Written evidence from NHS England and NHS Improvement (HCS0068)

Dear Ms Harman,

Thank you for inviting us to give evidence to the committee’s inquiry on Human Rights in Care Settings recently.

As agreed with committee officials, we are writing to follow up on two points raised in the hearing on 1) care of people with dementia and 2) staff training.

Care of people with dementia

NHS England and NHS Improvement (NHSEI) is committed to delivering high-quality dementia care and support and there has been a shift towards addressing dementia (as well as mental health problems) through a human rights-based approach that reinforces the obligations of healthcare providers to protect people’s human rights. Central to this is the provision of personalised care, which takes a whole-system approach, integrating services around the person including health, social care, public health, and wider services. This is summarised in the Dementia Well Pathway and Dementia wellbeing in the COVID-19 pandemic documents, which are integral to this human rights based approach.

In addition, NHS Long Term Plan commitments include:

• Extending the application of the NHS Comprehensive Model of Personalised Care, with a focus on enhancing access to social prescribing and personal health budgets for people with dementia – thereby giving people a greater choice over the support and interventions they require to meet their personal needs.
• The expansion of service models such as Anticipatory Care and Enhanced Health in Care Homes (EHCH), which will help provide proactive and integrated care in the community. Key to this is the establishment of ‘enhanced community multidisciplinary teams’ comprising a range of staff such as dementia workers, physiotherapists and others joined by social care and the voluntary sector.

The Mental Health Safety Improvement Programme

To align and drive improvement work to reduce harm caused to people using inpatient mental health (including dementia), learning disability and autism services, the NHSEI Mental Health Safety Improvement Programme (MHSIP) has set up Mental Health Patient Safety Networks across regions in England. These are being supported to engage with local systems through the following initiatives:

• Work to reduce restrictive practices began in response to a Care Quality Commission (CQC). In their report, The State of Care in Mental Health Services 2014 to 2017, the CQC found that some patients were still receiving ‘overly restrictive’ care, despite the concept of least restriction being a guiding principle in the Mental Health Act since 1983.The MHSIP patient safety networks are currently focused on creating safer inpatient services by using a systematic approach to reducing restrictive practices (RRP).

• Mental health trusts are utilising quality improvement methodology to scale up and spread a package of resources to support RRP to providers. These resources were developed and refined for the MHSIP by the National Collaborating Centre for Mental Health (NCCMH) in a national pilot launched in 2018.The pilot saw wards testing over 300 practical changes over 18 months, which by February 2020 had resulted in 24 out of 38 wards seeing reductions ranging from 25% to 100% in one or more measures of restrictive practice (number of physical restraints, seclusions and use of rapid tranquillisation).

• The number of wards engaged has now increased to 168 within 47 out of 52 Mental Health and Learning Disability Trusts and five private organisations, who provide NHS inpatient services. This includes at least eight wards who provide care for older adults with dementia. Our aim over the coming year is to engage 100% of mental health trusts.

All areas of work within the MHSIP have been co-produced from the outset and throughout with patients and carers with experience of inpatient mental health services and the programme’s specific areas of focus, and are fundamentally focused on addressing inequalities and protecting the human rights of people using inpatient mental health, learning disability and autism services.

Mental Health Units (Use of Force) Act 2018

NHS organisations are governed by the Mental Health Units (Use of Force) Act 2018, which clearly sets out the measures needed to both reduce the use of force and ensure accountability and transparency about the use of force in mental health units. The Act applies to all patients (of all ages) being assessed or treated for a mental health disorder in a mental health unit (NHS and independent hospitals providing NHS-funded care), whether they are detained under the Mental Health Act 1983 or as an informal or voluntary patient.

The Act clarifies key definitions and specifies Mental Health Units must:

• Employ a “responsible person” who will be accountable for ensuring the requirements in the Act are carried out.
• Develop a written policy setting out the steps the unit is taking to reduce the use of force.
• Publish information about the rights of patients in relation to the use of force.
• Undertake staff training requirements and the topic areas that this should cover
• Record the use of force locally.
• Investigate following a death or serious injury as a result of the use of force in accordance with relevant guidance.

Implications of the Mental Health Units Act 2018 for Providers

The implications are for all providers of inpatient mental health services delivering NHS commissioned care so includes the Independent Sector and NHS Trusts. These are:

• The majority of the requirements of the Act are within the NHS Standard Contract for providers.
• As of April 2020, the NHS Standard Contract stated providers of mental health services required training to be delivered by an accredited training provider and an executive be responsible for reducing restrictive interventions across an organisation.
• Restrictive practice data is collected and made available through a dashboard, which helps monitor rates, support RRP and drive improvement.
• NHSEI also monitors the NHS Standard Contract which requires mental health services to submit data and information to commissioners on a quarterly basis.

2) Staff Training

In the UK all public authorities, including NHS organisations, have a duty to respect and promote human rights. The Equality and Human Rights Commission’s aims to help the health and social care sector comply with the Human Rights Act (HRA) through:

• Increased knowledge, understanding and ability to meet duties to respect, protect and promote human rights, including by addressing inequalities.
• Increased knowledge, understanding and ability to translate human rights concepts and protections into higher quality service design and delivery.
• Improved care experiences for patients, service users, their families and carers, through embedding a human rights-based approach into service delivery.

The Commission has also brought together educational resources for the sector, from external websites and providers, including, but not limited to, Age UK, Dignity in Care, Human Rights in Healthcare and Skills for Care.

Alongside this general approach to ensuring human rights are embedded in staff training and development, there are other examples worth highlighting.

Core Skills Training Framework

Skills for Health and Health Education England (HEE) are working together to ensure a robust Core Skills Training Framework (CSTF) with agreed requirements for learning outcomes and training standards in NHS Trusts. Human rights training sits within the CSTF under an Equality, Diversity and Human Rights Module with a provision that it has to be repeated every 3 years.  It is also informed by relevant legislation such as the Equality Act 2010 and the HRA and is targeted at all NHS staff, including unpaid and voluntary staff.

The CSTF seeks to ensure that the following learning outcomes are incorporated into education and training for all staff groups so that each participant can:

• Understand the terms Equality and Diversity and Human Rights and how they are applied within the context of the health sector.
• Understand how a proactive, inclusive approach can be promoted.
• Understand the purpose and benefits of monitoring equalities and health inequalities.
• Understand the benefits that an effective approach to equality and diversity and human rights can have on society, organisations and individuals.
• Understand how legislation, organisational policies and processes can empower individuals to act appropriately and understand people’s rights.
• Know how to treat everyone with dignity, courtesy and respect and value people as individuals.
• Know what to do if there are concerns, including how to use whistle blowing policy procedures and other related policies such as Bullying at Work and Dignity at Work.

Training of Mental Health, Learning Disability and Autism Staff on Human Rights

As referred to in our oral evidence, we have also commissioned some human rights training specifically for health staff:

In autumn 2019, a National Quality Improvement Taskforce was established to improve current specialist children and young people’s inpatient mental health, autism and learning disability services in England. As part of its improvement work, the Taskforce has commissioned the British Institute for Human Rights (BIHR) to deliver Human Rights Training to over 2000 staff. This training is bespoke to inpatient Children and Young People Mental Health Learning Disability and Autism services and supports providers’ wider commitments to reduce restrictive practices. It has been co-produced with BIHR and people with lived experience and includes guidance on providers’ legal duties under the Human Rights Act and how this applies to service delivery.

The training provides organisations and staff with a common framework for the explicit assessment of human rights including a practical decision-making tool which will enable staff to make appropriate decisions both operationally and strategically. This is expected to become part of patient care records going forward and during the course of 2022/23 will become a contractual requirement.

NHSEI has also contributed to the pilot being undertaken by HEE and Skills for Care for Oliver McGowan Mandatory Training on learning disability and autism for health and social care staff. This training ensures staff working in health and social care receive training, at the right level for their role so they can have a better understanding of people’s needs to improve services and ultimately health and wellbeing outcomes.

We hope that you find this information helpful to your inquiry.

Yours Sincerely,