Professional Documents
Culture Documents
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1.4 Recommendations to the ‘Putting things right Project’
1.4 a) Improvements to how problems are put right
This part talks about how things could be better. How to make it easier
and safer, to say thank-you, or to complain. How to help service users
to feel that someone is listening to them. How to help service users feel
that someone understands why they are upset.
It says that the service user needs to agree with the way things will be
for them in future.
It says that the staff must be ready to try new ways of doing things, if
this could help.
Sometimes the service user feels that their problem is not being solved
fairly, or not being solved in the right way. The paper says that there is
a need for someone to come from outside the health service to help
improve the way the problem is sorted out.
3.2 Communication:-
• Listening, understanding and being heard and understood are frequently a
problem
• Honesty and openness by staff is essential to build LHB and full involvement,
but is frequently not experienced
• Delivering bad news is high risk. Clients must be kept safe
• Our privacy matters. We want to know who will see our information, and how
they will use it
• Telephone calls and letters must be carefully managed. Where there is a
need for support or any risk, a face to face meeting should be arranged
instead.
3.6 Information
• In contrast to physical health, there is little ‘objective’ information in patient
records. Most of it is ‘perception’, ‘opinion’, and ‘interpretation ‘
• Our lives are deeply affected by these perceptions, opinions and
interpretations, which in turn, are based on records, which are neither
consistently accurate nor reliable
• Sometimes staff decide that a claim is a delusion without checking the facts.
They can be wrong.
• Complaints investigations are based on inaccurate records, so cannot
substantiate or refute the client’s complaint
• Inappropriate decisions are often based on inaccurate interpretations, which
are not open to client challenge
• Information is a powerful resource for recovery in mental health
3.8 Safety
• It feels like the risk to the psychiatrist is more important than the risk to the
client.
• Crisis Intervention and Home Treatment teams, feel like they are keeping
people out of hospital, rather than keeping them safe.
• Up to one in five mental health patients die by suicide.
• Suicides can happen as a result of
o the way the service treats its clients
o the way complaints are managed.
• Many people self-harm when they are distressed.
• Distressing processes are high risk
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4) The Policy Context
The Welsh Assembly Government has demonstrated its commitment to improving
the experience of people who use the services it provides, such as the NHS. Many
policy documents talk of putting the ‘citizen at the centre’.
The Assembly have also pledged to make mental health a priority and have
promised additional funding to demonstrate that.
Policy seeks to involve service users more in decisions about their treatment and
their lives. Users should have access to services according to need, which prevent
deterioration, treat symptoms and their causes, reduce potential harm, and assist
rehabilitation. Service users and the public should be protected, there must be
support following hospital discharge, record keeping should follow the guidance of
individual professions, and professionals should be supported through supervision
with a constructive problem solving approach.
Further details on the gist of policies, with quotes from documents are given in
Appendix 6.
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5) Recommendations to the ‘Putting Things Right
Project’
5.1 Improvement to the compliments and complaints process
5.1 a) Starting right
• At the first appointment explain the following
o How to raise and solve a problem or make a comment
o Where to find help when doing this
o What safeguards exist whilst a problem or grievance is being solved
o Provide a leaflet to reinforce your explanation, but NOT to replace
it
• The process needs to be accessible to all, to be sensitive to different cultural,
religious, language and disability/ability requirements
• Language must show that the client is unhappy, and be sensitive to the
feelings of professionals, who do what they think is best. No-one seems
happy with the current terms
• All staff need to be trained to respond quickly and informally to problems or
grievances, to solve most problems without the need for any other processes.
• The identification of a first point of contact and alternate for any ‘official or
formal’ problem solving process needs to be done very early on in the client’s
contact with the service.
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• The NHS needs to coordinate with professional bodies to give their members
guidance on how to challenge existing norms, and to support them to
innovate safely, whilst keeping their members from encroaching on the roles
of other professionals.
• Staff members must be required to give a VERY good reason to refuse
‘personalisation of care’ in the absence of specific research, which shows a
request for personalisation to be detrimental.
• A client request for the involvement of a specific profession,
creates a platform through which to increase the effectiveness of
multidisciplinary working, and to ensure that all staff recognise that
professions within the team have protection of title, and are regulated in order
to provide a skilled and safe service to service users. ‘New ways of working’
does NOT provide a route to practising another profession without meeting
regulatory requirements.
• If a team chooses to refuse the client their choice of profession, because they
feel that there is an equivalent alternative, there needs to be guidance on the
evidence required by the team to underpin and justify their response. This
must :-
o Include evidence from an independent second opinion from a member
of the profession concerned
o Withstand scientific and legal challenge
o If the decision is based on a lack of resources, it must be supported by
a report of unmet need
o Give the client whatever evidence and reassurance they need of the
additional qualifications, experience and regulation held by the team’s
alternative to the profession requested, to underpin this extension to
their normal professional role.
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• The meeting discussed the need for ‘Patient Support Officers’ to act as
internal LHB advocates for service users with more minor concerns. This
would increase the chances of getting a result through influence within the
team
• If, a client is not enjoying the protections promised by complaints policies and
guidance, there must be rapid intervention by an independent body or person
to remedy the situation.
• There needs to be greater awareness of the Independent Complaints
Facilitator service. Client’s should be entitled to request this service from the
LHB.
• An independent facilitator would be more credible if they also had a
compliance role to ensure that the LHB complies with any regulations or
guidance on the complaints process.
5.1 h) Appeals
• There must be an opportunity to appeal following an investigation, within the
LHB or to an independent body.
• The independent Complaints Secretariat can be more flexible than the
Ombudsman because it is not limited by legislation. It is therefore essential
that it remains
• Because of the complexity of complaints and the difficulty clients with mental
health problems can have in communicating their thoughts and feelings, an
inflexible requirement for a written process only, excludes people. In order to
make the process fully accessible to people with disabilities, there must be a
procedure in place to enable complaints to be submitted verbally, where
necessary
• The clinical reviewer has to identify whether the explanation given to the
complainant is ‘adequate’. This cannot be done without speaking to the
complainant, because the adequacy of an explanation depends upon the
needs of the client, on their level of understanding and ability. It depends
ultimately on whether the complainant felt it was adequate.
• The scope of the independent complaints process needs to be extended to
include assessments of case management and the quality of clinical
decisions, to identify clinical error, and poor or dangerous clinical practice.
The clinical reviewer must be in a position to measure the performance of the
clinicians involved against national standards, eg against the National
Assembly’s CPA guidance, its National Service Framework for mental health,
and against National Occupational Standards for the professional groups
concerned
• In order for the process to have credibility with the public, and for it to provide
sufficient assurance to induce public confidence in the health service, there
must be a robust response to bad behaviour, or poor or dangerous practice
by individuals or teams.
• Whilst there is a fine line between positive individual and team accountability
and the need to avoid the maintenance of a ‘blame culture’, serious
problems will not be picked up early enough to save lives or prevent serious
harm unless the detail of who has done what and why, is addressed, and
remedial action taken
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• There needs to be a FULL report to complainants of any action taken to
address their concerns. They need to know, for instance, when a clinician is
reported to another organisation, specifically to help them to improve their
performance. They need to know where action has been taken to address the
way a particular team is working, where training or additional supervision has
been provided, as well as the organisational and management responses to
increase patient safety
• The quality of the independent complaints review process needs to be
improved. Guidance to reviewers, including clinical reviewers, needs to
include an ethical code regarding impartiality, and the need to declare any
conflicts of interest. It is wrong to assume that staff records will be more
accurate than patient and witness recollections. Such preferences leave
complainants feeling that the process is still biased against them, and
therefore not independent
• Before appointing a clinical reviewer, the client must be asked which
discipline they feel would be best placed to review their case
• At some point in the official process after local mediation of a complaint at a
LHB, there must be the opportunity for an independently chaired ‘hearing’. A
meeting where there can be discussion between all concerned, for
clarification, explanation, the hearing of external/independent witnesses, or
professional expert witnesses, or the opportunity to address
misunderstanding, misinterpretations or misinformation
• The current practice of sending out clinical review reports from the
Independent Complaints Secretariat to the LHB, without first checking them
for accuracy with the client, must stop
• Sometimes the clinical review report is likely to make the situation worse, not
better. The complainant needs to see the report before it is sent out to give
them the opportunity to prevent it being sent to the LHB
• Like any other clinical professionals, clinical reviewers must be accountable
for the quality of their work. Their reports must be open to challenge and
second opinion. For transparency, their names must be on the reports, just
as expert witnesses in court are not anonymous
• Any independent clinical review must involve a second opinion assessment of
the client, together with a discussion with the client of the clinical records and
case history to establish where accounts of the facts vary
• Where LHB records, or staff accounts, differ from that of the complainant OR
other credible witnesses, recommendations should be made by the
Secretariat, to the LHB, to improve the future accuracy of records. This may
include asking them to agree with a client what should be recorded at the time
of contact
• Agreement to care plans or records can only be evidenced by a client
signature
• The LHB should be asked to copy all documents or correspondence sent to
the Complaints secretariat/Ombudsman to the client, at the same time they
post it to the Secretariat or Ombudsman. The LHB must be accountable for
the accuracy of any claims they make to the Secretariat
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5.1 m) Behind the scenes
• There are organisations working behind the scenes to improve clinical safety
and performance. They do not take direct referrals from the public and
complainants are not always informed of their involvement, if a clinician or
team is referred to them. Confidence in the clinical service is essential,
especially in mental health where liberty is at risk, paranoia is a problem, and
stress is a trigger to worse symptoms and sometimes life threatening. There
is a need for more information to be given to complainants about how the
individual clinicians in their care, who have been involved in a problem will
change their practice to prevent a reoccurrence.
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6) Getting things right first time
– delivering a better service
It was clear from the day that much could be done to prevent complaints
happening in the first place.
It is recommended that work with people with mental health problems is
underpinned by the following key principles of mental health care
delivery, in order to deliver key outcomes.
Key Principles
6.1.1 Principle 1 – Good communication
Communication is clear, honest and accurate, available in the client’s
preferred language, and in different formats, to meet the client’s
individual needs.
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• Treatment and support are offered on the basis of need, irrespective of
diagnosis, age, disability, religion, sexuality, race or gender
• Client values, beliefs and culture are recognised and respected by staff, and
taken into account in all elements of assessment and treatment
• Staff follow the client’s ‘rules’ and ‘standards’ in the client’s home – eg
removal of shoes inside the house
• Treatment is offered without coercion through threats
• Procedures are in place to ensure that clients have information at all times
about, and access to, ways to raise any concerns they have about the way
they are being treated
• Measures are in place to ensure that the client is safe from abuse, especially
when alone with any member of staff, eg direct independent observation of
all contacts with the client is possible and in place, either through the
presence of an independent witness chosen by the client, or through audio or
video recording that can be viewed as evidence
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6.3.3 Key Outcomes of Principle 3
• The client feels more in control of their own life
• The client feels more independent
• The client feels involved
• The client takes a greater responsibility for their own care
• The client feels they are a part of their own recovery
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6.5.2 What this means
• Staff and service user, carer and/or families talk about their fears and worries,
and how to keep the service user and others (where applicable) as safe as
possible
• The line between over-protection and safety is consciously managed through
informed discussion, consent and acceptable risk taking in line with stage of
recovery
• Regularly means whenever anybody, staff, service user, carer, family, or
others propose a change to treatment or raise a concern, or whenever any of
these people feel a precaution, currently in place, is no longer needed.
• Risk includes the risks that arise from treatment and/or from the condition
• Plans might include self-management training, use of voluntary sector support
services, change in medication, hospitalisation, High dependency unit,
involvement of the police (section 136), or other sections as necessary
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6.7.1 Principle 7 – Continuous improvement
The standards of service are continuously improving, through
recognising, celebrating and sharing good practice, through learning
from mistakes, and through making advances gained through
innovation more widely available across Wales
8.1 Introduction
The purpose of this document is to help you to get your problems solved. It will give
you ideas based on the experience of other people, of what you need to do. It will
warn you about possible difficulties you may face, and will give you ideas about how
to try to avoid these problems. It will tell you about things that have been promised
by the Welsh Assembly to help you, and what you can do if these promises are not
kept. It will guide you towards the organisations that can help you, and give you
more information about the different ways that you can seek a solution to your
problem. It will help you to make a case, should you feel the way the problem is
being handled is unfair, or causes you distress. It will be realistic about whether
you are likely to be successful or not.
This document aims to help you to choose what you do with the best chance of
success, and full knowledge of what could go wrong.
8.2 Information
Some contact information is given in Appendix 4 on organisations involved in quality
assurance for the NHS.
If you telephone the switchboard of your LHB and ask to be put in through to the
complaints department, you will be put in touch with someone who can answer your
questions. This person is not involved in your care. It is their job to help you. They
will not tell anyone in the team that you have contacted them, when you are just
asking for information. They will provide you with leaflets giving information from the
National Assembly and from the LHB about the complaints process. Please note,
the information from the assembly is guidance, not law.
If you have access to the internet it may be worth seeking information from your LHB
website. You may find the LHB Complaints guidance and contact information there.
If you are not comfortable about speaking to someone from the LHB, your local
independent mental health advocate (see finding help) may be able to explain how
things work. People from MIND, Hafal, or providers of ‘floating support’, may be
able to advise you.
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There may be notices up in the waiting area, where you go to meet your care
coordinator, or in local organisations like Hafal or MIND, about where to find your
local Independent Mental Health Advocates.
Sometimes it is worth seeking advice and help from your local Assembly Member, if
your initial attempts to be heard are unsuccessful.
8.6 Who to go to
If you go straight to another member of your care team, your care-coordinator or a
local manager, they may be able to solve your problem. However, sometimes they
will treat your complaint as a symptom, and may even refuse to look into it for that
reason.
You are most likely to get a serious response if you go through the local NHS
complaints department, and ask them to see if they can help broker local problem
solving. You will need to be specific to ask the complaints staff to speak for you,
because if they just give you a name to phone or write to, you may find that that
person does not take your communication as a complaint.
Often the complaints department is able to solve the problem. If you are unhappy
with the information you get from the complaints department, you can still look for an
informal response yourself. A member of management may be in a position to help
solve your problem discretely. Ask the complaints department who would be the
best person to approach. If you are unhappy with the name they suggest, ask for
the next higher manager.
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It may be possible to speak to a manager directly on the phone. This is nice and
informal, and may help, but if you don’t get the result you want, you will not be able
to prove that your conversation took place. A phone call backed
up by a letter will provide the evidence you need. Sometimes the manager will not
speak to you, and may tell you through his or her secretary, that you should take
your concerns to someone else. This may be your care coordinator.
Some LHBs have a policy requiring someone to act as a first point of contact for a
service user who wishes to raise a problem. If you are unhappy with being told to go
to your care coordinator with complaints, tell the complaints department, and
suggest the name of someone who would be acceptable, or, if you don’t have
anyone particular in mind, just ask them to suggest someone else, maybe someone
who doesn’t have any say in your day to day care.
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The problem with a letter, is that it has to be very brief, even if the problem is
complicated, and because it is brief it can be misinterpreted. If not marked as a
complaint, this letter can be circulated to any other member of the staff team, and/or
placed on your clinical records where team staff can all see it. Even if you do mark
the letter as a complaint, staff may decide that some parts of the letter are a
complaint, and other parts are not, and then circulate it anyway. A letter invites, by
implication, a response in kind.
If you want a conversation about your problems, it is best to state only that you have
a problem, and want a meeting with the staff member/manager as soon as possible
to see if a solution can be found informally. The less information you give about your
problem, when asking for an interview, the more likely you are to get one, because
then the staff cannot convince themselves that they understand and can deal with
the problem in writing only.
There may be a problem that the staff member you are meeting may be very difficult
to understand. You may feel intimidated by their questions, and be unable to
respond ‘on the spot’. It helps if you can take notes with you about what is most
important to you, but you may find you cannot take a full part in the conversation
and look at your notes. An advocate, either independent or from the Community
Health Council, can help you to put your views across at a meeting. In the end, if a
meeting is only a partial success, you can still follow up with a letter. However, a
meeting may be refused once the correspondence has started, because the staff
concerned become worried that they will look bad, and will not want to be put on the
spot themselves.
8.10 Records of interviews
Whoever takes the minutes of your interview, you need to ask to see their record,
before it is finalised, because it is surprising how completely different a record of a
meeting can be, from your memory. Notes taken rarely reflect emphasis, and the
interpretation of the note taker of the events, can be re-interpreted again when
converting the note back into a report. The best record is a video or audio recording.
This is not yet standard practice in the health service. It is always worth asking,
because eventually, when enough people have asked, someone in the NHS will say
yes. In the mean time, ask the question, but expect a negative response.
8.11 Choice
You may not want to take all these precautions given above, and it may be possible
to solve your problem without them. But, if you choose to be low key, you must
accept that you may be disappointed, your problem may take longer to solve, and it
may get more complicated because of the way it is handled.
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8.13 A formal Complaint
At this stage it is very important to get help from someone who is not involved in your
care. You are likely to be most successful if your letter is calm, polite and
reasonable. This is very difficult when you are feeling very angry or very distressed.
Another pair of eyes may help you to ensure that your letter is less likely to be
misinterpreted. However, experience shows that what other people read into letters,
is unpredictable. Don’t expect people to read what you mean. Again, if you want a
meeting, say less in your letter and request the meeting to discuss fully the nature of
your problem, because you don’t feel able to put it all into writing.
Again, start the letter “This is a complaint and must not be put on my clinical file.”
For formal written complaints, and help at complaints meetings, in setting them up,
getting what you want discussed on an agenda, and ensuring a proper record is
kept, the Community Health Council Patient Complaints Advocates are very well
placed to get things working as well as possible.
8.16 Safeguards
No information about your complaint should be put on your clinical records
No-one not directly involved in the incident or grievance should be informed of your
complaint
1) Your care should not be affected in any way by your complaint
2) Your treatment, or referral for treatment, must not be deferred until after the
complaint has been investigated
3) You should not be discharged because of a complaint
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4) and you or your carers or family should not be punished in any way as a result
of your complaint
If you feel that you are not being protected in these ways, then tell whoever has
made your care less good, that they are acting against the complaints process. If
they do not immediately reverse the action that reduces the quality of your care,
remove information about your complaint from your records, or if you feel they are
punishing you, your carers or your family, then contact the complaints department to
explain your concern. If the problem isn’t put right, the Community Health Council
Patient Complaints Advocate may be able to help, or you may find a request for help
from your Assembly Member, gets your treatment plan re-installed at the same level.
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8.19 Response from the LHB
You should get the response to your complaint in writing. You may not be happy
about the contents of this letter. It would probably be a good idea if you can put off
opening the letter until someone is with you, who can help you if you are upset by it.
If you do not trust yourself to be so patient, ask in your first letter of complaint, for
the response to be sent to your independent mental health advocate, your support
worker, your carer, or a friend, so that they can be there for you when you read the
letter. Don’t read the letter on a Friday or Saturday, in case you go into crisis and
need additional support, which is harder to get at the weekend.
Whether you are happy with the letter or not, it is a good idea to write back to the
chief executive to thank him/her if you are happy, or to explain what you will do next
if you are not happy.
8.21.1 Forms
You should write to the secretariat giving full details of your complaint.
You will then be asked to sign a consent form, which will give the
secretariat permission to have a copy of your medical records and/or the
records of your complaint. If you don’t agree to access to these records
the Secretariat cannot investigate further than the information that you
have sent them.
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8.21.2 What happens to your complaint
A lay advisor and a lay reviewer will look at your complaint. They will look at the
local resolution correspondence.
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8.21.4 The response from the Secretariat
The secretariat will write to you as the complaint is processed, to let you know how it
is going. If you want to know what is happening, you can phone the office to find
out. The staff are very helpful.
At the end of the investigation the Lay Reviewer will write to you with his conclusions
and any recommendations to refer the case back to the LHB, convene a panel or
draw the issue to a close. He will also include a copy of any clinical report. Similarly,
a letter and the clinical report will be sent to the organisation complained about. It is
usual for NHS organisations to act on any recommendations made, but they don’t
have to.
The Independent Complaints Secretariat may send your complaint back to the NHS
service provider, if they feel that more could be done by them. They will make
specific recommendations to focus on actions that are needed eg a meeting, or
areas where more information is required. If you do not agree with the remit
suggested by the Secretariat for the LHB, you can write back to the Secretariat to
ask for greater clarity, or an expanded remit. Again they may not agree to this, but
they definitely can’t facilitate it, if you don’t ask.
If further Local Resolution is recommended and you remain dissatisfied after this has
taken place, then you can ask the Independent Complaints Secretariat for a second
review of your complaint.
If the Secretariat decides to take your case further themselves they will convene a
‘panel’. This includes the Independent reviewer, the independent advisor, and one
other person, all of whom are ‘lay’ (not associated with or working for, the health
service). It will also include 2 clinicians with the relevant speciality. You will have
the opportunity to agree the remit of the panel at this time. You will be invited to an
interview with the panel, where you can make your case. They will separately
interview the staff from the LHB, and any other witnesses. You will see a copy of
their report of the salient points from your interview only. You have the opportunity to
suggest corrections or amendments to that report, which will be considered, but may
or may not lead to a change in the report. The panel will them consider their
findings from this process, and may make recommendations to the LHB.
If you feel that the process of the panel interviewing people separately, rather than
together, is a problem, maybe because it permits misconceptions, biases, and
mistaken information to be perpetuated, you can ask for the process to be more
inclusive and open. It is generally believed by the service that the more open
process ‘would be unproductive’, but very occasionally they have done things
differently. It is worth asking if you want the panel to be run as an independently
chaired meeting, including all the people involved.
If you are unhappy with any aspect of the process of the Independent Complaints
Secretariat, you should write back to raise your concerns. They may be able to deal
with your issues, and will do so, if they can. If the reviewer feels they are unable to
accommodate your wishes, you could ask the secretariat manager if they could
authorise a special response.
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8.21.5 If you are still unhappy, what next?
If you are unhappy with responses to your concerns from the health service or
Independent Complaints Secretariat, and you have been advised that they can do
no more, you can go to the Public Services Ombudsman. This service only deals
with ‘maladministration and service failure’ . For more information and guidance, if
you feel you want to talk to someone before making your complaint, call the
Ombudsman’s office on 0845 601 0987. They cannot talk about your complaint in
detail at this stage but can give general guidance.
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You cannot guarantee that your complaint will be taken forward, or resolved to your
satisfaction. You need to be prepared for the worst.
Consultation Questions
1) If you were present at the Putting Things Right day, do you think this
report adequately represents the discussions on the day, and in
particular anything that you wanted to be heard? If not, please describe
what you think should be added
2) Look at the list of comments from the day. ( Appendix 5) Tick those
you agree with, add anything you think is missing. This will give us an
indication of the areas a number of people think are most important
3) If you were not present at the Putting Things Right day, what key
problems or possible solutions should be added to the report?
4) Would you like any further information added to this report?
A summary of the presentations
A report from the evaluation of the day
Other - please specify
Please return your comments to Penny Gripper c/o Eiriol, 59 King St,
Carmarthen, SA31 by 30th July 2009
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Appendix 2
Attendence - 22 service users
4 advocates
3 NHS LHB staff from
Complaints, CPA and patient involvement
3 NHS clinical staff
1 NHS LHB Manager
2 Welsh Assembly Government managers
3 Voluntary sector staff
1 volunteer
1 Carer
1 Officer of a Community Health Council
Total - 41
Booked but didn’t come - 3 advocates
3 staff (including one social worker)
2 service users
1 voluntary sector worker
Total no shows 9
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Make sure service user is fully informed of everything they need to know to make
informed choices about their own care
Resources
Not enough CPN's - cannot give enough time to everyone
Lack of on-going support
Bigger picture - need to consider that a little resource in the right place at the right
time, can massively reduce resource needed if not spending the money causes a
deterioration which leads to hospitalisation.
Listen to the service users - they know what works for them. Working with service
users, rather than against them will cost much less.
Feelings
Dissatisfaction with advocacy (by who?)
Feeling of not getting anywhere anyway
Stigmatised
Vulnerability - not heard
Stop being scared of us patients.
Staff don’t care
Staff dig in their heels as a matter of principle on particular issues, because they
fear that ‘giving in’ will encourage the service user to plead for something else.
Actually it would just feel that the service was responsive and caring, and that my
life mattered a toss to someone.
Needs
Alone - need easy access to a listener, easy access to information, short time span
to implement. Ability to pursue a complaint up to 6 months ? and more.
Easy access to information on complaints handling
Need to anticipate problems.
Advocacy support structures in the community - no follow on.
specific service info/guidance, and scenarios around confidentiality (possibly 1.
clinical care, 2. re; complaints)
Need more personalised packages of care
Frightening to go into hospital - need information, but may be given at the wrong
time
Discuss when best time is to give this to help understanding
Info on complaint procedure at the start and as an on going thing - explain what
advocacy is.
More info on alternative therapies
Choice without recrimination
Volunteer to take service user home and see basic needs can be met, and to have a
cup of tea. Need new post to do this.
House of safety run by services, 24 hour manned (use in Pembroke and Swansea.)
1) Safe contact/support prior to need for hospitalisation
2) Safe contact/support post hospitalisation
3) Better application of drugs prescriptions
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4) Increase police familiarity with metal health BY visiting wards, groups etc (out of
uniform) Advocate training classes.
Loads of needs, but how to find answers?
Better unmet need process - should be independent of NHS as they 'cover up' needs
so that they don't have to respond to them.
If people are not getting a service because there are not enough staff, it is still an
unmet need even if the service is there.
44
1) safe contact/support prior to need for hospitalisation
2) safe contact/support post hospitalisation
3) Better application of drugs prescriptions
4) Increase police familiarity with mental health BY visiting wards, groups, etc. out of
uniform) Advocate training classes.
Specific to complaints
Acknowledge evidence when it is offered
Clear guidelines may be adequate for post-acute/rehab stage, but acute care
different
CHC, MHA commission/, HIW, CSSIW
Being able to make a complaint to someone who is not providing your care.
Most problems stem from institutional acceptance of existing structures
Clarify (on both "sides") what a complaint means, what a suggestion means, but
they both should be considered
More honest up front communication and information to avoid complaints eg weight
gain due to medication
Complaints are negative at first, how to overcome this - communication between
complainant, person complained about and a third person.
Service user must have control over the complaints process, who is involved, and
what happens when. They must be able to pull out at any stage if they feel the risk
to their care, or even their life, is too great.
No report back to a complaint should be made until AFTER a face to face discussion
between the investigator and the service user, summing up the findings, and
allowing the service user to respond as to whether they feel the investigation actually
addresses their complaint at all.
Training
More mental health awareness of issues for service users
specific service info/guidance, and scenarios around confidentiality (possibly 1.
clinical care, 2. re; complaints
Manager should go and talk to people where it works well
Do something (?training?) about attitudes, values and its OK to talk - actually it's part
of the job and treat everyone as an equal.
Better manage situations when tension is rising between clinician and patient
through improving supervision.
Create opportunities to reduce institutionalised organisations eg ward staff -
community example given - if a community staff is rude you won't let them in your
house - don't have that choice on the ward
Recognising where things have gone wrong
Give them clear codes of conduct and have ward meetings with patients and staff as
'therapy' for both parties
GPs need training on complaints advocacy and mental health in general.
DACE do course on empowering service users
Advocate training (for police in mental health matters)
Need specific training to help them to be more aware of the effects of their
behaviour, and communication style on vulnerable/potentially paranoid people.
45
(for staff)
All staff should be trained in LHB policy on resolving problems, and on
confidentiality for this process, including consultants, at least once every three
years.
All staff should be trained in no blame problem solving, and in conflict resolution.
46
Can do philosophy
Advanced directives/ self management programmes (eg MDF)
NHS should be more proactive about going to voluntary organisations eg MIND,
MDF
Organisations are able to plan and are able to respond to unmet needs (which lead
to complaints) eg local services not England
Proactive home treatment for substance misuse
Use complaints constructively to have a positive effect and highlight what needs
improving
Better manage situations when tension is rising between clinician and patient
through improving supervision.
Recognising where things have gone wrong
Often only issue is to make sure that same doesn't happen to someone else.
Stop suppressing and controlling people
More info on alternative therapies
Choice without recrimination
Advocacy acknowledged as important
Advocacy high on list of priorities
Reports of events
Crisis resolution team - withdrew (telephone) number due to volume of calls
Nurse discharged someone without reason
Quality issues
1st point of contact
Quality improvement targets - asking people what they think of the quality of care (eg
questionnaires) sent to people centrally not by team providing the care.
Prioritise the parts of the system that have broken down.
Recognising where things have gone wrong
Stop suppressing and controlling people
Police
Police stripping people naked - need education
Police lack of education and respect
Community policing
Advocate service for people in police stations
Police duty of care
Place of safety other than police station
Ideas - Community police officers - go to , Mind, ward round, MDF meeting- out of
uniform
All talked of good experience - with some workers. Police good men in all walks of
life.
1) safe contact/support prior to need for hospitalisation
2) safe contact/support post hospitalisation
3) Better application of drugs prescriptions
4) Increase police familiarity with mental health BY visiting wards, groups, etc. (out of
uniform) Advocate training classes.
47
Problems with current complaints approach
Complaints system failing patients
Long, drawn out and difficult
Confidentiality being broken - in care and in the complaints process
Don't always get an apology
litigation
not knowing which policy to follow
confusion between informal and formal
managers speak language we cannot understand - need to speak clearly
concerns about whether you will be heard because you are very ill - should be
looked at again when better
"Attention seeking", "manipulative", - people can get blamed for not fitting the boxes
of what is available and seen as a pain.
Experience of complaints process - not following procedure, false information
Becomes adversarial - have to resort to legal side because they won't listen
Unequal power - system has its own support, but service user is alone, and including
the way things are written.
Advocates are limited in what they can do/advise
Difficult to find an independent solicitor
End up being caught in the system
Concern that services only worried about people making a claim, so act defensive,
don't listen
Long processes are detrimental to people’s mental health, can cause further
problems/relapse
Can cause trust to collapse in the service - could this then cause a need for further
services.
People can be worried about losing a service or being punished.
People who want changes made or to change their care team can be labelled and
fear recrimination
48
When is 'proof' one way or the other relevant? To the extent that it is greater
transparency about recording - note of meetings as drafts requiring approval by
service user/patent etc, might help. But as we know from other contexts, there are
often powerful motivations on both sides not to record the sort of matter that come
into dispute.
49
Confidentiality policy – needs to specifically include the additional confidentiality
between staff on complaints
Solutions
A lot depends on the way you are treated
Patient councils
Opportunity to chat through issues
Help with signposting
Raise issues with managers
Funding should not be left to the voluntary sector
Opportunities for peer advocacy?
Implement across the board
Example of water dispensers - letters ignored - press not
Patient councils - not all patients are in hospital, community captured views - bigger
challenge
Solution - listening to problem at start, spoken to and respected service user, do not
discriminate
Recognising where things have gone wrong
Miscellaneous comments
Doctors and nurses should try their own drugs. If they're good enough for them,
then maybe we could consider taking them.
Institutionalised
The staff canteen serves fresh, wards get cook chill
Alternative therapies are available to staff - but not to service users.
CBT was found to be less effective.
Voluntary sector need to look at themselves
Appendix 4
Copies of the Welsh Assembly Government’s leaflet “Complaints about the NHS
Treatment and Care – A guide to making a complaint about the NHS in Wales”, are
available from www.wales.gov.uk/nhscomplaints
52
In the case of informal concerns, which are usually received by telephone, the team
will attempt to resolve the issues as soon as possible. Sometimes , however, more
complex concerns will have to be dealt with by the appropriate manager. In all
circumstances the complainants are kept informed by the complaints department of
the steps that have been taken to resolve the issues raised.
Email: enquiries@waleschc.org.uk
Tel: 0845 644 7814
Fax : 02920 235574
Address:- Board of Community Health Councils in Wales
2nd Floor
33-35 Cathedral Road
Cardiff
CF11 9HB
53
Website : www.hiw.org.uk
Email hiw@wales.gsi.gov.uk
Website: www.mhac.org.uk/
Tel: 0115 943 7100
Address:- Mental Health Act Commission
Maid Marian House
56, Hounds gate
Nottingham
NG1 6GB
Care and Social Services Inspectorate for Wales
The inspectorate inspects social care services which are under license, such as
residential care, and child care. They are also responsible for inspecting social
services run by local authorities.
Website : www.cssiw.org.uk
Email : cssiw@wales.gsi.gov.uk
Tel: 01443 848450
Fax: 02920 823417
54
Address:- Care and Social Services Inspectorate for Wales
Cathays Park
Cardiff
CF10 3NQ
Website : www.ombudsman-wales.org.uk
Email : ask@ombudsman-wales.org.uk
Professional Regulators
These organisations keep a register of people who have the qualifications and
experience necessary to hold the professional title. They set the entry criteria, and
standards of training, and any requirements for professionals to maintain on-going
registration, such as complying with a code of ethics, conduct or practice, and
keeping up to date through ongoing training and experience, or meeting
performance criteria. Anyone who is not on these lists is not legally entitled to
practice in that profession.
(NB the psychotherapists will be subject to registration with the HPC (Health
Professions Council), from July 2009, but it will be a while before there are clear
entry requirements and a code of conduct. Until then they can in addition,
voluntarily belong to a professional body, which has entry standards and which will
expel people who do not comply with their ethical code. An example organisation is
given here)
55
Professional regulators have a role in investigating issues of professional conduct
(misbehaviour) and can apply sanctions if cases are proven. In serious cases they
may take someone off their list. If this happens that person will lose their job. If you
feel a professional you have seen is not fit to practice, you can get advice from
these organisations. They will provide you with copies of their codes, and will often
give advice over the phone regarding whether your complaint comes under their
area of responsibility and how to make a complaint.
Website: www.gmc-uk.org/
Email: gmcwales@gmc-uk.org
Tel: 02920 504060
Email; practise@gmc-uk.org
National Headquarters
Address:- 17 Belgrave Square
London
SW1X 8PG
56
RCP (continued)
Tel: 0207 235 2351
Fax: 0207 245 1231
Website: www.nmc-uk.org/
Address: Nursing and Midwifery Council
23 Portland Place
London
W1B 1PZ
Website: www.ccwales.org.uk/
Email: info@sswales.org.uk
Tel: 02920 226257
Minicom: 02920 780680
Fax: 02920 384764
Address:- Care Council for Wales
Southgate House
Wood Street
Cardiff
CF10 1EW
Investigations team Tel: 0845 0700 248
Fax: 02920 780 661
Email: investigations@ccwales.org.uk
Or write to the Investigations Team at the address above.
Website: www.hpc-uk.org/
Tel: 0845 3004 472
0207 840 9802
57
Fax: 0207 840 9801
Address:- Park House
184 Kennington Park Road
London
SE11 4BU
Website: www.bps.org.uk
Email: enquiries@bps.org.uk
Tel: 0116 254 9568
Fax: 0116 227 1314
Website: www.bacp.co.uk/
General Enquiries Tel: 01455 883300
Email: bacp@bacp.co.uk
Client Information Helpdesk Tel: 01455 883316
Professional Conduct: 0870 443 5217
Email: professionalconduct@bacp.co.uk
58
Appendix 5
The Mental Health Context – service user experience
The experience of the mental health service is one where the risks to the individual
service user, and sometimes to the community are potentially devastating and far
reaching.
The following key issues affect mental health service users:-
Staff achievements
• The mental health service is not an easy place to work
• Staff work very hard, and often at anti-social times
• Most staff are committed and caring
• The service helps a lot of people
• Because of the service many people live longer, happier and more useful
lives.
• Because of the service many people get better and become independent of
secondary care
Communication:-
• Mental health service users have, at times of illness, particular problems with
communication, both in their ability to listen and engage, and in their ability to
express themselves effectively
• Tendencies to paranoia, make honesty and openness by staff particularly
important
• It is important to ensure the client is supported and safe when being given
difficult information, e.g. if bad news is delivered by post to arrive on Friday or
Saturday, it may trigger a crisis, or even a suicide attempt, because there is
no-one available to help quickly
• It is essential that clients understand what is meant by confidentiality with
respect to their notes and any letters they send
• It can be useful for some service users and carers to have a leaflet, others
would be unable to read one because their distress or agitation makes it
impossible for them to concentrate
• Telephone calls are potentially a source of distress. If a member of staff
refuses to speak to a service user on the phone, the service user is likely to
read more negativity into that than is intended. On the other hand staff need
to be very careful on the phone to be aware of how the service user may feel
about what they say, and how they are saying it. If there is any need to
challenge the service user, it may be best to arrange a meeting. However,
reassurance and help are very valuable over the phone
Care Planning
• The care plan approach in mental health is intended to deliver an agreement
of a care plan together with all the agencies, the service user and the carer
59
• However the care plan does not have to be ‘signed off’ by the service user,
and therefore can contain elements which are contrary to the client’s wishes,
and with which they may not comply
• The care plan approach is meant to ensure that the service user is always
involved in decisions about their care, but because the team often make
decisions in the absence of the service user, this frequently does not happen
• Because decisions are made in a team, service users and carers may have
no opportunity to challenge the views of individual staff, or to have any
influence over that decision. “It was a team decision” can be used as an
abdication of responsibility when a service user is unhappy with a decision
• The approach is based on having a ‘care coordinator’ who in principle is
supposed to advocate for the client’s needs for services within the team, but
who in practice can become the team’s deliverer of bad tidings, and a gate-
keeper, rather than a gateway, to care.
• The approach requires the assignment of a ‘CPA level’, either ‘standard’, or
‘enhanced’. The Assembly give clear guidelines on the criteria for these
levels, but the actual application can be inconsistent with these criteria, and
between service users
• The care plan approach is intended to ensure continuity of care and smooth
transitions from one part of a service to another. However, whilst there
should be a care package in place BEFORE someone is discharged from
hospital or from the crisis and home treatment team, often there is not.
Balance of Power
• There is a real imbalance of power between the service user and the NHS,
which is exacerbated in the complaints process
• Withholding of information such as a diagnosis, can be perceived by the
service user as oppressive. Knowledge is power. Not having knowledge
excludes service users from involvement in their care
• In mental health the consultant has to be asked before medical records can
be released to the service user. Many people will not ask for records because
they fear that the consultant will be angry with them for asking, and may, not
only refuse access, but also punish them for asking. Fear of lack of access
to medical records, adds to the clients fear that they are being ‘locked out’,
and that bad practice can be hidden, or go unchallenged.
• Complaints can be seen as indicators of illness and therefore not legitimate
• If interpreted as a sign of paranoia, hallucinations or delusions of grandeur, a
complaint can lead to section and loss of liberty
• The imbalance of power feels more oppressive when complaints
investigations and decisions take place, ‘behind closed doors’. It is difficult for
a service user to accept a decision or investigation, which has not involved
talking to them about their experience and concerns,
and given them a chance to respond to the justifications, defences or
evidence presented by the people who are the subject of the complaint
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Collaboration and relationships
• Sometimes, if the service user doesn’t want a particular intervention the staff
will go to the carer or family to support them to impose the intervention. This
undermines service user trust in both the staff member and in their family or
carer.
• Mental health problems are generally long term, so potential damage to
relationships through making a complaint is a real disincentive to speak up
• Problems with relationships with staff are always detrimental to the care offer
• Because of the nature of psychological ‘recovery’, the service user has to be
an active part of the process, and has to take responsibility to some extent for
how much they benefit from the service. Unfortunately this means that when
things go wrong, professionals can (and often do), blame the client for not
engaging with the treatment, and by doing so the professional avoids the
need to; accept any culpability, or responsibility for the quality of the service
offer; reflect on whether they have made a mistake regarding the best
treatment approach or the involvement of the best placed professionals; or to
consider any need to change the way they do things. There is a strong and
frustrating feeling for service users, that professionals, especially
psychotherapists, can never be wrong.
• Because the client needs to be a part of the recovery process, they have to
believe in the treatment they are being offered, especially non
pharmaceutical solutions.
However, it can feel like the only person who has to change, to ‘collaborate’
is the client. The client has no power to do any other than accept what is
offered on the staff’s own terms.
Information
• In contrast to physical health, there is little ‘objective’ information in patient
records. Most of it is ‘perception’, ‘opinion’, and ‘interpretation ‘
• Our lives are deeply affected by these perceptions, opinions and
interpretations, which in turn, are based on records, which are neither
consistently accurate nor reliable
• Inaccuracy of records means that complaints investigations cannot access the
necessary evidence to substantiate the client’s complaint
• Treatment decisions are often based on second hand information, and can
become based on increasingly remote sources, on letters based on letters,
based on discussions in the team, based on presentations from staff who
carried out the assessment, summarised, filtered and prioritised according to
that individuals views. Sometimes , like Chinese whispers, an inappropriate
decision is based on inaccurate interpretations.
• Information is a powerful resource for recovery in mental health
61
Access to resources
• Assessments are often done by one professional in the field of another, and
hence decisions about the need for a service are made by people who don’t
work in that field, and don’t have professional qualifications in it. Eg, a social
worker might be assessing whether a client needs a nurse or an OT. This
kind of cross professional, ‘generic’ working is not an issue in many other
parts of the NHS, and creates the potential for unsafe clinical decisions,
which prevent client access to services that could help them
• Resources in mental health are severely limited, and mostly targeted at the
people who have become more severely ill. This is despite the Assembly’s
commitment to earlier intervention, and frequently results in people becoming
more ill and needing the higher level of intervention at a later date. It is
ultimately a high cost strategy.
• Inability to provide a service which is likely to help a service user is supposed
to be registered as an unmet need, in order to help redeploy resources or
plan for a better service. However, the process of recording an unmet need
is internal to the LHB. It would appear that staff are discouraged from
reporting unmet needs because it places an obligation on the LHB to provide
the appropriate service or to pay someone else to do so. The way unmet
need is defined in many LHBs, is as a service that they do not have the
physical structure (eg medium secure units) or the expertise (eg EMDR) to
deliver. However the most common cause of needs not being met is
insufficient staff time
Safety
• It is hard for staff to let clients take risks. But service users need to be
allowed to make mistakes sometimes, to build up their confidence and to
reduce their dependence
• It feels like the risk to the psychiatrist is more important than the risk to the
client. A psychiatrist is more likely to section someone who is manic, and
therefore unpredictable, than to admit, even on a voluntary basis, someone
who is at very high risk of suicide. The experience of hospitalisation becomes
contrary. It feels like, whichever option the client would prefer is the very
opposite to that which is enforced.
• Crisis Intervention and Home Treatment teams, feel like they are target
driven, based on keeping people out of hospital, even when they would be
safer in it.
• Depending on the diagnosis, 10-20% of mental health patients die by suicide.
The service therefore needs to be especially sensitive, to provide for safety at
any time of transition or when a decision, such as an assessment
recommendation, a diagnosis, or a complaint report is made.
• Suicides happen as a result of the way the service treats its clients. Any
advocate will be able to provide stories of when this has happened. Suicides
can also happen as a result of the way complaints are managed
62
• Many people self-harm when they are distressed. Self-harm in adults is not
taken seriously at present, and very little is done to prevent it, or to support
people after they have harmed themselves. This again means mental health
service users are more at risk if a complaint process is excessively drawn out,
if something goes wrong with it, or if they are unhappy with the outcome.
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Appendix 6
Policy Context
Document summaries
“One Wales”
This is a description of the 2007 National Assembly Government’s work
commitments for their term of office.
We will:-
“place a new priority on providing for mental health”
“draw up a charter of Patients’ Rights and legislation on NHS redress”
“deliver…. Improving patients’ experience”
“reform LHBs to improve accountability both to local communities and to the
assembly government.”
We note:
“ a positive experience of care speeds recovery”
For a fair and just society the Assembly is:
“unswerving in its adherence to the principles of inclusion, pluralism and fairness”
“Protects vulnerable individuals or groups from suffering harm or and discrimination”
“People, Places, Futures – The Wales Spatial Plan – Nov 2005”
This is a document which describes how Wales can achieve National and Regional
priorities
It aims include to:
4) “Address health inequalities”
5) “Achieving sustainable accessibility”
64
65
Making the Connections – Delivering Beyond Boundaries (Nov
2006)
This documents follows up from the last one by describing the actions the Assembly
will take to realise its vision.
It says:-
“The..report Beyond Boundaries …demonstrated that we need to drive through the
changes faster and more rigorously. It showed that we are on secure ground in
concentrating on behaviour and cultures….It called for public services to be much
more ambitious and innovative, making a step change in how they engage with
citizens…..”
Making the Connections – Building Better Customer Service
This document describes the commitment of the Assembly to improve users’
experience of public services. It describes five core principles, which are:-
• Access- : “Citizens will be able to find and access information and advice
about services……and get a timely
• response with information and advice they are able to understand.”
• Personal Experience- : “Citizens will be dealt with politely, shown care and
dignity, have options explained openly and constructively, and be kept
informed of progress…”
• Responsiveness - : “Citizens will be offered services that take into account
their needs, circumstances and any barriers they might face.”
• Language Options- : “Citizens who prefer to access and use services in
English or Welsh, or need to use minority ethnic languages or British Sign
Language will be able to do so.”
• Redress- : “Citizens will find it easy to complain and get things put right when
the service they receive is not good enough.”
The Assembly are also working on a statement about ‘public engagement’ and
another on ‘access transformation’. The latter will look at improving access to
services through the use of technology.
It says about complaints:-
“Research..has identified that citizens want to be able to complain if they are not
satisfied with public services, and they want to do so in a way that results in any
problem being put right quickly. They do not want to resort to a formal complaints
procedure as the only option.”
“Routine complaints should be dealt with quickly and with a minimum of formality for
the service user.”
“A good service is one where citizens:
• …will be listened to and responded to promptly, effectively, fairly and
objectively and be kept informed of progress. Their expression of
dissatisfaction will be recognised as a complaint
“…a good service will need to ensure that:
66
• complaints are seen as an opportunity to learn and improve the service for all
users; and
• training and support is provided to staff so that they understand how they
should respond to complaints.”
Equity
Mental health services should be available to all allocated according to individual
need
Empowerment
Users and their carers need to be integrally involved at all levels,.. Informed choice
for all users is central to this principle… Those detained under the Mental Health Act
should be encouraged to participate actively and willingly in their own care…
Effectiveness
Mental health services should provide effective interventions that improve quality of
life by treating symptoms and their causes, preventing deterioration, reducing
potential harm and assisting rehabilitation. …. Service providers must be
accountable for the quality of services.
Efficiency
….There should be interagency working especially between health and social
services, other parts of local Government, voluntary agencies and the private sector
….
67
In it’s aims and objectives the document describes many aspirations that would
prevent complaints if properly applied.
These include:
• “to protect services users and the public from avoidable harm, while
respecting the rights of users and their carers.
• “Discharge plans must ensure that all users are provided with suitable support
and follow-up after in-patient admission.”
• “Advocacy seeks to address ….imbalance by ensuring that their voice is
heard, their choice is real and their rights are safeguarded”
• “The rules of record keeping should follow the guidelines relating to individual
professional practice”
• “..regular supervision and professional support provided within a constructive
problem solving environment rather than pursuing a culture of blame”
Stronger in Partnership 2
This document gives guidance on how to improve service user involvement in mental
health, and underpins service user hopes for how they contribute to their own care.
Failure to deliver on these principles often leads to complaints.
The following are some of the things it says.
“..it is the people who use the services who are the experts on how they feel and
what the aims and ambitions for treatment and care should be…”
“…service providers are responsible for acting on advice from service users and
providing explicit feedback on action taken.”
“Empowering service users and carers involves professionals relinquishing a degree
of their own power and enabling service users and carers to have a greater choice
and control over their lives.”
“The Care Programme Approach (CPA) is a co-ordinated system of care
management that focuses on the needs of the individual where service users and,
where appropriate, carers are fully involved in the formulation of the service users’
own individual care plan. These should be formally agreed and signed by the
service user and appropriate health care professional and copies given to the
service user and with their agreement to any carer”
(italics from document editor)