Document type: / Human Rights Act
Staff group to whom it applies: / All clinical staff within the Trust
Distribution: / All clinical staff within the Trust
How to access: / Intranet
Issue date: / September 2009
Version / 2
Next review: / September 2011
Approved by: / EMT
Developed by: / Medical Director - Dr N H Booya
Director lead: / Medical Director and Director of Nursing, Compliance & Innovation
Contact for advice: / Medical Director
Contents
Section / Page1 / Introduction and Principles
2 / Definitions
3 / Duties
4 / Procedure
5 / Planned Discharge
6 / Clinical Standards for Non-Adherence Policy and Procedure
7 / Flow Chart Illustrating the Procedure for Managing Non-Adherence with Treatment Regimes
8 / Equality Impact Assessment
9 / Process for Monitoring Compliance of this Policy
10 / Process for Reviewing and Approving this Policy
11 / Dissemination, implementation and access to this Policy
12 / Associated Documentation
13 / References
APPENDICIES / Page
Appendix 1 / Guidelines for optimising adherence with medication treatment plans
Appendix 2 / Equality Impact Assessment
Appendix 3 / Checklist for the Review and Approval of Procedural Document
Appendix 4 / Version Control Sheet
1Introduction and Principles
1.1This policy and procedure will apply across all South West Yorkshire Partnership NHS Foundation Trust.
1.2This policy and procedure will be implemented within the Human Rights Act 1998 legislation with specific regards to Article 8 “All persons have a right for private and family life”. This right is guaranteed so far as interference is in accordance with the Law -
“There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of … public safety…, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others”
1.3Competent adult service users are entitled to refuse treatment, even where it would clearly benefit their health. The only exception to this rule is where the treatment is for a mental disorder and the service user is detained under the Mental Health Act.
1.4It must be acknowledged that a person who has capacity and whose mental health problem does not warrant intervention under the Mental Health Act has the right to refuse such services.
1.5People may not fully engage with specialist mental health services for a variety of reasons. The Sainsbury Centre for Mental Health’s 1998 report “Keys to Engagement: Review of care for people with severe mental illness who are hard to engage with services” highlights various reasons - social, economic and health related, as to why people may not engage and/or accept treatment. (A briefing of the report can be downloaded at It is the Trust’s policy that every effort should be made to engage with people when they are in need of mental health services, and that any withdrawal from treatment should lead to an assessment of risk and a revision of care plans. The Trust subscribes to a holistic approach to care and a recovery model.
The procedures set out here are intended to assist practitioners in delivering safe and appropriate care to people who may wish to refuse it. It should be read in conjunction with the following documents:
- The Mental Capacity Act, 2005. Policy and guidance for service users, carers and practitioners
- Clinical Risk Assessment, Management and Training Policy
- Care Programme Approach and Care Coordination Policy and Procedures
- Did Not Attend Medical Clinic Appointments and Cancellation of Medical Clinic Appointments Procedure
- Discharge from Services (incorporating leave of absence for informal service users)
- and relevant professional codes of conduct and guidance
1.6This policy document has been reviewed by the Lead Director and Medicines Management Pharmacist and wider consultation has taken place with Director of Nursing, Compliance & Innovation, Director of Corporate Affairs, Chief Operating Officer, the service delivery group Assistant Directors and Care Plan Approach (CPA) Manager.
2Definitions
2.1“Treatment” means any therapeutic intervention delivered by specialist mental health services professionals.
2.2“Non-adherence” means the active refusal by a service user to continue with treatment(s) agreed and set out in a care plan, such as refusal of medication, declining to attend therapy or avoiding home visits. It does not include missing appointments by mistake or with valid reason.
3Duties
3.1The lead Director (currently the Medical Director) is responsible for ensuring the policy is reviewed and approved.
3.2The appropriate Trust groups, currently the Executive Management Team will provide policy approval and ratification.
3.3All service delivery group Assistant Directors/Clinical Directors are responsibility for ensuring the policy is disseminated and implemented in their own Service Delivery Group (SDG) and include its monitoring within their annual audit plan.
3.4Service Managers will ensure dissemination and implementation of the policy within their area of responsibility.
3.5All healthcare professionals are responsible for working in full accordance with this policy.
3.6The trust-wide group covering clinical practice (currently the Practice Effectiveness Trust-wide Action Group) and its lead Director (currently the Director of Nursing, Compliance and Innovation) will ensure monitoring of the policy by ensuring its inclusion in annual audit plans of the SDGs and will consider themonitoring evidence put before them and request actions as appropriate.
4Procedure
4.1When a service user refuses treatment, the service user’s capacity to understand, for example, information about the benefits and risk of the proposed treatment and alternatives must be assessed and clearly documented in the clinical notes/RiO.
4.2The care coordinator/healthcare professional should first ensure that the member of the care team delivering the treatment has made every effort to re-engage the service user. This should include:
4.2.1Making adjustments to the treatment plan if appropriate
4.2.2Ensuring treatment plans take into account individual’s preference
4.2.3Ensuring treatment is regularly reviewed to take account of the service user’s changing needs
4.2.4Ensuring interventions are evidence based and most effective whenever possible
4.3.The care coordinator/healthcare professional should ensure that if the service user is not following their treatment plan, mechanisms are in place to protect individuals who may be at risk. All CPA care plans should include explicit contingency arrangements/plans for responding to non-adherenceand missed contact.
4.4.If prompt intervention is required, assessment under the Mental Health Act 1983 should be considered.
4.5.For those on Standard Care, the care coordinatormust decide whether to consider registration on CPA.
4.6.For those on CPA, the care coordinator/healthcare professional should call a CPA review meeting. This will consider:
4.6.1.The reasons for disengagement
4.6.2.Any changes to the care plan which would encourage re-engagement
4.7.The care coordinator/healthcare professional and multi-disciplinary team should update the risk assessment and formulate a care plan incorporating both risk management, changing service user needs and action to re-engage. The elements of this plan will vary widely according to circumstances, such as whether the service user is an inpatient at the time, or has disengaged entirely from community services. The following points should be considered:
4.7.1.Who is to be the main contact, and how often
4.7.2.Communication plan between all involved
4.7.3.Any changes in involvement of carers and relatives
4.7.4.Any changes in the service users needs (meeting these needs could assist in reducing risk)
4.7.5.Possible involvement of police and other agencies
4.7.6.Involvement of primary care
4.7.7.Possible use of Mental Health Act
4.7.8.Timing of review by CPA care team
4.8.The care coordinator/healthcare professional and team should also consider whether it is appropriate to:
4.8.1.Request a conference under the Multi-Agency Public Protection Arrangements (MAPPA)
4.8.2.Refer to the Trust’s Specialist Adviser for Vulnerable Adults
4.8.3.Refer to the Assertive Outreach Service (after discussion with locality based service to ascertain appropriateness of referral)
4.8.4.Inform the police if it is decided that the person presents a significant risk (e.g. of violence to others) but that this is not a result of a mental health problem requiring follow up by specialist services. Such a decision must be clearly documented and information shared on a need to know basis
4.8.5.Consideration should be given to views and involvement of carers with service user’s knowledge and consent
5Planned Discharge
5.1Service users should not be discharged back to primary care simply because they have disengaged without a full consideration of their mental health and risk factors, and clear communication of this to the GP.
5.2If the care plan ultimately fails to engage the service user, the multi-disciplinary team may conclude on review that the person’s needs are best met by primary care. An action plan to manage identified risks should be agreed with primary care, which will identify specific indications for re-referral.
5.3People with a history of significant violence when mentally unwell should not be discharged back to primary care unless there is an explicit care plan in place that has been discussed with primary care and agreed with the Clinical Lead. This will include a risk assessment (stating who may be at risk), a crisis plan and specific indication for rapid re-referral.
5.4The discharge procedure should also be followed where the service is unable to work directly with a person but has identified a potential for significant risk to self or others arising from a mental health problem. In addition, the relevant team should set up a crisis care plan enabling the person to access services promptly through a named care co-ordinator should they choose.
6Clinical Standards for Non-AdherencePolicy and Procedure
Number of Standards in this set – 7 / Audit instructionStandard 1
CPA care plans include explicit plans for responding to non-adherenceand missed contact / Check file
Standard 2
Efforts by the care team to re-engage the service user are recorded / Check file
Standard 3
If a CPA review was held, there is a record of the reasons for disengagement and proposed changes to the care plan / Check file
Standard 4
Records of the CPA review leading to a risk management and re-engagement plan indicate active assessment of risk and full consideration of the delivery of the plan / Check file
Standard 5
If a person is discharged back to primary care because of non-engagement with the specialist service, an assessment of their mental health and risk factors is clearly communicated to the GP / Check file
Standard 6
If non-adherence with medication treatment plans is identified a review of treatment choice is made in conjunction with service user/carer. Practical aids and support should be considered in accordance with Appendix 1 -Strategy for optimising concordance with medication treatment plans / Check file and notes
Document in care plan and medical notes
Standard 7
Consider views of carers or important others with service user’s consent and invite to CPA reviews if appropriate / Document in care plan and medical notes
7Flow Chart Illustrating the Procedure forManaging Non-Adherencewith Treatment Regimes
Staff/Service User/Carer1. Agree treatment plan
2. Provide clear information on treatments and likely consequence of non-
adherence
3. Monitor and evaluate ongoing effectiveness and risk
4. Take early action to address any problems
Service User Does Not Follow Treatment Plan
Staff/Service User/Carer
- Establish reasons at earliest opportunity for non-adherence and agree
2. Inform and consult all multi-disciplinary team involved.
3. Where appropriate and with service user’s consent, seek carers /
significant others views.
4. Form action plan and record.
8
8Equality Impact Assessment
The Trust aims to design and implement services, policies and measures that meet the diverse needs of the service, population and workforce, ensuring that none are placed at a disadvantage over others. The Equality Impact assessment tool has been utilised to ensure equality has been assessed within this policy. See Appendix 2.
9Process for monitoring compliance of this policy
Auditing the implementation of this policy will be included in the Trust’s annual audit prioritisation plan and be linked to care planning auditing.
10Process for reviewing and approving this document
This document will be reviewed biennially or whenever national policy or guidelines changes are required to be considered (whichever occurs first). The document will be reviewed jointly by the Medical Director and Director of Nursing, Compliance and Innovation following which it will be subject to approval and ratification by the Executive Management Team.
11Dissemination, implementation and access to this document
This policy will be implemented and disseminated throughout the organisation immediately following approval and will be published o the Trust’s intranet site. Staff will be alerted to changes to the policy through the Trust’s management briefing process.
12Associated documentation
This policy should be read in conjunction with appropriate Trustprocedural documents. Key documents include:
- Care Programme Approach and Care Coordination policy and procedures
- Clinical Risk Assessment, Management and Training Policy
- Mental Capacity Act policy and procedural documents
- Information Governance policies and procedural documents including Confidentiality Policy
- Medicines Code Section 16 – Self-administration & compliance
- and following guidance
- Antipsychotics in Clinical Practice
- Bipolar and Depression Guidance
13References
In additional to Trust policies and procedures there are a range of other documents relevant to this policy:
- Refocusing the care programme approach: Policy and positive guidance (Department of Health 2008)
- NICE Clinical Guideline 76 – Medicines Adherence
- The Sainsbury Centre for Mental Health’s 1998 report “Keys to Engagement: Review of care for people with severe mental illness who are hard to engage with services
- Mental Capacity Act 2005
- Mental Health Act 2007
- Human Rights Act 1988
- National Service Framework for Mental Health (Department of Health 1999)
- National Service Framework for Older People (Department of Health 2001)
Appendix 1
GUIDELINES FOR OPTIMISING ADHERENCE WITH MEDICATION TREATMENT PLANS
In line with NICE Clinical Guideline 76 Medicines Adherence, Involving patients in decisions about prescribed medicines and supporting adherence
1Introduction
This document was produced in response to recommendations of various reports and research that identify poor adherence with medicines as a risk for under treatment and relapse of illness, which in turn may lead to increased morbidity and mortality. One such document is the National Confidential Enquiry into Suicide and Homicide by People with Mental Illness. The guidelines include recommendations from the NICE clinical guideline 76 Medicines adherence published January 2009. The guidelines aim to reduce risk and improve care.
People do not take medication for a variety of reasons, both intentional and unintentional. The illness, the treatment, the person and the person’s relationship with the clinician influence concordance with treatment. Not taking medication can lead to relapse and morbidity and is preventable.
In order to improve concordance with pharmaceutical treatment a variety of approaches should be employed.
2MedicationTreatment Choice
2.1Medication treatment plans should be individualised based on:
2.1.1Previous response to treatment
2.1.2Features of the illness
2.1.3Side effect profile, discuss potential side effects and likely severity and duration prior to prescribing
2.1.4Patient preference, which should not be assumed and involvement in the decision making process prior to prescribing
2.1.5Physical health, relative and absolute contra indications
2.1.6Social circumstances, e.g. those living alone, work patterns, family commitments
2.1.7Dosage regimen
2.1.8Drug/drug and drug/food interactions
2.2Review at regular intervals of treatment, therapeutic effect, adverse effects and compliance should be carried out. Consider dose reduction or minimisation.
2.3Recognise that non adherence is common and that most service users are non adherent sometimes.
2.3.1Routinely assess adherence in a non judgemental way whenever you prescribe, dispense or review medicines.
2.3.2Consider assessing non adherence by asking the service user if they have missed any doses of medicine recently.
2.3.3Make it easier for them to report non adherence by:
- Asking the question in away that does not apportion blame
- Explaining the reason you are asking the question
- Mentioning a specific time period such as “in the last week”
- Ask if they have reduced the dose, stopped or started any medicines
2.4Information about medicine options, both written and verbal, should be readily available to patients and carers and provided at all opportunities, including dispensing. This should be offered at a level preferred by the service user.
2.5Be aware that the service user may wish to discuss, what will happen if they do not take the medicine, non pharmacological treatments, reducing and stopping medicines they have been on for a long time and how to fit medicine taking into their everyday life. A service user may feel they are taking too many medicines and wish to choose between medicines.
2.6Education on likely outcomes and the need for treatment should be provided. The Trust medication advice leaflets may be used as a basis for discussion of the relative risks and benefits of different medicines and non pharmacological alternatives. Provide access to, or direct the service user to,
2.7Do not assume that the leaflets provided by the manufacturers address all the individuals’ information needs. Address concerns which arise after the service user has read the leaflets.
2.8Accept that service users may have different views from healthcare professional about the balance of risks, benefits and side effects of medicines.
2.9Record a summary of all discussions and service user concerns. This may be helpful in future consultations.
3Practical aids
- Alarm watches, mobile phones and pagers with alarm functions
- Multi compartment boxes (e.g. Medidose®, Dosette®)
- Medication record cards
- Large print labels and information leaflets
- Labels and leaflets in a variety of languages
- Colour coded labels
- Practical devises for people with manual dexterity problems e.g. winged caps
4Personal support