, through
engaging with important individuals and organisations.
11
Capabilities for inclusive practice
Social inclusion capability framework
ESC1 Working in
partnership
’Develop and maintain constructive working relationships
with lay people and wider community networks.’
We take ‘community networks’ to include informal friendship
networks and formal community organisations that provide
access to valued roles in the community – Job Centre Plus,
colleges, community associations and the voluntary sector etc.
This includes but reaches beyond mental health services and
other helping agencies. The terms ‘networks’, ‘organisations’
and ‘agencies’ are used interchangeably.
Standards for better care
Clinical and cost effectiveness,
C6, D5b
Accessible and responsive care,
C17, C18, D11c
Public health, C22a, D13d
12
Capabilities of an inclusive organisation/service
> Compared with traditional services, staff resources are
invested and more time is dedicated to building relationships
with people in community organisations. This activity is
valued and monitored.
>
Assign staff (such as employment specialists and others)
to locate, understand and maintain positive relationships
with key contacts in under-represented groups and all
the major agencies offering access to valued roles in the
community. This includes agencies leading economic and
community regeneration.
>
Seek opportunities for service users to contribute advice
and guidance to the management of community
organisations (e.g. service users on the Student Forum at
the College).
>
Maximise funding and resource opportunities in partnership
with universal community agencies to pool budgets, jointly
fund projects and create partnership projects that promote
inclusive opportunities.
>
Build alliances with people involved in community
engagement and regeneration.
>
Ensure that relevant governance systems are in place and
used (e.g. equality schemes).
>
Recognise and reward practitioners who consistently work
in a socially inclusive way.
Capabilities of an inclusive practitioner
> Work actively to build, maintain and sustain partnerships
with other community agencies so as to foster
understanding, access resources and create a wide spectrum
of opportunities for people with mental health problems.
This work is recognised and valued by the mental
health organisation.
>
Identify and challenge discriminatory attitudes and practices
towards people with mental health issues. Promote
awareness of and uphold service users’ rights to access
all organisations.
>
Support community organisations to develop new responses
as needed (partly through linking with Community
Development Workers) so that citizens with mental health
problems have fair access and effective support.
>
Understand the impact upon service users of the value
systems, policies, performance indicators and procedures
within community organisations.
>
Work in partnership with people who experience mental
health problems to deliver mental health and inclusion
training to community organisations (perhaps with mental
health promotion colleagues). Agree appropriate training
messages and learning outcomes with the organisation.
Tailor training to the specific audience and compensate for
any limitations that accompany the choice of medium,
teaching style and key messages.
>
In consultation with service users, commissioners, providers
and other key stakeholders establish outcome based measures
to establish the local impact of interventions/activities.
13
Capabilities for inclusive practice ESC1 Working in partnership
Links to the core KSF dimensions
1 Communication
Effective communication is a two way process. It involves
identifying what others are communicating (e.g. through
listening) as well as communicating clearly oneself in order
to develop mutually beneficial partnerships.
A common language which is jargon free reference mental
health issues will need to be agreed and used in order to
limit the barriers to effective communication.
Communication should be in a form and manner which
encourages the active participation of all involved.
2
Personal and people development
Individuals will need to identify and acknowledge gaps in
their knowledge of potential community networks and
determine how these gaps will be filled.
Practitioners will need to be clear about the concept of
‘health promotion’ and how this can be incorporated into
practice, encouraging others to do the same.
Supporting and developing the mental health knowledge
of those colleagues working in community services will
be essential if working relationships are to be built on a
foundation of mutual understanding.
Practitioners are ideally placed to encourage, engage
and support service users and carers in delivering mental
health and inclusion training. They must develop a range
of training/teaching techniques if they are to contribute to
the training of a wide range of partnership organisations.
3
14
Health, safety and security
Support and advice can be offered to community partners
enabling individuals and services to learn healthier, safer
and more secure ways of working with this client group.
Offering information and advice on how to reduce risk will
encourage greater confidence across partnership networks,
thus encouraging fairer access and effective support.
4
Service improvement
Everybody has a role in supporting the implementation of
new ways of working and implementing policies as well as
improving services.
Developing and sustaining partnerships will foster a culture
of mutual support and development ensuring resources for
service improvement are used creatively and the spectrum
of opportunities maximised.
5
Quality
Effective team working is an important aspect of
maintaining high quality practice. As a member of the
‘community network team’, this relies on, amongst other
things, individuals presenting a positive impression of
their service, recognising, respecting and promoting the
different roles and diversity of services and raising quality
issues with partners.
6
Equality and diversity
It is the responsibility of every individual to act in ways
that support equality and diversity.
An inclusive practitioner also needs to develop an increasing
understanding of the nature and complexity of equality
and diversity in order that they can become more proactive
and challenging in the promotion of equality and diversity.
15
Capabilities for inclusive practice
ESC2 Respecting diversity
’Work in ways that respect and value diversity including age,
race, culture, disability, gender, spirituality and sexuality.’
‘Understand the impact of discrimination and prejudice on
mental health and mental health services.’
‘Provide care and treatment that recognises the importance of
housing, employment, occupational opportunities, advocacy,
social networks and welfare benefits.’
Standards for better care
Clinical and cost effectiveness,
C6, D2b
Governance, C7e, D5
Patient focus, C13, D8, D9a/b
Accessible and responsive care,
C17, C18, D11b
Capabilities of an inclusive organisation/service
> Alongside colleagues in public health, identify under-served
groups in the community and successfully compensate with
outreach so that the whole community has equal access to
mental health service information, opportunities, goods,
services, and employment.
>
In addition to on-site activities, deliver surgeries, support
and supervision sessions in other helping agencies (such
as GP surgeries) and in valued community venues,
especially in settings that reach under-served groups
(such as youth centres).
>
Provide support for user-led services and community
groups, including accommodation, adequate funding,
advice and supportive relationships.
>
Promote socially inclusive practices within the community
and maximise funding/resource opportunities to develop
and maintain community cohesion.
>
People from all backgrounds have opportunities to develop
socially inclusive practices.
>
Racism is unacceptable and a sense of belonging and
contributing is promoted.
>
There is a common and shared understanding of the
value that difference has to creating a strong and socially
inclusive society.
Care environment and
amenities, D12a
Public health, C22a/c, D13b/c
16
Capabilities of an inclusive practitioner
> Undertake specific searches for community resources which
are targeted at minority and under-served groups (search
for resources that target minority and under-served groups,
whether or not they have a mental health difficulty).
>
Respond sensitively to the cultural norms of community
organisations. This includes those that serve specific
communities and the ways in which; for example, the
workplace or sports culture differs from a care setting.
>
Actively work to link and align activities of other agencies
that may be active in supporting social inclusion and focus
attention on community cohesion.
>
Have a strong social awareness of the diversity of customs
and practices and values in different social communities
and across rural and urban environments.
>
Develops strong and positive relationships with people from
different backgrounds both in the workplace and in the
communities in which they serve.
>
Continuously work to develop their emotional and
social intelligence.
Links to the core KSF dimensions
1 Communication
Non verbal communication i.e. the way we appear and how
we conduct ourselves is as important as the content and
delivery of what we say.
Sensitivity and an appreciation of the cultural norms of
community resources and organisations must be demonstrated
by communicating with people in a form and manner
that is consistent with their level of understanding, culture,
background and preferred ways of communicating.
2
Psychology
In Nottinghamshire Healthcare
NHS Trust, Bob Diamond
has been using his expertise
in Community Psychology to
arrange training on social
inclusion and support the
development of Community
Mental Health Teams through
monthly group supervision.
These discussions utilise
written summary information
on themes such as recovery,
inclusion and the Essential
Shared Capabilities to prompt
reflection on case studies
brought by group members.
For example, a recent
discussion explored how
a Care Coordinator might
work with a service user
who consistently rejected all
attempts to be ‘included’ in
mainstream settings, preferring
instead to maintain his identity
as a mental health service
user and his social network
formed within the service.
Contact: Bob.diamond
@nottshc.nhs.uk
(continued overleaf)
Personal and people development
Practitioners must dedicate time to seeking out and
becoming informed of resources which can support
individuals and their uniqueness.
Practitioners must dedicate time to gaining a greater
breadth of knowledge of the cultural norms of specific
local communities.
17
Capabilities for inclusive practice ESC2 Respecting diversity
Psychology (continued)
3
Health, safety and security
A knowledge and appreciation of the cultural norms of
specific local communities will reduce the risk of offending
or misreading situations, thus reducing the likelihood of
antagonism or incident.
4
Service improvement
Applying, understanding and learning of diversity issues
by adapting ones own practice, and making constructive
suggestions as to how services can be changed to better
respect diversity, will inevitably lead to service improvement.
5
Quality
Contributing to a system which encourages participation
by all and relies on individuals assuming responsibility for
delivering high quality in all areas of practice.
This focus on workforce
development illustrates a
number of inclusion
capabilities:
ESC2 staff considered the
impact of discrimination and
prejudice upon one person
using services.
ESC3 recognise the rights and
aspirations of service users.
ESC4 promote support between
people who use services.
ESC7 care plans are unique.
Individuals representing their service and the user
population they serve must remain mindful of presenting a
positive impression, showing respect and sensitivity for the
cultural norms and practices of community organisations.
ESC10 participate in
professional development
and reflective practice.
6
18
Equality and diversity
Recognising and valuing difference relies on individual
practitioners creating and contributing to a working
culture and practices that recognise, respect, value and
harness difference.
ESC3 Practicing ethically
’Recognise the rights and aspirations of service users and their
families, acknowledging power differentials and minimising
them whenever possible.’
‘Demonstrate an understanding of the service user’s wider
social networks and the contribution made by carers, family
and friends to the recovery process.’
Capabilities of an inclusive organisation/service
> Arrange services so that getting help is offered in a
manner that nurtures (rather than disrupts) personal roles
and relationships beyond the service system. This includes,
but goes far beyond, inviting service users to book their
own appointment and review times. This will create an
environment where inclusive practitioners will be able
to ‘understand the importance of informal relationships’.
>
Use sensitive knowledge and information with integrity.
>
Recognise there are both rational and emotional elements
within relationships formed with partners and stakeholders.
>
Design services so that packages of care can be
personalised to each service user, rather than offering a
limited repertoire of standardised options. This includes
the promotion of direct payments and individual budgets.
>
Ensure that mental health services have access to expertise
(such as employment support specialists and others),
but that inclusion is recognised as part of everyone’s job,
rather than being left to inclusion specialists.
>
The vision and mission statements of the mental health
service show that inclusion is a core value.
>
Reconciles the organisations purpose with the needs
of the community and the people it serves.
Standards for better care
Clinical and cost effectiveness,
C5c, C6, D2a/b/c
Governance, C7e, D5a/b
Patient focus, D9a/b
Accessible and responsive care,
C17, D11b
Care environment and
amenities, D12b
19
Capabilities for inclusive practice ESC3 Practicing ethically
>
Has systems and processes in place which ensure that
the behaviour of the organisation is open to scrutiny and
that its people act with probity and proper consideration
for the environment in which they deliver services.
>
Complies with emerging good/positive social inclusive
practices.
Capabilities of an inclusive practitioner
> Understand the importance of informal relationships,
strengths and aspirations in the service user’s recovery
process and show this in assessment and planning processes,
such as through the Care Programme Approach.
20
>
Provide information, opportunities to visit and try out
participation in a variety of community settings, along
with personalised support, so that people with mental
health problems can make informed choices about their
own community participation within a wider approach
to empowerment.
>
Balance accountability to the service user, employing
agency, wider community and professional body so that
service user’s rights and wishes are respected. This may
mean that staff are more accountable to service users
than was the case in the past. It also means acknowledging
and working constructively with the inherent tensions of
exercising legal powers and duties in a way that helps the
person make their own choices and retain control of their
own lives as far as possible.
>
Manages the boundaries between formal and informal
roles. This includes the ability to: relate to service users in a
public place; support service users to develop connections
with other citizens; provide support to community
organisations; and enable service users to appropriately
move beyond the service and its risk assessments and
confidentiality protocols. This is likely to be more complex
than was the case when buildings, uniforms and user-only
groups assisted boundary-keeping.
>
Is self aware of own limitations in terms of knowledge skills
and experience.
>
Is self regulatory when dealing with difficult situations and
dysfunctional relationships.
>
Recognises when their own values are in conflict with those
of other people and has insight into how this may impact
on their practice.
>
Is emotionally resilient when dealing with relationship issues.
>
Their actions and behaviour are transparent and they are
clear about their intentions and how to respond appropriately.
>
Has highly developed personal insight into how their values
are reflected in the way in which they conduct themselves
with others.
Links to the core KSF dimensions
1 Communication
‘Listening’ and truly ‘hearing’ the voice of the individual
will better inform the direction of care.
Practitioners need to effectively manage the barriers to
effective communication which might be environmental
(e.g. noise, lack of privacy), personal (e.g. the health and
wellbeing of the people involved) or social (e.g. conflict,
violent and abusive situations, ability to read and write
in a particular language or style) in order that the service
user is fully supported on their journey of recovery.
Clarity and confidence in articulating one’s own role and
managing boundaries will be essential if practitioners are
to effectively advocate on behalf of individuals and are
to contribute to decision making, balancing a number of
different interests and complexities.
2
Personal and people development
An increased knowledge and skills base which promotes
and enables working within a recovery framework will be
essential for all practitioners.
21
Capabilities for inclusive practice ESC3 Practicing ethically
3
Health, safety and security
Whilst is it essential for practitioners to monitor and
maintain the health, safety and security of others, working
within a recovery framework promotes positive risk taking
and skills in supporting others to manage risks more
effectively, within healthy and safe practices, will be crucial.
Individual practitioners will need to feel competent and
confident in utilising robust risk assessments and risk
management plans if individuals are to be encouraged to
retain greater control over their lives.
4
Service improvement
Practitioners have an individual and collective responsibility
to modernise service delivery.
Inspiring and working collectively with others will enable
strategy and direction to be taken forward into service
improvements.
5
Quality
Individuals will need to ensure they are clear about their
role in relation to the individual and in relation to others
involved in the individual’s care, including those within the
individual’s wider social network.
6
Equality and diversity
Equality is about creating a fairer society where everyone can
participate and has the opportunity to fulfill their potential.
Individual practitioners must consider their own behaviour
and its effect on others.
22
ESC4 Challenging
inequality
’Recognise and understand the devastating effect that social
inequality and exclusion can have on the recovery process that
makes it difficult for service users to achieve their potential or
take their rightful place in society.’
‘Challenge and address the causes and effects of stigma,
discrimination, inequality and exclusion upon service users,
carers and mental health services.’
‘Create, develop and maintain valued social roles for people
in the communities they come from.’
Capabilities of an inclusive organisation/service
> Recognise the processes and explanations within services
that may disempower and harm users and compensate
with empowering approaches. Service users gain a sense of
power and agency, including the opportunity to influence
the mental health organisation (by sitting on Local
Implementation Teams and other planning groups).
>
Develop services that assist people to stay at home rather
that go to hospital, stay in their neighbourhoods rather
than move out of the area and receive services on a
voluntary rather than a compulsory basis. Where people
are already in hospital, out of area or detained, make
strenuous efforts to maximise independence.
>
Commissioners select services that challenge or redress
inequality.
>
Staff and service users who challenge injustice, inequality
and discrimination are effectively supported to deal with
the pain that this can engender.
>
Promote support between people who use services so that
there are opportunities for peer education, mutual self-help
and joint political action (perhaps through an advocacy
group that is funded to work within and beyond the mental
health service).
Standards for better care
Clinical and cost effectiveness,
D2a/b/c
Governance, C7e, C8a, D5b,
C13a, D10
Accessible and responsible
care, C17, C18, D11b/c
Care environment and
amenities, D12a
Public health, C22a, D13a/d
23
Capabilities for inclusive practice ESC4 Challenging inequality
>
Create structures that support user involvement in decisionmaking, user-run services, and user directed care (such as
individualised funding).
>
Promote the maintenance and further development of
positive roles and relationships between people who use
services and other citizens based on shared interests.
>
Ensures that people are treated with dignity and respect
and all actions and interventions are agreed and
transacted accordingly.
>
Seeks opportunities to strengthen the links within different
community and social settings.
>
Promotes participation based on person centred approaches.
Capabilities of an inclusive practitioner
> Demonstrate an understanding of people with mental
health problems, particularly as this relates to access to
community inclusion. This includes recognition of the
feelings of distress and shame that can be caused by
discrimination and how negative reputations can develop
and be sustained, and how they can be dismantled.
24
>
Recognise the processes of ignorance, fear, abuse of
power, stigmatisation and institutional discrimination within
communities that lead to the exclusion of people with
mental health issues.
>
Understand and use knowledge of legal rights and
obligations to challenge injustice and discrimination and
support individuals, families and the community.
>
Support service users to obtain and retain an included life
on their own terms (as evidenced in care and support
plans). This includes identifying ways in which community
facilities might accommodate the individual by adjusting
expectations, increasing feedback and support, and
changing physical aspects or procedures in the community
setting. It also includes the need to identify strategies for
the individual to maintain or regain roles and relationships
through the development of specific skills, disclosing
personal information and arranging support from a variety
of sources.
>
>
Recognises and understands other people’s rational and
emotional behaviour and seeks to understand their
intentions in order to respond appropriately.
Manages self and supports other to deal effectively with
emotional behaviour especially when dealing with people
who are frightened, angry, stressed or confused.
Links to the core KSF dimensions
1 Communication
Individual practitioners have a responsibility to advocate in a
range of ways on behalf of the service users they work with.
The individual practitioner will be required to constructively
manage barriers to effective communication to ensure clarity
and understanding of the individual’s needs and desires.
Confidence and competence in independent decision
making, as an autonomous practitioner, within a multidisciplinary and multi-skilled team will be essential, as will
the ability to articulate decisions.
Individual practitioners will need to develop the confidence
and skills for sharing decision making with others, including
users of services and their families.
They will need confidence and competence in order to
advocate on behalf of the individual when they have
experienced stigmatisation, discrimination and exclusion.
2
Nursing
In Leicestershire, nursing staff
at the Glenvale acute day
hospital offer short term and
intensive intervention to
people in crisis as an alternative
to hospital admission.
Each staff member holds
responsibility for one of the
following areas of community
participation: employment,
education, volunteering, arts,
sports and faith communities.
This ensures that initial
assessments include these areas
of life, promote retention of
these roles whilst the person
deals with the crisis, and
improves links between the
day hospital and mainstream
community organisations.
Contact: Martin.wyburn
@leicspart.nhs.uk
(continued overleaf)
Personal and people development
As well as clinical skills, practitioners will need to acquaint
themselves with the principles which underpin the delivery
of qualitative mental health services such as recovery and
social inclusion.
In developing this knowledge, they will also need to truly
appreciate the experiences of inequality which systems can
often inadvertently create and maintain. It is the service
user’s own experience which will provide the most insightful
learning opportunity for the practitioner.
25
Capabilities for inclusive practice ESC4 Challenging inequality
Nursing (continued)
3
Redesigning roles in this way
will give rise to a number of
inclusion capabilities:
ESC1 assign staff to locate,
understand and maintain
positive relationships with key
contacts in agencies offering
access to valued roles in the
community.
Whilst sharing information with community colleagues
may assist them in better accommodating an individual,
practitioners must remain mindful of policies and procedures
regarding confidentiality.
ESC4 support service users to
obtain and retain an included
life on the own terms.
4
Service improvement
The individual practitioner must assume personal
responsibility for improving service delivery, supporting
others effectively, as current practice is challenged and
changed, and should also proactively work with others to
overcome problems and tensions which might arise.
5
Quality
Practitioners will need to be sufficiently skilled in order to
manage or challenge quality issues which have resulted in
the service user experiencing stigmatisation, discrimination
or exclusion.
6
Equality and diversity
Practitioners will need to work closely with other
community services, sharing information and knowledge
regarding mental health issues which will help them adapt
and improve their work practices and which will ensure
greater provision of socially inclusive and accessible services
to those who experience mental health difficulties.
ESC5 provide information
about a wide range of
opportunities in the
community.
ESC6 carry out interventions
in a way that equips the person
to define and reach towards
their life ambitions in the
community of their choice.
ESC7 support service users to
participate in mainstream
community settings.
ESC8 job roles clearly include
promoting social inclusion.
26
Health, safety and security
Whilst practitioners should actively challenge procedures
and protocols, both within their own workplace and in
other services, which can result in the individual experiencing
inequality, it would be negligent not to appreciate, respect
and follow those procedures and policies which have
to be in place to ensure healthy, safe and secure
working practices.
ESC5 Promoting recovery
‘Recovery is what people experience themselves as they
become empowered to achieve a meaningful life and a
positive sense of belonging in the community.’
‘Work in partnership to provide care and treatment that
enables service users and carers to tackle mental health
problems with hope and optimism and to work towards
a valued lifestyle within and beyond the limits of any
mental health problem.’
‘Ensure that all efforts are made to present non-stigmatising
and positive views of people who experience mental
health problems.’
‘Facilitate access to community groups and networks that
enable the service user to participate in community activities.’
Capabilities of an inclusive organisation/service
> Service users are employed in the service (perhaps with
rates monitored through the Human Resources and
Occupational Health services), sit on management teams
and monitor quality (with local arrangements specified in
quality assurance and governance frameworks).
>
Support the development of a mentally healthy community.
Commission an appropriate level of mental health
promotion activity. This will expand the range of respectful
and relevant opportunities available to service users and
inclusive practitioners.
>
Ensure compilation and access to an up-to-date database
of community-based opportunities.
>
Create and maintain a culture of hope (evidenced through
cultural audits of the service, perhaps within Investors in
People or mechanisms for monitoring service user opinion).
>
Design mental health buildings and processes in a way that
reflects service users as citizens (e.g. by the provision of
private space on inpatient wards where the person can
spend time with their family).
Standards for better care
Client and cost effectiveness,
C6, D2b/c
Governance, D5a/b, D7
Patient focus, C13a, D8,
D9a/b, D10
Accessible and responsive
care, C17, D11b
Care environment and
amenities, C21, D12a/b
Public health, C22c
27
Capabilities for inclusive practice ESC5 Promoting recovery
>
Commissioners select services that are person centred and
promote recovery through socially inclusive practices.
>
Services are designed to produce impact measures
(e.g. through the recovery pathway and evidence socially
inclusive practices). This aims to build a body of evidence
to inform future service developments.
Capabilities of an inclusive practitioner
> Support service users to clarify their aspirations, celebrate
their successes, find strength in their resilience in the face
of adversity, tackle their mental health problems and plan
their recovery journeys (as revealed in assessment and
care planning documentation).
28
>
Demonstrate emotional resilience when coping with your
own sensitivities and emotions during times of stress,
uncertainty or change.
>
Exercise a hopeful and optimistic approach toward both
service users (recovery and social inclusion is within the
reach of everyone) and communities (discrimination can be
overcome, opportunities for participation can be found or
created, other citizens can offer a respectful welcome).
>
Demonstrate knowledge of a wide range of opportunities
in the community.
>
Provide information about current opportunities for
community participation to service users in an attractive
and accessible manner.
>
Understand and use a range of approaches to matching
individuals with community opportunities and adapt as the
‘degree of fit’ changes over time.
>
Promote opportunities for service users to create and
develop friendships with other citizens. Identify factors that
enhance ‘friendship-friendly’ organisations.
>
View service users’ lives as bigger than the services that
they receive. Deliver support in a way that promotes the
service user’s citizenship and community participation, and
enhances independence from formal services in as many
life areas as possible.
Links to the core KSF dimensions
1 Communication
Greater consideration of the content of communications
should be given in order that hope and optimism are
conveyed within the parameters of the reality of the situation.
2
Personal and people development
Practitioners who are accomplished in working within a
recovery framework should support and facilitate colleagues
in order that a ‘recovery’ culture develops and flourishes.
3
Health, safety and security
As practitioners increasingly work ‘off-site’ as they
seek to support the integration of the service user within
their community, they will need to ensure they understand
the need for and conform to policies, procedures and
guidelines which are designed to promote and protect
their health, safety and security such as ‘Lone Working
Policies’, ‘Community Visiting Policies’, and ‘Security
of Premises’ procedures.
4
Service improvement
Acquiring a broad knowledge base of the range of
opportunities available in the community promotes choice
and empowerment for the service users. It is also the
responsibility of the practitioner to avail themselves to
colleagues, sharing information in order that all service
users accessing the service are fully appraised of available
opportunities and are not limited to an individual’s
knowledge of local resources.
5
Quality
If the service user is to feel empowered and a qualitative
experience realised, individual practitioners will need to fully
engage with a service user on their journey of recovery,
appreciating the individual’s strengths and aspirations
and will need to create/facilitate opportunities which
promote choice.
6
Equality and diversity
Treating others with respect and dignity relies upon
acknowledgment of differing perspectives.
Individual practitioners will need to develop skills which focus
on an individual’s ability rather than disability, to consider
creative opportunities rather than limited availabilities.
29
Capabilities for inclusive practice
ESC6 Identifying people’s
needs and strengths
‘Work in partnership with the individual’s support network to
collect information to assist understanding of the person and
their strengths and needs.’
‘Agree health and social care needs in the context of the
preferred lifestyle and aspirations of service users, their
families, carers and friends.’
‘Carry out or contribute to a systematic, whole systems
assessment that has, as its focus, the strengths and needs of
the service user and the family and friends who support them.’
‘Work in a way that acknowledges the personal, social,
cultural and spiritual strengths and needs of the individual.’
Standards for better health
Clinical and cost effectiveness,
C6, D2b/c
Governance, C7e, D9a/b, D10
Patient focus, C13, D9a/b,
D10
Capabilities of an inclusive organisation/service
> Documentation and practice in initial assessments, eligibility
decisions and reviews of intervention pays attention to
people’s life ambitions and current assets. This includes a
focus on job retention and retention of other roles and
relationships, especially in early intervention, crisis resolution
and inpatient services.
Accessible and responsive care,
C17, C18, D11b/c
>
Family, friends and other acquaintances contribute to initial
and repeat assessments.
Care environment and
amenities, D12a
>
Value and harness the contribution of service users to
community life: as employees, volunteers, buddies, mentors,
friends and informal acquaintances. In some areas these
options will need to be promoted through the development
of specific projects.
>
The local suicide prevention strategy takes full account of
the social inclusion agenda.
>
Ensure primary healthcare needs and mental health needs
are addressed simultaneously with supporting the preferred
lifestyle and aspirations of the service user.
Public health, C22a/b, C23,
D13a/b/c
30
Capabilities of an inclusive practitioner
> Recognise that people are more complex than our
assessments show. Recognise the multiple levels of
exclusion and inclusion that might be explored (e.g. a
service user has good access to mental health services,
but is in conflict with neighbours. He has a part-time job
and talks to his old school friend about his feelings that
his Jewish faith isolates him from his work colleagues).
>
Gather information about the service user’s gifts, talents
and strengths.
>
Use initial and repeat assessments that have been
developed with the service user and other people in their
life to discover the extent of inclusion that a person
currently experiences, possible interests and skills to guide
inclusion planning, and to identify blockages to inclusion.
Carry out interventions in a way that equips the person
to make their own choices, manage their own recovery,
define and reach towards their own life ambitions in
relationship with others and the communities of their
choice. Provide just enough support.
Social work
Amanda Hesford is Head
of Social Work at Devon
Partnership Trust and is
planning a Board-level review
of the balance of work
of the whole mental health
service. This will encompass
the mission of the service, its
culture, investment, workforce
skills and development,
partnership with community
organisations and experiences
of people using the service.
Contact: Amanda.Hesford
@devonptnrs.nhs.uk
(continued overleaf)
Links to the core KSF dimensions
1 Communication
The development of basic counselling skills will be essential
to improve effectiveness. Listening and questioning skills as
well as non verbal skills and body language will be essential
if the individual worker is to elicit a fuller picture of the
service user’s life, the context in which they exist, their
strengths and aspirations.
Practitioners must work hard to develop and use language
which instills hope and optimism.
2
Personal and people development
Assuming greater responsibility for personal development
will include a more reflective approach and ongoing
self evaluation.
Practitioners will need to develop a comprehensive
understanding (acquiring knowledge and skills) in order that
they can undertake assessments and deliver interventions
within a recovery and social inclusion framework.
31
Capabilities for inclusive practice ESC6 Identifying people’s needs and strengths
Social work (continued)
3
Health, safety and security
In order to ‘provide just enough support’ to service users,
individual practitioners will need to ensure that they operate
within work areas and practices which maintain good
health, safety and security.
4
Service improvement
There is an ever increasing body of literature which
addresses and promotes the recovery framework and
social inclusion. Individual practitioners will need to make
constructive suggestions, as a result of acquired and applied
learning in these areas and gathering feedback from those
using mental health services, in order that good practice
from elsewhere can lead to local service improvements
and developments.
5
Quality
Lack of involvement and shared decision making with
users of services leads to poor quality service delivery.
This essential shared capability demands that individual
practitioners not only work collaboratively with the service
user, rather that they equip the person to feel confident
in directing and defining their own care.
6
Equality and diversity
‘Providing just enough support’ will require individual
practitioners to value and harness the difference and
individuality of service users in order to understand,
appreciate, respect and support the choices they may
wish to make.
This review could assist the
Trust to work towards all the
Capabilities, so the following
highlights are singled out:
ESC2 deliver surgeries, support
and supervision sessions in
a range of community venues
in order to serve hard-to-help
groups.
ESC3 arrange services so that
getting help is offered in a
way that nurtures rather than
disrupts personal roles beyond
the service system.
ESC4 develop services that
assist people whenever possible
to stay at home rather than go
to hospital, leave their home
area or be detained.
ESC7 expand supported
employment, links with
education and leisure and
supported living.
ESC8 monitor social inclusion
outcomes.
ESC10 promote social
inclusion as a core value in
the organisation.
32
ESC7 Providing service
user centred care
’Negotiate achievable and meaningful goals; primarily from
the perspective of service users and their families.
Influence and seek the means to achieve these goals and
clarify the responsibilities of the people who will provide any
help that is needed, including systematically evaluating
outcomes and achievements.’
‘Identify the strengths and resources within the service
user’s wider network which have a role to play in supporting
goal achievement.’
Capabilities of an inclusive organisation/service
> Audits show that care plans are unique and support the
person to establish and maintain their life in the mainstream
community rather than offering a standard package of
service in a segregated setting.
>
The mix of disciplines, grades and individual staff skills is
arranged to ensure that health and social care needs can
be met alongside their inclusion needs (e.g. access to skilled
advice on lifelong learning as well as symptom management).
>
Commission services to: expand supported employment;
link with education and leisure providers; replace
congregate residential care with Supported Living; and
build community capacity.
Standards for better health
(core and developmental)
Governance, D5a, D6
Patient focus, D8, D9a/b, D10
Accessible and responsive
care, C17, D11a/b/c
Capabilities of an inclusive practitioner
> Work positively and creatively with the service user and their
family, including at those times when their goals are in conflict.
>
Assess the individual qualities of each community opportunity.
>
Support service users to participate in mainstream
community settings to a maximum extent as a full and
equal member of the setting.
33
Capabilities for inclusive practice ESC7 Providing service user centred care
>
Provide support to people in the community agency in
order to facilitate inclusion.
>
Assist service users to transfer from the formal support of
a mental health worker to the natural support of reciprocal
and informal relationships with people from their local
community.
>
Ensure that language is clear and accessible to service users
and carers.
>
Enable service users to articulate goals that are meaningful
to them.
Links to the core KSF dimensions
1 Communication
The practitioner will need sufficient communication skills
to liaise with a number of agencies, building on sound
working relationships in order that a smooth transition for
the service user, from mainstream mental health services
to community services is ensured.
The practitioner may need to assume role of ‘broker’ or
intermediary, requiring tact, clarity of thinking, persuasion
and diplomacy, when the aspirations and goals of the
individual service users might not be shared by their family
or social networks.
Individual practitioners will be required to constructively
manage barriers to effective communication to ensure
clarity and understanding.
34
2
Personal and people development
Practitioners will need to ‘think outside the box’, critiquing
the way they conduct their practice, identifying how
evidence-based practice could be incorporated into their
own practice and then evaluating the outcome.
3
Health, safety and security
Practitioners need to ensure that the working practices
of other services are safe in relation to the user engaging
with the community service and disengaging from mental
health services.
4
Service improvement
The greater the engagement of the practitioner with
community partners, especially those who do not
specifically provide services for mental health users, the
more successful promotion of inclusion and the broader
the spectrum of choice for the service user.
5
Quality
All practitioners must ensure rigorous evaluation of goals
and outcomes of the individual’s care plan.
Individual practitioners will need the skills and be given
the support to identify ineffective quality systems
and approaches.
6
Equality and diversity
Through the development of creative and innovative care
plans, service users’ unique needs and qualities will be
considered when accessing a range of services. Practitioners
will need to equip themselves with knowledge of the less
well known agencies and not rely on outdated knowledge
of a few tried and tested services in order that services
can match the diversity of each individual.
35
Capabilities for inclusive practice
ESC8 Making a difference
’Facilitating access to and delivering the best quality,
evidence-based, values-based health and social care
interventions to meet the needs and aspirations of service
users and their families and carers.’
‘To work in this way practitioners will need to understand
the role of evidence-based and values-based ‘best practice’
as enshrined in NICE guidance and Psychosocial Interventions
training etc.’
Standards for better health
(core and developmental)
Clinical and cost effectiveness,
C5a/c/d, D2a/d
Governance, C7a
Public health, C22c,
D13a/b/c/d
Capabilities of an inclusive organisation/service
> Staff job advertisements, job descriptions, person
specifications, Continuous Professional Development
portfolios, supervision, training and research records reveal
that the work is about health, social care and social
inclusion interventions and outcomes.
>
Track the delivery of health, social care and social inclusion
interventions and outcomes through assessment
documentation, case records, performance monitoring,
audit and service level agreements.
>
Utilise community level indicators (such as measures of
economic activity, social capital and community well-being)
in service design and monitor staff activity in relation to
work with community organisations as well as with
service users.
Capabilities of an inclusive practitioner
> Utilise a thorough knowledge of how to become involved
in community life and how relationships are built
and maintained.
>
36
In partnership with community members, conduct
reviews of inclusion arrangements and revise support
plans accordingly.
>
Understand the concepts of both social inclusion and social
capital and incorporate insights into work with service users
and community organisations (this is more likely to be
successful where the organisation recognises the importance
of community well-being).
>
Within the context of personal reflective practice, analyse
the processes and strategies used to promote inclusion and
extend personal repertoire of effective skills.
>
Recognise the healthy and inclusive elements of the service
user’s current life and help them to sustain these.
>
Collect evidence, on a regular basis, of what works for
service users and carers.
Links to the core KSF dimensions
1 Communication
Service users themselves often report that practitioners
focus on limitations and weaknesses when developing care
plans. This approach is a wasted opportunity as there is a
richness of information to be gathered from understanding
the health and inclusive elements of an individual’s current
life, their aspirations and previous successes. Practitioners
must develop a language which instills hope, engendering
optimism with all those involved in the individual’s care.
2
3
Psychiatry
During an A level psychology
class, students needed to
undertake some work to help
them understand the difficulties
associated with a diagnosis
of schizophrenia. One member
of the class happened to be
the daughter of a Consultant
Psychiatrist, who agreed to spend
two hours with the students
discussing mental health.
Contact: Lindsey.Kemp
@icc.wkent.mht.nhs.uk
This simple, everyday story
illustrates a number of inclusion
capabilities:
ESC1 Building on informal and
personal connections. Almost
every school in the area will
have parents who are employees
of the mental health service.
ESC1 Delivering mental health
Personal and people development
A repertoire of knowledge and skills will be required to
facilitate a socially inclusive approach and to ensure that
appropriate resources are accessed and that the service
user experiences optimum choice.
training – and this is especially
valuable to train young people
at a time in their lives when
risk of mental health problems
amongst their peer group is high.
Practitioners must endeavour to maintain an up-to-date
knowledge base of evidence-based interventions, NICE
Guidelines and best practice and should evaluate its
integration into their practice.
ESC3 Acknowledge the
Health, safety and security
Practitioners can contribute to the development of policies
and protocols within their service and those of other
services, ensuring they minimise risks to the health, safety
and security of service users and colleagues.
contribution made by carers,
family and friends to the recovery
process. Assisting friends to
provide informed support
provides a useful contribution
to early intervention.
37
Capabilities for inclusive practice ESC8 Making a difference
4
Service improvement
A systemic approach to the evaluation of services including
working collaboratively (such as participation on Steering
Groups, attendance at partnership meetings, working
closely with other agencies etc) will facilitate greater
cohesive service improvement.
Individuals must enable and encourage others to
understand and appreciate the influences of best practice
on the service and why improvements are made.
5
Quality
Individual practitioners will contribute to improving
quality of service provision by increasing their knowledge
and application of evidence-based interventions and
values-based practice.
6
Equality and diversity
The individual practitioner will need to be able to identify
and take action when their own or others’ behaviours
undermines equality and diversity.
The individual practitioner must be able to support
the service user who may need assistance in exercising
their rights or enabling them to make the best use of
their abilities.
When necessary, they must feel equipped to actively
challenge individual and organisational discrimination.
38
ESC9 Promoting safety
and positive risk taking
’Empowering the person to decide the level of risk they are
prepared to take within their health and safety. This includes
working with the tension between promoting safety and
positive risk-taking, including assessing and dealing with
possible risks for service users, carers, family members and
the wider public.’
‘Demonstrate and promote understanding of the factors
associated with risk or harm to self or others through violence,
self-neglect, self-harm or suicide.’
Capabilities of an inclusive organisation/service
> Adopt a positive approach to risk-taking in the delivery of
healthcare, social care and inclusion support, so that everyone
has a reasonable chance to enjoy good health, develop
skills, earn a wage and live as safely as they wish.
>
Align the organisation’s vision statement, policies and
practices on disclosure, risk, lone working and working
hours so that they support inclusive practice.
>
Align staff working hours to facilitate service users’
participation in community opportunities (e.g. support for
leisure activities during evenings and weekends rather than
just within office hours).
Standards for better health
(core and developmental)
Safety, C1a, D1
Governance, D6, D7
Care environment and
amenities, D12a/b
Capabilities of an inclusive practitioner
> Acknowledge and respond to the trauma and distress
caused by exclusion. Include ‘risk of exclusion’ in risk
assessments by ensuring that risk assessments are hopeful
rather than pessimistic, informed by the service user’s
ambitions and increase rather than decrease opportunities
for recovery and a valued lifestyle. In this way, the principle
of the ‘least restrictive alternative’ is complemented with
the principle of the ‘most inclusive alternative’.
>
Work as part of a team and be creative, flexible, innovative,
tenacious and supportive.
>
Work flexible hours as needed to support the inclusive
aspirations of service users.
39
Capabilities for inclusive practice ESC9 Promoting safety and positive risk taking
Links to the core KSF dimensions
1 Communication
Promoting and ensuring safety and the management of
risk relies on honest and open communication networks.
Individual practitioners must ensure that accurate and
complete records and communications are consistent with
legislation, policies and procedures.
They will also need to support others to make difficult
decisions.
2
Personal and people development
Individual practitioners must ensure that they have an
understanding of the factors associated with risk or harm
to self and others.
They will need to equip themselves with knowledge and
skills which will facilitate and promote a positive approach
to risk taking including developing a comprehensive
knowledge and skills base in relation to identifying and
managing risk.
3
Health, safety and security
Skills will need to be developed in identifying how best to
manage risk within the working environment.
Skills will also be required in supporting others to manage
risks more effectively.
4
Service improvement
As an effective team member, one must enable and
encourage others to alter their practice, to share achievements
(thus creating a work culture of optimism and hope) and
to challenge tradition.
Changing practice successfully relies heavily on working
increasingly closely with service users and the public.
5
Quality
It is important that the individual practitioner works
within the limits of their own competence and levels of
responsibility and accountability, referring issues beyond
these limits and consulting with other relevant people to
ensure opportunities are maximised safely for service users.
As an effective team member one can support and enable
others to problem solve and address issues.
6
40
Equality and diversity
Efforts must be made to provide a range of options, which
positively address issues of diversity, for service users to
engage in.
ESC10 Personal
development and learning
’Keeping up-to-date with changes in practice and participating
in life-long learning, personal and professional development
for one’s self and colleagues through supervision, appraisal
and reflective practice.’
‘In order to meet this capability practitioners will need a
personal/professional development plan that takes account
of their hopes and aspirations that is reviewed annually.’
Capabilities of an inclusive organisation/service
> Support staff via work/life balance, mentoring and a
positive, encouraging culture to learn and solve problems
using imagination and creativity.
>
Utilise thorough management, supervision, mentoring and
training systems to identify and meet staff development
needs so that healthcare, social care and social inclusion
needs can be met.
>
Exercise effective arm’s length management for staff
working independently in the community.
>
Promote inclusion as a core value in the organisation.
>
Assist the development of knowledge about how to support
inclusive aspirations and lifestyles of service users.
Standards for better health
(core and developmental)
Clinical and cost effectiveness,
C5b/c
Governance, C8b, C10a/b,
C11a/c, D4b/c, D7
Patient focus, C14b/c
Accessible and responsible
care, C17
Capabilities of an inclusive practitioner
> Develop several possible explanations for what is happening
in the service user’s life and reflect on these. Understand
competing definitions, philosophies and practices of
inclusion and recognise the competition between inclusion
and other viewpoints and priorities.
>
As needed, work in a wide variety of community locations
rather than just in one office or workplace.
>
Often work on a 1:1 basis with service users and with
people from community organisations.
41
Capabilities for inclusive practice ESC10 Personal development and learning
Occupational therapy
Thinkarts is a project launched
by North East London Mental
Health NHS Trust that
provides arts-related events,
projects and vocational
opportunities for people who
use mental health services,
carers and volunteers.
Individuals are supported to
form a collective of artists able
to respond to requests from
the community. Thus they link
user groups to commercial
businesses, education facilities
to charities, and mental health
projects to other groups, such
as those for refugees. Some
service users have progressed
from volunteering to being
paid for their work.
>
Engage in independent decision-making alongside
appropriate consultation with colleagues or managers and
reference to practice guidance.
>
Design personalised support arrangements for service users
that are unlike those developed for others, monitor their
effectiveness, adapt them as needed and learn from
the process.
>
Find out what works by harnessing the insight and
contribution of service users, other citizens and researchers.
Links to the core KSF dimensions
1 Communication
Individual practitioners will need to demonstrate sensitivity
in what and how they communicate with service users in
community locations. It will require an increased awareness
of how one relates to a service user or their family in a
public place.
2
Thinkarts also provides open
forums in community-based
arts venues, exhibition
visits and art projects, many
of which are run with
professional artists, poets,
signwriters and so on.
It is important that the aspirations and hopes of the
practitioner are also acknowledged.
There is a need to increase the knowledge and skills base
by learning from the unique relationship and experience
of working with service users, their communities
and colleagues.
Individual practitioners must recognise the benefits of
engaging service users in developing and improving their
personal practice by encouraging and facilitating feedback
on their performance.
(continued opposite)
3
42
Personal and people development
As a minimum, all individual practitioners must engage
in reflective practice, supervision and a development
review process.
Health, safety and security
Individual practitioners will need to ensure that they
appraise themselves of the health, safety and security issues
associated with various community locations, in order that
work with the service user takes places in the most
appropriate environment.
4
Service improvement
The experience of the service user will greatly improve if
they receive an individually tailored package of care. In
turn, being able to review and learn from the process will
improve the delivery of the broader service – sharing with
colleagues can further enhance their practice.
5
Quality
Engaging with service users and their communities lends
itself to systems working, assists the bridging of gaps
between mental health and non mental health services
and facilitates a ‘seamless’ approach.
6
Equality and diversity
Equal opportunities are about addressing representation
and balance. The practitioner will need to elicit those
personal qualities and attributes of the service user which
they want to be considered as priority in developing their
care plan and will need to address them (e.g. accessing
services for women only, engaging with services which
can accommodate those with responsibilities for children,
identifying services which can support the individual’s
cultural or religious beliefs).
Occupational therapy (continued)
Volunteers support thinkarts
by organising and setting up
exhibitions, producing design
graphics, and co-facilitating
workshops. The Serpentine
Art Gallery, public transport
services and local further
education college have been
mainstream venues for their
work. The project aims to
produce and circulate a
monthly newsletter to its
mailing list of 3000 people
and organisations.
Contact: vivienne.wheeler
@nelmht.nhs.uk
As a single project, Thinkarts
demonstrates the following
inclusion capabilities:
ESC5 promote opportunities
for service users to create
and develop friendships with
other citizens.
ESC6 value and harness the
contribution of service users
to community life.
ESC9 by providing a number
of options for involvement,
people using the service
can self-manage risks whilst
pursuing opportunities for
social inclusion and
community contribution.
43
Capabilities for inclusive practice
References
Material from other publications has been substantially re-ordered and
extended in this document, so references are not individually cited in the
body of the table, but sources are acknowledged here.
Bates, P. (ed) (2002) Working for Inclusion: Making social inclusion a reality for
people with severe mental health problems London: The Sainsbury Centre for
Mental Health
Department of Health (2007) Standards for Better Health London: DH
Department of Health (2007) Creating Capable Teams Approach (CCTA) London: DH
Department of Health (2007) New Ways of Working for Everyone London: DH
Department of Health (2006) Our health, our care, our say. London: DH
Department of Health (2004) NHS Knowledge and Skills Framework London: DH
Department of Health (2001) Mental Health Policy Implementation Guide
Department of Work and Pensions, Department of Health, Department for
Education and Skills and Office of the Deputy Prime Minister (2005) Improving
the life chances of disabled people London: Strategy Unit
Disability Discrimination Act 2005
Hope, R. (2004) The 10 Essential Shared Capabilities – A framework for the
whole of the Mental Health Workforce London: Department of Health
National Social Inclusion Programme (2005) First Annual Report
National Social Inclusion Programme (2006) Second Annual Report
National Mental Health Partnership November (2006) Promoting gender equality
and women’s mental health
Ridgway, P. and Press, A. – subsequently edited for use in England by Allott, P.
and Higginson, P. (2004) Assessing the recovery-commitment of your mental
health service: A user’s guide for the Developing Recovery Enhancing Environments
Measure (DREEM) UK Version 1
Ritchie, P., Jones, C. and Broderick, L. (2003) Ways to Work Edinburgh, SHS Ltd
Social Exclusion Unit (2004) Mental Health and Social Exclusion London: Office
of the Deputy Prime Minister
Useful websites and contacts
www.socialinclusion.org.uk www.scie.org.uk [email protected] (10 ESCs)
44
Initial framework developed by
Peter Bates National Development Team (NDT)
Naomi Hankinson National Social Inclusion Programme (NSIP).
Thanks to
John Alcock National Workforce Programme
Peter Bates National Development Team
Sarah Davenport Royal College of Psychiatrists
Sharon Dennis Royal College of Nursing
Marie Diggins Social Care Institute for Excellence
Mark Hayward British Psychological Society
Roslyn Hope National Workforce Programme
Ann Jackson Royal College of Nursing
Philip Jones Social Care Institute for Excellence
Ian McGonagle National Workforce Programme
Sona Peskin National Social Inclusion Programme
Jane Rennison North East London Mental Health Trust
Brian Rogers Mental Health Nurses Association
Trish Stokoe CSIP South West RDC
…and also to all those who contributed to the consultation.
For further information: contact Naomi Hankinson –
[email protected] or [email protected]
©Crown Copyright 2007
Capabilities for inclusive practice can also
be made available on request in Braille, on
audio cassette tape, on disk and in large
print from [email protected]
This publication is available on the websites:
www.dh.gsi.gov.uk
www.socialinclusion.org.uk
NATIONAL SOCIAL INCLUSION PROGRAMME
VISION AND
PROGRESS
SOCIAL INCLUSION AND MENTAL HEALTH
2009
TEN KEY MESSAGES
Social inclusion is about getting people back to work but it is also about wider
participation
For people with mental health problems to recover and rebuild their lives they need access to those social,
economic, educational, recreational and cultural opportunities, and physical health services, that most citizens take
for granted.
Social inclusion is not just about access
Social inclusion is not just about having access to mainstream services – it is about participation in the community, as
employees, students, volunteers, teachers, carers, parents, advisors, residents; as active citizens.
The need to work across traditional boundaries
Reducing barriers to inclusion requires integrated effort across government and non-government agencies at
all levels, horizontally and vertically, influencing policy and practice through direct links to individual experience.
Social inclusion is supported through partnership working
The whole is more than the sum of its parts. Through partnership working, organisations from all sectors can
build the bridges required to support community participation, active citizenship and build social capital.
Not just talking about serious mental health problems
Social inclusion is also a key issue for people with more common mental health problems. It is about prevention and
mental health promotion: about maintaining support, building resilience and community wellbeing.
The public sector duty is an active duty, not a passive one
Public sector duties on physical and mental health disability provide for active promotion of equality and opportunity
within the requirement to act on discrimination. Statutory measures to promote equality are key to eliminating the
barriers that exclude.
No challenge to exclusion can succeed without the full involvement of people with mental
health problems
A co-productive approach, working with people with experience of mental health problems, is essential at every level
of development and delivery.
A sense of personal identity, aside from ill health or disability, supports recovery
and inclusion
People with mental health problems are more than just a diagnosis and have valuable contributions to make,
not just needs to be met. Services should support people to access the opportunities available within the many
communities to which they belong and to make valued contributions as active citizens.
To promote inclusion we need pathways from segregated service provision into
mainstream services
Groups or activities solely for people with mental health problems may reinforce segregation unless they are
part of a supported pathway into mainstream services accessed by everyone.
Healthy workplaces are necessary to mental health and wellbeing
Stress, depression and anxiety are the cause of more working days lost than any other work-related illness.
Workplaces and learning environments should support good mental health by providing an accommodating
environment and showing a positive and enabling attitude.
CONTENTS
VISION AND PROGRESS
SOCIAL INCLUSION AND MENTAL HEALTH
1
FOREWORD
2
EXECUTIVE SUMMARY
4
INTRODUCTION
6
CHAPTER 1 COMMUNITY ENGAGEMENT
12
CHAPTER 2 EMPLOYMENT
17
CHAPTER 3 LEARNING AND SKILLS
20
CHAPTER 4 HOUSING
23
CHAPTER 5 ARTS AND CULTURE
26
CHAPTER 6 LEADERSHIP AND WORKFORCE
32
CHAPTER 7 SOCIALLY INCLUSIVE PRACTICE: THE CAPABLE
ORGANISATION AND TRANSFERABILITY OF OUR WORK
38
ANNEX A
RESEARCH AND EVIDENCE
40
ANNEX B
PUBLICATIONS AND RESOURCES
41
ANNEX C
ACKNOWLEDGEMENTS
FOREWORD
1
THIS REPORT SETS OUT THE WORK OF THE NATIONAL SOCIAL INCLUSION PROGRAMME
(NSIP) AT THE NATIONAL INSTITUTE FOR MENTAL HEALTH IN ENGLAND, FROM THE
INCEPTION OF THE PROGRAMME IN 2004 TO DATE.
NSIP has worked to implement and influence policy but with people at the centre. It has been
enormously fortunate in recruiting the willing and active participation of so many people with
passion, commitment, experience and skills from so many places and sectors over time.
Though simple in aim, thanks to the variety of systems through which we work and the richness
of the people for whom we work, inclusion is diverse in nature. In going about this work, it has
been important to resist reductionism; to reduce the complexity of individuals or the
interdependent nature of communities to a single element or objective, as part of the change
process, may achieve simplicity but it also risks an underestimation of the complexity of human
life. Our starting point was to recognise this and from it, build broad consensus of purpose. We
have tried to think and act ‘outside the box’, acknowledging the many accounts of people who
use mental health services that tell us the clinical or professional box is precisely the problem.
These narratives have continued to guide action on social inclusion throughout the programme.
We express thanks to everyone who, over the past four years, has helped us to advance our
goals. Though not surprised, we have been constantly impressed with the way people from
highly diverse backgrounds have so readily brought wide ranging experience from multiple
communities to bear, during the course of this work.
If that was our starting point, we must acknowledge that there is no finishing point. The challenge
is continuing to effect cultural change, through the transformation of thinking and services across
complex organisational boundaries. Whole person approaches demand whole system responses.
This is neither simple, nor short-term. Having been well informed by the many examples of strong
values-based practice that are incorporated in this report, we hope that we have made a good
start. We need to make sure that these often inspirational approaches are positioned to inspire
others. Locally and regionally this is an agenda that needs to be led for the long haul, ensuring
that progress is sustained and shared through innovation in learning and evidence in practice.
As an issue of social justice, inclusion in mental health remains a moral imperative. Though this is
work in progress for the wider inclusion community, the people who individually and collectively
have contributed to our work have set a compass for its achievement.
David Morris
Programme Director
EXECUTIVE SUMMARY
THE NATIONAL SOCIAL INCLUSION PROGRAMME
HAS ALWAYS SOUGHT TO ENSURE THAT THE SOCIAL
INCLUSION AGENDA FOR PEOPLE WITH MENTAL
HEALTH PROBLEMS TAKES ACCOUNT OF THE MANY
AREAS OF LIFE ON WHICH EXCLUSION IMPACTS.
2
In 2004, the Social Exclusion Unit’s report set out what
needed to be done to address mental health and social
exclusion. This Vision and Progress report takes stock of
the progress we have made and addresses new and
future challenges in seven key areas.
COMMUNITY ENGAGEMENT
Social inclusion is not just about having access to
mainstream services but about active participation
in the community, as employees, students, volunteers,
teachers, carers, parents, advisors and residents.
We have:
Encouraged day services to be ambitious, to act not
just as a window on to mainstream communities but
as a bridge, whilst still providing a place for people to
feel safe and be mutually supportive.
Helped increase the number of people using
Direct Payments in lieu of mental health services,
resulting in more people now having greater choice
and control over the way in which they receive
services and support.
Highlighted the importance of adult mental health
services recognising people’s parenting roles and that
young people can be carers too. Joint working across
children’s and adults’ mental health services has
helped build the impetus to support joined-up
thinking and approaches at a national level.
Established the ‘Communities of Influence’
programme which enables Foundation Trusts
to engage and lead their governors and members
to build the community capacity needed to
strengthen socially inclusive outcomes for people
using their services.
EMPLOYMENT
Welfare systems can act as an enabler or be a barrier
to inclusion, and stress, depression and anxiety are the
cause of more lost working days than any other
work-related illness. Workplaces and employers should
support good mental health by providing an
accommodating environment and showing a positive
and enabling attitude. We have:
Helped to increase employment opportunities for
people with mental health problems. This includes
the publication of commissioning guidance on
vocational rehabilitation and feeding in to ‘Reaching
Out: An Action Plan on Social Exclusion’ which
led to the establishing of nine Regional Employment
Teams (RETs).
3
Worked with Department of Health, Department for
Work and Pensions and Cabinet Office colleagues on
delivery plans for the Public Service Agreement (PSA)
16 and its implementation.
Increased support for employers, such as:
establishing and hosting of the Employer Engagement
Network; ensuring that the RET initiative increases
organisational capacity at a regional level to deliver
current strategies and support stakeholders.
Developed good working partnerships with a number
of national arts bodies to raise awareness of: social
inclusion and mental health; arts organisations as
employers of people with mental health problems;
and the need for staff training.
LEADERSHIP AND WORKFORCE
Developed a mental health awareness training
package for trade union representatives.
Organisations, teams and individuals sometimes require
guidance, support and leadership to strengthen their
capacity for socially inclusive practice. High aspirations,
organisational support and a ‘can-do’ attitude are key to
improving social inclusion outcomes. We have:
EDUCATION AND SKILLS
Undertaken the Delivering Effective Local Leadership
for Social Inclusion (DELLSI) initiative.
Education, learning and skills are all important in their
own right and can act as a pathway to potential
employment. We have:
Supported the Partnership Programme which has
changed the climate of support for learners
with mental health problems and has consistently
advocated for them at a strategic level.
Contributed to the 2008 follow-up to the Learning
and Skills Council’s 2006 strategy, providing a
renewed vision to promote the social and economic
inclusion of people with mental health problems
through improved access to, and success in, learning
and skills.
HOUSING
Housing is central to providing a stable base from which
people can seek and make the most of socially inclusive
opportunities. We have:
Established the Housing Reference Group which
provides advice, and shares and coordinates
information on new policy developments.
Worked with the Department of Health, Communities
and Local Government and the Cabinet Office on the
development and implementation of the new Public
Service Agreement (PSA) 16.
ARTS AND CULTURE
Participation in the arts and cultural activity can give
people a positive alternative identity to that of ‘service
user’ and help them to be part of the wider community
by increasing self-esteem, confidence and social
networks. We have:
Contributed to research to better understand the
benefits of taking part in arts projects for people with
mental health problems, resulting in a government
working group on arts and health.
Established a commissioning network for social
inclusion to support effective commissioning practice.
Worked closely with four Expert Advisors who
have experience of mental health problems and a
Reference Group of people with mental health
problems and carers to ensure social inclusion
practice is developed in a co-productive way.
SOCIALLY INCLUSIVE PRACTICE: THE CAPABLE
WORKFORCE AND TRANSFERABILITY OF OUR WORK
Both individual and organisational capabilities are
required if socially inclusive practice is to be embedded
and sustained. There is considerable potential for
applying lessons learned in the mental health domain to
other efforts to address social exclusion.
Strong leadership is needed to ensure change within
and beyond services and to sustain best practice.
Social inclusion requires an overarching view of policy,
funding and implementation that cuts across a range
of sectors including employment, communities,
housing, learning and skills, and civic responsibilities.
The potential for synergy across other client groups
needs to be realised.
INTRODUCTION
“HAVING BEEN A SERVICE USER FOR 18 YEARS
I HAVE BEEN SOCIALLY EXCLUDED FROM SO MUCH
BY THE MERE FACT THAT I HAVE A MENTAL
ILLNESS. WHILST MANY OF THESE EXCLUSIONS
REMAIN, I HAVE BEEN EMPOWERED TO TRY
TO ENSURE THAT FURTHER EXCLUSIONS ARE NOT
PLACED UPON PEOPLE LIKE ME.” 1
4
‘Vision and Progress: Social Inclusion and Mental Health’
sets out the achievements of the National Social Inclusion
Programme (NSIP) since the 2004 ‘Mental Health and
Social Exclusion’ report by the Social Exclusion Unit
(SEU).2 It recognises the commitment and hard work of the
team (past and present), its Expert Advisors and
Reference Group, as well as all those partner organisations
who have contributed to these achievements.
This report reviews the last four years in light of our
activity at national, regional and local level. It highlights
the progress that has been made across the statutory
and non-statutory sectors and highlights the additional
value of work beyond our formal remit; work that has
sought to reach out to non-traditional services and
partners to champion the social inclusion agenda in
sometimes unfamiliar areas.
It also provides an assessment of the remaining and
continuing challenges that need to be addressed for
improved outcomes for people with mental health
problems. This is based on feedback from national and
regional social inclusion leads across mental health
and health services, local authorities and regional bodies,
as well as information gathered through an analysis
of progress and gaps with provider organisations at a
local level.
This report is intended to be a further resource for
policy makers, regional agencies and services to ensure
that this important work is sustained and developed in
the future.
BACKGROUND TO THE NATIONAL SOCIAL INCLUSION
PROGRAMME
NSIP is a programme within the National Institute for
Mental Health in England (NIMHE) as part of the Care
Services Improvement Partnership (CSIP) and it has
often taken a high level and strategic cross-government
role. The programme’s original remit was to coordinate
the implementation of the SEU report. More than
20 government departments and a range of external
agencies have worked together with NSIP to
successfully implement the report’s 27 cross-cutting
action points. However, NSIP’s work has highlighted how
complex the reality of this really is. Due to the multiplicity
and diversity of the wide number of agencies at all levels,
there still remains work to be done locally and nationally
to ensure that individuals and services are maximising
opportunities for social inclusion.
Effective inclusion will contribute significantly to reducing
discrimination, and NSIP has worked closely with Shift,
a five-year programme to tackle stigma and
5
discrimination (and responsible for action points 1– 4 in
the SEU report) by working in partnership on aspects of
the employment agenda, having co-terminus locations
and shared expert advice.
In 2006, the Cabinet Office invited NSIP to contribute to
the development of the Social Exclusion Action Plan 3
which led to our overseeing the creation of dedicated
regional employment teams (RETs) to provide further
support for the implementation of good practice on the
employment of people with severe mental health problems.
The programme has also worked with the Cabinet Office
in developing and implementing the Public Service
Agreement (PSA) 16 on employment and settled
accommodation outcomes for people with severe and
enduring mental health problems, supporting action to
ensure that the PSA drives change at local level.
THE NSIP APPROACH
When NSIP was first established, its primary function
was to implement policy. We have however, ensured this
implementation is linked back in to further policy
development. Our focus is therefore on both what it
takes to turn policy into practice and reality on the
ground and also on policy development and regulatory
frameworks which support positive outcomes. Over the
course of the past four years, we have contributed to the
development and delivery of a wide range of policy, using
the expertise in the team and our co-productive
working approach to establish a broad understanding of
what ‘good’ policy looks like from a social inclusion
perspective and how it can work effectively to promote
the core aims of social inclusion.
As part of NIMHE, NSIP is also connected to the
Department of Health. We have brought together a
breadth of skills and expertise in mental health and social
inclusion, as well as political and strategic experience.
Our small central team comprises secondees drawn
from across government, including the Department for
Work and Pensions, the Department for Innovation,
Universities and Skills, Communities and Local
Government and the Cabinet Office.
Central team members and regional colleagues from
NIMHE/CSIP development centres have worked
together as equal partners in the national programme
and this has allowed the team to become a hub of
expertise through which ideas and action have
influenced emerging policy. This is turn has enabled the
inclusion agenda to be embedded across life domains in
a way that addresses the needs of the most excluded.
The network of regional social inclusion leads has also
brought an in-depth understanding of regional priorities
and pressures. They have identified good practice and
accelerated policy implementation by helping us to
translate policy into practice for services and individuals
at regional and local level.
The team also includes people from both the voluntary
sector and professional bodies to ensure that our
focus is on the most important and influential areas of
policy and that staff working in the sector have resources
and information to help inform improved practice on
social inclusion.
We operate in a co-productive way, ensuring that our work
is informed by people who use services themselves, and
carers. The Expert Advisors are a small group who work
with NSIP to ensure the involvement of people with mental
health problems is maximised across the programme.
They also advise on the direction of certain initiatives and
provide specific expertise on a range of inclusion areas,
including day services, arts, education and employment.
“I find that much of the knowledge, skills and perspective
I have acquired at the national programme around policy,
strategy, new ways of thinking and good practice have
motivated and inspired me to constantly look for
opportunities to implement and develop the values and
principles of NSIP.” 4
The Reference Group is a wider network of people who
use mental health services and carers. It represents
people with interests that span the inclusion agenda from
all regions across England. Their role is to provide updates
from regional and local perspectives, disseminate national
messages and respond to government consultations so
that people can influence the services they receive.
We have also enabled richly diverse partners to come
together through extensive arrangements for joint
programme work with over 50 affiliated voluntary,
academic and professional body organisations. These
have committed funding and resources to the
programme, without which our successes would not be
so many or varied.
The following chapters consider the impact that NSIP
has had in a range of social inclusion policy areas. They
highlight the considerable progress already made, what
the remaining challenges are and what more needs to be
done both now and in the future.
1 NSIP Expert Advisor
2 Office of the Deputy Prime Minister, 2004, Mental Health and Social Exclusion,
Social Exclusion Unit.
3 Cabinet Office, 2006, Reaching Out: An Action Plan on Social Exclusion.
4 NSIP Expert Advisor
CHAPTER 1
6
COMMUNITY ENGAGEMENT
VISION
People need to engage with the wide range of communities
that they rely on for their incomes, social support, selfexpression and sense of continuity; these include communities
of place (neighbourhoods), common interest, and the major
life domains such as employment, education and housing.
For this to be successful, services and opportunities
need to be accessible, well organised, stable and secure.
Our vision is that:
Everyone is supported to access the opportunities available
within the many communities to which they belong.
Everyone understands and appreciates the mutual benefits
of contributions made by people with mental health problems
towards creating and sustaining a positive community.
Mental health services will work with individuals and
communities to promote active civic participation and
effective social support.
There will be equal opportunities for active citizenship,
increased social capital and less unwanted service
dependency.
7
PROGRESS SINCE 2004
This chapter sets out the progress that has been made
in implementing and developing policies to reduce
disadvantage in the areas detailed below. It also set out
how the process of removing the barriers that inhibit
people with mental health problems from achieving a
stable base in life has been developed.
DAY SERVICES
Day services have played a valuable role for many people
with mental health problems. They provide a place
to go, people to see and something to do. However,
they have often not been successful at reaching a wide
range of people or enabling them to move on and
access resources beyond mental health services.
Many services, which have historically provided both
segregated activities and a safe social environment, are
now focused much more on supporting people to
engage with their local community and the resources
and activities within it. This means that the term ‘day
services’ has become somewhat misleading as activities
may take place in the evenings as well as during the day,
and are often very different in nature from those that
people expect a day service to offer. Indeed many day
services have re-named themselves as ‘community
support’ or ‘community resource’ services in recognition
of their changed role.
NSIP has led the work on modernisation of day services
with the publication, in February 2006,5 of
commissioning guidance on day services for people with
mental health problems. It sets out the components that
a modernised day service could incorporate and
explained how commissioners could work towards them.
This guidance was linked to the Department of Health
publication ‘Supporting Women into the Mainstream’. 6
Eighteen months later a review of services 7 was carried
out to provide a snapshot of progress against the criteria
in the commissioning guidance. The review identified
where improvement had been made, highlighted
common issues and the approaches to addressing them
and provided examples of good practice.
“Having more things in my life has given me the reason
to be more independent.” 8
So far, the modernisation agenda has been primarily
focused on resources for providers and commissioners.
In response, NSIP produced ‘How will my newly
redesigned day service help me?’ 9 a booklet specifically
for people using day services that are facing changes to
how they are run.
Day services have also been concerned with working out
how to measure and demonstrate socially inclusive
outcomes. To address this we produced a Day Services
Outcomes Framework .10 Reflecting the different life
domains and functions of mental health day services, it
aims to help commissioners and providers to monitor,
evaluate and measure the effectiveness of services for
people with mental health problems using a number of
indicators. The framework was tested in several day
services across England during 2008. As a result of this
work, and responding to proposals that the framework
be widened out beyond day services,11 we have
identified the need for an outcome measurement tool,
which is currently in development and which will be
published in spring 2009.
In providing leadership on day services modernisation,
NSIP has promoted a role for services to facilitate peer
support for others who have shared similar experiences.
We have encouraged the development of user-run day
services and the use of peer support and co-productive
approaches in day service delivery.
blueSCI
blueSCI, Trafford, is an arts and cultural centre that
addresses segregation by opening its doors to a range
of mainstream organisations and the general public.
Alongside blueSCI’s reception sits a well-equipped
internet café, which is open to everyone in the
local community to use. By arrangement, anyone can
also use the professionally equipped music studio
downstairs. The inclusive approach at blueSCI
extends to mainstream local organisations as well,
with several partners including Jobcentre Plus,
Trafford College and a local housing association.
In addition to this, a wide range of community
organisations regularly run sessions within the building.
www.bluesci.org.uk
However, challenges within the modernisation agenda
remain. Anxiety about change is common amongst
people who use services but it is also felt by day services
staff themselves and provider organisations. It can
sometimes be difficult for services to develop a more
appropriate balance of provision that involves both peer
support and support to engage with wider communities.
This is particularly challenging if commissioners and
providers are not assisted to achieve this goal. Many
have felt isolated and value contact with others who
have shared some of their experiences and from whom
they can learn.
CHAPTER 1 COMMUNITY ENGAGEMENT
In order to address this, we have established a Day
Services Modernisation Network. This collaboration, the
first in which large voluntary sector agencies have
worked together on this agenda, brings together
Rethink, Richmond Fellowship and Mind with NSIP, to
provide a discussion and learning forum on day services
modernisation for senior managers in voluntary and
statutory sector provider and commissioning
organisations. A further learning and information network
has been put in place to support the dissemination
of key messages and resources. This wider network
comprises some 600 people working on day service
modernisation, including more than 80 commissioners.
DIRECT PAYMENTS AND PERSONALISATION
Direct Payments are known to offer people with mental
health problems greater flexibility about their own
support arrangements and the means by which they can
be met. In particular, Direct Payments can enable them
to more easily access mainstream services, helping to
promote independence and greater inclusion in local
communities by offering opportunities for employment,
education and leisure. However, take up in previous
years has been low (see below).
The SEU report 12 recognised that giving people greater
choice and control over the way in which they received
services and support, particularly through the
mechanism of Direct Payments, was an important way
to combat exclusion. In response to this, NSIP oversaw
the development and publication of ‘Direct payments for
people with mental health problems: A guide to action’ in
February 2006.13 It set out good practice in making
Direct Payments more accessible to people with mental
health problems and encouraged local authorities,
PCTs, mental health trusts and non-statutory providers
of mental health services to make Direct Payments a
standard option within mental health services.
This was then followed by an additional publication,14
which set out specific information for people eligible to
use mental health services, and carers. It was compiled
with the support of people and organisations involved in
mental health services and a wide range of Direct
Payments activity. NSIP has also been involved
in training and development activity at more than 40
training events and forums including people who use
mental health services, carers, Direct Payments support
staff and commissioners.
“More than anything Direct Payments has given
me choices and has helped no end with social inclusion.
My companion has introduced me to new friends and
8
I am finding it far easier to socialise with people,
my family have also noticed that my social skills are
improving all of the time. I would not hesitate in
recommending Direct Payments to other service users,
Direct Payments opens doors and improves lives.” 15
Over the past four years there has been a sustained
increase in the numbers of people using Direct Payments
in lieu of mental health services. The most recent
figures for March 2008 16 show a 62% increase over the
previous year taking the number to a total of 3,373,
with only four local authorities not making any payments.
This compares very favourably to the 520 made at
September 2004, when one-third of all local authorities
in England were not making any. The findings from the
recent Individual Budgets pilots 17 have shown that
people with mental health problems had the greatest
increases in both social care and psychological wellbeing
outcomes, with 71% choosing Direct Payments as the
way to manage their money.
‘IS IT FOR ME?’ AND ‘I’LL GIVE IT A GO’
The ‘Is it for Me?’ and ‘I’ll give it a go’ project
combines basic skills learning with the opportunity
to consider Direct Payments as a support option.
This training resource is now being disseminated
nationally. It recognises the importance of
Direct Payments as a means of developing ‘selfdirected support’ and thereby reflects the significance
of Direct Payments as a contribution to policy
developments in ‘personalisation’.
The Department of Health has indicated that it considers
mental health services to be suitable for initial work on
Personal Health Budgets. NSIP is already working with
the related ‘Staying in Control’ initiative that provides
support to the PCTs and local authorities which have
selected mental health as an area for the introduction of
Personal Health Budgets alongside social care Personal
Budgets.
Integrating our work on Direct Payments within the
Department of Health’s personalisation agenda has led
to a range of initiatives, notably the production of a guide
to implementation of Personal Budgets within mental
health services, and to support this a DVD reflecting the
experiences of those using Personal Budgets in mental
health. Also, in partnership with the North West
development centre and ‘In Control’ (a national
programme to increase the control exercised by people
who need support over their own lives and fulfil their
9
roles as citizens) we developed and now maintain the
national mental health and personalisation group. NSIP’s
employment, housing and personalisation policy leads
have worked with ‘In Control’ as part of the broader
discussion on how best to achieve integration of work on
personalisation with that of inclusion.
Additionally, NSIP has played an important role in
reviewing the exclusion criteria for Direct Payments,
including those that relate to certain sections
under the Mental Health Act. This issue has recently
been consulted upon and the findings are due to be
published in 2009.
However, some challenges remain. The roll out of
Individual Budgets should take account of the lessons
learned from the implementation of Direct Payments for
people with mental health problems, otherwise the risk
is that their low take up will be repeated and people with
mental health problems will be further excluded.
The personalisation agenda should work to ensure
that support is available to enable people with mental
health problems to exercise more choice and experience
greater dignity.
FAMILIES AND CARERS
Parental mental health problems can have a significant
impact on families, both in terms of a parent’s wellbeing
and family life overall.
The ‘Action 16’ steering group was set up to oversee the
implementation of action 16 of the SEU report 18 and was
jointly led by NSIP and the Social Care Institute of
Excellence (SCIE). Its broad membership included a
range of government departments, voluntary and third
sector organisations and PCTs. The group modelled joint
working across children’s and adults’ services and
helped build the impetus to support joined-up thinking
and approaches at a national level. The cross-cutting
nature of social inclusion policy supported this approach
and the diverse, informed membership combined the
skills and the overview necessary to bridge the divide
between children’s and adults’ policy and services.
It also provided a mechanism for reducing duplication
and adding value to other work streams, including the
Care Programme Approach review.19
The relationship with SCIE has also been of critical
importance. SCIE led the three-year research and
development programme on parental mental health and
child welfare, now nearing completion with the
production of cross-cutting health and social care
practice guidance due for publication spring 2009.
PARENTS IN HOSPITAL
This review of contact arrangements between parents
in mental health settings and their children identifies
the need to improve visiting arrangements
and facilities, and the support offered to parents.
The findings draw on data from Mental Health Act
Commission visits, hospital staff and importantly,
parents and children themselves.
www.barnardos.org.uk
NSIP also contributed to the Cabinet Office’s crossgovernment Families at Risk Review,20 which found that
families often do not get the most effective support when
they need it most and that when parents face a number
of difficulties in their own lives, such as mental health
problems, the impact for both themselves and for their
children can be severe and enduring.
“You want your mum when she’s ill, especially when
you’re just a kid.” 21
The experience of the ‘Action 16’ partnership shows us
that involving children, young people and their parents
who ‘tell it like it is’ is crucial to understanding the needs
of families, identifying service improvement issues and
motivating and raising awareness amongst providers and
policy makers. The challenge to services is fundamentally
one of listening actively to the stories and experiences of
all family members including children and young people.
TRANSPORT
Without appropriate and accessible transport people
with mental health problems are at risk of being further
excluded from a range of community opportunities.
The early implementation phase of the SEU report 22 has
seen mental health included within the 2004 Department
for Transport’s ‘Technical Guidance on Accessibility
Planning in Local Transport Plans’. In response, Local
Transport Authorities (LTAs) included accessibility
strategies within their Local Transport Plans in March
2006. Regionally, good practice has been identified in
the West Midlands by the CENTRO authority area
(Birmingham, Solihull, Coventry, Walsall, Wolverhampton,
Sandwell and Dudley).
A review of concessionary travel has also been
undertaken by the Department for Transport resulting in
the Concessionary Bus Travel Act 2007 23 and
accompanying guidance.24 However, further work needs
to be carried out in relation to the review to ensure
greater consistency in embedding the eligibility criteria
CHAPTER 1 COMMUNITY ENGAGEMENT
across all local authorities so that people with mental
health problems are not further excluded.
‘ALL ABOARD’ PROJECT
The ‘All Aboard’ project with Birmingham and Solihull
Mental Health NHS Foundation Trust has
incorporated the development of a DVD for train and
bus drivers, information road shows at Trust locations
and work with Community Safety Teams. People with
mental health problems were identified as a target
group to benefit from the Accessibility Plan (by
focusing on the needs of those using mental health
facilities) and addressing these specific needs within
the Local Transport Plan.
At a local level, we also recognise that more needs to be
done so that services can develop and maintain
partnerships with travel providers to ensure that the right
information about public transport is available and that
any future policy development does not impact
negatively on people with mental health problems.
CIVIC PARTICIPATION
Civic participation is key to enabling people to engage
within their own community. With Communities and
Local Government (and previously the Home Office)
identifying community engagement as a priority, it has
been essential to ensure that the policy development
process represents the needs of people who are on the
margins of active citizenship. NSIP worked with these
departments, the (then) Disability Rights Commission
and organisations such as RADAR to ensure the
inclusion of people otherwise excluded because of
discrimination from civic opportunities. As a result,
‘Together We Can’, the government strategy on
community engagement now addresses the risk of
people with mental health problems being excluded from
local civic structures. NSIP has continued to influence
the preparatory processes behind the forthcoming
Community Empowerment Bill.
Following identification by the SEU of certain institutional
areas of civic participation from which people with
mental health problems were being systematically
excluded, such as jury service and school governance,
NSIP has worked with relevant agencies to pursue the
removal of constitutional barriers. This includes
contributing to the development of a consultation on jury
service eligibility criteria (publication expected 2009).
We have also seen the revision of school governance
regulations which clarify the disqualification criteria on
10
mental health grounds. This has been published on
GovernorNet 25 but more needs to be done to raise
awareness of the revision with Local Education Authorities
and to promote the positive contribution that people with
mental health problems can make to civic institutions.
CRIMINAL JUSTICE SYSTEM
NSIP has overseen the completion of several of the
criminal justice action points from the SEU report
but there have been many challenges in this area which
have impacted on the successful implementation of
these action points such as the mental health awareness
training for probation and police officers. These
challenges include the division of duties between the
Home Office and Ministry of Justice in May 2007, the
merging of strategy across prison health, offender health
and community pathways throughout 2007/08 and the
amalgamation of the police training organisation
CENTREX with the National Police Improvement Agency.
Furthermore, the Bradley Review, on the treatment of
people with severe mental health problems in the
criminal justice system (expected spring 2009), is likely to
set a new strategic direction. This should provide the
opportunity for those working in criminal justice agencies
to become knowledgeable of the needs of people with
mental health problems and how to respond to them.
‘COMMUNITIES OF INFLUENCE’ PROGRAMME
“The Communities of Influence programme has been a
shared journey of discovery with other Trusts.” 26
The creation of Mental Health Foundation Trusts
provided different opportunities for influencing social
inclusion outcomes across trusts and communities.
This is a result of constitutional changes to allow for the
appointment of governors and members from wider
mainstream community audiences. In response, NSIP
has created the ‘Communities of Influence’ programme
in partnership with the Pacesetters programme in the
Department of Health’s Equalities and Human Rights
Group and the University of Central Lancashire (UCLan).
The programme seeks to enable Foundation Trusts to
engage with and lead their governors and members in
building the capacity of mainstream organisations
required to strengthen socially inclusive outcomes.
It involves trusts enabling their local communities to
become effective in securing and sustaining the social
inclusion of their fellow citizens with significant mental
health problems. There are currently 14 Foundation
Trusts in the practice network within ‘Communities
of Influence’.
11
The project, running initially until April 2009, consists of
an action learning set, followed by a series of trustbased development activities to identify and share
innovative practice, tailored to each site. A final national
conference in April will review what has been achieved
and showcase how social inclusion and community
engagement plans are to be embedded into the Trusts’
corporate goals.
CONCLUSION AND PROPOSED FUTURE ACTION
NSIP’s day service modernisation networks represent the
most comprehensive picture of mental health day
services and the most effective context for supporting
the development, available. It is important that they
are supported to continue to provide a platform for
shared learning and the modernisation agenda.
Commissioners and providers sometimes struggle at a
local level to make the necessary changes to day
services, and there is very little in the way of expert
support available to help them do this. Hands on support
in relation to both the modernisation process and the
development of modernised services would be
welcomed and would help increase the chances of
effective change happening. There is also a need for
research into the new approaches to delivering day
services to demonstrate their effectiveness and
the outcomes achieved.
The revised social inclusion outcome framework and
the accompanying outcome measurement tool will give
commissioners and providers the opportunity to use and
embed it within service specifications and contracts
across and beyond the range of mental health services.
There is the potential for findings to be pooled and
compared to provide benchmarking data, but this would
require the allocation of necessary resource.
27
Identification and assessment processes of parental and
family support have improved and many innovative
arrangements between services are being developed to
help to ensure better access support for affected
families. However, this is challenging, as working across
systems can be complex so we recommend that this
area of policy remains a priority for future activity.
NSIP has worked across departmental boundaries to
promote systems and practices through which people
with mental health problems can participate and
contribute equitably as active citizens to the civic life of
their community. We have tried to do this by influencing
the development of policy beyond mental health so that
it connects appropriately back to it. As localisation
and the empowerment of diverse communities become
more central to government policy, so the development
of inclusion practice will need to reflect and inform
that policy, promoting and connecting inclusive
communities with scope for active citizenship and
progressive social networks.
To support the development of community engagement
by participating Foundation Trusts, a certificate course in
Community Engagement, Mental Health and Social
Inclusion will be developed at UCLan for governors,
members and relevant staff in Foundation Trusts who join
the ‘Communities of Influence’ network.
5 Department of Health, 2006, From segregation to inclusion: Commissioning
guidance on day services for people with mental health problems.
6 Department of Health, 2006, Supporting Women into the Mainstream:
Commissioning Women-only Community Day Services.
7 Department of Health, 2008, From segregation to inclusion: where are we now?
A review of progress towards the implementation of the mental health day services
commissioning guidance.
8 NSIP, 2008, How will my newly redesigned day service help me?
socialinclusion.org.uk/publications/DayServicesLeaflet.pdf
9 Ibid.
10 NSIP, 2007, Outcomes Framework for Mental Health Day Services.
socialinclusion.org.uk/publications/DSdoccover.1.pdf)
11 NSIP, 2009, Outcomes Framework for Mental Health Services.
www.socialinclusion.org.uk/home/index.php
12 Social Exclusion Unit, op. cit., 2004.
13 Department of Health, 2006, Direct payments for people with mental health
problems: A guide to action.
14 Department of Health, 2006, An introduction to direct payments in mental health
services: Information for people eligible to use mental health services and carers.
15 Ibid.
16 Commission for Social Care Inspectorate, 2009, The state of social care in
England 2007–08.
17 Individual Budgets Evaluation Network (IBSEN), 2008, Evaluation of the Individual
Budgets Pilot Programme Final Report. The copyright is held by Social Policy
Research Unit, University of York.
18 Social Exclusion Unit, op. cit., 2004.
19 Department of Health, 2008, Refocusing the Care Programme Approach: Policy
and Positive Practice Guidance.
20 Cabinet Office, 2007, Reaching out: Think Family.
21 Barnardos, 2007, Parents in Hospital: How mental health services can best provide
family contact when a parent is in hospital.
22 Social Exclusion Unit op. cit., 2004.
23 Department for Transport, 2007, Concessionary Bus Travel Act 2007.
24 Department for Transport, 2008, Guidance for local authorities on eligibility for
disabled people.
25 www.governornet.co.uk
26 Leeds Partnership NHS Foundation Trust
27 NSIP, op. cit., 2009
CHAPTER 2
12
EMPLOYMENT
VISION
Everybody should be helped to be the best they can and those
who want, and are able, to work should receive the right support
to achieve their employment aspirations. Our vision is that:
Employers are supported to feel confident in recruiting
and retaining people with mental health problems and
recognise the commercial benefits of promoting mentally
healthy workplaces.
Employers have positive attitudes and high expectations of
what people can do, rather than focusing on what people
cannot do.
It is recognised that people with mental health problems
are just as capable as other employees and can effectively
contribute to business objectives.
Robust local mechanisms and partnerships support
individuals to consider and prepare for work and improve
their access to employment opportunities.
Strong links exist between employment and both
volunteering and learning and skills as important steps to
obtaining and sustaining employment.
13
PROGRESS SINCE 2004
“Work helped me to piece my life back together again.” 28
Most people with mental health problems want to work 29
and with the right support, many more would be able to
achieve their employment aspirations. There is strong
evidence 30 to suggest that a job or another form of
occupation is highly effective in improving wellbeing
and social inclusion.
COMMISSIONING GUIDANCE
In response to the SEU report,31 NSIP has published
commissioning guidance on vocational services for
people with severe mental health problems.32 It highlights
how important being in work is in both maintaining good
mental health and promoting the recovery and wellbeing
of those who have experienced mental health problems.
The guidance provides a framework on how to
commission evidence-based vocational services and
highlights tools for monitoring the effectiveness of such
services. It also includes methods that successfully
address the employment needs of people with severe
mental health problems, one of which is the ‘Individual
Placement and Support’ (IPS) model.
INDIVIDUAL PLACEMENT AND SUPPORT
The ‘Individual Placement and Support’ (IPS) model is
based on joining up services in order to deliver tailored
support. The approach involves assessing a person’s
vocational skills and preferences relatively quickly and
then placing them in employment settings that are
consistent with their abilities and interests and where
they can develop their skills in the work environment
whilst getting ongoing support. If needed, support is
also given to the employer and individual in the
workplace to ensure maintenance of the placement.
At a regional level, we have delivered a number of
workshops on the commissioning guidance to a broad
range of practitioners working in employment and mental
health services. They focused on progress since the
guidance was published, resolving tensions and
developing regional strategies to meet the vocational
needs of people with mental health problems. The
workshops stimulated the formation of local networks
where improvement targets can be set and monitored
over time, and have helped staff to clarify local service
delivery chains. This has led to improved employment
outcomes, the development of local action plans and a
reallocation of resources into the employment agenda.
To further demonstrate how to develop effective
vocational services we have also published ‘Finding and
Keeping Work’,33 to support positive employment
outcomes for people with mental health problems.
DEVELOPING EMPLOYMENT POLICY
Nationally, NSIP has supported a number of strategic
developments on mental health and employment. This
includes supporting the Department of Health and the
Cabinet Office on development of the Public Service
Agreement (PSA) 16, which sets out a direction of travel
for increasing the proportion of socially excluded adults
in settled accommodation and employment. The national
level indicator 150 34 is the proportion of adults in
contact with secondary mental health services who are
in employment. PSA 16 in relation to housing is also
discussed in Chapter 4.
NSIP has worked with government colleagues on the
response to Dame Carol Black’s report ‘Working for a
healthier tomorrow’ 35 and supported the development of
the National Mental Health and Employment Strategy 36
(due spring 2009). We have also helped to establish the
cross-government group on mental health and
employment to which subsequently we have made
significant contributions. Key aspects of this work involve
effecting cultural change on mental health and
employment, increasing awareness and take up of
available services and improving training for a broad range
of intermediaries and organisations. To achieve this we
have developed several training resources, including one
for intermediaries on how to best work with employers on
mental health problems, as well as resources for line
managers and for trade union representatives.
REGIONAL EMPLOYMENT TEAMS (RETS)
In 2006 the Cabinet Office published ‘Reaching Out:
An Action Plan on Social Exclusion’ 37 which outlined the
government’s strategy for targeting effective help at the
most excluded groups in society. Working through an
NSIP secondee to the Prime Minister’s Strategy Unit,
we supported development of action point 23,38 on
improving employment outcomes for people with severe
mental health problems through developing dedicated
regional employment teams (RETs) to promote good
practice and have since been responsible for
establishing and leading these teams. These nine RETs
over the ensuing two years, have formed partnerships
that encourage a coordinated and coherent effort among
key regional stakeholders such as Jobcentre Plus,
Government Offices, Regional Development Agencies
and Learning and Skills Councils, as well as health
professionals and the voluntary sector. A significant
CHAPTER 2 EMPLOYMENT
aspect of this effort has entailed working with localities to
improve employment outcomes with a particular focus
on supporting the mental health employment target in
PSA 16. To date, this has been effectively achieved;
improved practice being promoted by more effective
joined-up working between partners.
RETs have also supported local authorities to do more to
advance employment opportunities for people with
mental health problems with a particular emphasis on
those districts that have adopted National Indicator 150.
Activities undertaken by the regional partnerships
include:
Working strategically within partnerships to raise
awareness of the need to deliver holistic services.
Building capacity in health systems to deliver
increased employment opportunities.
Supporting and promoting activity that allows
individuals to increase capacity for obtaining and
retaining employment, such as the development of
structured volunteering arrangements.
Working to reduce stigma and discrimination,
especially in the workplace setting, such as
supporting the expansion of Mindful Employer 39 and
Shift’s ‘Line Managers’ web resource’.40
Promoting activity aimed at maintaining a mentally
healthy workforce. This includes supporting the
increase in people being trained on Mental Health
First Aid 41 and supporting the expansion of
recommended frameworks such as the Health and
Safety Executive ‘Stress Management’ standards.42
In addition to exploring links between national policies
and regional and local actions to overcome barriers, the
RETs have also looked at how best to influence existing
and developing policies and strategies, such as the City
Strategy Initiative,43 the roll out of Pathways to Work and
Increasing Access to Psychological Therapies.44
EMPLOYERS
“A successful return to work following an episode of
mental illness is possible, but it has to be managed well
– long-term recovery is not an accident. Good employers
will take ‘return to work’ practice seriously and
encourage a staged and supportive – even protected
return to work. Part-time work, for a time can be a
wonderful investment for long-term good health.” 45
In addition to our high level strategic work on
employment, we have also been working closely to
14
support employers and raise awareness and
understanding of mental health in the workplace by
developing and delivering, for example, a training
package for trade union representatives. We have
established an Employer Engagement Network to share
thinking and best practice on how to support employers
in the employment and retention of people with mental
health problems. The network has a membership of
more than 60 organisations including a range of
government departments, practitioners and academics.
One output has been that of hosted workshops on key
and developing policy issues such as how best to adapt
and make the ‘Access to Work’ programme more flexible
to help many more people with a mental health problem
to remain at work.
ROYAL MAIL
The Royal Mail is the UK’s second largest employer
after the NHS. NSIP is working in partnership with
Royal Mail to promote the employment opportunities
of people with mental health problems, to support
health-promoting initiatives within the workplace and
in challenging discrimination.
The RET partnerships have also increased organisational
capacity in the regions. They have supported the NHS
and public sector organisations to become ‘Exemplar
Employers’ of people with mental health problems.
This has encouraged PCTs and Mental Health Trusts to
consider greater volunteering and employment initiatives
within their organisations, and enabled trusts to consider
how the Care Programme Approach (CPA) process and
its outcome measurement tools can increase the
proportion of people who wish to (re) gain employment.
TRAINING
Ensuring that frontline staff are appropriately trained is
fundamental to improving employment opportunities for
people with mental health problems. NSIP has worked
with a wide range of stakeholders to develop a mental
health awareness training package for trade union
representatives. The training package was piloted during
2007/08, and was followed by the delivery of training
events across several regions. The training has been
embraced by a wide range of unions, including Unite,
Public and Commercial Services (PCS), Prospect and
Unison and has been delivered to more than
100 representatives.
NSIP has also met with Jobcentre Plus on how to
improve the quality of their customer service and
15
employment support that people with mental health
problems receive. This led to us working with Jobcentre
Plus training experts to develop a training module on
mental health and employment awareness, which has
now been formally adopted. We are also working to
finalise a training product for engaging and working with
employers on mental health problems.
INCOME, BENEFITS AND THE WELFARE SYSTEM
Since 2004, NSIP has supported changes to the
Incapacity Benefit linking rules so that returning to work
and the claiming of benefits is more flexible and
supportive for people with mental health problems. We
have also been instrumental in securing some positive
changes to the welfare benefits system.
BENEFITS DOWN-RATING
In 2004, building on a lengthy existing campaign by
Derbyshire Patients’ Council and Mind, we worked
with ministers and senior officials to highlight issues
concerning the impact of benefit down-rating for
people with long-term hospital stays. This resulted in
the end of ‘down-rating’, securing improvements in
the lives of 21,000 people, to the value of £60 million.
NSIP has sought clarification of guidance for voluntary
work, which now makes it clear that individuals can be
reimbursed for travel and meal expenses without it
affecting their entitlement to benefits.
We welcome Employment and Support Allowance as a
move towards a simpler benefits system which
recognises that some people need additional support. It
also encourages and supports those who can return to
work to do so. The extension of the Permitted Work
rules (PWRs) within Employment and Support Allowance
to apply equally to both income-based and contributionbased claimants enables more people to access
employment at a pace that suits them.
NSIP’s position on PWRs has also challenged the
inequality that exists for people on different types of
benefits. We have set out what needs to be done with
the Department for Work and Pensions so that PWRs
act as an enabler for people with mental health problems
trying to return to work.
REMAINING CHALLENGES
Over the last few years there has been an increasing
amount of health, employment and wider support
available to employers and people with disabilities, but
despite an overall improvement in the disability
employment rate, people with mental health problems
have not benefited as much as other groups. Specifically,
there has been little change in the very low employment
levels for people with more severe mental health
problems.
Improving employment rates for people with mental
health problems requires progress on a number of fronts.
Individuals may require more specialised and sustained
support to ensure that work becomes, or remains an
achievable goal. This support should take into account a
range of issues, such as low levels of skills or
confidence, debt, caring responsibilities and/or other
household circumstances. In addition, the attitudes and
perceptions of carers, health professionals and families
can be unhelpful and stigma and discrimination is still an
important issue.
Underpinning many of these challenges is the need for
more extensive research to develop the evidence base to
build and promote a strong case for the employment of
people with mental health problems. This will ensure that
individuals and employers can quickly access appropriate
help and support whenever they need it. For services to
be more effective and better utilised, they should meet a
wide range of need, be joined-up, simple to access and
show the benefits of adopting best practice and
delivering tailored support. It is equally important to
promote knowledge as to how providers can develop
effective employment services and staff skills.
Concerns remain about Employment and Support
Allowance as it currently stands, in respect of the
disparity within the benefit for those who have previously
paid contributions and those who have not. It is
important that Employment and Support Allowance
continues to be evaluated to ensure that it meets the
needs of those with mental health problems.
CONCLUSION AND PROPOSED FUTURE ACTION
Whilst Individual Placement and Support is an effective
structured approach to securing sustainable
employment, we recognise that it does not always work
for everyone, and that for some work is not an
immediate option. It will therefore be important to
consider what a suite of provision might contain and
ensure that appropriate systems and services are in
place in each area to meet the needs of individuals.
It is important to build upon the momentum created by
the RETs since this has provided a coordinated
approach to secure better employment outcomes for
people with severe and enduring mental health problems
and meet expectations of PSA 16.
CHAPTER 2 EMPLOYMENT
The need to deliver holistic support is even more critical
in the current economic downturn when the number of
people experiencing poor mental health is likely to
increase and when more people may become at risk of
long-term unemployment. The challenge will be to
demonstrate how the national mental health and
employment strategy will help change attitudes,
assist the development of an evidence base and
promote the creation of a comprehensive range of
mainstream and specialised information and support
which assists access to, and retention of, good
employment opportunities.
16
28 Department of Health, 2006, Action on Stigma: promoting mental health, ending
discrimination at work.
29 Within the Patient Survey (Healthcare Commission, 2005), 52% of respondents said
they had not received any help with finding work but would have liked it.
30 W Anthony, A Howell and KS Danley, ‘Vocational Rehabilitation of the Psychiatrically
Disabled’ in M Mirabi (ed.), The Chronically Mentally ill: Research and Services,
(Jamaica/New York, Spectrum Publications, 1084); G Shepherd, ‘The Value of Work
in the 1980s’, Psychiatric Bulletin, 13 (1989): 231–233.
31 Social Exclusion Unit, op. cit., 2004.
32 Department of Health/NSIP, 2006, Vocational services for people with severe
mental health problems: Commissioning guidance.
33 NSIP, 2008, Finding and Keeping Work.
www.socialinclusion.org.uk/publications/Toward_a_MH_employment_strategy_
revsied_after%20repairs.pdf
34 The national indicators are the means of measuring national priorities that have
been agreed by government.
35 Dame Carol Black, 2008, Review of the health of Britain’s working age population.
Working for a healthier tomorrow.
36 For the announcement of the development of the national mental health and
employment strategy see:
www.dwp.gov.uk/mediacentre/pressreleases/2007/nov/drc057-271107.asp
37 Cabinet Office, op. cit., 2006.
38 Action 23 reads “Building on current guidance and legislation, the Government will
develop dedicated regional teams to provide further support for the implementation
of good practice around employment of those with severe mental health problems.”
39 The Mindful Employer initiative is aimed at increasing awareness of mental
health at work and providing support for businesses in recruiting and retaining staff.
See website www.mindfulemployer.net/
40 See Shift’s line managers’ web resource site: www.shift.org.uk/employers/
41 www.mentalhealthfirstaid.csip.org.uk/
42 See the Health and Safety Executive stress website: www.hse.gov.uk/stress/index.htm
43 See Department for Work and Pensions’ announcement:
www.dwp.gov.uk/welfarereform/cities_strategy.asp
44 For information on Increasing Access to Psychological Therapies see:
www.iapt.nhs.uk/
45 Department of Health, op. cit., 2006
CHAPTER 3
17
LEARNING AND SKILLS
VISION
People with mental health problems, by accessing learning and
skills provision, should be able to lead active and fulfilling lives
as part of their communities and in employment, in a way that
sustains mental wellbeing. Our vision is that:
Learners with mental health problems have equal access
to the full range and diversity of learning opportunities in
their area.
Learners take a valued and active part in their education and
progress towards their goals in life and work.
Collaboration and partnership working with key stakeholders,
including learners with mental health problems, ensure that
holistic packages of provision meet learners’ learning, skills,
employment and mental health needs.
CHAPTER 3 LEARNING AND SKILLS
PROGRESS SINCE 2004
“Adult learning has enabled me for the first time to have
goals that I know, with effort and work, I can achieve.” 46
We know that involvement in learning can often have a
positive impact on a person’s mental health. In addition
to acquiring new skills, learning can promote confidence,
build resilience to stress and give people a greater sense
of purpose. It enables people to meet other students
and make new friends, and can lead to getting back into
employment or finding a better job.
As employers demand and need an increasingly skilled
workforce, taking up opportunities to participate in
learning as a route to employment and learning
opportunities at work is becoming more important,
particularly at a time of economic downturn. Ensuring that
learning and training opportunities support progression to
employment and prospects for getting on in the
workplace have been key elements of the work that NSIP
carries out through the learning and skills work stream.
There has been considerable progress since the
publication of the SEU report 47 in understanding the
learning needs of, and improving the levels of support
available to, people with mental health problems who
want to learn.
CARE PROGRAMME APPROACH (CPA) SOCIAL
INCLUSION PROJECT
In the East Midlands, work funded by NSIP with support
from the Learning and Skills Council (LSC) led to a
baseline being set for educational attainment for people
on the enhanced Care Programme Approach (CPA) not
educated to level 2, which is often seen as the key
indicator for employers on employability. The research 48
highlighted the level of educational disadvantage
experienced by many people with mental health
problems, and how this compounds the disadvantages
that they already face in the labour market.
“This course has allowed me to get to grips with my new
early rises at 8am, my laundry, my shopping and meal
arrangements, and begin to learn about the importance
of saving my money for a flat… I can still go on and do a
university course. Only now I have a little more experience
of being in education again. I also have living skills.” 49
PARTNERSHIP PROGRAMME
A Partnership Programme between NSIP, the National
Institute of Adult Continuing Education (NIACE) and the
18
Learning and Skills Council (LSC) has allowed us to
make an impact on the Further Education system and to
create a body of work that will have a positive effect on
the social inclusion of people with mental health
problems and leave an enduring legacy.
An LSC Task Group has been set up to oversee and
advise on the work of the Partnership Programme whose
membership includes the Department for Children,
Schools and Families; the Department for Innovation,
Universities and Skills; the Department of Health and the
Department for Work and Pensions; the Employers’
Federation; learners with mental health problems and the
voluntary sector.
NSIP contributed to the 2008 follow up strategy ‘refresh’
to the LSC’s 2006 ‘Improving services to people with
mental health difficulties’.50 This provides a renewed
vision promoting the social and economic inclusion of
people with mental health problems through improved
access to and success in learning and skills. The final
strategy will be launched March 2009 and will
incorporate an action plan to 2015 that will help
safeguard the interests of learners.
The Partnership Programme has successfully changed
the climate of support for learners within the LSC. At a
national and strategic level the programme has
consistently advocated for learners with mental health
problems and through it, we have also built the capacity
of providers to better meet learners’ needs by
developing resources, good practice guides and a
quarterly newsletter.
NSIP has developed learning resources to support
progression into learning and work, such as the ‘Really
Useful Book of Learning and Earning’.51 New procedures
and forums have been created to allow greater
involvement of learners with mental health problems in
the development of policy and practice for better
education and training provision. We have also
successfully encouraged the LSC and other learning
providers to sign up to be ‘Mindful Employers’
to support them in their role as an exemplar public
sector employer.
Regional Project Officers lead the regional
implementation of the Partnership Programme, with
great effect, resulting in major improvement in our
working relationships with each regional LSC. These
posts are crucial if we are to ensure national strategy is
implemented regionally, that it impacts on providers and
consolidates collaborative working with the Regional
Employment Team leads.
19
‘FAST TRACK’ SCHEME
In Portsmouth, the PCT’s Early Intervention Team
secured funding from the LSC and developed a
partnership with local colleges for a ‘fast track’
scheme for clients into Further Education with some
excellent outcomes, such as ‘Back on Track’, a
project tailored to meet the vocational needs of young
people with mental health problems.
Within the action plan, the Partnership Programme will
need to continue to build on successes and, in particular,
to drive further development of the work that has already
begun to improve learning and skills opportunities for
young people, aim to inform the work of the Integrated
Employment and Skills Service, carry out a review of
learning and skills within Forensic Services and Secure
Units, take a more proactive approach to being an
exemplar employer and continue to develop the capacity
of the learning and skills workforce.
COLLABORATIVE WORKING
We have undertaken a range of projects, including the ‘Is
it for me?’ initiative, which is described in more detail in
chapter 1. We have also encouraged better collaborative
working between Early Intervention in Psychosis Services
and Child and Adolescent Mental Health Services to
ensure that young people experiencing mental health
problems are supported to remain in education, training
and employment.
All of the work we carry out at national and regional
level is informed by a co-productive process of sustained
dialogue between policy makers, practitioners
and learners. Through the dissemination of information
and the sharing of good practice, policy informs
practice but the voice of the practitioner and the learner
clearly informs policy across government and sectors.
REMAINING CHALLENGES
The continued drive within the Further Education
system towards targets on the number of learners
achieving qualifications of level 2 and above has led to
a loss of the non-accredited and lower level courses in
the sector that have often been the first step into
learning for many people with mental health
problems. Funding for adult education has also been
increasingly directed towards work-based learning,
yet low take up of these opportunities by people with
mental health problems continues to be problematic.
The end of the LSC in 2010 as the primary funder of this
programme of work and the establishment of two new
agencies to take its place presents many challenges in
ensuring the continuation of the work of the Partnership
Programme.
CONCLUSION AND PROPOSED FUTURE ACTION
To work towards our vision of learners with mental health
problems leading fulfilling lives, we want to safeguard
their interests within the structures of the LSC’s successor
organisations. The LSC’s action plan should highlight the
need to manage that transition to the new agencies and
to the new requirements placed on local government.
46 NIACE/NSIP, 2008, The Really Useful Book of Learning and Earning.
47 Social Exclusion Unit, op. cit., 2004.
48 V Utting and C Law, 2008, East Midlands Care Programme Approach (CPA) Social
Inclusion Project, Final Report, NIACE downloadable from
www.niace.org.uk/mentalhealth/docs/EM/EM-CPA-project-final-report.pdf
49 Ibid
50 Learning and Skills Council, 2006, Improving Services for People with Mental Health
Difficulties.
51 NIACE/NSIP, op. cit., 2008.
CHAPTER 4
20
HOUSING
VISION
Stable and appropriate housing is important if people with
mental health problems are to work and take part in
community life. Being able to live independently is equally
important to creating a socially inclusive community.
Our vision is that:
People with mental health problems have a place to live that
provides a sense of well-being, belonging and continuity.
Effective joint working between specialist and mainstream
housing, health and social care agencies improves
outcomes.
The barriers to flexible choice are removed.
Reliance on specialist accommodation and services is
reduced.
Commissioning of services meet people’s needs in a holistic
way and is effectively integrated.
21
PROGRESS SINCE 2004
“We need our independence and we want support only
when we need it, but we still want to be safe and secure.” 52
Since the SEU report,53 NSIP has coordinated
implementation of the action points on rent arrears
management to reduce non-payment and evictions,
leading to the publication of ‘Improving the effectiveness
of rent arrears management’,54 and local authority
allocations schemes which resulted in ‘Implementing and
Developing Choice Based Lettings: A guide to key issues’.55
Following on from these, we produced mental healthspecific briefing documents for housing, health and
social care staff on rent arrears management 56 and
Choice Based Lettings 57 to encourage better joint
working between services and increase support for
people with mental health problems to improve their
housing situation. This has helped prevent evictions and
improve opportunities to achieve independent living.
NSIP has also coordinated the SEU report’s actions on
homelessness. This includes the revision of the Code of
Guidance for local authorities which set out revised
definitions of those in priority need of housing.58 We also
worked with the NIMHE/CSIP regional development
centres on a series of events to engage staff and people
using local homelessness services in the research
process to inform the development of ‘Getting Through:
Access to mental health services for people who are
homeless or living in temporary or insecure
accommodation: A good practice guide’.59
To help drive progress forward, NSIP has brought
together key government departments, housing
agencies and stakeholders into a national Housing
Reference Group. The group’s role has shifted on from
advising on the production of guidance documents to
becoming a flexible resource, consulting and
disseminating information on new policy and emerging
practice. As a result, we have been able to respond
rapidly to and advise on any new housing and mental
health developments or initiatives.
NSIP is committed to ensuring that people with mental
health problems using housing services are listened to
when developing local and national policy. For example,
we have coordinated a series of consultation events,
working on behalf of, and across health policy areas to
gather the views of the wide range of people using
services funded by the Supporting People programme,
including people with mental health problems, and to
feed them into the development of the Supporting
People national strategy.60
MENTAL HEALTH AND LIAISON OFFICER
Telford PCT and the local authority mental health
service jointly fund a post for a Mental Health and
Housing Liaison Officer, whose brief has been to
foster understanding and co-working between these
two sectors at local level. Key activities include
coordinating a mental health and housing referral
panel that has highlighted unmet need, providing
advice to frontline staff, developing a training package
for both sectors, and organising two annual
conferences to enhance information sharing and
networking between local agencies.
We have contributed to the joint Communities and Local
Government and Department of Health ‘Housing Learning
Improvement Network (LIN) guidance’ on mental health
assessments of those who are homeless or insecurely
housed.61 We have also worked on other Housing LIN
initiatives, such as the current review of the Turnbull ruling
on Housing Benefit eligibility, the growing role of ‘extracare
housing’, and a study of the experiences of people with
mental health problems who have been homeless.
NETWORK FOR CHANGE
Network for Change, a voluntary sector mental health
support service in Leicester, is coordinating an
action learning set that brings together specialist
mental health housing workers and local
homelessness and housing resettlement staff with the
aim of increasing awareness of mental health and to
improve communications between staff in the related
agencies. It has demonstrated how to enhance
recognition of mental health issues and how to build
networks and relationships.
Recognising the importance of the Care Programme
Approach (CPA) as a vehicle for promoting social
inclusion within secondary services care and support
planning, NSIP has contributed to the housing section
within the revised CPA guidance,62 helping to raise the
profile of homelessness and non-secure housing as
priority issues for new CPA allocation.
One of the most significant developments concerning
housing and mental health since the creation of
Supporting People has been the new Public Service
Agreement (PSA) 16 to increase the proportion of
socially excluded adults in settled accommodation and
employment. NSIP has provided expert advice to the
Cabinet Office on both housing and mental health but
CHAPTER 4 HOUSING
also on wider social inclusion issues. We have since
worked with the Cabinet Office, Communities and Local
Government and the Department of Health to secure
agreement on the approach to PSA implementation and
continue to provide high level input to the regional roll
out. This has been done by raising awareness and
securing engagement with regional Government Offices
and the Cabinet Office. The NSIP Reference Group
(consisting of people with mental health problems and
carers) has also made an invaluable contribution to the
PSA development and delivery process. Chapter 6
explains the role of the Reference Group in more detail.
REMAINING CHALLENGES
Although considerable progress has been made, we
have identified a number of potential challenges that will
need to be addressed. The SEU report called for
mainstreaming of mental health awareness training for
all housing staff but this has still not been achieved.
We would recommend that all new and existing staff
receive mental health awareness training to enable them
to respond to people in a supportive and flexible way.
Improved communications are often needed between
those working in housing and mental health services to
help support people with severe and enduring mental
health problems with independent living. However, PSA
16 should raise awareness of the need for cooperation
and local performance framework structures, especially
the Joint Strategic Needs Assessment, to identify unmet
need and less effective coordination of services.
Both the PSA and the CPA guidance stress the need for
effective and proactive work with those in secondary
care who are, or who become, homeless. Yet there is
also work to be done on how to meet the mental health
needs of homeless people who are not in contact with
secondary mental health care. Here, new approaches
may be needed, and Practice-Based Commissioning via
primary care could be equally or more suitable.
Greater pooling of resources at a local level will help
make sure that services respond flexibly to the needs of
their local communities and the development of shared
local priorities. However the removal of the ‘ring fence’
for the Supporting People grant presents risks to
local services and commissioning, such as resulting in
funding being diverted away from providing much
needed supported housing for people with mental
health problems.
22
and Communities Agency and the Tenant Services
Authority could bring a risk of the loss of the
commitment to housing for the most at risk groups.
Certain challenges remain which may act as barriers to
the inclusion of people with mental health problems in
mainstream communities. For example most people with
mental health problems live in their own homes, but
those with higher support needs may still be
inappropriately living in residential care. Similarly, a lack of
suitable move-on accommodation can result in extended
stays in hospital. Also people with mental health
problems report that they are likely to be allocated less
desirable properties and neighbourhoods, than the
general population.
With greater local accountability for all services, including
social housing, it is important that people with mental
health problems and carers, and mental health services
engage in these local debates on the housing that
people need.
CONCLUSION AND PROPOSED FUTURE ACTION
Commissioning and system change will require vision
and local leadership. We believe such a vision comes not
just from managers and commissioners but also frontline
staff, carers and people using services themselves.
Housing has become an increasing focus of concern for
mental health services and the work of NSIP has been
instrumental in converting generalised concern into a set
of achievable actions. With the impetus provided first by
the Public Service Agreements and also by new work on
inequalities, public health and the social determinants of
health, we are confident that this work agenda has a
solid foundation and will continue to progress.
52 Telecare Services Association, 2008, Telecare and Telehealth – Centres of Excellence
53 Social Exclusion Unit op. cit., 2004.
54 Office of the Deputy Prime Minister, 2005, Improving the Effectiveness of Rent
Arrears Management: Good Practice Guidance.
55 Office of The Deputy Prime Minister, 2005, Implementing and Developing Choice
Based Lettings: A guide to key issues.
56 NSIP, 2006, Improving the Effectiveness of Rent Arrears Management for People
with Mental Health Problems.
www.socialinclusion.org.uk/publications/Rentarrearsbriefing.pdf
57 NSIP, 2006, Choice Based Lettings for People with Mental Health Problems
A Briefing Guide. www.socialinclusion.org.uk/publications/NSIP_CBL_briefing.pdf
58 Communities and Local Government, 2006, Code of Guidance for Local Authorities.
59 NSIP, Department for Health, Communities and Local Government, 2007,
Getting Through: Access to mental health services for people who are homeless or
living in temporary or insecure accommodation: A good practice guide.
60 Communities and Local Government, 2007, Independence and Opportunity –
Our Strategy for Supporting People.
61 Communities and Local Government/CSIP Housing Learning and Improvement
Network, 2008, Housing LIN Briefing: Understanding Homelessness and Mental Health.
62 Department of Health, op. cit., 2008.
Major restructuring of the housing regulatory and funding
frameworks took place in December 2008 and the
creation of entirely new organisations such as the Homes
CHAPTER 5
23
ARTS AND CULTURE
VISION
Arts, cultural engagement and community participation are
fundamental to the development of socially inclusive society.
People with mental health problems should have access to the
same diverse range of arts and cultural activity as others in
the places where they live. Our vision is that:
The role that arts and culture play in improving wellbeing, health
outcomes and personal identity is recognised and resourced.
Community and large-scale arts organisations will work
with and alongside people with mental health problems,
to understand how to remove barriers, be accessible and
reduce stigma.
The use of arts and culture raises awareness of mental health
problems and supports the challenge against stigma and
discrimination.
CHAPTER 5 ARTS AND CULTURE
PROGRESS SINCE 2004
Arts and culture include all creative activity whether
engaging by seeing, listening or taking part. Participation
in the arts can give people a positive alternative identity
to that of ‘service user’ and help people be part of the
wider community by increasing self-esteem, confidence
and social networks.
Arts and culture also play an important role in health and
healthcare provision. They help deliver real and
measurable benefits across a wide range of priority areas
for health and can enable the Department of Health and
the NHS to contribute to key government initiatives.
Strong leadership through promotion, development and
support, is required to create an environment in which
people with mental health problems can prosper through
their involvement in arts and health.
The SEU report 63 highlighted the need for research to
understand improvements in health and social outcomes
as a result of participation in arts projects. In response to
this, ‘Mental health, social inclusion and arts: developing
the evidence base’ 64 was published. It found that:
There were significant improvements in
empowerment, mental health and social inclusion.
There was a significant decrease in the proportion of
participants identified as frequent or regular users of
services.
The improvement in empowerment and mental health
amongst people with more severe issues at baseline
indicates that arts projects can benefit people with a
range of mental health needs, including those with
more significant problems.
“When I am painting I forget everything else. Realising
that I can develop my artistic skills I feel proud of what
I have achieved and it has done wonders for my
self-esteem.” 65
In response to these findings, NSIP successfully
established a working partnership with The Wallace
Collection, the Museums, Libraries and Archives Council,
Tate Modern, Portugal Prints and the V&A. Museums
and galleries can address social exclusion not only by
encouraging participation in the arts, but also by
connecting people with experience of mental health
issues to the wider community, and by promoting access
to training, volunteering and employment opportunities.
‘Open to All’, a training package launched by the Health
Secretary at a joint NSIP event at The Wallace Collection
in September 2008, is designed to encourage museums
24
and galleries to involve people with experience of mental
health problems, thereby helping to build the necessary
bridges to museums and galleries and the wider
community. Commissioned by the partnership, it was
developed by the University of Nottingham, Nottingham
County Teaching PCT and the Lost Artists Club and will
be available for staff in museums, libraries and galleries
at a local level throughout the country, from
mid 2009 onwards.
NSIP has also widened its arts focus to include
participatory arts, such as theatre, dance and music.
A range of innovative practice is underway through our
partnership working with the Arts Council (England)
and each of the Arts Council Regions, NIMHE/CSIP
regional development centres, theatres and community
arts organisations and practitioners.
THEATRES SOCIAL INCLUSION PARTNERSHIP
A group of London-based theatres including the
Royal Court, Roundhouse, National, Southbank,
Half Moon and Tricycle are working in partnership
with NSIP and the Arts Council to become leaders in
social inclusion. They are developing ways to include
social inclusion issues through their local communities
and policies. A seminar held in November 2008 was
hosted by the Roundhouse in order to celebrate this
unique partnership, widen the debate and to explore
further opportunities. Ongoing work will include the
coordination of web-based and real discussion
groups to pool experiences, ask questions and define
goals for a co-produced programme.
We have established a national arts evaluation advisory
group with membership from arts practitioners, arts
therapists, academics, people with mental health
problems, health practitioners and commissioners as
part of its work stream on evidence and innovation. The
group has developed evaluation guidance and support
for arts organisations and practitioners which will both
add to the evidence base and help organisations who
want to commission arts and cultural initiatives. This
guidance will be published spring 2009.
Work is also underway in both the North West and
South West, where arts organisations are working in
co-production with health and social care partners to
create healthy, sustainable communities. The South
West work will be launched in May 2009 with a
conference in Dartington.
25
NSIP has carried out a review of regional and local arts in
health programmes in order to develop and build
regionally focused networks. These bring together NSIP
social inclusion leads, service improvement leads, arts
practitioners, voluntary and community arts
organisations, academic institutions and arts council
regional leads and links these to a pan-European
network of arts, inclusion and wellbeing in practice.
SING YOUR HEART OUT (SYHO)
Singing workshops are run by a professional voice
coach in Norfolk, for people who use mental health
services, friends, family, support workers and staff.
In 2008, NSIP commissioned an evaluation of the
socially inclusive benefits of the workshops. Its
evaluation looked at the way in which SYHO
provided:
An opportunity for individuals to develop skills and
resilience that support their recovery and social
inclusion.
A bridge to connect with socially inclusive
opportunities within the local community.
A vehicle to tackle the stigma, discrimination and
inequalities encountered by people who
experience mental health problems.
The evaluation established significant evidence
that SYHO has provided a great opportunity for
individuals to develop a range of singing and choral
skills. These skills, together with a supportive
environment have encouraged the development of
varying degrees of interpersonal skills. Social
interaction has enabled a sense of inclusion and
impacted positively on the recovery of those involved.
www.socialinclusion.org.uk
REMAINING CHALLENGES
There is a risk that arts and culture activity is not given
enough attention within a landscape of public service
agreements and local area agreements. Projects are
often funded for time-limited periods, which can make
evaluation and continuity difficult.
CONCLUSION AND PROPOSED FUTURE ACTION
NSIP has worked with a range of key stakeholders to
ensure that arts and culture in relation to mental health
and social inclusion retains a high profile within the wider
policy agenda.
We would like to see more partnership working across
central and national structures as the complex nature of
this work demands a more co-productive approach in
the future. There is greater scope for the Department of
Health, Department for Culture, Media and Sport and
Department for Innovation, Universities and Skills to
focus on arts and cultural development together,
enabling more innovative and creative activity.
NSIP is working in partnership with the Cultural
Olympiad 66 to ensure the social inclusion of people
with mental health problems. We are working in
partnership with the South West Cultural Olympiad and
are part of the advisory group on local cultural activity.
This work is in its very early stages and it is envisaged
that it will be developed alongside other localities in
preparation for 2012.
NSIP is working in partnership with the London Arts in
Health Forum to establish a network of key organisations
to coordinate activity in arts and wellbeing. We have
supported the development of evaluation guidance
leading to an accessible evidence base.
The publication of the Arts Council and Department of
Health joint prospectus on arts in health in 2007 has
seen the beginnings of positive development in the arts
and health sector. This work should be built upon to
ensure that it addresses the inclusion needs of people
with mental health problems.
63 Social Exclusion Unit, op. cit., 2004.
64 Anglia Ruskin/UCLan Research Team, 2007, Mental Health, Social Inclusion and
Arts.
65 Ibid.
66 london2012.com/get-involved/cultural-olympiad/index.php
CHAPTER 6
26
LEADERSHIP AND
WORKFORCE
DEVELOPMENT
VISION
Strong leadership and a skilled, effective workforce are both
essential in setting the direction that makes a positive
difference to the lives of people with mental health problems.
Our vision is that:
Commissioning for socially inclusive outcomes drives the
commissioning of all services.
Corporate and strategic sign up to social inclusion shapes
service delivery.
Social Inclusion is an integral part of professional
pre-registration training and continuous professional
development (CPD).
People with mental health problems and their carers lead
the development and promotion of socially inclusive services
with staff and organisations.
27
PROGRESS SINCE 2004
Lessons learned included:
NSIP has supported projects at both local and national
level that reflect the importance of leadership and
workforce development throughout the NHS and its
provider organisations, services and staff. We have also
actively developed a close relationship with a number of
professional bodies of staff working in mental health
services which has had a positive impact on both
the national strategy and guidance that they provide.
It has also given us a direct route to clinicians and
practitioners, and to influencing practice on the ground.
The importance of adding value at a strategic level by
alignment with organisational priorities, whilst avoiding
reliance on a top-down directive approach to motivate
participation.
DELIVERING EFFECTIVE LOCAL LEADERSHIP FOR
SOCIAL INCLUSION (DELLSI)
Taking a team approach, so that different groups and
individuals pursue their issues of concern and build
from their strengths.
The aim of the DELLSI initiative has been to facilitate the
bringing together of leadership development and
service improvement at a local level to promote social
inclusion. To achieve this, three NHS Trusts 67 were
recruited through the Mental Health Network of the
NHS Confederation and these took part in the
programme between September 2006 and May 2008.
Key features included:
Developing the position of participating organisations
within their local communities and supporting
their work in promoting the social inclusion of people
using their services.
Focusing on outcomes of agreed local importance.
Exposing and promoting the positive core of
the participating organisations and the individuals
within them.
Using assessment tools and research-based
approaches to strengthen team working among
senior leaders and managers within and across local
organisations to promote effective partnerships.
A Development and Delivery Team (DDT) was
established with support from NIMHE to oversee the
initiative and coordinate the work. Working with local
staff to help build capacity and sustainability,
‘learning and exchange events’ were held where teams
from the three Trusts came together in a supportive
atmosphere to share experiences. Bespoke initiatives
were developed covering issues such as governors’
awareness of and involvement in social inclusion
work as part of the establishment of a Foundation Trust,
building relationships with local resources for leisure
(based on the assessed need and involvement of
people using services), engaging with community leaders
and developing care planning processes to be more
socially inclusive.
The need to ground plans in a systematic assessment
of what people using services say they want and
need.
Building from participants’ own understanding and
evaluations of social inclusion locally.
Maintaining a ‘can-do’ approach and remaining
hopeful even in the face of resistance, apathy or
events not going as planned.
Using senior stakeholders to broker relationships on
behalf of the team.
Engaging people who use services to communicate
the project messages throughout the organisation.
Being realistic about the time frame needed to
achieve improvement and consciously promoting
sustainability from the outset.
The DELLSI initiative has been positively evaluated
and work is underway with new partners to develop a
second phase with twice the number of sites.
EXPERT ADVISORS AND REFERENCE GROUP
“There is no doubt that we have set a high and
successful standard for service user involvement and
this is probably one of our greatest achievements.” 68
NSIP has always recognised the importance of
meaningful involvement and participation of people with
mental health problems and carers to co-producing our
work. We have been working since 2006 with four
Expert Advisors, recruited from the existing Shift Board
of Advisors. Helping to forge stronger links across the
two programmes, participating on recruitment panels
and in the active measurement of good practice in a
range of service settings, contributing to the
development of key resources such as our website,
evaluation tenders and publications; the impact and
contribution of our advisors has been enormous.
In addition, they have contributed to the public profile of
inclusion work by playing an integral part in the planning,
organisation and delivery of NSIP hosted events, most
CHAPTER 6 LEADERSHIP AND WORKFORCE DEVELOPMENT 28
notably at a key conference held at Charlton Athletic
Football Club in 2008, and presenting at these events on
a range of issues. They have also supported the
development of the Reference Group.
“Being at the cutting edge of a new form of user
involvement, where involvement is no longer the
appropriate word, because that puts the onus on
the professionals. Cooperation in its literal sense of
working together.” 69
The Reference Group, with its 15 formally appointed
members, started life in 2005, initially to work specifically
on the employment and benefits issues within the
programme. However, such is the collective contribution
of the group that its perspective has been broadened to
cover the entirety of our work, offering NSIP a practical
means of integrating its strategic work with individual
experience.
The Reference Group also provides regional progress
updates to the national team and feedback on national
progress to the regional groups; a way of gathering local
information and inputting to national policy and
consultations to empower people to influence the
services they receive. Group members reflect the
national context of the work undertaken by NSIP both in
terms of the rich variety of interests and geographic
spread that they represent.
The group has contributed to a number of important
pieces of work including:
i
Meeting with government officials to feed in the
perspectives of people with mental health problems
on a range of policy, such as:
HM Treasury’s review of mental health
programmes.
The operation by the Department for Work and
Pensions of Disability Living Allowance.
The Department for Work and Pensions’ Disability
Standards booklet ‘Help if you are ill or
disabled’,70 proposing suggestions for the way
forward for improving customer services.
ii
Working with ministers and senior officials to
highlight issues surrounding the impact of benefit
down-rating for people with long-term hospital stays,
securing £60 million in benefits.
iii Providing briefing for Department for Work and
Pensions’ ministers on the operation of the benefit
system and employment programmes and inputting
to a departmental position paper on Permitted Work,
to ensure inclusion in the roll out of the Public
Service Agreement 16 targets.
iv Feeding into the roll out by Jobcentre Plus of
Employment and Support Allowance.
v
Taking part in the consultation on the Independent
Living Strategy by the Office for Disability Issues.71
vi Directly feeding into the consultation on future
service provision of the Learning and Skills
Council.
vii Contributing to the Royal College of Psychiatrists’
book on socially inclusive psychiatry, due to be
published late 2009.
viii Working alongside a community engagement
specialist conducting site visits as part of the
‘Communities of Influence’ project.
COMMISSIONING NETWORK
NSIP has contributed to a number of regional initiatives
aimed at supporting commissioners. In response to
demand from mental health commissioners, and
particularly those with joint commissioning
responsibilities, we established a commissioning
network for social inclusion in early 2008. As well as the
network meetings with workshops held in London and
the East Midlands, a considerable amount of activity is
self-generated by commissioners, who share ideas and
requests with each other. There have been continued
close links with the day services programme and
network members have requested the production of
broader socially inclusive outcomes guidance for
commissioners and providers,72 adapted from the day
services framework.73 This network is ready for
development and will need to find a new host in 2009.
NSIP has supported the embedding of inclusive
outcomes into ‘World Class Commissioning’ which
needs to be delivered within a social as well as clinical
framework, and which will be a key driver for delivery
organisations. If commissioning is to ‘add years to life
and life to years’ 74 then socially inclusive outcomes will
need to be pivotal in shaping this agenda. Whilst the
statutory responsibility for implementing the social
inclusion agenda lies with local authorities and
PCTs, it has often been mental health services that
have championed action, with many appointing social
inclusion leads and staff. Partnerships between
all the local players, including third sector organisations,
are essential.
29
ACADEMIC AFFILIATES
The Collaborative Academic Network is a co-designed
learning network, led and coordinated by the
University of Central Lancashire (UCLan). Its members
work together to advance practical and relevant
commissioned research and developmental work on
social inclusion in mental health and to facilitate the
spread of inclusive learning into practice and evidence.
The network’s key tasks are to:
Collaborate to clarify a set of metrics that can be used
by commissioners and regulators to assess the
effectiveness of mental health social inclusion work at
a local level.
Develop a community of practitioners and researchers
who actively link research into practice and vice versa,
in order to enhance social inclusion in mental health.
Develop and disseminate evidence-based practice to
inform every level of the mental health system.
Many members of the Academic Network were formerly
part of NSIP’s earlier Research and Evidence Coalition.
This coordinated and supported a range of research
initiatives on inclusion and mental health, some of which
attracted significant funding and profile both nationally
and internationally.75 For more information please see
Annex A.
In 2007/08, NSIP produced a data report for each of the
regional employment teams (RETs). The reports drew on
existing national data sources, as far as possible
breaking down data to a local level and exploring trends
over a three-year period (2005–2007) in relation to
employment, benefits and education issues for people
with severe mental health problems. The reports
provided each team with information and analysis they
could use as a starting point in discussions with service
providers, commissioners and other partners to inform
the targeting of their interventions. Background
information was included on the data sources, including
commentary on the data quality and any limitations of
the data sets.
Ongoing challenges in relation to this work are:
Variations between data sources in their definition and
classification of mental health problems, in the
populations they cover and the frequency of data
collection.
The extent to which national data can be reliably
disaggregated to provide locally relevant information.
The need for expertise and continuity of approach to
reproduce any of the analysis to monitor progress
over time and the resource implications that this
would have.
The lack of clarity about what is realistic to expect in
terms of progress and the extent to which changes
can be attributed to national policies and initiatives.
PROFESSIONAL NETWORKS
Workforces need to have the right professional and
leadership skills if they are to reflect the emerging
demands of delivering socially inclusive practice. NSIP
has supported putting strategic and professional level
structures in place to ensure that appropriate
development takes place and that frontline workers get
the right support at the right time.
The SEU report 76 referenced the barrier to inclusion
constituted by low expectations and negative
assumptions by frontline staff about the capabilities of
people with mental health problems. In order to challenge
these perceptions and improve the experience of people
using services, NSIP commissioned the identification of
socially inclusive ways of working, using the framework of
the ‘The 10 Essential Shared Capabilities’ (ESCs) 77 to
allow staff to reflect on their practice.
The Royal College of Nursing (RCN), the College of
Occupational Therapists (COT), the British Psychological
Society (BPS), the Royal College of Psychiatrists (RCP)
and the Social Care Institute for Excellence (SCIE) fielded
representatives to a working group which led to the
publication of the ‘Capabilities for Inclusive Practice’.78
This provided a mapping of individual capabilities to the
‘Knowledge and Skills Framework’ 79 and organisational
capabilities as described by the Healthcare Commission
in ‘Standards for Better Health’.80 The professional
bodies have continued to show strong commitment to
the social inclusion agenda. Good practice examples
include:
Publication by the BPS of ‘Socially Inclusive
Practice’ 81 and supporting the secondment of a
clinical psychologist into the NSIP team. The BPS has
also established a Social Inclusion Steering Group
with work streams on Children and Families,
Offenders in prison and Return to work.
A two-year secondment of an occupational therapist
into NSIP, funded by the COT, and publication of a
mental health strategy document ‘Recovering
Ordinary Lives’ 82 influenced by the NSIP agenda. Also
a joint publication of ‘Work Matters’,83 a guide to
CHAPTER 6 LEADERSHIP AND WORKFORCE DEVELOPMENT 30
employment for occupational therapists in mental
health services.
A Social Inclusion sub group hosted by the RCP,
currently working on a publication to help define and
develop the role of psychiatry in relation to social
inclusion.
A joint SCIE and NSIP symposium to support the reengagement of social care staff with social inclusion
as a legitimate part of the social work role.
A multi-disciplinary event in early 2009 hosted by the
RCN with NSIP to showcase policy and practice
developments in social inclusion and equality,
providing a means of formally consolidating the
commitment of all the professional colleges to include
socially inclusive oriented practice and associated
skills development.
All of these professional bodies are looking to influence
the incorporation of socially inclusive practice as part of
both their undergraduate curricula and continuing
professional development (CPD). However, this remains
a challenge; while the professional bodies have actively
engaged with NSIP during its lifetime, they may have
many competing agendas to meet. Promoting social
inclusion for socially inclusive practice could depend on
individual colleagues who have contributed to this work
continuing to be in a strong position to take this forward
within their own organisations.
STAFF DEVELOPMENT
In order to make the capabilities clearly applicable in the
workplace for staff, NSIP commissioned the development
of two measurement tools. The first 84 measures staff
capabilities and was developed by South Essex
Partnership NHS Foundation Trust, and the second,
developed by people using the services of ‘2gether’ NHS
Foundation Trust, is a user and carer-led evaluation tool
(due for publication spring 2009) that assesses socially
inclusive practice within organisations and Local
Implementation Teams.
MEASURING INCLUSIVE PRACTICE
Sussex Partnership Mental Health Foundation Trust
has independently used the ‘Capabilities for Inclusive
Practice’ to develop a tool for measuring inclusive
team practice,85 and is now sharing this with a local
authority housing service to promote good practice
across agencies.
If we are to see the potential of these tools realised and
embedded in changing staff and organisational practice,
their greater promotion, dissemination and uptake will
need to be secured. This will be a key challenge where
the current national network of regional development
centre-based social inclusion leads will no longer exist. It
may be that both the academic network and professional
bodies and their networks will be able to ensure that
these tools are accessed by practitioners in the future.
‘COMMUNITIES OF INFLUENCE’
In engaging trusts across England in the ‘Communities
of Influence’ project we are linked directly to 14 largescale organisations and their workforces. While the
project focuses on members and governors being key to
engaging with their local communities, the Trusts have
also identified their staff as being an important
community to work with. ‘Communities of Influence’ is
described in more detail in Chapter 1.
It is of vital importance that corporate values and actions
reflect inclusion at strategic and operational levels.
While many mental health and care trusts include social
inclusion in their organisational vision and values,
regular revisiting of how this is done needs to take place
at corporate, service and team levels to ensure that
organisations are meeting their objectives.
VOLUNTARY SECTOR CAPACITY BUILDING
At a regional level, NSIP has worked with the Mental
Health Foundation in delivering a section 64 86 funded
project with the voluntary sector in Northamptonshire.
Using ‘Capabilities for Inclusive Practice’ 87 as the
framework, workshops were provided with the aim of
increasing voluntary sector capacity and capability
in this area. A further outcome has been the
development of an intensive two-day training programme
for staff. A one-day intensive training session for trustees
is currently in development.
CONCLUSION AND PROPOSED FUTURE ACTION
Further work is required to achieve our ambitious goals.
Practitioners promoting socially inclusive practice can
only be effective if the services or organisations that they
work in also promote inclusive working. There is
outstanding work to be done on the tariff or value to be
placed on achieving socially inclusive outcomes
in the context of the new model NHS Mental Health
(NHSMH) contract. It is believed this may link helpfully to
quality premiums and/or Patient Reported Outcome
Measures (PROMS).
Commissioning is still not always informed by the social
inclusion agenda. It can sometimes focus too much on
31
the clinical aspects of mental health and too little on
wider outcomes. Integrating commissioning for social
inclusion into ‘World Class Commissioning’,88 with
inclusion outcomes identified as driving service delivery
needs to remain a priority.
67 The three Trusts are Kent, Leeds and West London.
At a local level, our work has helped us to identify a
number of key learning points about what is needed to
support effective local leadership for social inclusion in
the future. These include:
72 NSIP op. cit., 2009.
68 NSIP Expert Advisor.
69 NSIP Expert Advisor.
70 See following link:
www.jobcentreplus.gov.uk/jcp/stellent/groups/jcp/documents/websitecontent/
dev_015974.pdf
71 Office for Disability Issues, 2008, Independent Living – A cross-government strategy
about independent living for disabled people.
73 NSIP op. cit., 2007.
74 Department of Health, 2007a, World Class Commissioning: Vision.
75 As exemplified by the work of Professor Peter Huxley et al in developing, with NSIP,
a framework of inclusion measures.
76 Social Exclusion Unit, op. cit., 2004.
The need to have senior sponsorship and interest.
77 Department of Health, 2004, The 10 Essential Shared Capabilities – A Framework
for the whole of the Mental Health Workforce.
Looking at how to align objectives with organisational
priorities.
78 Department of Health, 2007, Capabilities for Inclusive Practice.
Ensuring that strong local ownership exists at
team level.
81 British Psychological Society, 2008, Socially Inclusive Practice.
Embedding socially inclusive outcomes in
assessments of what local people say they want and
need and engaging with a range of stakeholders and
partners at the earliest stage.
The importance of linking into national developments
to add profile to local projects and promote learning
and innovation.
79 Department of Health, 2004, NHS Knowledge and Skills Framework.
80 Department of Health, 2007, Standards for Better Health.
82 College of Occupational Therapists, 2006, Recovering Ordinary Lives: The strategy
for occupational therapy in mental health services 2007-2017 literature review.
83 College of Occupational Therapists, 2007, Work Matters: Vocational Navigation for
Occupational Therapy Staff.
84 South Essex Partnership NHS Foundation Trust, 2008, www.socialinclusion.org.uk
85 Will be available on www.socialinclusion.org.uk
86 Now known as Third Sector Innovation and Excellence in Service Delivery Fund.
87 Department of Health, op. cit., 2007.
88 Department of Health, op. cit., 2007a.
CHAPTER 7
32
SOCIALLY INCLUSIVE
PRACTICE:
THE CAPABLE ORGANISATION AND TRANSFERABILITY
OF OUR WORK
VISION
Mental health services support both individuals and
community organisations.
Community organisations are flexible enough to allow people
with mental health problems to make a contribution.
Policy makers, funders and regulators build expectations
and ensure that people with mental health problems are
involved at all levels.
33
Whilst NSIP’s work has focused on the specific
experiences of people with mental health problems,
this work should not be entirely separated from the
circumstances of other people who experience
exclusion. This chapter considers the potential for
applying lessons learned in the mental health sphere to
other efforts to combat social exclusion.
MENTAL HEALTH SERVICES
As we set out in ‘Capabilities for Inclusive Practice’,89
both individual and organisational capabilities are
required if socially inclusive practice is to be embedded
and sustained.
Individual capabilities include:
A commitment to understand and combat the barriers
through which exclusion has a long-term and damaging
impact on an individual and their community.
The ability to build positive, hope-filled relationships
with those who have mental health problems that
focus on recovery and inclusion by appropriately
addressing mental health problems in the context of
the person’s wider ambitions.
The ability to build positive relationships with
community organisations that open up new
opportunities for participation and that challenge
instances of discrimination.
The skills in matching the person with the right
community activity (such as a job, training or leisure
activity), negotiating opportunities and adjustments,
monitoring progress and helping to repair things if
they are at risk of breaking down.
Organisational capabilities include:
Prioritising a public commitment to social inclusion.
Universal and specialist training programmes.
Sufficient resources invested in building and
maintaining alliances with key community
organisations.
Effective monitoring arrangements that examine the
service outcomes (gaining a job, home or new
relationship) and the activities which lead to these
outcomes.
As already discussed, NSIP has worked to embed these
capabilities through a range of interventions including:
Contributing to the ‘10 Essential Shared Capabilities
Training Materials’ 90 and their uptake by local mental
health services.
Building commitment by professional bodies so that
the values and capabilities are built into pre-qualifying
training and continuing professional development for
all mental health staff.
Publishing guidance for commissioners on day
services.
Creating learning communities where people
have an opportunity to share successes, challenges
and solutions.
Throughout the development of these resources, we
have identified the following as key determinants of
socially inclusive practice in mental health organisations:
leadership; coherence of policy and practice; and
achieving specialisation without fragmentation.
Whilst some mental health services have appointed a
social inclusion lead and others have sought to embed
socially inclusive practice in all roles and activities, we
know that progress cannot be made without effective
and strong leadership. The culture change necessary in
some services creates certain barriers that slow progress.
Determined leadership efforts are needed to remain
optimistic, to relentlessly pursue change both within and
beyond the service, and sustain positive practice. In
particular the role of people with mental health problems
and carers as ‘experts by experience’ needs to be further
recognised and built upon, particularly if the aspirations
of co-production are to be realised. This requires a radical
rethink about the nature of leadership in public services
that pays greater attention to building from strengths,
ambitious futures, better outcomes and the challenge of
working with complex systems of care and support.
If the mental health system is to promote socially
inclusive opportunities for people who use their services,
its own activities need to be organised in a way that
aligns with these priorities. It must create a mentally
healthy workplace, employ a representative proportion of
people who have mental health problems and listen
respectfully to people who use its services, carers and
frontline staff. It must build meaningful partnerships with
informal community organisations, whilst building up
external capacity and promoting creative and responsible
risk taking to further the interests of all partners.
Promoting social inclusion tends to be seen as important
but not urgent work, and so it can be repeatedly pushed
aside by crises unless dedicated time is allocated. As well
as specialising in inclusion work, substantial progress can
be made when workers share out responsibility for
community connection and capacity building in
CHAPTER 7 SOCIALLY INCLUSIVE PRACTICE
mainstream community services. For example, if one staff
member builds ongoing links with the local university and
another establishes a relationship with the gym or the
church, then sustained change can be achieved. Such
partnerships create not only opportunities to bring fresh
skills and perspectives; they can also be an avenue to
obtaining new sources of funding and expertise.
ARTS AND MINDS NETWORK
Leeds Partnership NHS Foundation Trust (LPFT) has
developed a multi-agency partnership with a range of
arts organisations as well as voluntary and statutory
partners to establish the Arts and Minds Network.
The partnership secured Arts Council funding for a
series of arts initiatives in health and social care
settings and seed-funding for an arts development
post. This funding has now been mainstreamed by
LPFT with an Arts Development Manager and
Development Worker.
www.artsandmindsnetwork.org.uk
COMMUNITY ORGANISATIONS
NSIP has made significant progress because it has
ensured action to coordinate strategic and national
intervention with local activities. For example, the Castle
Museum, in Nottingham has had a long standing
association with mental health services and their local
work has been enhanced by involvement with the ‘Open
to All’ national programme of mental health training for
museum staff commissioned by NSIP (see Chapter 5).
Similarly, the 15-year history of links between the mental
health service and a large Further Education college has
been strengthened by the national network of education
regional project officers formed through our partnership
with NIACE.
Our strategic and national interventions have created a
supportive climate for local service delivery in several
areas of community life including employment,
education, the arts and community development. These
interventions have blended obligation (such as
information to employers about their duties under the
Disability Discrimination Act) with good practice
examples of what is possible, for example the
awareness-raising activities targeted by NIACE at local
Further Education providers; and the formation of
learning communities, such as the NSIP Affiliates
Network.
It is also worth noting that while we have worked with
large, networked, regulated and centrally funded
34
organisations we have felt it to be as important to work
with small, independent and self-run groups. Much
community activity is informal, unregulated and shortlived and so the task of assisting such groups to offer
people with mental health problems opportunities to
contribute must rely upon their individual relationships
with mental health services.
Achieving spread and sustainability relies largely on
effective relationships between mental health services
and community groups and organisations. These
relationships need to assist people who use mental
health services to make the transition into engaging with
the community beyond the service, whilst retaining
needed supports. They need to monitor what is working
and be able to take action when support arrangements
are found to be inadequate. They need to collaborate on
building sustainable communities whilst ensuring that
funding is used for the right purpose.
DEVELOP (THE DEVELOPING VALUED LIFESTYLES
PARTNERSHIP)
Develop was formed in 2003. It is an informal
consortium of local mainstream organisations, mental
health service providers, people with mental health
problems, their families and associates who work
together promoting social inclusion in the London
Borough of Bromley. Develop coordinates
collaborative networks and inclusive practice forums
using one comprehensive infrastructure to support
inclusion at individual, service and community levels.
www.developbromley.com
POLICY MAKERS, FUNDERS AND REGULATORS
Social inclusion work requires a panoramic view of
policy, funding, regional and local implementation,
regulation and impact across a range of areas. These
include employment, housing, learning and skills,
transport, families, relationships and leisure. Also human
rights, civic responsibilities, access issues,
neighbourhoods, service delivery and development.
Sustainable success demands:
Effective links with local services and people, so that
problems are quickly identified and addressed, while
solutions are easily tested to see if they are fit for
purpose. This is important as frontline workers
sometimes accept ineffective policy and regulation
rather than set about changing it, while policy makers
sometimes pay insufficient attention to local realities.
35
Resources (people, skills and time) to scan the horizon
across a wide range of policy areas and respond to
issues that might hinder or advance the inclusion
agenda for people with mental health problems. These
resources can be scarce at local level.
Strategic alliances with mainstream community
organisations to create dialogue, workable solutions
and convincing cases for change.
A long-term approach that combines both insistence
that change is not delayed with the recognition that
policy, funding priorities and inspection criteria are not
changed overnight.
TRANSFERABILITY TO OTHER GROUPS
There is potential for synergy across traditional client
groups. For example, services for people with learning
disabilities are currently seeking to increase the numbers
in employment as part of the PSA 16 target because
there are so few people with learning disabilities in work.
As a result there has been little focus to date on job
retention for this group, while retention has been a major
feature of employment work in mental health.
STEPPING STONES
A multi-agency programme, launched in 2008,
enables Swindon’s key public sector employers to
maximise their disability equality initiatives by working
together and directly linking to local supported
employment agencies. Between them these agencies
support hundreds of highly motivated disabled people
who are actively seeking employment or work
experience opportunities. The initiative is led by
Swindon Borough Council and now encompasses
Capita, Swindon PCT, Great Western Hospitals NHS
Foundation Trust and Wiltshire Police.
Similarly, the employment activity in learning
disability generates ideas about how to introduce a new
group into the workforce and so offers solutions for
people with long standing mental health problems who
have never worked. Coordination across traditional client
groups will be increasingly important as more health and
social care services adopt outward-facing approaches
and so need to avoid, for example, employer, learning
and volunteer organisations being inundated with
uncoordinated requests for supported access and
reasonable adjustments.
There are also positive examples of how links between
social inclusion and public health are being brought
together to have a positive impact on the experience of
people using mental health and other services.
SMILE (SERIOUS MENTAL ILLNESS LEARNING
AND EVALUATION)
The project utilised funding to create innovation
schemes that improved the physical health of people
with serious mental health problems across a diverse
group of agencies using a range of interventions.
Much more remains to be done if a socially inclusive
approach is to be embedded in the day-to-day
practice of frontline mental health staff and if the barriers
that remain in mainstream community organisations are
to be removed.
CONCLUSION
“I was in such a hopeless place I ended up in secondary
mental health services. Then I took back control of me
and have managed to travel quite a distance down my
recovery path. I have a life again.” 91
This report has detailed the work that has taken an
essentially panoramic view of what was to be done. It
has been rich in content and participative in process.
We, the NSIP team, have been fortunate in having the
opportunity to undertake work that is challenging and
satisfying in equal measure and which could lay
foundations or set a compass point. We hope to have
made the most of the opportunity, building on the
previous effort of others to make at least some progress
in the wide range of areas at which we have looked,
taking the brief to do so from the equally broad remit of
the SEU report.92 Thanks to external partnerships of
great goodwill and the immense collaborative commitment
of so many friends and colleagues, this progress, in a
once new, now well-established area of policy, has been
cost effective and is progress of which we are proud.
The still central role of services and their expectations for
people with mental health problems has determined
something of the focus of our work. There is a major
challenge in how the role of services is to be transformed
in the future. The fundamental importance, and value, of
engaged communities will need to be affirmed ever more
widely. Work on inclusion needs to look critically at the
ways in which services become part of, and accountable
to communities themselves.
We need to see the changes of the last four years
embedded in the activity of the next. This will require
CHAPTER 7 SOCIALLY INCLUSIVE PRACTICE
long-term coordination, regional support and local
implementation. It will also demand wide-ranging, robust
and imaginative leadership, coupled with rigorous
monitoring of person-led, rather than service-led,
outcomes and a strong, collaborative and practical
approach to evidence development.
Combining these efforts will continue to involve
passionate commitment to the dignity of the individual
but it will need to balance this with closer and active
reference to the potential of community life in the many
and diverse communities of which people with mental
health problems are a part. In this, there will be a need
for funding and prioritisation of resources to grow
mainstream capacity and to commission it effectively. We
have tried to use an opportunity, limited by time, to
create a web of action that can impact in such diverse
settings because this is work that is often connected and
contingent rather than linear. Continuing progress will
mean extending this impact.
Responsibility, leadership and a level of effective
coordination remain vital and the growing commitment of
commissioner and regulator alike to the inclusion agenda
is both welcome and essential. Nevertheless, the
practical requirements of innovation, engagement and
shared learning across awkward and complex
boundaries over time will demand a pluralism in
approach to change. Like much else, inclusion can
reasonably be held to be everyone’s responsibility and in
this context, simple delivery solutions based on orthodox
assumptions of responsibility for action may produce an
outcome that is short-lived, especially in a structural
environment in which authority for action is highly
devolved.
This report is a resource to help with the process of local
progress in the future. It conveys ideas, reflects
experience and points to the range of practical tools and
specific resources that we have produced to help
with this local progress. Again, we thank everyone who
has supported our efforts and allowed us to capitalise
theirs. The work continues in ways that are and
must be evolutionary. Inclusion in mental health is a
moral imperative. Its achievement will necessarily be
work in progress.
89 Department of Health, op. cit., 2007.
90 Department of Health, op. cit., 2004.
91 NSIP Reference Group Member.
92 Social Exclusion Unit, op. cit., 2004.
36
37
ANNEXES
ANNEX A RESEARCH AND EVIDENCE
PROGRESS SINCE 2004
Research and evidence is an underpinning strand of
work that has run across the NSIP work streams.
In 2004 the key focus was to identify reliable sources
and gather national and regional data to establish a
baseline against which progress can be assessed over
time. However, there have been areas in which routine
data are not readily available and areas in which the
evidence base is weak. Although research projects have
been commissioned as part of the implementation
programme to address some of the identified gaps,
further work has been needed. NSIP and Shift have both
helped to continue strengthening the evidence base on
mental health and social inclusion. For example by:
i
Hosting a symposium bringing together researchers
and representatives from a range of organisations
and networks with an interest in mental health
and social inclusion research and evidence.
From this, a collaborative research and evidence
coalition has been established as a mechanism
for developing a strategic approach to strengthening
the evidence base.
ii Supporting the INDIGO project (International Study of
Discrimination and Stigma Outcomes), which will
establish detailed international data on how stigma
and discrimination affect the lives of people with a
diagnosis of schizophrenia, from the point of view of
people with mental health problems themselves. The
project has been completed and is due to be
published early 2009.
iii Establishing an Interactive Inclusion Database to
provide a multi-layered search tool allowing a
gradually narrowing search across regions, life
domains, towns and project names. The database
contains good practice and information about existing
socially inclusive projects throughout the country and
is a useful resource both regionally and nationally.
iv Sitting on a mental health group, convened by the
Sainsbury Centre for Mental Health (SCMH), to work
on key performance indicators for work and
employment. It will produce a toolkit that can be used
to monitor employment services and outcomes –
including indicators on local employment context,
client characteristics, service effectiveness indicators
and individual level outcomes and this is due for
publication in 2009.
v Sitting on the advisory group for the Adult Psychiatric
Morbidity Survey 2006/07; new topics introduced
38
include social capital and participation, discrimination
and sexual identify, religion and spirituality.
vi Contributing to a research study on the benefits and
outcomes of participation in mental health arts
projects. The study was conducted by a team from
Anglia Ruskin University and the University of Central
Lancashire (UCLan). Its purpose was to identify
appropriate indicators of mental health aimed at social
inclusion outcomes and, to develop and implement
an evaluation framework based on these. The work:
Included a survey of arts and mental health
projects in England to map the range of activity and
establish what evaluation data projects collect.
Conducted a retrospective analysis of data from
two projects in relation to their health and social
benefits.
Developed indicators and measures to evaluate
arts projects.
The research team also validated a measuring tool for
the impact of arts participation on promoting social
inclusion.
NEXT STEPS
This work is critical to developing and measuring the
impact of social inclusion policy implementation. The
research network has supported the development of
effective research approaches to inclusion and the move
towards evaluating progress in key areas.
There is a need to continue to grow an effective and
practical evidence base for inclusion. Academic/practice
partnerships will be key to this. Through UCLan, NSIP
has established an academic network involving some ten
universities and is linked to international academic
settings to develop this work. Led by UCLan from a new
organisation within the International School for
Community, Rights and Inclusion, the network will seek
to drive the research agenda in practical ways,
collaborating on bids and working to support local
evaluation and knowledge transfer.
A strategic network for social care leads in trusts has
been established in partnership with SCIE and a
commissioning network has been created to develop
socially inclusive outcomes. Specific work is being
undertaken in the Eastern region with the regional
development centre and Strategic Health Authority to
support local PCTs with outcomes development.
Equally, it will be important to work in the other domains
of community life where there are still major barriers to
39
social participation. We will seek to challenge those
barriers and in the process help reduce the
discrimination that they cause. We will do this by
optimising shared learning and innovation; building
further the evidence base for inclusion in practical ways;
working with our partners in support of real change at all
levels in services and beyond; and taking particular
account of new regional and local organisations and the
opportunities that they represent.
The key priorities for the coming year include:
Identifying a range of stakeholders and expanding
membership of the group, particularly focusing on the
engagement of researchers with experience of people
with mental health problems in the process.
Developing communication and dissemination
systems, including links with service providers and the
academic community, as a means of sharing relevant
evidence and research findings more widely.
Coordinating research activity and facilitating
communities of interest around specific topics and
issues.
Exploring opportunities for collaboration to
secure funding for research to strengthen the
evidence base. Also for influencing existing research
streams to ensure a focus on social inclusion issues
and outcomes.
ANNEX B PUBLICATIONS AND RESOURCES
Outcomes Framework for Mental Health Services
Direct Payments for people with mental health
problems: A guide to action
www.socialinclusion.org.uk/home/index.php
www.socialinclusion.org.uk/publications/
2009
40
Direct_Payments_web.pdf
National Social Inclusion Programme Fourth
Annual Update
www.socialinclusion.org.uk/publications/4th_AnnualReview.pdf
An introduction to Direct Payments in mental health
services: Information for people eligible to use
mental health services and carers
2008
www.socialinclusion.org.uk/publications/Direct_Payments_SU_
How will my newly redesigned day service help me?
Guide.pdf
www.socialinclusion.org.uk/publications/DayServicesLeaflet.pdf
Finding and Keeping Work
Choice Based Lettings for People with Mental Health
Problems: A Briefing Guide
www.socialinclusion.org.uk/publications/Toward_a_MH_emplo
www.socialinclusion.org.uk/publications/NSIP_CBL_briefing.pdf
yment_strategy_revsied_after%20repairs.pdf
‘Open to All’ Mental health and Social Inclusion
Awareness Training for Museums and Galleries
www.socialinclusion.org.uk/work_areas/index.php?subid=93
2005
Direct Payments in mental health: What are they
being used for?
kc.csip.org.uk/upload/Examples%20of%20DP.pdf
From segregation to inclusion: Where are we now?
www.socialinclusion.org.uk/publications/NSIPDSReview.pdf
National Social Inclusion Programme First Annual
Report
The Really Useful Book of Learning and Earning
www.socialinclusion.org.uk/publications/
www.socialinclusion.org.uk/publications/ReallyUsefulBook.pdf
NSIP_AnnualReport_FIN.pdf
2007
JOINT OR COMMISSIONED PUBLICATIONS WITH
PARTNER ORGANISATIONS
National Social Inclusion Programme Third Annual
Update
www.socialinclusion.org.uk/publications/NSIP32007.pdf
Outcome Indicators Framework for Mental Health
Day Services
Connect and Include – an exploratory study of
community development and mental health CDF,
commissioned by NSIP
www.socialinclusion.org.uk/publications/CDFFINAL.pdf
www.socialinclusion.org.uk/publications/DSdoccover1.pdf
2006
National Social Inclusion Programme Second
Annual Report
Work Matters: Vocational Navigation for
Occupational Therapy Staff, jointly published with
the College of Occupational Therapists
www.socialinclusion.org.uk/publications/
www.socialinclusion.org.uk/publications/NSIP_AR2006.pdf
Work%20Matters%20Booklet%20for%20CD.pdf
Improving the effectiveness of rent arrears
management for people with mental health problems
Mental Health, Social Inclusion and Arts: developing
the evidence base
www.socialinclusion.org.uk/publications/Rentarrearsbriefing.pdf
www.socialinclusion.org.uk/publications/MHSIArts.pdf
Vocational services for people with severe mental
health problems: Commissioning guidance
www.socialinclusion.org.uk/publications/
Getting through: Access to mental health services
for people who are homeless or living in temporary
or insecure accommodation. A good practice guide
DOH_Vocational_web.pdf
www.socialinclusion.org.uk/publications/Gthroughguide.pdf
From segregation to inclusion: Commissioning
guidance on day services for people with mental
health problems
Action on Mental Health: A Guide to Promoting
Social Inclusion
www.socialinclusion.org.uk/publications/Day_Services_web.pdf
Action_on_Mental_Health%20Fact_Sheets.pdf
www.socialinclusion.org.uk/publications/
Mental Health and Social Exclusion
www.socialinclusion.org.uk/publications/SEU.pdf
ANNEX C ACKNOWLEDGEMENTS
CURRENT TEAM MEMBERS (INCLUDING SECONDEES
AND PART-TIME CONTRIBUTORS)
EXPERT ADVISORS
Malcolm Barrett
Local Liaison and User Development
Sona Peskin
Peter Bates
Development Consultant
Rosemary Wilson
Victoria Betton
Trust Development Associate
Diane Hackney
Fran Singer
REFERENCE GROUP
Les Aqil
Alex Burner
Service User Involvement Lead
Susan Ambury
Marco Carrera
Programme Coordinator
Randall Chan
David Clarke
Regional Employment Team Coordinator
Penny Connorton
Fabian Davis
Associate Director
Kaaren Cruse
Claire Etches
Social Exclusion Lead
Lorraine Looker
Gerry Bennison
Bev Chipp
David Cooke
John Holmes
Tony Martin
Dave Gardner
Commissioning Associate
Naomi Hankinson
Assistant Director
Fiona Hill
PA to David Morris
Kathryn James
Assistant Director Learning and Skills
Robin Johnson
Housing Lead
Neil Lowther
Assistant Director Employment
David Morris
Programme Director
Robin Murray Neill
Personalisation Lead
Marian Naidoo
Arts Lead
Steve Onyett
Leadership Associate
Zoe Robinson
Business and Communications Director
Stafford Scott
‘Communities of Influence’ Manager
Ben Taylor
Day Services Lead
Micheal Osbourne
Lizzie Walker
Robert Walker
Mike Walsh
PAST TEAM MEMBERS
Sue Christoforou
Voluntary Sector Lead
Christa Drennan
Assistant Director Community Participation
Simon Francis
Employment Lead
Antonia Furmston
Administrator and Events Coordinator
Sarah Hill
Business and Communications Director
Clare Mahoney
Children and Families Lead
Rebecca Mitchell
Programme Coordinator
Annette Reinli
Programme Coordinator
Miles Rinaldi
Head of Delivery
41
ANNEX C ACKNOWLEDGEMENTS
CSIP
Paddy Cooney
CSIP Executive Lead
NIMHE
Peter Horn
NIMHE Executive Lead
NSIP would like to thank all of the people and
organisations that have helped to improve social
inclusion outcomes for people with mental health
problems, especially:
Barnardos
British Psychological Society
College of Occupational Therapists
Community Development Foundation
SOCIAL INCLUSION AND REGIONAL
EMPLOYMENT TEAM LEADS
Carey Bamber
Marion Blake
Sarah Joy Boldison
Stephany Carolan
Barbara Crosland
Shawn Crowe
Trish Crowson
Huw Davies
Mary Dunleavy
Jennette Fields
Lynne Hall
John Howat
Louise Howell
Neil Johnson
Brendan McLoughlin
Kate O’Hara
Jude Stansfield
Colin Williams
Learning and Skills Council
Mental Health Foundation
Mind
New Economics Foundation
National Institute of Adult Continuing Learning
Richmond Fellowship
Royal College of Nursing
Royal College of Psychiatrists
Rethink
Sainsbury Centre for Mental Health
Social Care Institute for Excellence
University of Central Lancashire
42
design: www.gilldavies.co.uk
www.socialinclusion.org.uk
Outcomes Framework
for
Mental Health Services
National Social Inclusion Programme
2009
A. INTRODUCTION
What this Framework is for
This framework is focused on adults of working age with mental health problems.
It is a development of the outcomes framework for day services published in
2007 as part of the work of the National Social Inclusion Programme (NSIP) on
day services modernisation and the programme’s wider work on the life domains
in which exclusion occurs. It sets out some suggested outcomes for inclusion as
a resource to commissioners and providers looking to advance inclusion practice
through locally established outcomes for monitoring and evaluating service
effectiveness.
Many health and social care services are being refocused to promote social
inclusion, including the role of work and gaining skills, in line with current policy
and legislation. Changing the way services are delivered will improve lives and
help achieve a range of objectives, including those laid out in the following policy
documents and guidance:
•
•
•
•
•
•
•
•
•
•
Mental Health and Social Exclusion (2004)
Reaching Out: An action plan on social exclusion (2006)
From Segregation to Inclusion: Commissioning guidance on day services
for people with mental health problems (2006)
Supporting Women into the Mainstream: Commissioning Women-only
Community Day Services (2006)
Vocational services for people with severe mental health problems:
Commissioning guidance (2006)
Direct Payments for people with mental health problems: A guide to action
(2006)
Our health, our care, our say: a new direction for community services
(2006)
Putting People First: A shared vision & commitment to the transformation
of Adult Social Care (2007)
Refocusing the Care Programme Approach (2008)
Working for a healthier tomorrow (2008)
Monitoring and evaluating outcomes locally is key to ensuring the effectiveness
and positive impact of redesigned or refocused services. Fundamental refocusing
and redesign takes time, and impact should increase as services develop. It is
important to set realistic local targets to clarify what is expected of services in the
short and medium term.
The initial framework has been broadened to provide for possible application in
mental health services more widely, specifically those seeking to support people
to become more included such as outreach, employment and housing support
services.
2
Outcome measurement is an increasingly important and valued tool in monitoring
the effectiveness of health and social care services to improve lives and achieve
targets. As such, it is important that commissioners and providers have
resources that enable them to do this effectively.
Definitions
When discussing monitoring and evaluation, terminology is very important as
people often have differing understandings of how a term should be used.
The definitions used in this paper are taken from those developed by the
Charities Evaluation Service (CES, 2004 & 2006; CES/BLF, 2004) and are
summarised in Appendix 1. This paper is designed to include both quantitative
and qualitative outcomes, which have been aggregated to demonstrate the
impact of a service.
How to Use the Framework
The framework is divided into categories to reflect the different life domains and
functions of mental health services. All of the outcomes, with the exception of
those under the heading ‘Service Outcomes’, (Service User Satisfaction, Service
User Involvement and Diversity) relate to outcomes for individual service users.
Neither the outcomes nor the indicators listed are intended to be either definitive
or prescriptive. The number of outcomes in each category has been limited to
two, as has the small number of key indicators. These were selected as being
those felt to be most suited to evidencing progress in each category and there
will inevitably be additional intended and unintended outcomes and potential
indicators.
Outcome Indicators in each category are divided into Key and Additional
Indicators in order to support the application of the framework in different ways
according to local circumstances. For example, commissioners may want a
relatively small number of key indicators for providers to report against but
providers may want to measure against a wider range of indicators in order to
demonstrate the breadth of their work and to monitor the progress of an
individual.
The indicators are mostly expressed in terms of the number of people to whom
they apply (i.e. those who have chosen this life domain as a personal goal).
However, commissioners may choose to request information based on the
proportion of service users to whom the indicators apply.
3
There is more than one way of utilising this framework and its use will be locally
determined. Possible approaches include:
1. Counting the number or proportion of service users who have achieved each
outcome indicator through the support of a service in a given timeframe (e.g.
quarterly, six monthly, annually) giving easily comparable data, and to
supplement this with a small number of case examples (e.g. two for each
outcome area), giving a more detailed sense of the work undertaken and change
achieved.
2. Creating a table which, for each indicator, measures a baseline, people
supported to achieve that outcome indicator and people supported to sustain that
change or activity.
3. Discussing the categories and indicators with people using services as part of
a needs assessment or support planning process. People using the service may
want to add indicators that feel particularly relevant to them.
It is important to recognise that there is some necessary variation in the design of
mental health services across the country and that various frameworks of
outcome objectives will already be in place (see below). Expectations of services
with regard to outcome monitoring may differ according to their design and the
indicators that are monitored should be selected according to the aims and
purpose of the service. For example, an employment service may major on
most, if not all of the employment related indicators, but have fewer or no
indicators relating to independent living.
Methods for monitoring outcomes and the selection of tools to support this are
also a matter of local choice. Section D contains a list of possible tools that could
be used to support outcome measurement. It also highlights possible sources of
supporting evidence in demonstrating that the outcomes have been achieved.
However, in recognition that some commissioners and providers would like an
outcome measurement tool which links directly to this framework, a simple
measurement tool is currently in development to accompany the framework and
will be available on www.socialinclusion.org.uk by spring 2009.
Links to National and Regional Outcome Indicators
Commissioners and providers will be aware of a range of regional and national
outcome indicators against which they are expected to report and against which
targets may be set. The outcomes in this framework are designed to incorporate
information which contributes to this reporting, but some indicators may need
to be adjusted to fit with the expectations in a particular region or locality.
Information relating to the new NHS contracting arrangements, HealthCare
Commission Standards and PSA targets can be found in Appendix 2.
4
Possible sources of supporting evidence
The following may provide sources of evidence that socially inclusive working
practices are in place and that social inclusion outcomes are being achieved:
•
•
•
•
•
Individual, holistic assessments of needs
Individualised person-centred recovery plans
Working partnership agreements with mainstream services and
organisations
Operational plans and development plans for services
Standardised outcome measures.
5
B.
INTENDED OUTCOMES & INDICATORS FOR
INDIVIDUALS
Important
It is suggested that services using this framework should only record outcomes
against the indicators when the service has been involved in successfully
supporting an individual to make the relevant change in their lives. Therefore an
outcome for beginning voluntary work in a mainstream organisation should only
be recorded when the service user has begun the work, rather than when they
receive the support.
It should not be assumed that every indicator is appropriate to every individual as
a measure of social inclusion. For example, an individual may have a high level
of educational attainment and so would find this indicator irrelevant. Conversely,
an individual may have low educational attainment but would prefer a vocational
route to employment. Indicators should only be used where they relate to a
personal goal set by an individual in discussion with their support/key worker or
care co-ordinator.
Services should only record outcomes against the indicators when the outcome
is, at least in part, attributable to the interventions or support of that service, and
not when it was achieved independent of and coincidental to the service being
provided.
Some of the indicators include value judgments (e.g. ‘positive new relationships’).
This is necessary to capture significant positive outcomes without inadvertently
capturing negative outcomes. It is important that there is self-definition in
deciding whether these indicators have been met (i.e. it is the service user who
makes the value judgment).
Community Participation
Intended Outcomes
•
Increased number of
people with mental
health problems
volunteering in
mainstream settings
•
Increased number of
Key Outcome Indicators
• Number of people supported to begin volunteering
in mainstream organisations
• Number of people supported to begin accessing
mainstream sports, exercise, arts, cultural or other
leisure groups or facilities
Additional Outcome Indicators
• Number of people supported to take up a new or
develop an existing/dormant leisure pursuit
6
people with mental
health problems
participating in or
engaging with local
community activities
•
•
•
•
•
•
Number of mainstream organisations supported to
offer more welcoming access to people with mental
health problems
Number of people supported to begin voluntary
work within a mental health service they are using
Number of people supported to apply for voluntary
work in a mainstream organisation
Number of people supported to begin engaging
with local civic organisations, for example, as
members of local Foundation Trusts
Number of people supported to sustain regular
volunteering or access to leisure groups or facilities
for six months
Number of people supported to access chosen
faith activities
Social Networks
Intended Outcomes
•
Increase in the size
and range of social
networks for people
with mental health
problems
•
Increased number of
people with mental
health problems
maintaining social
and caring roles
Key Outcome Indicators
• Number of people supported to develop positive
new relationships/friendships
• Number of people supported to strengthen existing
relationships with family or friends
Additional Outcome Indicators
• Number of people enabled to begin giving support
to others
• Number of people supported to begin accessing
peer support or self-help groups
• Number of people supported to access appropriate
family interventions
• Number of people supported to maintain parenting
and caring roles through a crisis period
Employment
Intended Outcomes
•
Increased number of
people with mental
health problems
preparing for
employment by
Key Outcome Indicators
• Number of people supported to begin paid
employment: Full Time (over 16 hours a week) and
Part Time (under 16 hours a week)
• Number of people supported to access job broker
or other employment support service
7
Additional Outcome Indicators
building their work
capacity and skills or • Number of people supported to access advice
looking for work
about employment issues
• Number of people supported to develop CVs
• Increased number of
and/or interview skills
people with mental
• Number of people supported to develop skills
health problems
which increase their employability
entering and/or
• Number of people supported to apply for paid
retaining paid
employment
employment
• Number of people supported to attend a job
interview
• Number of people supported to make reasonable
adjustments or change to more suitable
employment
• Number of people supported to maintain/retain
employment through a crisis period
• Number of people supported to become selfemployed
• Number of people supported to begin work
experience or work placement
Education and Training
Intended Outcomes
•
Increased number of
people with mental
health problems
accessing education
and training
opportunities
•
Increased number of
people with mental
health problems
attaining
qualifications
Key Outcome Indicators
• Number of people supported to begin a
mainstream education or training course
• Number of people supported to complete a
mainstream education or training course
Additional Outcome Indicators
• Number of people supported to apply for a
mainstream education or training course
• Number of people supported to attend an interview
or information session for a course
• Number of people supported to identify funding for
an education or training course
• Number of people supported to obtain a
qualification (state level)
• Number of people supported to maintain/retain an
education or training course through a crisis period
• Number of people supported to begin a discrete
(mental health only) education or training course
8
Physical Health
Intended Outcomes
•
Improved physical
health for people
with mental health
problems
•
Increased number of
people with mental
health problems
taking regular
exercise
Key Outcome Indicators
• Number of people supported to begin regular
physical activity/exercise
• Number of people supported to begin accessing
support relating to their physical health
Additional Outcome Indicators
• Number of people supported to access health
promotion activities such as smoking cessation
• Number of people supported to make positive
changes to their diet or lifestyle leading to
sustained health benefit
• Number of people with mental health problems
taking regular exercise
• Number of people supported to make changes
leading to a reduction in physical health symptoms
• Number of people supported to address substance
misuse issues
Mental Wellbeing
Intended Outcomes
•
Improved quality of
life, confidence and
self-esteem for
people with mental
health problems
•
Increased ability to
manage own mental
distress for people
with mental health
problems
Key Outcome Indicators
• Number of people supported to develop and begin
using new coping strategies
• Number of people supported to decrease their
reliance on mental health services
Additional Outcome Indicators
• Number of people supported to make changes
leading to enhanced confidence and self-esteem
• Number of people supported to make changes
leading to a reduction in mental distress
• Number of people supported to be positively
involved in decisions about their medication or
treatment
• Number of people supported to develop a Wellness
Recovery Action Plan (WRAP) or similar recovery
plan
• Number of people supported to train as Peer
Support specialists
• Number of people supported to avoid the need for
a hospital admission
9
Independent Living
Intended Outcomes
•
Increased number of
people with mental
health problems
living in independent
accommodation
•
Increased number of
people with mental
health problems
receiving
appropriate benefits/
financial advice
Key Outcome Indicators
• Number of people supported to move to more
independent accommodation
• Number of people supported to effectively manage
their own finances
Additional Outcome Indicators
• Number of people supported to move to more
suitable (but not more independent) housing
• Number of people supported to address and
reduce a debt problem
• Number of people supported to open a bank
account or savings scheme
• Number of people supported to develop new skills
for independent living (e.g. cooking, shopping)
• Number of people supported to access advice
regarding their finances, benefits or debts
• Number of people supported to begin leaving the
house and/or using public transport independently
• Number of people supported to manage
relationships with neighbours
• Number of people supported to resolve issues with
their landlord
Personalisation & Choice
Intended Outcomes
•
Increased number of
people with mental
health problems
controlling their own
support
•
Increased number of
people with mental
health problems in
receipt of direct
payments or
individual budgets
Key Outcome Indicators
• Number of people supported to begin accessing
direct payments or individual budgets
• Number of people supported to become more
actively involved in decision making regarding their
support
Additional Outcome Indicators
• Number of people supported to begin using direct
payments to fund daytime activity or community
participation
• Number of people supported to assert their needs
with a health or social care provider
•
Number of people supported to access exercise,
arts or books on prescription
10
C.
SERVICE OUTCOME INDICATORS
These Indicators refer not to outcomes for the individual, but to outcomes for
mental health and related services. They can be used to help identify service
gaps and improvements required.
Service User Satisfaction
NOTE: Achievement against these indicators can be measured using a service
user questionnaire incorporating questions directly relating to the indicators
Intended Outcomes
Key Outcome Indicators
• Increased levels of
• Proportion of service users expressing that the
satisfaction of
service helps them engage with their local
service users with
community
the delivery and
• Proportion of service users expressing that the
outcomes of the
service enables them to achieve their personal
service
goals
Additional Outcome Indicators
• Increased proportion • Proportion of service users expressing that the
of service users
service helps them manage their mental health
reporting that they
needs
have achieved their
• Proportion of service users expressing that the
goals
support they receive is responsive to their needs
• Proportion of service users expressing that the
support they receive assisted them to achieve their
life goals
• Proportion of service users expressing that the
support they receive meets their cultural needs
Service User Involvement
Intended Outcomes
• Increased levels of
involvement of
service users in the
design, delivery,
management, review
and development of
services
•
Key Outcome Indicators
• Number of user run activities taking place within
the service
• Number of service users involved in service design,
delivery, management, review & development
Additional Outcome Indicators
• Number of service user representatives on the
organisation’s Board (or equivalent)
• Number of user led evaluations of services
Increased number of • Proportion of staff recruitment panels that include
people with mental
service users
health problems
• Proportion of people employed in the service who
involved in delivering
have mental health problems
11
services and/or
activities
•
Number of service users providing training for
mental health service staff
Diversity
Intended Outcomes
•
Equality of access to
day services for all
people with mental
health problems
•
Services which
specifically meet the
needs of underrepresented groups
Key Outcome Indicators
• Balance of service users responds to the needs of
local population in terms of: age, ethnicity, gender,
disability, sexuality and faith
• Number of specific services or arrangements to
meet the needs of under-represented groups
Additional Outcome Indicators
• Number of people supported to use mainstream
organisations to meet their specific diverse needs
• Number of mainstream organisations engaged to
provide tailored services
12
D. OUTCOME MEASUREMENT
Approaches to Outcome Measurement
Some of the most commonly used approaches to data collection are:
•
•
•
•
•
Questionnaires
Interviews
Observation
Record Keeping
Case note review
People who might contribute to making an assessment regarding outcomes
include:
•
•
•
Service Users (self-assessment)
Carers and significant others
Staff
It is often helpful to incorporate more than one of these approaches and sources
of assessment into an outcomes monitoring system in order to achieve as
complete and accurate a picture as possible of the outcomes that have been
achieved.
Recognised Social Inclusion Outcome Measurement Tools
These tools may prove useful in helping to measure and monitor outcomes.
This is not intended to be a comprehensive list and further tools will emerge
over time.
1. Recovery Star (Mental Health Providers Forum/Triangle Consulting)
The Recovery Star has been developed by the Mental Health Providers Forum.
It is a tool for supporting and measuring change when working with adults of
working age who are accessing mental health support services. As an outcomes
measurement tool it enables organisations to measure and summarise:
the progress being made by service users
the service being delivered through a project
The Recovery Star is also a key working tool and can be used to undertake a
needs assessment, to support planning as well as for outcome measurement. It
is designed to support individuals in understanding where they are in terms of
recovery and the progress they are making, providing both the client and worker
a shared language for discussion mental health and wellbeing.
13
Core dimensions of the Recovery Star
The Recovery Star identifies and measures ten core areas of life:
Managing mental health
Self-care
Living skills
Social networks
Work
Relationships
Addictive behaviour
Responsibilities
Identity and self-esteem
Trust and hope
The Recovery Star helps to identify any difficulties people using service are
experiencing in each of these areas and how far they are towards addressing
them and moving on.
You can find out more about the Recovery Star on the Mental Health Providers
Forum website: http://www.mhpf.org.uk/recoveryStarApproach.asp
2. The Outcomes Star (London Housing Foundation/Triangle
Consulting)
The Outcomes Star (on which the Recovery Star was based) was developed for
use in services for homeless people, and has a broader remit than just
measuring social inclusion outcomes, although this forms an important element
of the tool. It is a visual tool which looks to measure change on a 10 point scale
in each of 10 areas of life:
•
•
•
•
•
•
•
•
•
•
Motivation and Taking Responsibility
Self Care and Living Skills
Managing Money and Personal Administration
Social Networks and Relationships
Drug and Alcohol Misuse
Physical Health
Emotional and Mental Health
Meaningful Use of Time
Managing Tenancy and Accommodation
Offending
As with the Recovery Star (and Inclusion Web), this is primarily a tool to promote
individual planning, but data can be aggregated as a means of monitoring
changes in a population over time.
The Outcomes Star and associated materials and guidance are available to
download through a Creative Commons Licence from
www.homelessoutcomes.org.uk
14
3. Inclusion Web (National Development Team)
The ‘inclusion web’ is a visual tool that can be used to enable service users to
map significant people and places across life domains (employment, education,
volunteering, arts & culture, faith communities, family & neighbourhood, physical
activities & services). Whilst this is primarily a tool to promote individual planning,
data can be aggregated as a means of monitoring changes in a population over
time.
Further information about the web can be found at www.ndt.org.uk or at:
http://uk.groups.yahoo.com/group/TheSocialInclusionWebGroup/.
15
E. REFERENCES
A Prospectus for Arts and Health (DH & ACE, 2007)
Advanced Evaluation and Monitoring (Training Pack) CES, 2006
Guidance Paper 3: Key Terms and Definitions, CES, 2004,
www.ces-vol.org.uk
Capabilities for Inclusive Practice (DH, 2007)
CES/BLF, 2004, Your Project and Its Outcomes
Supporting Women into the Mainstream (DH), 2006b,
Commissioning Women-only Community Day Services
Day Services Outcomes Framework (NSIP, 2007)
Delivering Race Equality in Mental Health Care (DH, 2005)
Developing a Framework for Vocational Rehabilitation (DWP,2004)
Direct payments for people with mental health problems: A guide to action (DH,
2006)
Ending child poverty: everybody's business (DCFS & DWP, 2008)
From Segregation to Inclusion: Commissioning Guidance on Day Services for
People with Mental Health Problems (DH), 2006a,
Health, work and wellbeing – caring for our future (DWP, DH, HSE, 2005)
High Quality Health for All (DH, 2008)
Independence, wellbeing and choice (DH, 2005)
In work, better off; next steps to full employment (DWP, 2007)
Mental Health and Social Exclusion (Office of the Deputy Prime Minister, 2004)
Mental Health Social Inclusion and Arts: Developing the Evidence Base (DH),
2007,
Our health, our care, our say: a new direction for community services (DH, 2006)
National Action Plan on Social Inclusion 2006- 2008 – Working together (2006)
National Suicide Prevention Strategy for England (DH, 2002)
No one written off, reforming welfare to reward responsibility - Welfare Reform
Green Paper (2008)
Putting People First: A shared vision & commitment to the transformation of Adult
Social Care (DH, Dec 2007)
Reaching Out: An action plan on Social Exclusion Report (Sep 2006)
Ready for Work: full employment in our generation (DWP, 2007)
Ready for Work, Skilled for work (DIUS & DWP, 2008)
Refocusing the Care Programme Approach (Mar 2008)
Report of the Review of the Arts and Health Working Group (DH, 2007)
Supporting Women into the Mainstream (DH/NIMHE, 2006)
Tackling Health Inequalities, A Programme for Action (DH, 2003)
Vocational services for people with severe mental health problems:
Commissioning guidance (DH & DWP, 2006)
Working for a Healthier Tomorrow (DH & DWP, 2008)
Working Neighbourhoods Fund (DCLG & DWP, 2007)
16
F. ACKNOWLEDGEMENTS
This framework was produced by the National Social Inclusion Programme.
Many thanks to all those who developed and contributed to the development of
this document and its predecessor - the Mental Health Day Services Outcome
Indicators Framework, and in particular:
The 5 organisations who piloted the Day Services Framework during 2008
and fed back on their experiences:
Bromley Mind
Community Restart at Lancashire Care NHS Trust
Huntingdon Recovery and Partnership Team at Cambridgeshire
and Peterborough Mental Health Partnership Trust
Quest Day Opportunities at Staffordshire Council
Richmond Fellowship in Wigan
Plus the 22 mental health commissioners who commented on the
framework.
17
G. APPENDICES
Appendix 1
Definitions (Adapted from the Charities Evaluation Service)
Aims Describes the changes you are trying to achieve
Quantitative Measures Those “where you count numbers of things that happen,
such as the number of people who found jobs following some computer training”
(CES/BLF, 2004)
Qualitative Measures Those “where you assess people’s views and
experiences, such as how safe older people feel going out at night” (CES/BLF,
2004).
Outcomes The changes, benefits, learning or other effects that actually occur as
a result of your activities.
Outcome Indicators The things you can use to assess whether the expected
outcome is occurring. They assess progress towards meeting aims. They are a
type of performance indicator and can be qualitative or quantitative.
Objectives Describes the mechanism/process and planned activities by which
you are going to achieve your aims
Outputs The activities, services and products provided by an organisation.
Output Indicators The things you can use to assess whether you have achieved
your outputs. They assess progress towards meeting objectives and are a type of
performance indicator.
18
Appendix 2
NHS Contracting Arrangements
A new NHS standard contract, covering agreements between PCTs and
providers for the delivery of NHS funded services for mental health, will be
implemented from April 2009.
The outcome indicators framework can be used by commissioners to support
development of each of the three key sections of the contract as appropriate –
the mandatory elements (centrally set), mandatory elements to be defined by
local agreement, and the additional elements to be defined by local agreement.
Visit www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091451
for more information.
Regulation of national standards and targets
The Care Quality Commission will come into force in April 2009, and take over
the functions of the Healthcare Commission, the Commission for Social Care
Inspection (CSCI) and the Mental Health Act Commission (MHAC). Its remit will
cover both health and social care services.
The existing inspection bodies are responsibly for providing assurance that NHS
Trusts and adult social care services in England are meeting essential standards
of quality and safety for everyone.
This is currently undertaken by the through a variety of methods including the
Annual Health Check (HCC), national reviews (HCC & CSCI) and staff and
patient surveys. Assessment of services in relation social inclusion domains can
be found within each of these elements. For example, the community patient
survey asks specific questions relating to employment, support groups and
benefits advice.
The outcomes framework can be used to generate evidence for commissioners
and providers that they are meeting relevant national standards.
Summary of key PSA Targets which the refocusing of mental health
services can contribute to:
•
•
PSA 8 –
PSA 15 –
•
PSA 16 –
Employment opportunity for all.
Address the disadvantage that individuals experience
because of their gender, race, disability, age, sexual
orientation, religion or belief.
Increase the proportion of socially excluded adults in settled
19
•
PSA 17 –
•
•
•
PSA 18 –
PSA 19 –
PSA 21 –
accommodation and employment, education or training
employment and housing outcomes for socially excluded
adults.
Tackle poverty and promote greater independence and
wellbeing in later life.
Promote better health and wellbeing for all.
Ensure better care for all.
Build more cohesive, empowered and active communities.
20
Indicators of occupational need:
- a brief guide to what may indicate service user need for occupational therapy
helping people lead ordinary lives in extraordinary circumstances
Occupational therapy focuses on the nature, balance, pattern and context of occupations and activities in the dayto-day lives of individuals, family groups and communities. It is concerned with the meaning and purpose people
place on occupations and activities, and with the impact of illness, disability and social or economic deprivation on
their ability to carry them out. Occupational therapy uses the knowledge that the relationship between occupation
and health is reciprocal – individuals experiencing health problems will likely see it impact on their abilities and
occupational performance, whereas positive occupational experience and success undertaking activities carries
health benefits and promotes recovery, thus helping people successfully resume ordinary lifestyles despite
extraordinary circumstance.
The main aim of occupational therapy is to maintain, restore, or create a match, beneficial to the individual,
between the:
-
abilities of the person,
-
the demands of her/his occupations
-
the demands of the environment
The desired outcome of occupational therapy intervention is that the person achieves a satisfying performance,
and balance of occupations, in the areas of self care, productivity and leisure, that will support recovery, health,
wellbeing and social participation (Creek 2003).
To achieve this, the therapist looks with the service user at her/his range and balance of occupations, and
together they identify problems, deficits, and strengths. The therapist then narrows her/his focus of
attention and works on the specific activities, tasks or skills that will best utilise the individual’s assets,
remediate deficits, and enable the person to enact her/his occupations more effectively. Where this is not
possible, the therapist will adapt the desired activity so the individual is able to carry it out, or help make
changes to their client’s physical, cultural, institutional or social environments to facilitate occupational
performance. The therapist then shifts the focus outwards again, to see what effect the action has had on
the person’s overall pattern of occupations. This shift of perspective happens many times during the period
of contact between occupational therapist and service user (Creek 2003).
Where teams have access to occupational therapy, it is likely to be a limited resource. This can mean
the occupational therapist becomes overwhelmed with demand for in-put or conversely, due to
unfamiliarity with what can be provided, or belief that the resource cannot be accessed, colleagues
may rarely make specific demands for occupational investigation (be it through consultation; full
assessment; short or longer term intervention, or any combination of these things) . Discussion with
occupational therapists, managers and team leaders is developing consensus on what constitutes a
priority for occupational therapy input, The following summary is to assist teams identify when a
person might benefit from occupational assessment or intervention.
There are three overriding conditions identified as necessary components for occupational therapy to
progress appropriately:
x
that the individual can articulate some level of dissatisfaction regarding the balance,
range and meaningfulness of their day-to-day activities, and/or their level of ability in
performing occupations; or in circumstances where the service user does not have insight
or capacity to express such dissatisfaction, the carer/family member may themselves do
so;
Occupational Therapy - Indicators
Page 1
June 2009
Refs: Creek J (2003) Defining occupational therapy as a complex intervention College of Occupational Therapists, London
nd
Wilcock A (2006) An occupational perspective of health (2 edition) Slack New Jersey, USA
x
that the person with capacity to consent, does consent to the occupational therapy
intervention; where the person does not have capacity, the therapist is required to
observe for signs of implied consent and act accordingly;
x
that there is a likelihood of the person benefiting from the intervention.
The following represents key indicators suggesting a consultation with an occupational therapist be
sought, an assessment offered if appropriate, and where indicated, interventions provided. This
flow represents the order of priority given to the indicators of need:
Occupational assessment should be considered where there is:
Urgent need for person to maintain dignified independence in daily
living skills, or increase level of safe functioning
For example: Where mental illness or cognitive impairment severely impacts
on independent living skills; level of support has changed/will imminently
change; carers unable to continue with level of input; environmental change
necessitates increased independence
And/or
Marked limitation to range of occupations- severe imbalance
between occupational domains
For example: All/most of the person’s energy taken up in one area of life
resulting in very impoverished lifestyle & range of experiences in other
areas; marked dissatisfaction with current occupations expressed as
frustration, boredom, and very low esteem & sense of self-efficacy that
may arise from loss of independence and reduced choices;
And/or
Major change in life role/threat to role
For example: loss of sense of purpose and few opportunities to be
productive; impact of serious or multiple illnesses requiring marked role
adaptation/re-assessment of future plans; changes in family structure;
repeated losses of friends and opportunities; loss, or threat of loss, or
change to, or take-up of work roles.
In addition to direct input with individuals working to meet identified occupational goals, the occupational
therapist will prioritise working as part of the team contributing expertise on the following issues:
x
Promoting healthy lifestyles;
x
Protecting and promoting peoples’ opportunities for social inclusion;
x
Developing teams’ insights into identifying and addressing occupational risk (Wilcock 2002),
working so that the relationship between health and occupation is more fully understood and
made use of.
We hope the above is helpful in highlighting when to explore occupational performance in more detail, and
welcome discussion of service users’ potential needs following consideration of the above factors.
Occupational Therapy - Indicators
Page 2
June 2009
Refs: Creek J (2003) Defining occupational therapy as a complex intervention College of Occupational Therapists, London
nd
Wilcock A (2006) An occupational perspective of health (2 edition) Slack New Jersey, USA
Welcome
to Green Light – Issue 21
October 2009 – Page 1 of 2
NICE Clinical Guideline 23 Update
(Depression in Adults)
The review of the NICE clinical guideline on Depression in
Adults was published in October 2009. The general
recommendations re prescribing choices are: ♦ Discuss the choice of an antidepressant with the patient
including side effect profile, discontinuation symptoms, any
potential interactions with other medication including herbal
medicines and the individual perception of previous
treatment and its effect.
♦ The initial choice of antidepressant should be an SSRI that is
available as a generic drug (currently Citalopram, Fluoxetine,
Fluvoxamine, Paroxetine and Sertraline).
♦ Consider that Fluoxetine, Fluvoxamine and Paroxetine have
a higher propensity for drug interactions.
♦ Paroxetine is associated with a higher risk of discontinuation
symptoms.
♦ Take into account the toxicity in overdose for people at
serious risk of suicide and be aware that
o Venlafaxine is associated with a greater risk of
death in overdose
o The greatest risk of overdose is with tricyclic
antidepressants (except lofepramine)
♦ When prescribing antidepressants other than an SSRI take
into account the increased likelihood of the patient stopping
treatment because of side effects and the need to increase
the dose gradually with Venlafaxine, Duloxetine and tricyclic
antidepressants.
♦ Consider the specific cautions, contraindications and
monitoring requirements for some drugs
♦ Prescribing of the following should only be undertaken by a
specialist mental health professional.
o The non reversible MAOIs such as Phenelzine,
the combining of antidepressants and
augmentation with lithium
♦ Dosulepin should not be prescribed
♦ When prescribing in older adults the dose prescribed should
be age appropriate taking into account the physical health
and concomitant medication.
♦ Side effects should be monitored closely when prescribing in
older adults.
.
Dosulepin
The NICE review has highlighted again
the risks of prescribing Dosulepin
(Dothiepin). A recent outcome of an
SUI and the annual suicide audit has
highlighted that there are still patients
who are being prescribed Dosulepin. It
is the recommendation of the SUI and
the audit that all patients who are
currently prescribed Dosulepin should
be reviewed.
Escitalopram and Duloxetine
The NICE committee examined the
benefits of prescribing Escitalopram
and Duloxetine.
For Escitalopram they concluded that
the evidence showed only a small
advantage over other antidepressants
and this was not considered clinically
important. There was a small economic
advantage over three other
antidepressants but this was
considered by the committee to have
limitations and was insufficient to make
a specific recommendation.
The NICE committee found that
Duloxetine was no more clinically
effective than other antidepressants,
the economic evidence was
contradictory and therefore no
recommendation could be made.
Agomelatine (Valdoxan)
The NICE committee did not review
Agomelatine as part of the guideline
review although a technical appraisal
may be released at a future date. The
Scottish Medicines Consortium have
not accepted the use of Agomelatine in
Scotland on the basis of insufficient
robust economic evidence.
Welcome to Green Light – Issue 21 October 2009 – Page 2 of 2
Augmentation of an Antidepressant Regime
The following recommendations are made for augmentation of an
antidepressant regime
♦
The drugs that can be used to augment an antidepressant are lithium, an
antipsychotic such as aripiprazole, olanzapine, quetiapine, or risperidone,
another antidepressant such as Mianserin or Mirtazapine.
♦
Consideration must be given to the potential increase in side effects
♦
When prescribing lithium the monitoring of lithium should be undertaken
as per the Trust guidelines
♦
Patients prescribed antipsychotics must be monitored for weight, lipids,
glucose level and relevant side effects.
♦
The following drugs should not be used to augment an antidepressant
regime: - buspirone, carbamazepine, lamotrigine, valproate, pindolol and
thyroid hormones.
♦
Benzodiazepine should only be used concurrently with an antidepressant
for a maximum of two weeks.
. The D&T Committee reviewed this drug at
the July meeting subject to the outcome of
the NICE review. The committee considered
that: ♦
♦
♦
♦
The following chart shows a summary of common interactions between
individual SSRIs and physical health drugs
The drug should be made available for
individual patients on a Consultant
request in writing to the Medical
Director/Chief Pharmacist but would not
be placed on the formulary
The prescribing cannot be handed back
to the GP for ongoing prescribing and
should remain in Secondary Care.
Where the drug is prescribed the
monitoring of the liver function tests
must take place as outlined in the
product licence i.e. before treatment,
after 6, 12 and 24 weeks of treatment
and then as appropriate.
The prescribing must cease where the
liver enzymes exceed three times the
upper limit
Management of Discontinuation
Symptoms with Antidepressant
Treatment
♦
♦
♦
♦
♦
♦
Advise people that discontinuation
symptoms may occur on stopping,
missing doses or occasionally reducing
doses
Explain they are mild and usually self
limiting over about 1 week but can be
severe if the drug is stopped abruptly.
Gradually reduce the drug over 4 weeks
(except Fluoxetine) reduce the drug
over a longer period for short half life
drugs e.g. Paroxetine and Venlafaxine
Advise the person to see their
practitioner if they experience significant
discontinuation symptoms.
Monitor and reassure the person if
symptoms are mild
Consider reintroducing the original
antidepressant if symptoms are severe
and reduce dose very gradually
Swapping Antidepressants
Advice on swapping antidepressants is
available on the Pharmacy intranet page