It’s 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 received accreditation.
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,” she says.
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,” she says.
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.
There 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”
And 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.”
He 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.
Pegler 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.
However, 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.”
Collingwood 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 through AIMS.
Last 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.
Head 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’.”
The 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.
The 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”
Collingwood 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.
Weddle says she feels she has helped create a team where everyone “feels they can contribute”.
Newcastle patient representative organisations also gave a positive picture of Collingwood Court.
“As 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 members.
“Yes, 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.”
Equally, 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.”
However, 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.
AIMS’ accredited wards:
* 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