King's College London

Ash Ryan won the prize for substance at this year's  Policy Idol, the Policy Institute's annual student competition. This piece is based on her pitch at the final.

20 per cent of mental health patients in England “don’t feel safe in NHS care”. Despite this, the power dynamics on mental health wards, where staff hold enormous power over patients’ lives, leave many patients afraid to complain about their treatment.

 

Patients are disengaged and afraid to speak up. Almost half (48 per cent) are “unlikely” to complain. The three main reasons are because they are worried about causing “trouble” (40 per cent), indicating they fear staff members’ reactions; feel it is “pointless” to speak up (37 per cent), revealing they do not believe complaining will achieve change; and because they fear that complaining will affect how they are treated (25 per cent). Almost one third, 32 per cent, believe staff will not take their complaint seriously. 69 per cent of patients were never told, by any health professional, how to complain if they needed to.

 

The quality of inpatient care is “largely” getting worse, particularly on adult acute mental health wards, with 44 per cent of services underperforming (the CQC rated 38 per cent as requires improvement and 6 per cent as inadequate).

 

Patients’ reluctance to complain is particularly worrying given over a third of NHS mental health services need to improve on safety (30 per cent of services require improvement, while 4 per cent are deemed inadequate). Looking specifically at safety on acute and psychiatric intensive care unit (PIQU) wards, 71 per cent of wards need to improve their performance (in 2017, the CQC rated 60 per cent as requires improvement, and 11 per cent as inadequate).

 

The combination of unsafe mental health wards, and disempowered, disengaged patients, is extremely dangerous. It is also no coincidence. Wards do not become unsafe overnight, but after months and years where patients’ voices go unheard. At best, this leaves ward managers unaware of problems. At worst, when staff aren’t held accountable, unprofessional behaviour can escalate, putting patients’ mental health, and sometimes even their lives, at risk.

 

The situation can be effectively addressed by a package of four measures to ensure patients know their rights, and are empowered to speak up. First, all patients should receive an accessible handbook upon admission, explaining their rights, how to complain, and how they will be protected (if necessary) during a complaint. Second, friendly posters in every bedroom should reinforce the handbook by asking simple questions such as “Do you feel safe?", and signposting patients to help if things aren’t right.

 

Third, installing a phone booth on every ward will enable patients to call their advocate and the Patient Advice and Liaison Service (PALS) in privacy. Finally, comment cards, issued to every patient upon discharge and placed into a locked box outside the ward, will allow patients to speak freely and, if they wish, anonymously. Asking quantitative, tick-box questions, such as “Did staff treat you with respect?” will make it simple and quick for patients to give feedback, even if they don’t feel up to making a formal complaint.

 

A monthly dashboard of key performance metrics can be created, enabling ward managers to identify and resolve issues at an early stage, rather than problems worsening over time, risking a negative CQC rating and associated improvement notice. Statistics would be displayed on the wards and online. Concrete details of the actions taken as a result of complaints should be published, showing patients their views are taken seriously and result in meaningful change.

 

Wards with few complaints are currently seen as performing well. But patients’ silence can also be caused by fear, disempowerment and disengagement. Culturally, change is needed; low patient engagement in offering feedback should be understood as cause for concern.

 

Complaints are often understood as a negative, absorbing time and resources. A well-designed patient feedback system will, however, record positive experiences just as surely as negative ones. Feedback will identify problems for resolution, but will also highlight outstanding staff and excellent care. The top-performing wards can be identified, and their ways of working analysed. Disseminating such best-practice information would provide a practical model for lower-performing wards to implement.

 

Instead of every ward manager having to individually figure out the answers to problems that are common to most or all wards, efficiencies of scale in learning will enable rapid change, saving staff time for the NHS as a whole. Patients will receive more consistent care, regardless of where in the country they live.

 

Acute and PIQU wards are short-term stabilisation units, providing a place of safety where healthcare professionals work to stabilise patients’ mental health. Particularly if a patient has been sectioned, they may not be allowed to leave the ward for long, if at all.

 

The ward environment, including staff behaviour, is therefore a major factor in how effectively a patient’s mental health can be stabilised. If patients feel unsafe, or even (re)traumatised by their hospital experience, it is more likely they will relapse after discharge, possibly requiring readmittance.

 

In 2015–16, the 30-day emergency readmittance rate for mental health patients in England varied between 1 and 17 per cent (the median average was 8 per cent). Precise figures are not available, but estimating from the available data, emergency readmissions for mental health cost the NHS approximately £94.5 million a year.

 

When patients’ voices are heard, problems can be solved, improving ward conditions and enabling patients’ mental health to be stabilised faster. This could decrease both the average initial hospital stay and the likelihood of emergency readmission. If the median average readmission rate can be reduced by just 1 per cent, the NHS will save around £11.8 million every year. These four policy measures, costing approximately £1.82 million to introduce, will therefore pay for themselves six times over within 12 months.

 

The financial and ethical case is clear: there is an urgent need to redesign the patient feedback system to take account of the power dynamics in operation on mental health wards.

 

Ash Ryan is a final-year student on the War Studies BA programme who returned to study as a mature student to transition her career into policy. She completed the one-week EDIP internship for the Civil Service, and intends to apply for the Fast Stream after graduation because: “Good policy is a powerful way to make a difference to people’s lives.” Ash is the founder and manager of Shield, a defence and security blog, and a student journalist for the Tab. You can contact her on LinkedIn or Twitter @AshRyanWrites.