new scheme hopes to boost standards of care in psychiatric wards.
investigates its chances of success
now two years since the Healthcare Commission gave a grim portrayal
of the state of NHS inpatient psychiatric wards.
Its audit of violence found almost
80 per cent of mental health nurses and 36 per cent of service users
had either been personally attacked, threatened or made to feel
unsafe. Moreover, one third of inpatient staff accept that they
or colleagues have threatened to use medication or seclusion to
control patients. Then, last year, the Mental Health Commission
stated that more than half of England and Wales's psychiatric wards
were untherapeutic and unpleasant.
At the heart of the problem lies
patient boredom, low staff morale, high staff turnover, mixed sex
wards, no gardens or open air environments, drug and alcohol abuse
on wards and poor training in the prevention and management of violence.
Although there's no evidence to
suggest standards have since improved, there have been – and
continue to be – initiatives to push up standards.
For example, The London Development
Centre and the Kings Fund were, from 2004-5, involved in a "collaborative"
project with 34 inpatients wards across London to boost standards.
It claimed to have produced "realistic small changes".
Another project, the Star Wards scheme run by the charity Bright,
is working with 99 wards around England on networking and "information-sharing"
to improve care.
Now mental health professionals
have united to try and turn the tide. The Royal College of Psychiatrists,
in partnership with the Royal College of Nursing, the British Psychological
Society and the College of Occupational Therapists, has launched
a national accreditation scheme for inpatient psychiatric wards.
Significantly, organisers say their
scheme will have the teeth to both incentivise hospital and ward
managers to undertake sustained improvements to their wards, while
also promoting a national sharing of good practice between staff.
The Accreditation for Acute Inpatient
Mental Health Services (AIMS) assesses wards on more than 100 standards,
covering everything from a ward's physical environment, staff support
and training, to patient advocacy provision, to making sure that
on the day a patient is admitted and well enough they are notified
who their primary nurse is, and how to arrange to meet with them.
Its data is based on anonymous feedback
and opinions from staff, patients and carers, combined with a site
visit by AIMS peer-reviewers. These peers then produce a report
and, if standards are judged to be satisfactory, accreditation is
awarded. The four-tiered accreditation means wards will be, at best,
"excellent" and, at worse, "a significant threat
to patient safety, rights or dignity and/or would breach the law."
The four levels are "accredited with excellence", "accredited",
"accreditation deferred" and "not accredited"
After a pilot involving 16 wards,
57 wards have now signed up to AIMS, with 10 wards having already
Importantly, Dr Paul Lelliott, director
of the Royal College of Psychiatrists' research and training unit
which oversees AIMS, says that staff, when assessing their own wards,
are candid. "Staff are being brutally honest," says Lelliot.
"Staff in the front line are motivated to tell how it is. They
do not have the same pressure as people higher up the organisation
who have to tick boxes and meet targets. They are refreshingly honest."
Mind, which runs a campaign aiming
to improve psychiatric wards, backs AIMS. Its policy officer, Emily
Wooster, does, however, have one reservation. She has closely examined
the standards (decided upon by a AIMS steering group), and feels
they lean more towards assessing safety and risk management than
creating a therapeutic environment. "Safety is clearly a priority
with the [AIMS] document, and we not want to see an emphasis on
risk that will over-ride all the other important aspects,"
AIMS is also not mandatory. Wards
choose whether or not to pay AIMS the £1,600 to participate,
and then, if they gain accreditation the £5,760 to see their
accreditation through for four years. There are therefore concerns
that of the 500 inpatient psychiatric wards in England, Wales, Ireland
and northern Ireland that AIMS wants to reach, only top-end wards
will participate. Poor wards might not want to.
Marion Janner, a service user who
set up Star Wards and serves on AIMS' steering group, recognises
this limitation. "Those wards that do [participate in AIMS]
are those wards which function well anyway. The challenge will be
to get enough wards to take up AIMS," she says. "Standards
are only standards – they are not enough. The challenge is
to help poor wards achieve those standards."
To this end, AIMS is promoting the
Star Wards scheme, and Tanner is adamant that poor wards can make
radical changes at "virtually no cost". For Janner, it
is ward managers (responsible for heading new initiatives) and healthcare
assistants (who have the most everyday patient contact) who are
key to bringing about change on wards. "Something needs to
happen to inspire and staff to provide a much better service,"
Lelliot adds that he believes AIMS
can boost standards across the board because he believes the Healthcare
Commission will encourage wards to participate in AIMS. "In
its review of inpatient acute wards, which the commission is presently
working on, they [commissioners] will enquire whether wards are
participating in AIMS," says Lelliot.
Lelliot also highlights the Royal
College of Psychiatrists' accreditation scheme for ECT clinics.
He says this scheme, which 90 clinics have participated in, has
driven up national standards. He hopes AIMS will result in a similar
upward quality trend for psychiatric wards. "Some ECT clinics
which have failed have been subsequently closed down, or they have
merged with other better ECT clinics. We have found that management
takes very decisive action," says Lelliot.
are other possible limitations. For example, AIMS is presently working
only with non-secure psychiatric wards, although the scheme may extend
to secure units. And none of AIMS's standards assess race equality,
although Lelliot says that "this is something we hope patients
[when assessing wards] will tell us"
there is also out-and-out dissent. Jason Pegler, chief executive
of mental health publishing firm Chipmunka Publishing and who was
a patient in six wards between 1993 and 2000, questions why the
NHS itself is not running national accreditation, instead of leaving
professional organisations "who have their own interests"
to manage it. "NHS should be doing this in-house," he
says. "It seems like the NHS is getting someone else to clean
up their own mess."
also suggests that patient advocacy organisations should have a
more prominent role in accreditation. Yet even though Pegler goes
as far as to say that AIMS is a "waste of money" he does
see that it is has some benefits. "At least people on psychiatric
wards are actually being asked interviewed on how they feel about
things," he says.
said his experience of psychiatric care mirrors that reflected by
some national reports, adding he saw patients being "threatened"
to take their medication "20-30 times per day". "It's
still like this now," he says.
all those involved with AIMS stress how keen they are to "focus
on the positive". Lelliot
says: "We don't mention enough those things that are positive,
and the excellent work that people on these wards do."
Court is a purpose-built 15 all-male inpatient ward in Newcastle
run by Northumberland, Tyne and Wear NHS Trust. In February it became
the first ward to receive AIMS accreditation. Two more of the trust's
wards have also been accredited. The trust aims to put all its wards
year 20 staff (including administrative and domestic staff), 20
patients and 20 carers completed the AIMS anonymous self-review
questionnaires. Charge nurse Gary Butler said respondents were able
to be upfront and honest. "You could absolutely say what you
wanted," he said.
of Nursing Elizabeth Moody also emphasised that the questionnaires
were an opportunity for patients to vent grievances. "If staff
had said [on the questionnaires] 'we are caring', then patients
would be the first to say 'well, actually it's like a prison'."
self-review was followed by a visit from an AIMS peer-review team,
consisting of a manager of an acute ward from another trust, an
occupational therapist and a carer. They examined the ward's clinical
records, met with patients and staff and completed a documentation
and record-keeping audit.
peer-review team then sent Collingwood its final report, which included
the original questionnaire data and peer review findings. AIMS concluded
that Collingwood Court was therapeutic with a "lovely atmosphere",
"good leadership" and a "committed team"
staff are markedly positive about the service they offer. They speak
highly of ward manager Rachel Weddle who has created a "non-hierarchical"
team. Occupational therapist Esme Watson is enthusiastic about the
range of activities offered to patients. "We have a solid activity
programme which creates a positive environment," she says.
says she feels she has helped create a team where everyone "feels
they can contribute".
patient representative organisations also gave a positive picture
of Collingwood Court.
inpatient units go – and seen within the context of ward service
provision – it's actually pretty good," said Alisdair
Cameron of user-led organisation Launchpad which has around 1000
it is a therapeutic environment. If there is any ward that I had
to be admitted to in and around Newcastle, Collingwood would be
first choice," says Cameron, himself an inpatient in Collingwood
seven years ago. "It's the best of what there is on offer."
Jacqui Jobson, manager of Newcastle Advocacy Centre, praises Collingwood
Court's bid to develop good practice. "The staff there encourage
[its patients] to use advocates – this is often a sign that
staff have high standards and goes hand-in-hand with developing
good practice. We have been providing regular drop-ins at the ward
and issues are dealt with quite quickly."
Cameron states that Collingwood has developed more of an "edgy"
feel to it compared to two years ago. He says this is mainly because
of reduced bed availability meaning patients have to be more unwell
than previously to be admitted. "This means our members feel
more on edge than before," he said.
West Midlands Dudley Primary Care Trust - Bushey Fields Hospital
- Clent Ward; Kinver Ward; Wrekin Ward
North East Lincolnshire Primary Care Trust - Diana Princess of Wales
Hospital - Diamond Suite; Sapphire Suite
* Northumberland, Tyne and Wear NHS Trust - Collingwood Court (St
Nicholas Hospital); Ward 21 (North Tyneside General Hospital); Warkworth
Ward (St George's Park)
Kent & Medway NHS & Social Care Partnership Trust - Brocklehurst
Ward (Priority House)
Manchester Mental Health & Social Care NHS Trust - Grafton Ward
(Manchester Royal Infirmary)
A shortened version of this article appeared in Mental
Health Today magazine
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