Review of Mental Health Act must address excessive detention rates

My Post (4)Theresa May’s speech at the Conservative Party Conference on Wednesday 4 October was one mired by illness, a prankster and a backdrop that fell apart, presenting journalists with countless opportunities for cheap metaphors. But while the gaffs of her mea culpa overshadowed the announcement of new policies, for those that could see past the cringe-induced spectacle there were a number of interesting points.

One of these announcements was how the Government would be carrying out an independent review of the Mental Health Act. Building on her Brexit speech in January, where she vowed to correct the ‘burning injustices’ in modern society, May explained how a particular priority for her was ‘tackling the injustice and stigma associated with mental health’ (May, 2017).

She emphasised her desire for parity between mental and physical health through reiterating the Government’s pledge of increased investment in mental health. Recent announcements of an additional £1.3 billion to transform mental health services by 2021 (Health Education England, (HEE), 2017) were met with mixed reactions from key health bodies. It was said the funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services (Department of Health, 2017). However, organisations such as the Royal College of Nursing said the Government’s proposals ‘appear not to add up’ (Royal College of Nursing, 2017). Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services and the integration of mental and physical health services for the first time.

The Mental Health Act

The Mental Health Act was passed in 1983 and is the main piece of legislation that sets out when and how a person can be detained and treated in relation to their mental illness. People detained under the Mental Health Act need urgent treatment for a mental health disorder and are deemed to be at risk of harm to themselves or others. In May’s speech she argued that the three decades old legislation is leading to ‘shortfalls in services and is open to misuse’ (May 2017). While the Mental Health Act was amended in 2007, it is felt by many that a more substantial revision is needed. This amendment was originally a proposed bill, but many felt it was ‘too draconian’ (BBC news, 2007).

The Five Year Forward View for Mental Health called for the Mental Health Act to be revised ‘to ensure stronger protection of people’s autonomy, and greater scrutiny and protection where the views of individuals with mental capacity to make healthcare decisions may be overridden to enforce treatment against their will’ (Mental Health Taskforce, 2016).

Reducing detention rates

Current detention rates under the Mental Health Act are too high. The latest published figures show the number of detentions under the Act are rising annually, increasing by 9% to 63 622 in 2015–2016, compared to 58 399 detentions in 2014–2015 (NHS Digital, 2016). Over the last 10 years they have increased by almost 50%. Of those detentions, a disproportionate number are of people from black and minority ethnic populations — four times as many black people as white people are detained. It is unclear why there are disproportionate detention rates between different communities, but this must be identified to ensure equal access to earlier intervention and crisis care services.

While reviewing the Act will use changes in legislation to help reduce the rates of detention, the difficulty will come in figuring out how the delivery of care must be changed so that detention can be avoided in the first place (Wessely, 2017). Additional focus is needed on the provision of earlier support. By identifying vulnerable people and addressing their mental health needs early, they can receive the support and care they need before detention becomes an unavoidable necessity.

For those that are detained, there needs to be a review of the areas constituting a ‘place of safety’. Police custody is not an appropriate area of safety. Around half the deaths that take place in or following police custody involve detainees with some form of mental health problem (Independent Police Complaints Commission (IPCC), 2017). Although police custody is only used as a last resort, it can exacerbate a person’s mental state, and has the effect of criminalising people who are in need of medical attention (IPCC, 2017).

Undertaking the review

The review will be carried out by Sir Simon Wessely, professor of psychological medicine at the Institute of Psychiatry, King’s College London. He is the former President of the Royal College of Psychiatrists and current President of the Royal Society of Medicine. Wessely will produce an interim report in early 2018 and develop a final report containing detailed recommendations, by autumn 2018.

References

BBC News. Ministers lose Mental Health vote. [Online]. 2007. [Cited on 25 Oct 2017]. Available from: http://news.bbc.co.uk/1/hi/uk_politics/6374547.stm

Department of Health. Thousands of new roles to be created in mental health workforce plan. London: The Stationery Office; 2017 Aug 30 [cited 2017 Oct 18]. Available from https://publichealthmatters.blog.gov.uk/2017/08/30/moving-forward-with-theprevention-of-mental-health-problems/

Health Education England. Stepping forward to 2020/21: The mental health workforce plan for England. Leeds: Health Education England; 2017 [cited 2017 Oct 18]. Available from https://www.hee.nhs.uk/sites/default/files/documents/CCS0717505185-1_FYFV%20Mental%20health%20workforce%20plan%20for%20England_v5%283%29.pdf

Independent Police Complaints Commission. Mental health and police custody [Internet]. Sale: IPCC; 2017 [cited 2017 Oct 19]. Available from https://www.ipcc.gov.uk/page/mental-health-police-custody

May T. Theresa May’s Conservative conference speech, full text [Internet]. London: The Spectator; 2017 Oct 4 [cited 2017 Oct 18]. Available from https://blogs.spectator.co.uk/2017/10/theresa-mays-conservativeconference-speech-full-text/

Mental Health Taskforce. The Five Year Forward View for Mental Health. Leeds: NHS England; 2016

NHS Digital. Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment. Uses of the Mental Health Act: Annual Statistics, 2015/16. London: Health and Social Care Information Centre; 2016

Royal College of Nursing. RCN responds to Mental Health Workforce Plan. London: RCN; 2017 [cited 2017 Oct 18]. Available from https://tinyurl.com/yavm3ulq

Wessely S. The Prime Minister Has Asked Me To Lead A Review Of The Mental Health Inequality In Britain – Here’s Why. London: The Huffington Post; 2017 Oct 6 [cited 2017 Oct 19]. Available from http://www.huffingtonpost.co.uk/professor-sir-simonwessely/mental-health-act_b_18192476.html

Taken from British Journal of Healthcare Management, published November 2017.

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New cross-specialty guidelines on peripheral arterial diseases

My Post (3)New guidelines on peripheral arterial diseases (PADs) have been jointly published by the European Society of Cardiology (ESC) and European Society for Vascular Surgery (ESVS) (Aboyans et al, 2017). These guidelines mark the first time that ESC recommendations on PADs have been developed as a collaborative effort between cardiologists and vascular surgeons. Management of hypertension is achieved through a combination of medication regimen and lifestyle changes. However, the results of the studies examining the level of adherence among hypertensives indicated that the target was not achieved. Saarti et al (2015) found that the level of adherence for medication regimen is 29.1%.

What are PADs?

Over 40 million people in Europe are affected by PADs (Fowkes et al, 2013)—a term used to describe all arterial diseases except those affecting the coronary arteries and aorta. Peripheral arterial diseases include atherosclerotic disease of the extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries.

Multidisciplinary approach

The Task Force was led by ESC Chairperson, Professor Victor Aboyans, and ESVS Co-Chairperson, Professor Jean-Baptiste Ricco. Building on recommendations laid out in the 2011 ESC guidelines (Tendera et al, 2011), it was felt by both societies that a multidisciplinary approach for the management of patients was needed.

Collaboration between specialisms has meant that there is now a single European document on the management of patients with peripheral arterial diseases. Professor Aboyans said:

‘Working together has enabled us to be comprehensive in our recommendations.’

Speaking to theheart.org | Medscape Cardiology, Aboyans stressed the need for multidisciplinary management of patients with PADs. Given the different areas of the body affected by PADs, it is necessary that other specialties beyond cardiovascular medicine and surgery are involved. An example of this would be in the case of carotid disease.

Aboyans said:

‘Talking about the management of carotid disease, we also need the input of a neurologist; the same for nephrologists or gastroenterologists.

‘We cannot think any more about a patient at a consultation and the surgeon says: “Ok, I’ll operate on you, I’ll fix the problem, and then it’s over,” because this is just the beginning of another story, which is the long-term management and reassessment of these patients, as with coronary risk,’ he added.

Complications of PADs

According to Aboyans, patients suffering from PADs often have difficulty walking— particularly those with arterial disease of the extremities. This is owing to insufficient blood flow to the lower limbs brought on by stenoses or occlusions of the peripheral arteries. This can pose a complication, as many patients may be unaware that they have a more serious condition. This is because they do not suffer from common symptoms of circulatory problems, such as shortness of breath, due to being sedentary.

‘They may have heart failure, but they don’t really complain about shortness of breath, just because they don’t walk any more,’ he said.

The benefit of cross-specialty assessment is therefore apparent. This ensures that all possible areas for concern are taken into consideration.

‘It is really mandatory that, if a patient comes to one specialty, to also have the call with other specialties, and this complementary approach is of benefit to the patients,’ he said.

‘It is one thing to fix the local-territory issue, the other is the cardiovascular health of these patients and, in the end, the prognosis.’

Changes to the guidelines

In putting together these guidelines, a comprehensive review of the published evidence was carried out. The Task Force was made up of experts in the field selected by the ESC. It included representation from the ESVS and European Stroke Organisation (ESO). This ensured all professionals responsible for the medical care of patients with this pathology were involved. The Task Force considered published articles on management of a given condition according to the ESC Committee for Practice Guidelines policy. These were then approved by the ESVS and ESO. A critical evaluation of diagnostic and therapeutic procedures for PADs was carried out, including an assessment of the risk– benefit ratio.

A number of changes have been made since the 2011 guidelines were published and new recommendations set out for the management of PADs. A chapter devoted to the use of antithrombotic drugs has been introduced for the first time. There is also a new chapter on the management of other cardiac conditions frequently encountered in patients with PADs. These include heart failure, atrial fibrillation and valvular heart disease. The chapter on mesenteric artery disease has been entirely revisited. Ricco said:

‘We have updated this chapter with new data showing the interest of endovascular surgery in these often frail patients.’

The Task Force has recommended revascularisation of asymptomatic carotid stenosis only in patients at high risk of stroke. This is despite no new major trials on the management of asymptomatic carotid artery disease since the last guidelines were published. However, there are new data on the long-term risk of stroke in patients with asymptomatic carotid stenosis.

‘The previous guidelines recommended revascularisation for all patients with asymptomatic carotid stenosis, so this is an important change,’ said Aboyans.

‘Trials showing the benefits of revascularisation compared to best medical therapy alone were performed in the 1990s but stroke rates in all patients with asymptomatic carotid stenosis have decreased since then— regardless of the type of treatment— so the applicability of those trial results in the current management of these patients is more questionable.’

There is now a strong recommendation against systematic revascularisation of renal stenosis in patients with renal artery disease. This is following the publication of several trials.

WIfI classification

A new classification system (WIfI) has been proposed as the initial assessment of all patients with ischaemic rest pain or wounds. The system takes into account the three main factors that contribute to the risk of limb amputation, which are:

  • Wound
  • Ischaemia
  • foot Infection.

Professor Ricco emphasised the impor¬tance of the new WIfI classification in lower extremity artery disease.

Guidelines into practice

The new guidelines encourage health professionals to consider its recommendations when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies. However, they make clear that they do not override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition. This should be done in consultation with that patient or the patient’s caregiver where appropriate and/or necessary.

References

Aboyans V, Ricco JB, Bartelink MEL et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extrem¬ity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2017; [Epub ahead of print]. https://doi.org/10.1093/eurheartj/ehx095

Fowkes FG, Rudan D, Rudan I et al. Comparison of global estimates of prevalence and risk fac¬tors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329–1340. https://doi.org/10.1016/S0140-6736(13)61249-0

Tendera M, Aboyans V, Bartelink ML et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(22):2851–2906. https://doi.org/10.1093/eurheartj/ehr211

Taken from British Journal of Cardiac Nursing, published November 2017.

Is now the winter of our discontent? Exploring seasonal pressure on the NHS

My Post (1)Around this time every year, the media is strewn with forewarnings of how winter will put undue strain on the NHS. In a system already struggling to cope, there are concerns that the seasonal pressure pushes services to breaking point. The NHS’s ability to handle yearly increases in demand has led the British Red Cross to go as far as to call it a ‘humanitarian crisis’ (Campbell et al, 2017).

This article will consider the causes of winter pressure on NHS services and how they differ to those experienced throughout the rest of the year. It will explore whether the warnings are genuine or mere hyperbole, and look at some of the ways the NHS attempts to combat these pressures.

Causes of winter pressures

The leading cause of winter pressure is difficult to pinpoint, and can vary from year to year. However, there are a number of recurring contributing factors. While most health problems are not caused by extremes of cold, the weather indelibly has an effect on the number of patients attending accident and emergency (A&E) departments.

Cold weather increases the risk of heart attacks, strokes, respiratory illnesses, flu, falls and other diseases (NHS England, 2013; Public Health England, 2017). Vulnerable people— such as the very young, elderly and those with pre-existing conditions— are those predominantly affected by changes in the weather (National Institute for Health and Care Excellence (NICE), 2015). The effect of winter on the NHS becomes apparent in early December. Performance in A&Es is measured through their ability to meet a 4-hour waiting target. One of the core standards of the NHS Constitution states that a minimum of 95% of patients attending A&E departments in England must be seen, treated and then admitted or discharged in under 4 hours (NHS England, 2015). Breaches of the 4-hour waiting standard result in trusts having to pay penalties (House of Commons Health Committee, 2016).

A&E attendances
Annual attendances at A&E departments have increased. The number of people arriving at major (type 1) A&E departments has seen a 7% rise from 2010 to 2015—from an average of 36 731 attendances per day in August 2010, to 39 220 in August 2015 (Fisher and Dorning, 2016).

Consequently, only 87.9% of patients in type 1 departments were admitted, transferred or discharged within 4 hours in 2015–16 (House of Commons Health Committee, 2016). This is clearly far below the expected standard. The Royal College of Emergency Medicine (2016a) has estimated that the increased attendance over the past 5 years is equivalent to the workload of 10 additional medium sized emergency departments.

Contrary to expectation, the highest number of A&E attendances does not take place in winter. Instead, there is an observable ‘dip’ in visits to A&E around December and January (Fisher and Dornin, 2016). The highest overall attendances are actually in the summer months. The important factor affecting winter pressure is the number of patients subsequently admitted to hospital. The highest proportion of the patient population in summer is under 60 years of age. By contrast, in the winter, it tends to consist of those over 60 years. This spike in the number of more vulnerable, elderly patients is significant because they tend to stay longer in A&E, and are more likely to be readmitted to hospital (Fisher and Dornin, 2016).

Hospital admissions
Like attendances, hospital admissions have also increased. Similarly, they have seen a 7% rise from 13 723 in August 2010 to 14 666 in August 2015 (Fisher and Dornin, 2016). There is a notable ‘peak’ of admissions during the middle of winter (Fisher and Dornin, 2016).

The difference between the proportion of patients admitted is 27.9% in winter, compared with 25.8% in the summer months (Department of Health (DH) et al, 2017).

‘Congestive hospital failure’
The rise in hospital admissions has caused a subsequent decrease in the number of available hospital beds, with the percentage of beds occupied peaking in winter (Fisher and Dornin, 2016). Due to the number of beds available for admission of acutely ill and injured patients continuing to fall over the past 5 years, the UK now has the lowest number of beds per capita in Europe, and England has the lowest number within the UK (Royal College of Emergency Medicine, 2016a). The consequence of limiting bed capacity has been a growth in general and acute bed occupancy from 86.3% in 2010–11, to 91.2% in 2015–16 (Royal College of Emergency Medicine, 2016b).

A lack of available beds reduces flow through A&Es as it slows the accommodation of new attendances (Royal College of Emergency Medicine, 2016a). This in turn affects the ability of ambulance services to off-load patients—an issue known as ‘congestive hospital failure’ (NHS England, 2013).

Another factor influencing occupancy rates is delayed transfer of care, which leaves systems less resilient to operational pressures. Unnecessary delay in discharging patients who no longer need to be in hospital led to 1.15 million bed days being lost in acute hospitals during 2015 (National Audit Office, 2016).

Combatting pressures

To help combat winter pressures, the NHS conducts strategic planning each year. For the 2017/18 winter, formal planning began at its earliest time yet in July (Philip, 2017). Local plans were submitted in September covering resilience arrangements from the start of December up to Easter 2018.

As part of this preparation, Public Health England (2017) publishes a Cold Weather Plan every year to help protect the population against harm from cold weather. A mixture of past experience and forward-planning will help build future resilience. Below are some of the key methods of combatting pressure.

Best use of ambulance services
An expansion of the ‘hear and treat’ and ‘see and treat’ services provided by ambulance services can help alleviate demand on A&E departments. ‘Hear and treat’ services refer to 999 calls that are successfully completed without dispatching an ambulance vehicle response. Examples of this include over-the-phone advice, instructions for self-care, or referral to other urgent services (Urgent and Emergency Care Review Programme Team, 2015).

‘See and treat’ services refer to a model of care where a patient is clinically assessed at scene, before being provided with immediate treatment and subsequent discharge and/or referral (Urgent and Emergency Care Review Programme Team, 2015). By avoiding taking patients unnecessarily to A&E, they can be referred to more appropriate services that better fit the patient’s needs, or further support can be provided at home or in a community setting. ‘Hear and treat’ and ‘see and treat’ services now cover 3.5 million people (NHS England, 2017b).

This winter will see the full rollout of phase two of the Ambulance Response Programme, with the introduction of new call standards that accurately reflect the type and urgency of care needed by patients (Quaile, 2017). Along with the new dispatch on disposition system, giving call handlers more time to triage 999 calls, it is hoped that many patients can avoid being taken unnecessarily to A&Es.

Boosting flu vaccinations
Flu outbreaks within health services can be crippling and are a genuine concern each winter. Last year, 49% of NHS staff were vaccinated against the influenza virus and, this year, the number of vaccinated staff has been raised to 63% (NHS England, 2017b).

Additionally, free flu jabs will be provided to hundreds of thousands of care-home staff at a cost of up to £10 million; and numbers of vaccinations for young children and vulnerable people will be increased (NHS England, 2017a). Being vaccinated is the best way to prevent the spread of flu infection and reduce avoidable deaths. As it is possible to have flu without showing any symptoms, health professionals could find themselves working with flu but not realising it. It is essential they are vaccinated to avoid spreading the illness to vulnerable people.

Increasing funding
The spring budget announced an additional £100 million to support improvements in emergency departments through the implementation of a primary-care streaming model (Philip, 2017). Here, patients are streamed away from highly pressured emergency departments, to co-located GP-led primary care services, for conditions more suited to assessment and treatment in primary care (NHS Improvement, 2017).

Achieving ‘good’ patient flow
According to Monitor (2015), improving patient flow through hospital departments other than A&E is ‘the most important systemic means’ of avoiding sharp declines in A&E performance during winter. Health systems that have better patient flow are much better at coping with external pressures than those who don’t (NHS Improvement, 2017). Within ambulance services, good patient flow is seen as the handing over of a patient to an emergency department within 15 minutes of arriving (NHS Improvement, 2017).

My Post (2)Encouraging self-care
Further promotion of self-care is essential to reducing demand on health services. Giving people the confidence and information to look after themselves can help prevent ill health and reduce pressure (British Medical Association, 2016). However, for this to work, support needs to be easily accessible.

Improving housing conditions
Housing conditions for vulnerable people play an important part in the number of excess winter deaths and illnesses. In the coldest 10% of homes, the death rate rises approximately 2.8% for every degree Celsius drop in the outside temperature (NICE, 2015).

In England, there is a relatively sharp increase in the risk of death when outdoor temperatures fall to around 6°C (NICE, 2015). Improving heating and insulation for vulnerable people is therefore highly important for reducing avoidable illness or death.

Addressing growing GP demand
General practice is on the brink of crisis as a result of inadequate resourcing, an insufficient workforce, and an unsustainable workload (British Medical Association, 2016). The number of GP consultations in England rose from 303 million in 2008/9 to 361 million in 2013/14 (Royal College of General Practitioners, 2015). However, despite this 19% increase in demand, there has been no change in resourcing and staffing, putting undue strain on GP services (British Medical Association, 2016).

Increased funding in social care
Social care has been struck by considerable funding cuts in recent years, creating a knock-on effect on the number of people receiving services.

There were 500 000 fewer people who accessed social care in 2013/14 compared to 2008/9 (Franklin, 2015). This is despite an increasing ageing population, where the number of over-85s will double over the next two decades. It is also anticipated that adults with a learning disability will increase by at least a third (Local Government Association, 2016).

The cut of £5 billion in local authority social care budgets over the last 5 years has placed significant pressure on services (Local Government Association, 2016). Delays in arranging community nursing or social care has a considerable impact on delayed transfers, with 60% of trusts believing the increase in delayed transfers of care is owing to reductions in social care capacity (Monitor, 2015).

Conclusion
This article has sought to explain the reasons behind additional pressures on health services brought on by the winter season. While attendances at A&E are lower during the winter, the number of hospital admissions of vulnerable patient groups rises, largely because of seasonal illnesses such as flu and norovirus. This causes a reduction in the number of beds available and reduced patient flow within hospitals.

To combat these pressures, longer term investments are needed to address the insufficient workforce, lack of social care, and demand on primary care services. Although there has been additional investment in vaccination against flu; primary-care streaming; and resilience funding for ambulance services for this winter; it is unclear what impact—if any—this will have on health services.

References

British Medical Association. Beating the effects of winter pressures: Briefing paper. 2016; London: BMA

Campbell D, Morris S, Marsh S. NHS faces ‘humanitarian crisis’ as demand rises, British Red Cross warns [Internet]. London: The Guardian; 2017. [cited 2017 Oct 23]. Available from http://tinyurl.com/y73vemzg

Department of Health, NHS England, NHS Improvement. Written evidence submitted by the Department of Health, NHS England and NHS Improvement (WIP0035) [Internet]. 2017. [cited 2017 Oct 23]. Available from http:// tinyurl.com/y7vlmu5r

Fisher E, Dorning H. Winter pressures: what’s going on behind the scenes? London: Quality Watch; 2016

Franklin B. The end of formal adult social care: A provocation by the ILC-UK. 2015; London: ILC-UK

House of Commons Health Committee. Winter pressure in accident and emergency departments: Third Report of Session 2016–17. 2016; London: The Stationery Office

Local Government Association. Adult social care funding: 2016 state of the nation report. 2016; London: LGC

Monitor. A&E delays: why did patients wait longer last winter? [Internet]. 2015. [cited 2017 Oct 23]. Available from http://tinyurl.com/ ofw2uv3

National Audit Office. Discharging older patients from hospital [Internet]. 2016. [cited 2017 Oct 23]. Available from http://tinyurl.com/hnyuy2p

National Institute for Health and Care Excellence. Excess winter deaths and illness and the health risks associated with cold homes. Clinical Guideline 6. 2015; London: NICE

NHS England. NHS leaders unveil action to boost flu vaccination and manage winter pressures. [Internet]. 2017a. [cited 2017 Oct 21]. Available from http://tinyurl.com/ycp5k8er

NHS England. The Handbook to the NHS Constitution. 2015; London: The Stationery Office

NHS England. Understanding Winter Pressures in A&E Departments [Internet]. 2013. [cited 2017 Oct 21]. Available from http://tinyurl.com/ yblaeduc

NHS England. Urgent and emergency care [Internet]. 2017b. [cited 2017 Oct 21]. Available from http://tinyurl.com/y9dctbsp

NHS Improvement. National priorities for acute hospitals 2017. Good practice guide: Focus on improving patient flow [Internet]. 2017. [cited 2017 Oct 23]. Available from http://tinyurl. com/y7t6mfam

Philip P. Letter to all CCGs and providers regarding planning for winter 2017/18, and other operational priorities [Internet]. 2017. [cited 2017 Oct 22]. Available from http:// tinyurl.com/y82kelxe

Public Health England. The Cold Weather Plan for England: Protecting health and reducing harm from cold weather. 2017; London: The Stationery Office

Quaile A. What’s next for England’s ambulance services? J Paramed Pract. 2017;9(10): 443-444

Royal College of Emergency Medicine. Why does winter in A&E get worse every year? 2016a; London: The Royal College of Emergency Medicine

Royal College of Emergency Medicine. Written evidence submitted on behalf of the Royal College of Emergency Medicine (WIP009) [Internet]. 2016b. [cited 2017 Oct 23].Available from http://tinyurl.com/y8naucxs

Royal College of General Practitioners. Patient safety implications of general practice workload. 2015; London: RCGP

Urgent and Emergency Care Review Programme Team. Transforming urgent and emergency care services in England: Clinical models for ambulance services. 2015; Leeds: NHS England

Taken from Journal of Paramedic Practice, published November 2017.

Leading support for those with mental health issues and learning disabilities

Adobe Spark (3)The Chief Nursing Officer has told mental health and learning disability nurses they need to ‘step up and take the lead’ in delivering ambitions set out by NHS England for mental health and learning disability services. Speaking at the NHS Expo in Manchester, Professor Jane Cummings said:

‘Nurses are creative, they’re innovative, they’re leaders, and they can really drive that change that we all want to see.’

Cummings outlined the important leadership role that mental health nurses have in delivering the Five Year Forward View for Mental Health (NHS England, 2016), and that learning disability nurses have in delivering the Learning Disability Transforming Care programme:

‘I think that nurses and midwives should be at the driving edge of change and improvement. I think there is a wealth of knowledge, a wealth of experience. And there’s a huge amount of skill set that nurses can have to really drive the change that everyone wants to see.’

Five Year Forward View for Mental Health

The Five Year Forward View for Mental Health was launched in February 2016 in an attempt to improve mental health outcomes across the health and care system, and includes an additional £1.4 billion of investment in mental health services by 2020/21. The funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services. Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services, and the integration of mental and physical health services for the first time.

Cummings said that improvements to mental health services is one of the ‘national priorities’ for NHS England, emphasising how there is a massive amount of work going on around mental health, with a real focus on improving access to services:

‘We are particularly focusing, through the Maternity Transformation Programme, on perinatal health. As part of that we have a big workstream looking at perinatal mental health and supporting women to cope with any problems they get post birth.’

According to Claire Murdoch, National Director for Mental Health, the priorities of the Five Year Forward View for Mental Health are built on a core set of pre-existing services that are transforming and developing to create an ‘absolute, quiet and steady revolution in mental health care.’

Murdoch echoed Cummings by also calling mental health nurses to ‘step forward and step up.’ However, in order to do this she said nurses need to become vocal about their skills, and experts in co-production and working alongside mental health service users in their own care. As part of plans laid out in the Forward View, Murdoch said the NHS will see an additional 1 million extra patients. This will include 70 000 more children and young people, who will have increased access to specialist eating disorder services within the community.

Murdoch explained how further evidence-based interventions, made earlier in the pathway of illness or distress, will ‘fundamentally change the outcomes for people’s lives so that we don’t create unwittingly long-term patients for the future.’ She added that there will be more tier 4 specialist beds for children and young people suffering from serious mental health problems, particularly in London and the south, where occupancy often outstrips demand. Additional improvements in respite care, crisis houses and home treatment teams were also assured.

According to Murdoch, nurses are leading community mental health teams for children and young people. Working alongside psychologists and doctors, she explained that they are playing a key role in the management of conditions such as eating disorders. Community eating disorders services for young people largely did not exist until last year, and Murdoch commended the mental health nurses, who she said were not only leading those teams, but also breaking new ground in having to work alongside families, the young people themselves, and deliver evidence-based care in completely different settings.

One of the greatest concerns Murdoch highlighted was the current pressure on the mental health crisis care pathway. In particular she stressed the need to prevent beds overspilling into the private sector and long waits in accident and emergency (A&E) departments. However, she announced that nurses have led the way in redesigning the care pathway through the ‘development of intensive current treatment teams’ and the ‘establishment  of the psychiatric liaison teams in A&E and acute hospitals more widely.’

She believes nurses will play a ‘fundamental part’ in ‘bringing an end to inappropriate out-of-area placements.’ An example she cited was in Birmingham, where nurses are working alongside the police to dramatically reduce the use of Section 136 of the Mental Health Act, which allows the police to take a person who appears to be suffering from a mental disorder to a place of safety. She said this has enabled better outcomes for people in distress.

Though she raised concerns that large numbers of nurses are leaving the profession and that recruitment will be an additional challenge, she said ‘there has never been a better time to be a mental health nurse.’ However, she urged mental health nurses to be vocal about their skills, whether that is their skill of assessment or complex working in networks of care.

‘We need to become the experts in co-production and working alongside mental health service users in their own care. We need an effort to come up with a care plan that hasn’t been produced at least in partnership, even at times of great crisis. We need to become the experts in that space. Housing, debt, employment, the physical health care, these are the domains of mental health nurses.’

Transforming care for people with learning disabilities

Alongside improvements to mental health services, a national plan to develop community services and close inpatient facilities for people with learning disabilities has meant better care for this patient group. The focus of the Learning Disability Transforming Care programme is on giving people with learning disabilities the opportunity to live in the setting they think is home. It also aims to stop overmedication and improve access to annual health checks.

Vicki Stobbart, a disability nurse and Executive Director of Nursing and Quality for Guildford and Waverley CCG, said that while learning disability nurses may not be as high profile as other areas of nursing, their impact and value in supporting people with learning disabilities should not be underestimated.

‘Learning disability nurses are the only professional group specifically trained to work with people with learning disabilities,’ said Stobbart. ‘This level of preparation, currently provided at degree level, alongside the breadth, competence and knowledge they develop, makes them a unique and critical component on the delivery of comprehensive skills.’

Alongside presentations on the leadership role of mental health and learning disability nurses, Professor Cummings led a panel discussion with healthcare staff and service users on how nurses can play a key role in the care of mental health and learning disability patients. Organised by NHS England, the Health and Care Innovation Expo saw over 5000 delegates learn about developments and innovations taking place across health and social care.

Looking at the progress made since the launch of the Five Year Forward View, it identified a number of key areas of priority, including urgent and emergency care, primary care and general practice, cancer, and mental health.

Taken from British Journal of Mental Health Nursing, published November 2017.

Jeremy Hunt’s plans to reduce prescribing and medication errors

Adobe Spark (2)A new initiative aimed at reducing prescribing and medication errors across the NHS has been announced by Health Secretary Jeremy Hunt.

Hunt said medication-related errors are responsible for 5–8% of hospital admissions. This is due to 1 in 12 prescriptions involving mistakes relating to dosage, course length or type of medication. With just under  150 prescriptions handed out in primary care every second, Hunt has called the potential for errors ‘huge’.

Writing in the Health Service Journal, he said:

‘Up to 1 in 12 prescriptions may include a mistake and whilst we’re lucky most don’t cause harm to patients, there is more we can do to tackle the problem and make the NHS safer…That’s why I’ve launched a new scheme working with the NHS to reduce these errors and protect patients.’

According to Hunt, the scheme will explore a number of areas where he believes the NHS ‘can do better’. This includes improving the way that technology, such as electronic prescribing, is used, to ensure prescriptions are processed more efficiently; re-evaluating the way that patients are informed and educated about their medicines, to look along the pathway from prescribing to administration and monitoring; supporting 7-day clinical pharmacy services, where possible, in acute hospitals; and providing pharmacist support for care homes and GPs.

Hunt also said the programme will look at how the transfer of information about medicines when patients move between care settings might be improved, as it is during these transition points when things can often go wrong.

According to the Department of Health, the programme is likely to be launched later this year or early next year. It is aimed at helping the NHS meet the World Health Organization’s global patient safety challenge, which hopes to reduce severe avoidable medication-related harm by 50% globally in the next 5 years. An expert group is being put together to help scope the programme and establish how to improve patient safety.

Speaking at the Royal Pharmaceutical Society Annual Conference, Steve Brine MP, Parliamentary Under Secretary of State (Public Health and Primary Care), confirmed how Jeremy Hunt will be working with the Chief Pharmaceutical Officer, Keith Ridge, to tackle the challenge of prescribing and medication errors:

‘Studies currently indicate that up to 8% of prescriptions have a mistake in dosage level, course length or medication type—a risk which the WHO identifies as a leading cause of injury and avoidable harm in healthcare systems across
the world.’

How might this affect nurses?

While the initiative is likely to predominantly affect GPs, it will also have an impact on the 70 000 qualified nurse and midwife prescribers. The Nursing and Midwifery Council (NMC) recently launched a consultation on proposals for nurses and midwives to prescribe earlier in their careers.

The proposals, if implemented, would enable nurses and midwives to gain prescribing practice experience as soon as they qualify. They would, therefore, do the prescribing training as part of their degree so that they have more of an understanding when they graduate.

It is unclear how this may affect patient safety or the number of medication errors carried out by nurses. Nurse Prescribing contacted the NMC, but as their proposals are only in the consultation phase, they said they were unable to comment at this time.

Deborah Robertson, Senior Lecturer and Programme Leader in Non-medical Prescribing at the University of Chester highlighted how nurse prescribers are very aware of the risk of prescription errors, and that best practice is needed to ensure errors are minimised:

‘Nurse prescribers are already very conscious of the risk of prescription errors and in prescribing education—we spend a good deal of time ensuring that they know the legalities of prescription writing as well as the need for best practice advice to ensure the minimisation of errors.’

‘We always reiterate the benefits of team working in prescribing practice and establishing good relationships between prescribers and dispensing pharmacists to ensure prescribing errors are picked up in a timely manner and how to avoid confrontation. This also highlights the need for ongoing continuing professional development in all areas of prescribing practice.’

Taken from Nurse Prescribing, published November 2017.

New techniques at pilot sites to improve bereavement care for parents

Adobe Spark (1)A new pathway has been launched to improve the quality of care for parents who have lost a baby. The National Bereavement Care Pathway (NBCP) seeks to offer individualised, safe and sensitive care for parents and families at all stages of pregnancy and baby loss up to 12 months.

Led by Sands, the stillbirth and neonatal death charity, it has been produced in collaboration with a core group of charities and professional bodies, comprising the Institute of Health Visiting, the Royal College of Midwives, NHS England, the Royal College of Obstetricians & Gynaecologists, the Royal College of Nurses, Neonatal Nurses Association, Bliss, Antenatal Results & Choices, The Lullaby Trust and Miscarriage Association. It also has the support of the Department of Health and the All-Party Parliamentary Group on Baby Loss.

The first wave of 11 pilot sites has been rolled out across the UK to coincide with Baby Loss Awareness Week and includes Wirral University Teaching Hospital NHS Foundation Trust, Liverpool Women’s NHS Foundation Trust, and Hull and East Yorkshire Hospitals NHS Trust. The sites were chosen to be ‘representative of geography, capacity and specialism’, and will trial the use of new materials, guidelines and training for professionals to help improve the care that bereaved parents receive.

The latest figures show that in 2015 there were over 2,500 infant deaths (that is, deaths under 1 year of age) in England and Wales, with stillbirths and deaths of infants under 7 days accounting for around 6.5 deaths per 1,000 total births (Office for National Statistics, 2017).

Clea Harmer, chair of the NBCP Core Group and CEO of Sands, comments: ‘I am delighted that we have so many enthusiastic partners across the country who want to work with us in improving bereavement care for parents when a baby dies.

‘As a collaboration, we were inundated with offers of support and I am excited by the potential impact that the pathway will have in these 11 sites, in the first instance. We  look forward to learning from their experiences before wave 2 begins and the wider rollout later next year.’

A spokesperson for the Institute of Health Visiting says: ‘The Institute is pleased to be one of the key partners in the project group working to deliver a National Bereavement Care Pathway for England, with the support of the Department of Health and All-Party Parliamentary Group for Baby Loss.

‘We are really keen to support the project group with identification of community health providers [which employ health visitors] that are willing to be included in the second pilot phase. This will ensure that the pathway offers clear, consistent guidance to health visitors and enable them to work confidently alongside parents, providing compassionate and parent-centred care to those affected through use of the pathway.’

Sue Cooper is the bereavement midwife at Hull and East Yorkshire Hospitals NHS Trust. She highlighted the important role that bereavement midwives play in providing support for parents who have lost a child:

‘Losing a child is an incredibly difficult experience and something that no parent should ever have to go through,’ Cooper says. ‘If they do, however, it’s important that we, as health professionals, are able to provide the right advice, information and support for bereaved parents.

‘The quality of care and the empathy shown to parents at a time when they are struggling with a whole range of different emotions is crucial, and our role in guiding bereaved parents through this difficult time is not to be underestimated. How we care for bereaved families when their baby dies can have long-lasting effects. Good care can’t remove parents’ pain and grief, but it can help them through a devastating experience.

Cooper is hoping bereavement care in Hull and East Yorkshire will improve as a result of being one of the pilot sites on the new pathway: ‘We’re really pleased to have been chosen to pilot the new care pathway,’ she says. ‘We’re not only hoping to improve the care we personally provide for bereaved parents, but it will mean a lot to know that what we do here in Hull and East Yorkshire will go on to shape and improve services provided for others right across the country.’

Since the project was initiated, it has engaged with over 200 professionals and 60 parents, completing a gap analysis of current pathways, guidance and research. A number of pregnancy and baby loss pathways have been created, with input from members of the NBCP Parental Advisory Group, which shared their stories to help inform the pathway.

Cathy Warwick, chief executive at the Royal College of Midwives, says: ‘This is important work because it is about giving bereaved families better care following the sad loss of a baby and we need to get it right. Learning from parents and the results of the work at the pilot sites will mean care can be better tailored to meet the needs of families.’

According to Carmel Bagness, Royal College of Nursing’s professional lead for midwifery and women’s health, it is the responsibility of healthcare staff to support bereaved parents: ‘The loss of a baby is an absolute tragedy and it is up to healthcare staff to provide the best care possible for bereaved parents and families,’ she says. ‘This pathway could really help to improve the care they receive during this difficult time. We hope this pilot is just the first step towards better care throughout the country for parents and families suffering from this terrible loss.’

Caroline Lee-Davey, Chief Executive of Bliss, adds: ‘Bliss is proud to be partnering on this project to improve bereavement care for pregnancy and infant loss. We know that being supported in the right way can help grieving parents and families at this heart-breakingly difficult time, and we look forward to working with the pilot sites to deliver consistent, high-quality and parent-centred care.’

A second wave of pilot sites is planned for April 2018, with a national rollout expected later in October.

References

Office for National Statistics. Childhood mortality in England and Wales: 2015. London: ONS; 2017.

Taken from Journal of Health Visiting, published November 2017.

Working in the early days of the NHS

Adobe Spark‘It was to be a big wide world but I wanted to be part of that.’ Ethel Armstrong was 18 when health secretary Aneurin Bevan launched the NHS on July 5 1948. Now 87, Ethel went on to enjoy an illustrious career within the health service. Spanning over four decades, she worked across the country in various roles, mainly in radiodiagnosis and in nursing. After retiring in 1989/90, she has continued to support the NHS through two charities, the NHS Retirement Fellowship (nhsrf.org.uk/) and Cavell Nurses’ Trust (www.cavellnursestrust.org/), making it a remarkable 70 years of unbroken service. They would love to hear from retirees from any disciplines who are now retired or coming up to retirement.

Born in Durham, Ethel began her career as a cadet. The cadet scheme was aimed at 17 year olds who didn’t know what area of the health service they wanted to get into. It offered them the chance to work in different fields before choosing a career path. She was encouraged to join by her headmaster, who told her about a ‘new scheme coming, with brand new free care for everybody from cradle to the grave.’ Feeling she had the requirements necessary for the role, he put her name forward for the scheme.

Ethel had wanted to become a doctor or dentist, but, like many in the years following the Second World War, was not in a position to pay to study for a qualification. ‘They didn’t have grants in those days,’ she says. ‘If your parents couldn’t afford to send you to university then I’m afraid you had to do it the hard way.’

Before the NHS

In the days before the NHS, healthcare provision in the UK was notably different. ‘It was a different ball game altogether; your doctor did absolutely everything,’ says Ethel. ‘The doctor’s man came round and he collected 4p for a husband and wife, and a penny for each child, so that they were put on that GP’s books.’

One of the differences Ethel recalls was the cost for the delivery of a child, which she says was one shilling and sixpence. This meant that, for those lucky few who were born on July 5 1948, their parents were saved the fee. ‘If they were born a day earlier their mothers would have had to pay one and six, but because [there was now an] NHS they got it free,’ she says.

The early years

Ethel’s first step into health care was at a large mental health hospital in Newcastle in 1947, where she worked on rotation in a number of departments. When the NHS was launched in 1948 she began studying radiodiagnosis at the city’s Royal Victoria Infirmary, which ‘wasn’t as posh as it is now’.

‘The corridors had black and white tiles, there were wooden forms all the way along and patients brought their sandwiches,’ she says. ‘You were there for half a day and you saw a medical man or you saw a surgeon.’

Qualifying in 1951, she emphasises how, in the early days of the NHS, there was a strict adherence to appearance and discipline.

‘You were taught protocol, code of conduct and dress code, and that was important,’ she says. ‘You knew who you could speak to and how you could speak to them. And that now seems to be sometimes lacking.

‘[It] made your day if the consultant stopped and said “good morning”. But most times, you were taught from a very early age that if a consultant was coming up the corridor you waited, and if there was a door to open, you opened the door. That was the discipline in 1948,’ she adds.

An evolving health service

Ethel entered the world of nursing and midwifery several years after beginning her career, but ended up returning to radiodiagnostics, her preferred area of health care. Throughout her time in the NHS she saw considerable change and advancements in technology.

‘I’ve seen more changes than you can shake a stick at,’ she says. ‘The important ones are the ones that improve lives—the other ones you just forget about, but advances in maternity services and knee replacements, hip replacements, have been tremendous.’

Next year the NHS will celebrate its 70th anniversary. Since its inception it has continued to grow. It now employs more than 1.5 million people and treats over 1 million patients in England every 36  hours. However, an ageing population has meant it is finding it increasingly difficult to meet patient demand, and many have called it unsustainable. For Ethel, though, there will always be an NHS.

‘The NHS will definitely still be here in 70 years,’ she says. ‘It will be a different format. I think you’ll be given a do-it-yourself box, everybody will have to go on a computer course, you will all have to know how to access this, that and the other. It will be, I’m quite sure, a high-tech world.

‘I connect with nurses and midwives, as well other NHS workers. My passion and commitment since retirement in 1990 is continuous, totalling a staggering 70 years. I have been overwhelmed by requests for media coverage and I have been asked if I will do it all again next year. My answer is an emphatic YES as I support every one of the workforce past and present.’

Taken from British Journal of Nursing, published October 2017.