John L Taylor Northumberland, Tyne & Wear NHS Foundation Trust and Northumbria University

2. Psychologists as Approved Clinicians:An Exercise in Power through LeadershipACP-UK Inaugural ConferenceRoyal College of Physicians of Edinburgh28th March 2019, John L Taylor Northumberland, Tyne & Wear NHS Foundation Trust and Northumbria University john.taylor@ntw.nhs.uk

3. Mental Health Act 2007 – which amends the MHA 1983 • Introduces non-medical Approved Clinicians (AC) • AC responsibilities include acting as the responsible clinician (RC) for detained and CTO/GO patients -- and so having overall responsibility for the patient’s case (Ref. Guide to MHA 2007)

4. MHA Code of Practice 2015 – Chapter 36 Allocating or Changing a Responsible Clinician • The selection of the appropriate responsible clinician should be based on the individual needs of the patient concerned • Hospital managers should “… ensure that the patient’s RC is the available AC with the most appropriate expertise to meet the patient’s main assessment and treatment needs” (CoP 36.3, p. 373) • “For example, where psychological therapies are central to the patient’s treatment, it may be appropriate for a professional with particular expertise in this area to act as the responsible clinician” (CoP 36.5, p. 373)

5. Approved Clinician Instructions 2015: Schedule 2 -- Relevant Competencies A comprehensive understanding of the AC and RC roles Applied knowledge of the legal and policy framework Assessment – a demonstrated ability to identify the presence and severity of a disorder and if it warrants compulsory confinement Treatment – an understanding of different treatments, skills in formulation, review, communication and assessing capacity to consent to treatment A demonstrated ability to manage and develop care plans Abilities in effective leadership and multi-disciplinary working Up-to-date knowledge and understanding of equality and diversity issues Effective abilities in communication – verbal, written records, statutory reports for courts and tribunals

6. The Issue of ‘Objective Medical Expertise’ • European Convention on Human Rights (ECHR) - Article 5 (Liberty & Security) • Essentially, deprivation of certain rights can be effected if a person is ‘of unsound mind’ • To establish this, objective medical evidence is required -Winterwerp v. The Netherlands (1979) 2 EHRR 387

7. The Issue of ‘Objective Medical Expertise’ The Government’s view: • No case law defining what constitutes medical expertise • Winterwerp did not seek to lay down which sort of qualifications available in a national system are/are not acceptable (this is within the “margin of appreciation”) • The ECHR is a “living instrument” that must be interpreted in terms of contemporary conditions and practice • In a modern workforce it is appropriate for MHA functions to be allocated to those with the relevant competencies • Before a person can become an AC they must demonstrate the ability to identify the presence and severity of a mental disorder, and thus have objective medical expertise

8. Approved Clinician Instructions 2015: Schedule 2 -- Relevant Competencies A comprehensive understanding of the AC and RC roles Applied knowledge of the legal and policy framework Assessment – a demonstrated ability to identify the presence and severity of a disorder and if it warrants compulsory confinement Treatment – an understanding of different treatments, skills in formulation, review, communication and assessing capacity to consent to treatment A demonstrated ability to manage and develop care plans Abilities in effective leadership and multi-disciplinary working Up-to-date knowledge and understanding of equality and diversity issues Effective abilities in communication – verbal, written records, statutory reports for courts and tribunals

9. Identification of Potential AC Candidates An applicant should be “a senior clinician who is sufficiently experienced to capably, and with authority, exercise the autonomous decision-making required of an AC” “Be mindful of the challenge to existing and traditional roles and conventions … consider potential cross-professional issues and conflicts, especially the relevant responsibilities & authority of the RC and medical AC …” (2017, p.5)

10. Exercising Clinical LeadershipA Case Study

11. MHA 1983 Detention of People with ID Proportion of people in general population with IQ scores <70 is approx. 2.5% (assuming normal distribution) Census data shows that a disproportionate number of people with impaired intellectual functioning are being detained under MHA 1983, as at 31st March 2014 More than three times the expected number overall (7.7%) More than double the expected number in NHS hospitals (5.6%) More than five times the expected number in independent hospitals (13.1%) Source: The Health & Social Care Information Centre (2014)

12. Impact on People with ID On 31st March 2010 there were 3,642 people with ID residing in inpatient services in England and Wales The median length of stay for men with ID was x5 greater (31 months) than that for male mental health inpatients (5.8 months) and x11 greater for women with ID vs mental health (31 months and 2.5 months respectively) Over a 3-month period 28% of ID inpatients had been subject to one or more physical assaults compared with 11% of inpatients in mental health services Source: Care Quality Commission (April 2011)

13. Delayed Discharges • Delayed discharges disrupt therapeutic processes, increase dependence and waste resources • They are caused by: • A lack of partnership working • Poor discharge planning • Timely and effective discharge is facilitated by: • Effective clinical leadership • A clear risk management model • A defined discharge protocol • Rapid follow-up arrangements • Partnership working across agencies Adapted from: Department of Health (2007). A Positive Outlook

14. Alnwick Unit, Northgate Hospital Male locked rehabilitation unit – 18 beds: 2 x 9-beded flats Patients detained under the MHA (1983) - range of sections (3, 37, 37/41) Mild/borderline levels of intellectual functioning and ASD High levels of Dissocial and Emotionally Unstable personality disorder characteristics Patients historically viewed as having refractory problems, difficult to place and ‘slow stream’ in rehabilitation terms Average length of stay in hospital is > 7 years

15. Alnwick Unit, Northgate Hospital – Changing the Model Psychologist RC responsibility for 9/18 patients taken in 2011 An active discharge planning pathway and protocol was developed using risk management principles within a formulation-based approach (Dr Suzey Breckon and clinical team)

16. Northgate Active Discharge Planning Protocol Key stages: Development of a Community Service Specification Identification of an appropriate community service in accordance with the service specification Development of a Transition Plan Provision of Risk Management Planning Workshops Guidance on the writing of Care Plans & Risk Management Plans Post-discharge support through outreach clinics and Community Transitions Team involvement

17. Alnwick Unit, Northgate Hospital – Changing the Model Psychologist RC responsibility for 9/18 patients in 2011 An active discharge planning pathway and protocol was developed using risk management principles within a formulation-based approach (Dr Suzey Breckon and clinical team) Patients are closely involved in the process though an innovative ‘Discharge House’ approach to shared working and formulation The process is managed through a series of scheduled pre-discharge panning meetings It is led by the RC (authority and accountability)

18. Alnwick Unit, Northgate Hospital – Changing the Model An active discharge planning pathway and protocol was developed using risk management principles within a formulation-based approach (Dr Suzey Breckon and clinical team)

19. Alnwick Unit, Northgate Hospital – Outcomes • Psychologist RC responsibility for 9/18 patients taken in 2011 • The active discharge planning protocol was developed and piloted during the first 12-18 months • During the first two years 8/9 patients were discharged from hospital • Length of stay (N = 8) • Mean = 9.5 years • Range = 2.4 – 22.6 years • During the same period 1/9 patient transferred from the non-intervention group

20. Alnwick Unit, Northgate Hospital – Outcomes 2 • The discharge protocol intervention was then extended to all Alnwick Villa 14 patients • During the 4-year intervention period 37 patients were discharged: • Mean length of hospital stay = 6.7 years • Range = 1 month – 22 years 6 months • Alnwick Villa 14 – mean length of stay: • 2011/12 = 2 years 7months • 2012/13 = 3 years 9 months • 2013/14 = 1 year 7 months • 2014/15 = 1 year

21. Alnwick Unit, Northgate Hospital – Outcomes 3 N = 37 patients discharged Mean age = 35.7 years; range 24-54 years Mean full scale IQ = 64; range 49-79 49.4% criminal sections; 22% s37/41 restricted patients 81.1% sex offence histories 78.4% violence offence histories 18.9% firesetting histories

22. Alnwick Unit – Four Year Pre- and Post-Intervention Discharge and Readmission Rates

23. Alnwick Unit – Average Length of Stay for Discharged Patients

24. Alnwick Unit – Four Year Pre- and Post-Intervention PRN Medication and Restraint Rates

25. Alnwick Villa 14 – Four Year Pre- and Post-Intervention PRN Medication and Restraint Rates PRN Medication • Pre: 262 incidents for 40 patients; M = 6.5 per patient • Post: 67 incidents for 67 patients; M = 2.4 per patient • Overall 39% reduction Restraint • Pre: 77 incidents for 40 patients; M = 1.9 per patient • Post: 40 incidents for 67 patients; M = 0.6 per patient • Overall 48% reduction

26. Non-Medical ACs: The Numbers

28. AC National Survey – Oates et al. (2017), IJL&P • N = 39/56 (70% response rate) • Male = 51%; Female = 49% • Psychologist = 24; nurse = 9; SW = 3; OT = 1; ? = 2 • North = 21; M&E = 6; L’don = 3; South = 3; Wales = 4; ? = 2 • Working in CYPS, AMH, OPS, EDS, PDS, Forensic, LD

29. AC National Survey – Oates et al. (2017), IJL&P • Motivation to become an AC • To benefit service users • To benefit themselves • To meet organisational needs • To make a difference • Support to be become an AC • Mentorship and support • Peer learning and support • Training course and ALS • Time requirements for preparation • Lack of organisation/management buy-in • Attitudes/behaviour of psychiatrist colleagues

30. The Exercise of Power • Power affects (perceived) authority and status • It is empowering and emboldening • It carries responsibility • It can be used to effect change for the good: cultural, clinical, professional • Clinical leadership is the vector through which this statutory power is exercised • It can result in improved outcomes for patients (and colleagues)

31. Summary • The MHA 2007 introduces non-medical AC/RCs • It cements in a statutory framework important developments in clinical leadership and distributed responsibility • The introduction of these extended roles supports the aims of NWW and the patient choice agenda • The focus is on clinical leadership • This allows new clinical approaches and models to be applied • The numbers involved to date are small but are growing towards a critical mass in large specialist mental health Trusts • A critical issue is the exercise of power

32. THANK YOU john.taylor@ntw.nhs.uk