Royal College of Psychiatrists Consultation Response DATE: 06.08.09 RESPONSE OF: THE ROYAL COLLEGE OF PSYCHIATRISTS RESPONSE TO: Draft guidance on provisions to deal with nuisance or disturbance behaviour on NHS premises in England The Royal College of Psychiatrists is the leading medical authority on mental health in the United Kingdom and is the professional and educational organisation for doctors specialising in psychiatry. We are pleased to respond to this consultation. This consultation was prepared by faculties and divisions at the College. The Consultation was approved by: Prof Sue Bailey-Registrar For further information please contact: Claire Churchill on 020 7235 2351 ext. 293 or e-mail cchurchill@rcpsych.ac.uk 1
General Comments We welcome the recognition that NHS staff and patients deserve to work and receive treatment in an environment which is safe and free from nuisance or disturbance behavior. We assume that healthcare premises located outside the hospital, such as primary care facilities are excluded, (unless they are located within the hospital grounds), because they were not included within the original section 119 and section 120 of the Criminal and Justice Immigration act 2008. There may be some statutory reason for this, but it appears counter intuitive and indeed discriminatory that health professionals working in other premises such as GP surgeries are excluded. We apologise if this is covered in some other statute. 1. Does the guidance adequately describe nuisance or disturbance behaviour? We recognise that to operationalise a wide variety of behaviours that are perceived and impact on the victims in different ways, is a challenging task. Given that this is a challenging task, it would be critical that the authorised officers receive fit for purpose training in their role (see question 11) and that it is open to peer review audit and evaluation. In general yes, while we understand the reasons why physical violence or assaults on NHS staff by patients are not covered by the guidance, we consider that such behaviour is still a very serious issue. For example, guidance from the Department of Health is at present lacking, with respect to the specific issues of patients in mental health inpatient wards. Particularly, as to when and how after assaultive behaviour, it may be taken through to prosecution (the Department of Health have now been working on this guidance for over 3 years). 2. Does the guidance adequately describe reasonable excuse for causing a nuisance or disturbance? No. We are not confident that the guidance as it stands in 2.2 will be sufficiently clear, as to be operationalised on a day to day basis in a consistent manner. The examples given are relevant, but do not go far enough in helping the difficult decision to be made as to whether there it is an extant legitimate reason for carrying out a nuisance or disturbance on an NHS premises. There is a generic difficulty with this guidance, in that language used for those arrested on suspicion of having committed a criminal offence, has been introduced in the sections, which are dealing with the nuisance or disturbance being dealt with on site, without any involvement from the police. 2
3. Does the guidance adequately explain what constitutes a refusal to leave and a reasonable excuse for refusing to leave the premises? No. This is a difficult process to explain with clarity, but as they stand the scenarios add to the uncertainty. This provision could be viewed, as giving patients a license to commit an offence. It makes no sense to consider patients NOT committing an offence if they present themselves to NHS premises after 8 hours. They seem to be committing an offence if they return within 8 hours of previous attendance. (p19) 4. Does the guidance adequately describe when a person is on the premises, to seek medical advice, treatment, or care? No. We recognise that this is a difficult process to describe, but as this stands the guidance lacks clarity. The guidance would benefit from use of flow charts. 5. Are the recommended steps in section 3.1 of the guidance useful, in terms of assessing whether a person should be removed from the premises? Yes, as we found that this section had more clarity than the others. However, we find that this section relates to the possibility of the reasonable excuse for their behaviour as being due to an underlying mental impairment. The terminology used is confusing; the writers should be referring to mental illness or learning disability. If there are to be case scenarios, they should cover a wider range of mental disorders, which are beyond Asperger s syndrome and Alzheimer s disease. The case scenarios highlight the need for more fit for purpose training, particularly in Accident and Emergency, and for first stage mental state examinations, with clear pathways to refer onto more specialist assessments. Whilst we recognise that the authorised officer will be contacting a mental health or learning disability practitioner to consider whether the person had committed an offence (again we would say the wrong terminology) the guidance, should also suggest the person undertaking a full mental health and/ or learning disability assessment. This would allow the person s needs to be met and would avoid any possible risk to self to be managed. 6. Does the guidance adequately explain what considerations should be made when attempting to safely remove a person from NHS premises? Yes. However, there is insufficient guidance on dealing with people with mental health problems; a case example would be very useful in addition to the 3
existing scenarios. This guidance should also be linked up to section 136 of the Mental Health Act 1983 in particular. 7. Overall, does the guidance make it clear what constitutes an offence and who can/cannot be removed? No, as highlighted in out responses to questions 1-6, the guidance is not sufficiently clear. It would be helpful if the guidance included what the options are where removal from the premises isn t deemed appropriate and yet there is significant nuisance behaviour (obviously it depends upon the reason for the behaviour and the persons underlying medical/clinical needs). There is a reliance on following usual trust guidance, but this can be lacking. 8. Do you have any other suggestions on assessing whether a person can be removed, for example an alternative assessment procedure(s)? No, we would suggest that this document would benefit from consideration of care pathways and/or flowcharts. 9. Does the guidance clearly explain the distinction between authorised officers and appropriate NHS staff? No, the distinction is not clear. 10. Is the guidance useful, in terms of describing which staff members might be appointed as authorised officers and appropriate NHS staff? Yes. 11. Do you think the recommended training requirements are sufficient? Yes. However, the training should incorporate knowledge and understanding of the Mental Health Act 1983. 12. Do you have any additional suggestions about how trusts might raise public awareness of the offence and power of removal? We may have more suggestions when we have seen the revised guidance. 13. Is the guidance helpful in explaining best practice around record keeping for each of those responsible (the NHS body; authorised officer; local security management specialist)? Yes. 4
14. Overall, do you think the guidance is useful? Yes, but we feel it needs a major redraft. 15. Do you have any other comments? There is insufficient mention of the impact of nuisance behavior on other patients, the focus is just on staff, if staff are affected it is likely patients are too. There is a need to take account of the vulnerability of the patients in the clinical setting; a person swearing or being abusive towards a receptionist might have a significant effect on patients waiting, if these are for example young people. It will be helpful to have clarification as to whether in mental health trusts being an authorised officer is likely to be voluntary. The position has implications for consultants, in regards to terms and conditions of service and job planning. We will need clarification on what level of training, quality of training and suitability has to be considered. This requirement is likely to pose logistical issues. Are GP receptionists or A&E receptionists seriously expected to diagnose conditions such as autism or dementia and then be expected to accept any form of verbal insult or intimidating behavior from such people? More nuanced provision in the guidance would be helpful. The response of the staff to abuse by someone with a likely diagnosis should depend on principles of proportionality. Aggressive abuse may not be a reasonable excuse despite a diagnosis, if it is disproportionate. August 2009 5