Monthly Archives: March 2013

Prof. Ian Shaw ~ It’s starting…

ishaw2It was only 3 short years ago that the White Paper was published aiming to establish a National Care service, free to service users. That was at a time when the recession had started and the Coalition Government had been formed. Now it looks like a completely different world with not a free service, but a cap to social care costs to be established locally in what many commentators are calling a `dogs dinner’ that will lead to multiple challenges and court cases for local authorities.

But it doesn’t stop there… The NHS Confederation (who are meant to be one of the `good guys’) has this week (18/3/13) published a report which contains amongst its pages a suggestion of introducing charging to see a GP out of hours and to charge patients for home visits by GPs and by community nurses.

It’s not just the NHS confederation, the Daily Mail has also latched onto the idea and has included charging patients for their meals while in hospital.

It’s not surprising that the Twitter lines were burning last night in response to this and Roy Lilley blasted the idea as `What Were They Thinking’ (or more likely weren’t thinking) in his blog. One thing that Roy didn’t pick up on – surprisingly for him – is that the costs of the pointless NHS reforms that come into force on April 1st are estimated to over £1 billion in redundancy payments alone and that doesn’t include all the other costs of the NHS reorganisation… it seems patients are being asked to pay for that.

The government has recently had to hastily re-write Section 75 of the Health & Social Care Act 2012 regulations, the first draft of which would have forced commissioners to open just about every part of the NHS up to private sector competition. Following howls of protest from almost everyone. The re-write though was rushed, botched, and there are significant concerns about its intent and how it will be implemented. In particular, there are concerns that the fear of litigation on CCGs if they don’t open up to the market will ensure they do anyway.

The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth. At its launch by the then minister of health, Aneurin Bevan, on July 5 1948, it had at its heart three core principles:
– that it meet the needs of everyone,
– that it be free at the point of delivery, and
– that it be based on clinical need, not ability to pay.
– Publicly funded out of taxation

Despite earlier reassurances by The Kings Fund to the contrary, it seems these founding principles are coming under attack….

Ian Shaw, Professor of Health Policy, University of Nottingham (19/3/2013)

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Event ~ Professor Nikolas Rose Free Public Lecture, 15 May 2013

A date for the diary!  Professor Nikolas Rose will be giving a public lecture on 15 May 2013 at 4:30pm entitled, ‘What is ‘Mental Illness Today?  Five Hard Questions’.  This talk is part of the School of Sociology and Social Policy’s Seminar Series and will be held in B63 in the Law and Social Sciences Building.

Further information about Professor Rose and his planned lecture is below:

What is ‘mental illness’ today – five hard questions

Nikolas Rose
Department of Social Science, Health and Medicine
King’s College London

Abstract

In this talk I want to characterize the ‘territory’ of mental illness today by posing five hard questions that seem to me to represent genuine empirical, conceptual, professional and ethical dilemmas.   My questions are: Is there an‘epidemic’ of mental disorder?;  Does the path to understanding mental disorder lie through the brain?;  What is the role of diagnosis and of diagnostic manuals?;  Should we seek early identification of those at risk of future mental pathology? What is the place of patients, users, survivors, consumers in the mental health system?  On the basis of this discussion, I will conclude by trying to draw out some lessons for the politics of mental health today.

Nikolas Rose

Nikolas Rose is Professor of Sociology and Head of the Department of Social Science, Health and Medicine at King’s College, London.  He was previously Martin White Professor of Sociology, and Director of the BIOS Centre for the Study of Bioscience, Biomedicine, Biotechnology and Society at the London School of Economics and Political Science.  He is also co-PI for the EPSRC funded Centre for Synthetic Biology and Innovation (CSynBI). His most recent books are The Politics of Life Itself : Biomedicine, Power, and Subjectivity in the Twenty-First Century (Princeton, 2006); Governing The Present (with Peter Miller, Polity, 2008) and Neuro: the New Brain Sciences and the Management of the Mind (with  Joelle Abi-Rached, Princeton, forthcoming, 2012).  He is a longstanding member of the Editorial Board of Economy and Society, co-editor of BioSocieties: an interdisciplinary journal for social studies of the life sciences, Chair of the European Neuroscience and Society Network, and a member of numerous advisory groups including the Nuffield Council on Bioethics.

In addition, the following poster is available for display and circulation:

Nikolas Rose poster, 15 May 2013

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Centre for Mental Health: “What the Francis report means for mental healthcare”

Centre for Mental Health ~ “What the Francis report means for mental healthcare”

Please find below the link to this CMH piece.

Sean's blog

(Originally posted in the HSJ blog Leadership in Mental Health, 6 February, 2013).

“A considered response to Francis should include a full assessment of what it will entail for mental health services”.

http://blog.centreformentalhealth.org.uk/2013/03/13/what-the-francis-report-means-for-mental-healthcare/

 

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Neoliberalism and Healthcare

There was an article in Time magazine last month, discussing the impact of a neoliberal ideology on the healthcare system in the United States.  Given the direction of the NHS currently, we felt it worth highlighting this article, perhaps to kickstart the debate within the IMH, and beyond.

The article is quite long, and as it is not a blog either, we have not reproduced it here, but you can access it on the Time website here.  Please do comment on this post if you would like to join the debate.

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Amanda Keeling – Deprivation of Liberty Revisited

Before I was a PhD student, I worked as a research assistant in an intellectual disabilities research group on a project looking at the Deprivation of Liberty Safeguards. As an academic researcher, I was sceptical of the ‘DoLS’ – I thought they were cumbersome and missed the point. Now, my grandmother, who is in the ever-advancing stages of Alzheimer’s has recently been the subject of a DoLS authorisation process, and as a result, I’ve been thinking about them again, what they were for in the first place, and where we are with them now.

Firstly, what are the DoLS? The Deprivation of Liberty Safeguards are an amendment to the Mental Capacity Act 2005, designed to provide a framework for depriving an adult who lacks capacity to make a relevant decision of his/her liberty in his/her best interests. The legislation was brought about in response to the European Court of Human Right’s ruling in HL v United Kingdom. The case concerned HL, a man in his 40s with autism and intellectual disabilities who had been living in the community with adult foster carers, but had been re-admitted to hospital as the result of an incident of self-harming behaviour at his Day Centre. His foster carers wanted him back home, but the psychiatrist responsible for his care felt that he required further care and observation in hospital and would not let his foster carers visit in case he wanted to return with them. As HL was considered ‘compliant’, he was not detained under the Mental Health Act, but rather treated as a ‘voluntary patient’, and therefore not subject to any of the reviews, nor had any access to the tribunal system, embedded within the MHA. In theory, he was ‘free to leave’ whenever he wished – his ward was not locked – but he was sedated and his care team noted that had he actually tried to leave, he would have been stopped.

The challenge at the European Court was that the treatment HL had experienced was in breach of his article 5 right to liberty under the European Convention on Human Rights – that he had been deprived ‘arbitrarily’ of his liberty. The Court agreed with HL; while they agreed that sometimes, a deprivation of liberty was necessary for an individual, in the case of HL, he had been detained without his consent, and without any formal process or safeguards. There was no limit to how long he could be detained, and no formal review process for the end of that review – it was, therefore, in breach of the rules for lawful detention in European human rights law. The fact that he was in an unlocked ward was, the court said, irrelevant to the determination of whether his liberty was deprived. There was ‘complete and total control’ over his life, and he was subject to almost constant supervision.

This judgment resulted in the DoLS, an extraordinarily complex piece of legislation which sets out a framework for assessment of whether an individual is deprived of their liberty, and whether that deprivation is in their best interests. It does meet a lot of the criticisms of the ECtHR, setting out clearly who can do the required assessments, for how long any authorisation can be in force, and a procedure for review. However, it is immensely cumbersome and time consuming, and one can only assume that it is considerations of policy – the burden of both time and cost – that are at the back of the minds of the judges who have made domestic decisions on what a ‘deprivation of liberty’ is in domestic law since the coming into force of the DoLS. In a string of decisions over the past few years (most prominently, Cheshire West and P and Q), the definition of deprivation of liberty has been further and further narrowed, such that it seems almost impossible that a deprivation of liberty could be found unless someone was being terribly abused. The courts’ approach has been to adopt one of ‘normality’ – essentially, if it can be shown that the restrictions on an individual’s liberty are ‘necessary’ and are commensurate with the ‘normal life’ that someone with the same type of disability would have, then it could not possibly be a deprivation of liberty. There are many things wrong with this analysis from a legal perspective, not least that it is collapsing the objective test of deprivation of liberty, with the assessment of whether or not a course of action is in the individual’s best interests.

I can see why the courts have done this – they are no doubt concerned that, if the threshold for deprivation of liberty is set too low, then too many people will fall within the scope of the legislation and the number of DoLS authorisation processes will shoot up (though, at the moment, we are still some way below the estimates of application numbers suggested by the original impact assessment). However, to me, this approach somewhat misses the point. HL was a man who undoubtedly had multiple and complex needs – maybe he even benefited from that period of hospitalisation. What was wrong was that one person (his psychiatrist) was able to assume control over every aspect of his life, and ignore all and any other views on the situation, including his and those of people who cared for him day-to-day and knew him well. She was able to assume this control without any formal review process, or any appeal mechanism against it.

The point of the DoLS, what they should be for, is to ensure that adults with complex needs are never put in the position where any restrictions are put in place without some kind of monitoring. The direction of the case law has concerned me for some time as an academic, but being part of the process from the ‘other side’ if you will, with my grandmother, was my real ‘lightbulb moment’. Ultimately, the application for my grandmother was not authorised, as the assessor found that the restrictions on her life fell short of the (now very high) threshold in English case law. Yet, she is subject to some quite restrictive practices – in particular, the application had been made because of concerns about the frequency of restraint staff at the home were having to use to assist her personal care. My grandmother’s care home is not Winterbourne View – it is a great care home, with patient and caring staff, who only want to do what is best for the residents. However, it is inescapable that they are in a position of considerable power. My grandmother has my mother and aunt, who are very involved in her care and what goes on in her life; but what if they weren’t there, or were just happy to go along with whatever the care home thought was best? The restrictions on my grandmother may indeed be ‘normal’ for a woman with advanced Alzheimer’s disease, and the care home is entirely acting to ensure that she does not get ill unnecessarily, and that her quality of life can remain as high as possible for as long as possible. However, simply because their aims and objectives are admirable, does not mean they should not be subject to scrutiny.

The DoLS should not just be about ensuring that abusive practices, such as those at Winterbourne View, do not happen, nor, even, that some homes and hospitals’ practices are not ‘out of the ordinary’. It should be about ensuring that the any control exercised over an individual’s life is completely necessary, continues to be necessary for as long as it is exercised, and that it is done so for the shortest amount of time. The DoLS does not need to be the frankly bureaucratic nightmare of form-filling that it currently is, and in designing it this way, it seems to be a system which is only for the ‘really bad’ practices of a few, rather than what is should be, which is a constant monitor for the good care practice of all. A lower threshold for deprivation would probably require some reform in the structure of the DoLS, but then, I’m not convinced that would be a bad thing.

Amanda Keeling
PhD Student, School of Law

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Institute of Mental Health “Research Day” Monday 13 May 2013

From:  Peter Bartlett and Melanie Jordan

Re.: IMH Research Day, Monday 13 May 2013 

The IMH will be hosting a Research Day to highlight the work of our doctoral candidates, Managed Innovation Networks (MINs), and early-career researchers (including research assistants and research fellows) on Monday 13 May 2013. 

We hope you will be able to join us for this free event – to hear the presentations and meet the researchers.

The event will be chaired by Peter Bartlett and Melanie Jordan. There will also be plenary sessions from inspiring and established academics (e.g. Nick Manning).

Please register as a delegate via Karen Sugars by 1st May 2013.  Her contact details are: Tel.: 0115 82 32416; Email: Karen.sugars@nottshc.nhs.uk. Lunch will be provided. This full-day event will be held at the IMH on A Floor.  Full details re. timings will be supplied to registered delegates nearer the time.

Thank you,

Peter Bartlett and Melanie Jordan.

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