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MENTAL HEALTH OFFICER SERVICES: STRUCTURES AND SUPPORTS
CHAPTER SIX: FOCUS GROUP FINDINGS
INTRODUCTION
6.1 Five focus groups were conducted, four of which were attended by MHOs only. The MHO groups, which involved 39 participants in all, covered similar ground but with a particular emphasis in each, to explore:
- MHO work within a multi-agency team
- Working as an MHO in an urban environment (with particular attention to out of hours arrangements)
- Working as an MHO in remote and rural areas
- Working as an MHO with specialist client groups and clients with complex needs
6.2 Using the vignette shown in Annex 1 as an illustrative case study, participants were asked to describe their experiences of MHO practice and the operation of their local MHO service
6.3 A fifth group involved nine health care professionals only, working within one authority. These were made up of: two GPs, one consultant psychiatrist, three CPNs (one from the out of hours team and two from community services), two in-patient nurse managers and an LHCC manager.
6.4 Caution must be exercised in interpreting the findings reported below as these are drawn from in depth discussion with a relatively small number of practitioners. However, the focus groups provide a valuable opportunity to explore experiences and perceptions in some detail from the perspectives of these individuals.
ACCESS TO MHO SERVICES
Advice
6.5 From the accounts provided by focus group participants, it appeared that NHS and other professionals were able to gain access to advice from an MHO via the duty rota, as well as through more informal approaches. It was noted that approaches are often made to a specialist mental health team for advice rather than to the MHO specifically.
6.6 MHO services had worked to promote awareness among GPs of MHO functions and methods of communication. However knowledge and awareness among GPs continued to be variable. MHOs in some areas reported that GPs would not contact MHOs until a crisis point was reached; elsewhere GPs were said to be increasingly likely to access MHOs for advice at an earlier stage and to have a heightened awareness of the patient's rights to assessment.
6.7 It was reported that MHOs in some areas had made targeted efforts to accommodate the rotation of hospital junior doctors and build contacts with new post holders. Some hospitals had developed training for junior doctors in the role of MHOs.
6.8 Health professionals reported varying degrees of contact with MHOs. MHOs were perceived to have important functions in supporting, sometimes co-ordinating, the detention under the MHA (1984) process, in clarifying and explaining patient rights and in devising alternatives to detention, drawing on their knowledge of community resources. It was generally considered that MHO services were accessible, though noticeably stretched and heavily reliant on the commitment of individual MHOs. GPs were less clear than other health professionals about MHO roles.
6.9 With the exception of GPs, health care professionals reported that they had regular opportunities to share information with MHO colleagues, mostly in relation to individual service users. Health care professionals considered that there were insufficient opportunities to discuss wider practice issues and to network with other mental health professionals including MHOs. This was seen to be increasingly important with developments in legislation.
Assessment
6.10 MHOs indicated that duty rotas operated in most but not all areas. These rotas varied from daily to weekly. There was sometimes confusion among referrers who might contact a CMHT MHO, rather than go through the duty system. Some CMHT MHOs reported being constantly 'on call' while at work.
6.11 Where use was made of out of area hospitals, there could be confusion amongst the Responsible Medical Officer about which MHO service to contact.
6.12 Timing of requests for assessment was raised as an issue in rural areas in particular. Problems were reported if insufficient notice were given of the need for MHO involvement, compounded by the perceived reluctance to use holding powers in some hospitals.
6.13 The volume of referrals could be high and most of those working in busy urban environments had back-up MHO rotas to absorb peaks in demand.
6.14 On-going opportunities for communication and discussion among professionals were considered valuable to be able to take preventative action and avoid crises developing.
In one area, MHOs were doing joint assessments with GPs in the community, as routine good practice.
Social Circumstances Reports
6.15 Under the 1984 Act, MHOs have a duty to complete a Social Circumstance Report (SCR) for cases where a relative gives consent for detention under Section 26. Referrals could also be made to MHOs for non-statutory SCRs to provide information for the Responsible Medical Officer and Mental Welfare Commission. Early guidance in 1990 from the Scottish Office had indicated that it was good practice to prepare SCRs for all cases subject to compulsory detention .
6.16 In the each of the MHO focus groups, SCRs were regarded as an important part of the detention process. However, participants described considerable variability among their authorities in the extent to which they were able to undertake non-statutory SCRs. Differences in practice could result in inconsistencies for patients using the same hospital services, but from different LA areas. It was noted also that the opportunity to complete SCRs had diminished because of the demands of other statutory and non-statutory work and because of changes in practice. Requirements for statutory SCRs had diminished as there was now less reliance on relatives' consent in the detention process.
6.17 MHOs need to be notified of detentions if they have not been directly involved in the process of an application itself. It was stated that the timely completion of SCRs was contingent on notification from Medical Records to the MHO service of detention. This was variable, depending on the capacity of the latter and on whether it was established practice to notify the relevant social work service of detention. A number of MHOs involved in the focus groups considered that systems of communication between social work and Medical Records had been damaged with the removal of MHOs from hospital settings and had not recovered. Poor IT systems to facilitate information sharing between social work and Medical Records in some authorities were regarded as an additional contributory factor.
MEETING NEEDS
MHO work in relation to complex needs
6.18 Views varied about whether it was important to have MHOs with specialist skills in, for example, childcare, addictions or criminal justice work. It was perceived to be valuable to have an understanding of the interplay of mental health with other needs. However, it was also noted that MHOs could draw on such expertise from other social work colleagues working in these fields. A key issue was to retain the distinction between MHO and social work functions and ensure there was clarity about the capacity in which practitioners were working.
Continuity and communication
6.19 Continuity was an important consideration, in particular in relation to S18 applications for detention for up to six months. Some authorities aimed to achieve continuity from the point where someone was subject to emergency detention under S24/25. Processes of allocation tended to promote continuity where practicable by ensuring, for example, that if service user was already known to an MHO, that worker would be allocated the SCR. It was not always possible to ensure continuity, and timing and workload considerations could mean that cases had to be handed over to MHO colleagues. Transfer of cases might also be desirable to provide access to a more appropriate service. It was noted that continuity of response could be more readily achievable for CMHT clients than for others. One area was reported to be reviewing the organisation of services to ensure that an MHO (and other workers) could stay with a crisis for up to a week.
Out of hours
6.20 Communication between out of hours and daytime MHO services was seen as good on the whole, although there could be tensions at the point at which the out of hours service took over. Good communication and negotiation of responsibilities were considered to be key.
6.21 In one area, there were reported to be discrepancies in the handover times of daytime and out of hour services which resulted in gaps in coverage. In another area, difficulties were reported with the handover of S26 consent requests to standby services, because the latter excluded 'planned work'.
SUPPORT TO MHOs
Sources of professional advice and information for MHOs
6.22 The principal source of advice for MHOs was reported to be their peers, with line managers as the next port of call, but only if they themselves were trained MHOs. Local MHO forums were a further source of support, although experiences varied, depending on the size and formality of the forum and the opportunities it afforded for practice support and networking.
6.23 MHOs who were not in mental health teams were considered to be at particular risk of professional isolation. It was repeatedly stressed that inexperienced MHOs required support to gain confidence and experience. Some areas used peer mentoring to facilitate this.
6.24 There were mixed views about advice from the Mental Welfare Commission (MWC). Some MHOs had found the Commission an invaluable source of reasoned and impartial advice; others reported receiving contradictory advice from different Commission staff or were frustrated by the perceived tendency of the Commission to 'sit on the fence'. Some MHOs had found that the responses they received from the MWC's tended to imply that it was the MHO's responsibilities to 'sort out' issues and concerns and to downplay the responsibilities of other professions to contribute to finding a resolution.
6.25 Some MHOs reported poor access to information, such as professional newsletters or web based resources, which added to feelings of professional isolation. In relation to MHO casework, it was noted in one group that access to advice tended to be post hoc and was generally not available at the point of assessment for detention. At a more general level, it was perceived to be important that MHOs had information which afforded opportunity to review and learn from practice after a decision had been made.
Legal advice
6.26 In some areas it was considered that contact with council legal sections had improved markedly since the development of policies and procedures on the AWIA. Some council solicitors attended their local MHO forums and this had been found to improve communication and mutual understanding of roles.
6.27 In other places the relationship with in-house legal services was perceived as more distant, with little direct contact and involvement. Legal sections were said to be under considerable pressure as a result of demand arising from the AWIA.
Support, supervision and accountability
6.28 For MHOs who did not work within a mental health team, the attitude and training of their line manager and the extent to which the manager understood MHO functions were critical. Where the manager lacked understanding of the MHO role, difficulties were likely to occur in relation to issues of workload management and of skill development. Non-MHO managers were less likely to prioritise MHO tasks and more likely to impose other priorities.
6.29 The independent practitioner status of MHOs was perceived by some MHO focus group participants to create tensions in terms of management and accountability. Supervision was seen as relevant to other aspects of caseload and workload but not to the MHO statutory role. There was a view that the perceived lack of clarity about MHO accountability might make some managers reluctant to become involved in MHO work.
6.30 Taken together, these factors occasioned concern among practitioners how poor practice might be challenged. There was also some uncertainty about the jurisdiction of LA policies, for example on complaints, in relation to MHO work.
WORKING WITH OTHER AGENCIES AND PROFESSIONS
Contact with courts
6.31 Experience of different Sheriff Courts and different Sheriffs varied greatly, in relation to the degree of formality and to the requirement for GP, consultant or MHO to be present at initial and formal hearings. MHOs in some areas were accustomed to giving evidence, others would always be represented by a solicitor. The importance of good relationship with the Sheriff Clerk was noted, as well as good communication with other parts of the legal system.
6.32 It was observed that S18 applications were becoming more protracted processes and while this was regarded positively, in keeping with the spirit of human rights legislation, there were workload consequences for MHO services.
Joint working with health
6.33 In general, communication between MHOs and other professionals was facilitated where MHOs were part of multidisciplinary teams, with greater opportunities for formal and informal communication. It was thought that senior managers did not always recognise the importance of developing and maintaining working relationships with non-social work colleagues.
6.34 Occasional problems with communication between RMOs and MHOs were highlighted in one group. MHOs reported concerns about arriving to assess for detention to find that the RMO had completed the formalities required and was not available for discussion.
6.35 It was commonly held that MHOs regarded themselves, and were perceived to be, responsible for the 'paperwork' associated with detention. At times ensuring that the necessary formalities were observed could entail significant MHO effort and times, for example 'chasing' GPs to ensure errors in paperwork were amended.
Resolving disputes
6.36 Disagreement could generally be resolved through discussion. This was easier where those concerned had developed a working relationship and was harder in the context of single encounters.
6.37 The confidence to voice disagreement with a medical professional opinion was seen as the product of MHO experience. There was concern about who within social work would support an MHO, if a disagreement arose with a doctor, for example about detention under the MHA (1984).
6.38 No-one was able to identify a mechanism to resolve disputes and it was felt that this would be useful. Both MHOs and the health care professionals considered that MWC should be advised in the case of unresolved disputes or disagreements.
STRUCTURE AND CAPACITY
Structures
6.39 MHOs in non-mental health teams or settings were less likely to have opportunity to practice: they were more rarely on duty and faced pressures from other demands. This could result in lack of exposure to the full range of MHO duties and functions, such as the use of s26/18 or the preparation of SCRs. It restricted the opportunity to develop skills and confidence as an MHO and caused concern about potentially poorer standards of practice.
6.40 MHOs were aware of problems with attracting recruits to undertake MHO training from criminal justice or childcare, each of which can also entail complex statutory work. Staffing pressures within child and family services were also thought to militate against MHO recruitment.
6.41 A wider issue was raised about the lack of MHOs in senior management within social work. This perpetuated the poor understanding of MHO functions and roles within authorities and also impacted on supervision and support for senior MHOs who continued to practice while holding management positions. In one area, the reorganisation associated with the implementation of Joint Future was said to have reduced senior management capacity within mental health services.
6.42 There was strong opposition to the variation in practice across local authorities in offering MHOs enhanced remuneration as recognition of the responsibilities of MHO. It was considered that there should be a uniform practice across all local authorities that would provide an incentive to recruit MHO staff, acknowledge the levels of responsibility involved, ensure equity and avoid attrition.
Capacity for MHO service provision in small and rural areas
6.43 Those MHOs working in remote and rural areas considered that the relatively low numbers of MHOs in some rural and island areas compounded problems posed by the geography and remoteness of the area:
- The challenges common to all MHOs in developing and maintaining links with other professionals and in keeping up their own practice competence and confidence were severely accentuated for those in rural areas and the islands
- A low base line of MHO capacity had an impact on support and supervision available
- The time and cost involved in participating in training could be considerable
- There were concerns from more remote areas about the costs associated with the new Act, including costs of travel to tribunals
- Geography and service configuration in rural authorities made it difficult to comply with codes of practice and guidance, which were perceived to be ill adapted to the realities of MHO service provision in such contexts
- Workload management issues could be exacerbated in a rural area, for example a S24 might take a full day in a remote location
Workload management
6.44 This was perceived to be a major issue for MHOs. The unpredictability of demands for MHO functions and the tight deadlines to be met often meant other work had to be set aside, to prioritise statutory duties. Workload difficulties in managing competing demands were considered to be more of an issue where MHOs worked in non-mental health teams. Even for practitioners who were in mental health teams, MHO duties could still seem like an addition to 'ordinary' work.
6.45 Because of the need for prioritisation, it was reported that some tasks and functions were being dropped or reduced. Supervising trainees was seen as an important MHO role but one which also added to workload, and fewer MHOs now seemed prepared to take this on. Some areas were said to have cut down SCR work. Non-statutory work including support service users and taking part in joint planning had also had to be set aside.
Monitoring of activity
6.46 Routine monitoring (for example of the number of detentions under the MHA (1984) undertaken), was necessary but, as currently collected, not sufficient to give a true record of the volume and scope of MHO activity. MHOs were involved in a considerable amount of informal discussion and liaison as an essential element of their work. However, this remained largely hidden as it went unrecorded. The AWIA was considered to have added considerably to this 'unseen and unsung' work.
Maintaining practice competence
6.47 In maintaining practice competence, access to the local MHO forum or Support Group was considered valuable, to keep up to date. Recent formal training had been focused on the AWIA. There was also felt to be a need for regular practice development in relation to work under the new MHA (2003), including more opportunities for joint training and practice development with health colleagues.
6.48 The importance of having opportunities to practice was emphasised, in order to be able to develop and maintain competence and confidence. One area was developing a system which would require MHOs to demonstrate continuing competence, assessed through personal development reviews. This initiative was viewed as positive by MHO practitioners from other areas.
6.49 Looking ahead, some practitioners perceived a risk that the MHO role would become increasingly legalistic and technical, resulting in it dominating other aspects of practice to the detriment of wider skills and experience.
Capacity to discharge current functions and readiness to respond to new functions and duties
Adults with Incapacity Act 2000
6.50 Initial training for AWIA was generally considered to have been good and in some areas had included joint sessions with non social work colleagues.
6.51 Authorities were often still in the process of developing or refining procedures to guide implementation. MHOs had found that they had had to seek out information about the AWIA and that there were few reliable sources of information within their management structures. Although there was still considerable wariness about implementation, MHO confidence in dealing with requirements of the AWIA was growing, if variable.
6.52 It was considered that statutory work within the jurisdiction of the MHA (1984) tended to be governed by practice experience, not procedure or protocol. This was contrasted with the AWIA, where procedures had been laid out more fully.
6.53 There appeared to be variation in the extent to which social work staff other than MHOs were involved in AWIA implementation. In some areas, MHOs were taking on the bulk of AWIA work, elsewhere it was shared with other social work staff. Overall, the AWIA had had considerable impact on nature and volume of MHO workload. MHOs tended to be approached by other health and social work professionals for advice, which was time consuming. One consequence of this was a greater appreciation among health professionals of MHO roles and functions.
6.54 Divergent practice was a potential cause for concern and MHOs were not reassured that the expectations set out in the AWIA legislation were being honoured in practice. Many elements of practice indicated in the legislation had yet to be addressed, such as capacity issues for adults in residential care. 'Full' implementation was considered to have major resource implications. In some areas, there had been moves to apply the provisions of the AWIA to groups of clients en masse, for consideration for guardianship or interventions orders, particularly where an institution was closing. Use of the AWIA in this vein was thought by MHOs to be ill-considered and ill-informed, but required their involvement nonetheless.
Mental Health (Care and Treatment) (Scotland) Act 2003
6.55 Concerns were expressed about the implementation of the new Act in the context of concurrent developments in health and social care, including Supporting People, free personal care and direct payments. In addition there was a need to clarify the interface between the new Act and other pieces of legislation including the AWIA. The volume and complexity of the MHO workload remained the overriding concern. MHOs were alarmed at the capacity of the service to implement the requirements of the Act.
SUMMARY OF KEY ISSUES FROM FOCUS GROUPS
- Local MHO services had been working to promote awareness and understanding among their health care colleagues of the MHO role and of the routes to access the service. There were indications that this was gradually producing positive results, although GP awareness and understanding continued to be an issue
- For rural areas pressures could be acute in developing and maintaining links with other, often physically distant, professionals and in maintaining practice competence. Services in some rural areas relied, to varying degrees, on practitioner good will and commitment
- MHOs had differing views about the relative benefits and disadvantage of dispersal of MHOs across local teams and specialisms other than mental health
- In considering the functionality of the MHO service structure and its capacity to perform effectively, MHO practitioners highlighted a set of prerequisites:
- Opportunity to develop and maintain MHO practice competence and confidence, in particular for those MHOs whose place in the structure made them more isolated
- Access to support and advice on MHO functions from peers and seniors
- Access to advice on specialist client needs when required
- Good internal communication and continuity of care in relation to handover and case transfer
- Opportunity to develop effective ongoing working relationships with health colleagues that fostered trust and respect
- Understanding and support from senior management within the LA to sustain and protect MHO functions and acknowledgement of the levels of responsibility carried by MHOs
- Capacity of the local MHO service and individual MHO workload remained a significant concern: perceived low baseline of MHO capacity, difficulties of recruitment and retention, unpredictability and irregularity of MHO work, lack of effective mechanisms to monitor and manage workload, increases in demand on the service and anticipated further growth in demand with the new Act combine to pose major challenges for the future
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