THE ROLE OF THE RESPONSIBLE CLINICIAN AND THE IMPLICATIONS FOR MULTI-DISCIPLINARY WORKING LESLEY COHEN HEAD OF PSYCHOLOGY, FORENSIC DIVISION NOTTINGHAMSHIRE HEALTHCARE NHS TRUST

NOTTINGHAM PSYCHOLOGISTS 1990 NOTTINGHAM PSYCHOLOGISTS DECLARE U.D.I.

RECOVERY FROM MENTAL DISORDER Maintaining medication Learning to live with psychotic experiences Establishing / re-establishing social networks Meaningful activity and work Social inclusion

NWW IN PSYCHIATRY CONTEXT ‘NWW is about supporting & enabling psychiatrists to deliver effective person-centred care across services’ [by] ‘using the skills, knowledge & experience of consultant psychiatrist to best effect by concentrating on service users with most complex needs’ ‘Promoting distributed responsibility & leadership across teams’ ‘This is a big culture change … not just tinkering around the edges of service improvement’ ‘New ways of staffing & delivering services’

MEDICAL TREATMENT 1983/2007 1983 - Includes nursing, and also includes care, habilitation and rehabilitation under medical supervision. 2007 - Includes nursing, psychological intervention and specialist mental health rehabilitation, rehabilitation and care.

NEW ROLES Approved Clinicians (ACs) under the 2007 Mental Health Act will undertake the majority of the functions previously performed by the responsible medical officers, whose role will end on the implementation date of the 2007 Act.

NEW ROLES Approval need not be restricted to medical practitioners, but may be extended to suitably qualified practitioners from other professions, namely nursing, psychology, occupational therapy and social work.

NEW ROLES A patient’s responsible clinician should be the available approved clinician with the most appropriate expertise to meet the patient’s main treatment needs.

DUTIES / POWERS OF RESPONSIBLE CLINICIANS Overall responsibility for the patient’s care and treatment. Renewal of detention (with another professional). Discharge on to and extension of Supervised Community Treatment (with AMHP). Discharge from detention (except restricted patients) and Supervised Community Treatment. Recall to hospital (with AMHP).

CONSTRAINTS There may be circumstances where the responsible clinician is qualified with respect to the patient’s main assessment and treatment needs but is not appropriately qualified to be in charge of a subsidiary treatment needed by the patient (e.g. medication which the responsible clinician is not qualified to prescribe). In such situations, the responsible clinician will maintain their overarching responsibility for the patient’s case, but another appropriately qualified professional will take responsibility for a specific treatment or intervention.

MULTI-DISCIPLINARY EMPHASIS The RC will not be expected to carry out all of a patient’s treatment his or herself, but will have overall responsibility for the patient’s care, working with the input of a multi-disciplinary team.

MULTI-DISCIPLINARY EMPHASIS e.g. before a RC renews hospital detention or initiates, extends or revokes a CTO - RCs must consult with a person ‘who has been professionally concerned with the patient’s medical treatment …’ - but who belongs to a different profession from the RC - and who must make a statement of agreement that the conditions required are met.

COMPETENCIES, FUNCTIONS & PROFESSIONS The AC/RC is a function, not a post: You will be bringing existing / demonstrable professional capabilities to that function. A non medical professional is not assuming the competencies of a psychiatrist, but is taking on a previously privileged function. And, in practice, will assume all of the responsibilities, associated with that function, for which that non medical professional has competence.

COMPETENCIES 1. ROLE OF THE AC & RC A comprehensive understanding of the role, legal responsibilities and key functions of the AC and RC

COMPETENCIES 2. LEGAL & POLICY FRAMEWORK Applied knowledge of - Revised MHA (1983) - Codes of Practice - National & local policy & guidance Other relevant (to decisions of AC / RC) policy & statutory framework - Human Rights Act; Mental Capacity Act, Children Act Relevant NICE guidelines

COMPETENCIES 3. ASSESSMENT (Key to ECHR compliance as possessing the necessary ‘objective medical expertise’) Demonstrated ability to identify presence, severity, kind/degree of mental disorder warranting compulsory confinement. Demonstrated ability to assess all levels of clinical risk: safety to patient & others, within evidence-based framework for risk assessment & management. Demonstrated ability to undertake mental health assessments incorporating biological, psychological, cultural & social perspectives.

COMPETENCIES 4. TREATMENT An understanding of physical, psychological & social interventions for mental health. The applicability of different treatment approaches for different patients. Demonstrated ability in determining capacity for consent to treatment. Ability to formulate, review & lead on treatment for which the clinician is appropriately qualified in context of MDT. Ability to clearly communicate aims of treatment to patients, carers & MDT.

COMPETENCIES 5. CARE PLANNING Demonstrated ability to manage & develop care plans combining health, social services & other resources within CPA.

COMPETENCIES 6. LEADERSHIP & MDT WORKING Ability to lead MDT Ability to assimilate diverse views of professionals, patients & carers, whilst maintaining independent view. Ability to manage & take responsibility for making decisions in complex cases. Understands & recognises limits of own skills & recognises when to seek other professional views to inform decision.

COMPETENCIES 7. EQUALITY & CULTURAL DIVERSITY Contemporary knowledge of equality issues: race, disability, sexual orientation, gender. Ability to identify, challenge, redress discrimination and inequality in AC practice. Promote sensitivity, equality, diversity. Understanding how cultural factors & personal values affect judgements & decisions in application of mental health legislation.

COMPETENCIES 8. COMMUNICATION Ability to effectively communicate decisions taken & reasons. Ability to keep effective records & awareness of such legal requirements. Demonstrates understanding & ability to manage tension between confidentiality & information sharing, to benefit of patients and others. Ability to complete statutory documentation & compile reports as required of AC. Ability to present evidence to courts & MHRTs.

IMPLICATIONS FOR MULTI-DISCIPLINARY TEAM WORKING? Sharing Leadership in MDT MDTs led by a range of professionals MDT to match patient’s needs

RESOURCE ISSUES Nottinghamshire Healthcare NHS Trust – Local Services Consultant Psychiatrists Consultant Psychologists Consultant Nurses Consultant Occupational Therapists Nottinghamshire Healthcare NHS Trust – Forensic Services Consultant Psychiatrists Consultant Psychologists Consultant Nurses Consultant Occupational Therapists

REFERENCES The British Psychological Society – Understanding mental illness – Recent advances in understanding mental illness and psychotic experiences. National Institute for Clinical Excellence – Schizophrenia – Core interventions in the treatment and management of schizophrenia in primary and secondary care. NHS – Mental Health – Modern Standards and Service Models – National Service Framework Home Office – Department of Health – Managing Dangerous People with Severe Personality Disorder – Proposals for Policy Development. National Institute for Mental Health in England – Personality disorder: No longer a diagnosis for exclusion. Department of Health – New ways of working for psychiatrists: Enhancing effective, person-centred services through new ways of working in multi-disciplinary and multi-agency contexts. The British Psychological Society – New Ways of Working for Applied psychologists in Health and Social Care. Department of Health – Mental Health: New Ways of Working for Everyone. Department of Health – Creating Capable Teams Approach (CCTA) Home Office – Department of Health – Mental Health Act 2007