Service User And Care Involvement Analysis Social Work Essay
This review will consist of an introduction, aims of the review, and methods of data collection, findings on a series of questions and answers on the extent of service user involvement in the discharge process, conclusions, and possible recommendations for change. It will conclude with a reflection piece.
The following review will discuss the issue of service user involvement in the discharge/transfer procedure. The review was compiled by the author within a nineteen bedded Forensic Mental Health unit. The ward was at full capacity at the time of writing this review.
The service users’ all had different levels of mental illness, each with a different history, level of cognitive awareness, degree of institutionalisation and willingness to adapt and change. This review will assess to what extent service users are involved with the discharge planning process in the ward, if any, and give possible recommendations on how this process may be improved.
Aims of the Review
During this placement the author decided on a subject to review, this subject was service user involvement in discharge planning. While collating information for the review some questions arose these questions were:
Does the service user feel included in decision making?
How does the staff involve the service user in the decision making if at all?
Has discharge been discussed with the service user?
These questions lead to the author constructing some key questions to carry out in the review these will be discussed further in the findings.
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Methods used to construct review
The data for the review was collected over a ten week period within the ward. The author consulted service users’ notes, attended multidisciplinary team meetings and conducted a series of semi-structured, one to one interviews with service users and staff, including a consultant, doctors, ward manager, nurses, nursing assistants and occupational therapists.
A literature search was also carried out using accredited databases including CINAHL and the British Nursing Index. Relevant journal articles were found on these databases using keywords such as service user, involvement and mental health services. Nursing research books were also used to gather information along with web sites underlining national policies and models for mental health nursing.
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Findings
How are decisions made within the placement area regarding discharge planning?
A Forensic Mental Health Unit is not part of the prison services it is a service that specialises in the assessment and treatment of people who have a Mental Disorder. According to the Mental Health Care and Treatment Act 2003 a mental disorder is an illness such a personality disorder or learning disability defined by the act, whereby the mental disorder has been a contributing factor to the person offending.
Throughout the weeks on this placement research was carried out by the author on policies and procedures for discharge planning. The one in particular that was found to be relevant was the Care Programme Approach (CPA). CPA is about early identification of needs, assignment of individuals or organisations to meet those needs in an agreed and co-ordinated way and regular reviews of progress with the service user and care providers. CPA is also about involving family or carers at the earliest point. The Care Programme Approach requires that service users should be provided with copies of their care plans and it has been increasingly common for service users who have been the responsibility of forensic psychiatrists to have copies of documents relating to their care. (DOH 2008).
Systems were in place for comprehensive care planning. There was evidence to show that the service users’ social, educational and occupational needs were taken into account in the care planning process and other specialist interventions were available.
In addition to this, in some cases, discharge/transfer planning was evident from an early stage (not long after admission), although in other cases a few months had elapsed before any document noted those discussions. Discharge planning is enhanced by the Care Programme Approach (CPA) a multi-disciplinary care planning systematic approach that involves service users and their carers’. Care Programme Approach is the framework for care co-ordination and resource allocation in mental health services. Decisions for discharge are made through the multi-disciplinary team which consists of consultants, ward manager, nursing staff, occupational therapy and social workers. discharge guidance 4. This will go forward to a tribunal where the service user will be invited to take part, here all the evidence will be put forward and a decision will be made. If the service user is restricted then the decision will be made by the First Minister. When a service user is restricted it means an order has been applied to them as they are seen by the act to be a more serious offender, this then means that the Home Office is responsible for granting discharge and a representative will be invited to the Tribunal (MHCT Act 2003 SECTION 37/41).
Most service users have long term mental health problems and complex social needs and have been in contact with mental health services for more than twenty years so never think about discharge. Being in hospital for so long has become part of their lives so service users see it as pointless being discharged, “what would I do”. 488
SECTION 117 AFTER-CARE
Prior to 1983, no statutory provision was made for the after-care of patients discharged from hospital. Section 117 introduced and defined formal after-care. In particular it stated:
“It shall be the ditty of the health authority and the local authority to provide in conjunction with voluntary agencies after-care services for any person to whom this Section applies, until such time that the health authority and local authority are satisfied that the person concerned is no longer in need of such services “.
Section 117 of the 1983 Mental Health Act applies to patients who have been detained under Section 3,37, 37/41, 47/49, 48/49.
Before a decision is taken to discharge or grant leave to a patient, it is the responsibility of the RMO to ensure, in consultation with other members of the multi-disciplinary team, that the patient’s needs for health and social care have been fully assessed, and that the care plan addresses them.
The Section 117 meeting
The aim of the meeting is to draw up an after-care plan, based on the most recent multi-disciplinary assessment of the patient’s needs.
During the meeting the following areas should be covered as appropriate:
Housing Finances Relationships/family Employment Social needs
Psychology/mental health difficulties Relapse predictors Known risk factors
When the care plan is agreed the team should ensure that a key worker is identified to monitor the care plan. The Care Co-Ordinator can come from either of the statutory agencies, and should not be appointed unless they are present at the meeting, or unless they have given their prior agreement.. The process for Sec 117 can be found in Trust Policy and Procedure and applies to all patients accepted by psychiatric services.
What decisions/involvement does the service user have in this process?
Within this placement the care and treatment plans are reviewed on a regular basis. Service users are expected to meet with their key worker and other team members on a regular basis, care plans are reviewed at these meetings and a mutual agreement will be decided, on the best way forward, once the care plan has been agreed by all the service user has to adhere to the care plan.(discharge guidance)no.16
Rights, Relationships and Recovery (2006): The Report of the National Review of Mental Health Nursing in Scotland
Service users’ are encouraged to be fully involved in all aspects of their care as far as they are able to. Service users past and present wishes should be taken into account, their views and opinions with regards to their treatment plan must also be recorded, as stated in the Mental Health (Care and Treatment) Act Scotland 2003. These wishes and aspects will be turned into a care plan that is individual to the service user. The principles of the act underpin any decision made relating to a detained service user in Scotland. The Milan Committee devoted a chapter in the act that referred to high risk patients it stated that service users should have the right of appeal to be transferred from a high or medium secure facility to that of a facility with lower security conditions. (Mental Health Care and Treatment Scotland Act 2003). This however seemed to be the problem across the board, lack of medium/low secure facilities to discharge /transfer appropriate service users to.
Service users have the opportunity for regular one-to-ones with their key workers (weekly basis) or more regularly if they require. Service users have the opportunity to put forward their thoughts on discharge and any other aspect of their care at the review, such as their rights, beliefs and their right to a tribunal. The author attended these independant tribunals while on this placement and at these tribunals people had stated that their human rights had been violated (The Human Rights Act 1998). They felt they were still being discriminated against for offences they had committed 20-30 years ago and feel they were being held under “excessive security” hence the reason for the tribunal to appeal against this level of security. this would mean they would be granted grounds access on a trial period which may be supervised, then become unsupervised for a trial period to see how the service user would cope, this in turn will lead to a further tribunal taking place in a set time agreed for example 4 or 6 months away, where the service user may be granted discharge/transfer to a lower secure unit depending that all provisions that had been put in place had been adhered to, for example, risk assessment reviewed, treatment regime being followed, attend all social/therapy/strategy groups that were agreed.
The review takes place every four months, again this is a multi-disciplinary meeting and service users are invited to attend with the support of advocacy or someone of their choice. The Human Rights Act 1998 gives legal effect in the UK to certain fundamental rights and freedoms contained in the European Convention on Human Rights (ECHR). These rights not only affect matters of life and death like freedom from torture and killing, but also affect your rights in everyday life: what you can say and do, your beliefs, your right to a fair trial and many other similar basic entitlements.
During the time spent on this placement it was noted that service users and key workers met at the beginning of the week to discuss how they felt things had been for them, the service user has the opportunity to discuss what changes they would like to happen, this is then recorded in the service users’ notes and taken forward to the clinical team that week where it would be discussed if any changes in care and treatment would take place, the service user is then informed of any changes and decisions made which they have the right to appeal against (The Human Rights Act 1998). The opportunity arose for the author to take part in these weekly reviews, during this one-to-one time most service users were able to express their thoughts and feelings about issues they had encountered that week and describe what therapeutic strategies they used to get through it.
The service user will be provided with a copy of the Treatment Plan Objectives, or informed in detail of the contents of the treatment plan, in the event that any learning or specific reading or language difficulty information should be provided in a way that is most likely to be understood.
Arnstein (1969) constructed a “ladder of participation” which described eight stages of user participation in services, including mental health. These stages ranged from no participation to user controlled services. The above service users would be placed on the sixth rung of the ladder in the partnership range as they agree to share planning and decision-making responsibilities.
Partnership
Partnership, like community, is a much abused term. I think it is useful when a number of different interests willingly come together formally or informally to achieve some common purpose. The partners don’t have to be equal in skills, funds or even confidence, but they do have to trust each other and share some commitment. In participation processes – as in our personal and social lives – building trust and commitment takes time. discharge guidance 16.6 908
Does this placement area reflect its practice on local or national policies regarding service user involvement in discharge planning?
(Mental Health Care and Treatment Scotland Act 2003).
(The Human Rights Act 1998).
When asked their views on the subject the Ward manager and senior nursing staff presented documentation which reaffirmed current practice within the ward. The Ten Essential Shared Capabilities (ESC’s) DOH (2004) he explained was the model now being followed on the ward, has just been implemented into this area of placement within the last two years, which the ward staff have adopted well by providing a person-centred approach as much as possible. This new person-centred model embraced the ethos of the above, and senior staff stressed that good practice dictated that service users have the opportunity to appropriately influence delivery of care and support. A review of policies and procedures as well as discussions with staff provided evidence that the policies were actually in place.
Throughout the placement, the author noticed that efforts were being made all the time to nurse according to the new model. Included were regular one to one sessions between nurses and service users to hear their views and thoughts, these already took place before the ESC’s were introduced. Moreover some staff do find it difficult to adopt the ESC’s and the mental health act due to the restraints of the environment (secure ward); however they are prepared to embrace the opportunity for further education and support. 211
Identify barriers and constraints.
Before a decision is taken to discharge or grant leave to a patient, it is the responsibility of the RMO to ensure, in consultation with other members of the multi-disciplinary team, that the patient’s needs for health and social care have been fully assessed, and that the care plan addresses them.
Section 117 of the 1983 Mental Health Act applies to patients who have been detained under Section 3,37, 37/41, 47/49, 48/49.
While on placement and conducting this review the author noted that one of the barriers to effective involvement came from some of the service users, due to the complex nature of the area the service users had become institutionalised and found it difficult to be thinking about discharge at this stage in their lives, so they just accept the way things are and do not get too much involved as far as care plans are involved and just say what they think the staff want to hear.
In secure settings engagement of service users in assessment and treatment can be difficult, as there is a potential risk of perceived coercion. Moreover with the lack of medium secure facilities around this can hinder service users from moving on within the specified time limit agreed, as there are no provisions.
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Recommendations for Development
SMART
Most service users were more concerned about their futures and life post discharge. They wanted their time between now and then to be concerned with preparing them for discharge. It was frustrating for many service users that they felt that little in the way of such preparation was taking place. Continue to provide service users with support and skills needed appropriate to their function and skills already held, for example cookery groups, IT groups.
Provide groups that enhance social skills such as coping strategy groups, anger management, alcohol/drug treatment/groups.
High secure units should ensure that at the point of discharge patients have a copy of their discharge care plan in a suitable format which includes appropriate information about the circumstances that might result in their return to a secure mental health provision such as??????
However a recommendation that high secure units should ensure that factors to be weighed in assessing relapse are part of the risk assessment included in the discharge plan of all service users.
The National Service Framework for Mental Health states that ‘Service users and carers should be involved in planning, providing and evaluating training for all health care professionals’ (Department of Health, 1999). This is the case in most health care provisions but for more education, training and information to be more readily available.
Strengthening the user perspective and user involvement in mental health services has been a key part of policymaking in many countries, and also has been encouraged by World Health Organization (WHO) in order to establish services that are better tailored to people’s needs and used more appropriately.
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Reflection
In this review, I need to reflect on the situation that took place during my clinical placement to develop and utilise my interpersonal skills in order to maintain the therapeutic relationships with service users. In this reflection, I am going to use Gibbs Reflective Cycle Gibbs (1988). This model is a recognised framework for my reflection. Gibbs (1988) consists of six stages to complete one cycle which is able to improve my nursing practice continuously and learning from the experience for better practice in the future.
During the first week of placement I was encouraged to work closely with my mentor. This gave me the opportunity to orientate myself to the ward and get an overview of the needs and requirements of the service users. This also provided me with the chance to observe how the nursing team worked on the ward. During this time I had learned that if the concept of inter-professional working is to succeed in practice, professionals need excellent team working and communication skills. Good communication, as we have staged in our group work theory, (skills for practice 3) is crucial in the effective delivery of patient care and poor communication can result in increased risk to the service users. I have learned the valuable skills required for good communication and will transfer these into practice by adapting to the local communication procedures (expand). The NMC advices that at the point of registration students should have the necessary skills to communicate effectively with colleagues and other departments to improve patients care (NMC, 2004).
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