Most people who have been hospital patients will have experienced a hospital ward round. For many, the experience will not have been a pleasant one a sudden onrush of people in white coats, Big Boss in the middle ; no introductions ; someone picks up your chart and reads out figures and other bits of the medical story ; then a few questions, a few answers ; and away they all go again.
If you are in hospital with a broken ankle, your ward round experience is unlikely to leave scars. The self is intact and can cope with all this. It is only the material edges that are in bits and we can all stand aside from those.
If your state is more serious, it may be a different story. I have heard from several people suffering from life-threatening illnesses who have found the detachment of that circle of white coats offensive and deeply painful. The experience can leave you feeling reduced and de-personalised, at this time of extremity and question - not just bits of you in question, but your being in question.
For psychiatric patients the ward round can be utterly traumatic. In their case, they can expect to be called into one of the wards meeting rooms, where a circle of professionals will be gathered (at the time of writing we still get reliable reports of ward rounds made up of as many as 12 professionals). Sometimes the patient will still be in pyjamas, creating a powerful addition to his/her sense of exposure, difference and loneliness. The professional group are likely to include several strangers. Many users of mental health services remember the ward round as merely part of the bad memory of their breakdown, an experience both terrifying and humiliating.
The code set out here is the result of listening over a period of several months to users of mental health services talking about their ward round experiences. Then, as a co-operative exercise, a list of articles was slowly put together, detailing what should have happened. The code is thus a set of guidelines that protects a vulnerable individual from the insensitive treatment that traditional ward rounds have inflicted upon them.
In 1997 a pilot version of the Code was published by the magazine Open Mind. In 2000 it was adopted as official policy by the CNWL Mental Health NHS Trust, operating in central London. Other Trusts have also adopted it - if not word for word, then versions very similar.
Later, a Hyphen-21 steering group member paved the way for some of the Westminster User groups to present the code to the All-Party Parliamentary Group for Mental Health at the Houses of Parliament. The presentation took place in Portcullis House, in November 2002. Soon afterwards it was presented to the biennial conference of the World Federation for Mental Health, which took place in February 2003 in Melbourne, Australia.
Both presentations were successful, with the following results.
Soon after the Portcullis House event, the UK Department of Health acknowledged the code as good practice (see Julie Nichols quote in the side bar).
In March 2004, NIMHE went a step further and committed itself to active promotion of the code at all levels (see Malcom Rae quote in the side bar).
The response to the codes presentation at the Melbourne Congress of the World Federation for Mental Health, 2003 was also very positive (see Pirkho Lahti quote in the sidebar). Incidently the Congress was genuinely interesting in its own right and included talks by remarkable people and reports on notable initiatives. It truly felt as if here was the cutting edge of mental health work, distilled from all over the world. The code presenters took notes and the resulting report was read out to mental health staff and service users in central London later in 2003. The report is offered on the right.
In 2004 the code was featured again in OpenMind, this time as a news feature (November/December 2004). It is also displayed on the web-site of the Sainsbury Centre for Mental Health.
There are various further things still to say on this subject, just as there are various things still to do.
The code does not just apply to hospital ward rounds. It applies to CPA meetings too. In principle it applies to any meeting in which mental health service users meet mental health service staff, not least meetings whose remit includes user consultation.
There is real and urgent cause to believe that the code applies beyond mental health to all aspects of health and social care.
Adopting the code as policy is one thing ; making it stick is another. Advocacy Services can monitor the success of its implementation, and Audit Departments can regularly examine how well or badly it is being followed. But in the final analysis, policing it from the outside will only supply crime figures. It wont facilitate an improvement in practice. Although the Code needs to be a requirement from above, it also needs to be assented to actively and creatively at the level of the practitioner.
We think that worker teams should take responsibility for themselves in maintaining this code, regularly reviewing their work with it and setting their own targets for what improvements might be necessary. After all, every worker present in a ward round comes from a discipline which has its own code of good practice. Each of these codes will doubtless talk of treating patients with respect.Which means that each time a patient is treated carelessly in a ward round, all the workers present are acquiescing in the breaking of their respective codes of professional good practice. It follows that everyone involved in a ward round should support each other in ensuring that the code is closely followed.
Here, then, are some ideas for taking the code past the stage of Policy Directive and embedding it in the system as normal practice. Some of these ideas are practiced in CNWL Mental Health NHS Trust. - The code is given out to all new in-patients as part of an information pack, spelling out their rights.
- The code is displayed prominently in the ward environment
- Local advocacy services help to promote the code, and monitor its practice
- The code features in staff training and supervision
- Each psychiatric team is asked to review on a regular basis its own practice in following the code.
- Every six months there is a rotation of Senior House Officers (junior psychiatrists still in training). User group representatives have a slot on the Induction Day of each new intake and use it to present the code and explain its importance.
- Each month CNWL Mental Health NHS Trust runs an Induction course. All new staff are required to attend, whatever their status. Often as many as fifty people are present. At the initial suggestion of the writer, a video has been made for showing at each Induction course the Trust puts on. Produced to a high professional standard, the video employed a cast made up entirely of service users and seeks to convey what its like to be at the receiving end what helps and what hurts. The code is featured on the video and a mock ward round is acted out. The video represents a significant investment by CNWL and a step into untried territory ; its management team are to be commended . The video is apparently unique of its kind.
Ward round practice
Grampian Mental Health Services, Royal Cornhill Hospital, Aberdeen
I read with interest and surprise the paper A survey of ward round practice by Hodgson et alPsychiatric Bulletin, May 2005, 29, 171-173). This paper greatly disappointed me in that standard practice in the West Midlands indicates that ward rounds are being run for the professionals rather than for patients. I wonder how the professionals surveyed would feel if they were interviewed by the consultant psychiatrist in front of a room full of strangers at a time when they were acutely ill and vulnerable. I have vowed never to subject patients to this practice. (
A brief survey of the adult mental health teams working in Aberdeen City and Aberdeenshire who admit patients to the acute wards at Royal Cornhill Hospital, Aberdeen found that none of the 15 teams carry out ward rounds in the way suggested in the paper. The teams discuss detailed care plans for the next week at the weekly team meeting involving ward-based staff. Any interviews between patients and professionals are carried out separately and in privacy as patients have consistently indicated to us that this is their preferred model for in-patient assessment.
I am also surprised by the findings that no pharmacists attend the ward rounds of 96 consultants, since I and my colleagues clearly showed the benefits of pharmaceutical input to mental health teams as long ago as 1996 (Kettle et al, 1996). Within the service for which I am responsible, pharmacy staff are regarded as core and essential members of mental health teams and in our experience make an invaluable contribution to team meetings.
ReferencesKETTLE, J., DOWNIE, G., PALIN, A., et al (1996) Pharmaceutical care activities within a mental health team. Pharmaceutical Journal, 25, 814 -816.
What to expect in hospital
Upon arrival your relative will be met by the nursing staff who will probably be dressed in everyday clithes and identified only by thier name badges. Your relative should be introduced to a named care-coordinator (key worker) or the primary nurse who will be responsible fr co-ordinating their nursing care. Itis this nurse that is likely to be the person who explains to your relative about their rights under the Mental Health Act, and their expected treatment and progress.
The hospital ward
The regime of daily activity in hospital
This will vary and will depend upon the types of ward your relative is staying in, and what their individual care and treatment needs are.
High dependency wards often accommodate people who are often quite unwell and not ready to engage in therapeutic activity, and may have high levels of supervision. In these wards there is likely to be less pressure for people to be active than wards where people are less unwell, and have less need for constant supervision.
For people experiencing an acute psychotic episode where they are experiencing symptoms, and may potentially wish to harm themselves or act aggressively towards others, staff within theses types of wards may sometimes have to take actions such as restricting activity or even locking the ward for periods of time in order to protect the safety of the patient(s).
Rehabilitation wards are where people are moved to when they are ready to engage in more activity, under less supervision. Recovery is likely to be under way at this stage and occupational therapy and talking treatments may be offered to patients. At this stage your relative will start to develop new relationships with other specialist professional staff.
There may be unrestricted visiting in some hospitals, while others may have flexible hours. The ward manager will be able to give details of visiting arrangements. Visiting may be restricted in some cases if your relative's treatment team feels that recovery could be achieved more quickly by the patient acting independently of support from their family.
The ward round
Your relative will also be involved in the weekly ward round where all the members of the treatment team meet your relative - and the informal carer, though sometimes separately for confidentiality reasons, to discuss the treatment plan.
by Thomas Szasz, emeritus professor of
in: British Medical Journal, Dec 2003
Psychiatric patients are routinely treated against their will. Legally enforceable psychiatric protection orders would protect patients from coercive psychiatric interventions
The avowed desires of patients and doctors conflict more often in psychiatry than in any other branch of medicine. People known as "mental patients" are routinely subjected to "diagnostic" and "therapeutic" interventions against their will. Many such people see being committed (sectioned) and treated against their will as a personal violation -- a "psychiatric abuse" -- and want to protect themselves from future involuntary psychiatric hospitalisation and treatment. At present former psychiatric patients, even when legally competent, have no means to defend themselves from such a contingency.
Mental health laws -- reflecting the point of view of psychiatrists and society -- protect (or are said to protect) mentally ill patients from the dangers they pose, because of their illness, to themselves and others. Many mental patients view -- and have always viewed -- psychiatrists as posing a danger to them. Respect for the self defined interests of such patients requires that the law protect them from further unwanted psychiatric interventions.
The psychiatric protection order
Courts recognise the validity of "psychiatric wills" (psychiatric advance directives) only when they prospectively authorise treatment; courts do not recognise them when the "psychiatric testator" rejects psychiatric "help." To remedy this defect, especially when patients are released into the community after a period of involuntary treatment for mental illness, I propose a new legal safeguard: the psychiatric protection order. Such an order, similar to the protection order used in domestic conflicts, would make it a criminal offence to impose involuntary psychiatric interventions on people protected by the order.
In free societies only psychiatric patients are routinely treated against their will. (Public health laws explicitly serve the interests of the public, not the therapeutic needs of particular persons.) Competent patients with uraemia are not treated against their will and can use a "medical will" to protect themselves from undergoing dialysis. If psychiatry were like any other medical specialty competent patients with schizophrenia would not be treated against their will and could protect themselves with a psychiatric will from being treated. But they cannot: neither psychiatrists nor the courts recognise the validity of the psychiatric will. Mental health laws trump psychiatric advance directives.
Not by coincidence the history of psychiatric interventions forcibly imposed on patients is long and depressing. In a letter he wrote to me in 1988 Karl Menninger summarised the history of psychiatry with these sad words: "Added to the beatings and chainings and baths and massages came treatments that were even more ferocious: gouging out parts of the brain, producing convulsions with electric shocks, starving, surgical removal of teeth, tonsils, uteri, etc." To this list Menninger might have added the use of straitjackets, tranquillising chairs, confining chairs, cold baths, emetics, purgatives, Metrazol shock, inhalations of carbon dioxide, and neuroleptic drugs.
Freedom from enforced psychiatry
From the beginnings of the specialty, psychiatric patients have had no opportunity to free themselves from their protective-oppressive relationship with psychiatrists. In this brief paper I focus on a single issue: the desire of some psychiatric patients to free themselves, once and for all, from what they regard as an abusive relationship with the psychiatric profession. The Anglo-American legal system has always denied this option to these patients. This denial resembles the denial of slaves' opportunity, in a slave society, to leave their master; of the wife's opportunity, in traditional marriage, to leave her husband; and of citizens' opportunity, in the modern totalitarian state, to leave their country and its rulers. These people may enjoy all manner of benefits and privileges, but they cannot, without the permission of the repressive authority, leave the system for good.
The English and American legal systems maintain the fiction that the relationship between a family member responsible for committing a "loved one" and the incarcerated individual -- as well as that between psychiatrists and involuntarily detained patients -- is always one of "care" and "treatment." It can be otherwise only in "unfree," "totalitarian" countries; such was the case in the Soviet Union and is now the case in China. That self serving rationalisation is at the core of the problem facing us.
Anglo-American law assumes, as a matter of fact, that the relationship between a person and a legal agent of the state is adversarial. Justice Potter Stewart of the US Supreme Court famously remarked: "To force a lawyer on a defendant can only lead him to believe that the law contrives against him."The law student is taught the duties and roles of both prosecuting attorney and defence attorney. Both jobs are legitimate and proper.
In contrast Anglo-American psychiatry assumes, as a matter of law and psychiatry, that the relationship between a person and a psychiatric agent of the state is therapeutic. Forcing psychiatrists on mental patients is routine practice, and the patient who protests is likely to be given a diagnosis of paranoia. The medical student is taught only the duties and roles of the psychiatrist making diagnoses and providing treatment. The psychiatrist has no other legitimate duties or roles; only the job of the coercive psychiatrist is legitimate and proper. The psychiatrist who tries to help the coerced "patient" to reject the patient role is ostracised, or worse.
The gatekeepers: the family
We are hypocrites if we ignore who the parties are that support the enactment of mental health laws and deny patients the option of rejecting psychiatric services. Everywhere the supporters of mental health laws are psychiatrists and the relatives of so called mental patients. In the United States the relatives are now also in control of a powerful lobby, the National Alliance of the Mentally Ill, that legitimises the abuse of family members (mainly adult children) as the care of "loved ones. "Organisations of former psychiatric patients -- who call themselves "victims of psychiatric abuse" -- are not among the parties clamouring for more psychiatric coercions or "services."
People subjected to involuntary psychiatric hospitalisation and treatment often feel victimised in much the same way as do wives (less often husbands) who are abused by their spouses. Until recent times women had no effective protection from their abusers, whom the law defined as their protectors. In many parts of the world women are still in that situation. Similarly, in the days of Dickens children were not protected from abuse by their parents.
Specific treatments may have changed since this 1818 drawing, but psychiatric patients are still forced to undergo unwanted interventions
We in the West now recognise that the family is not just the primary locus of affection, care, and security for its members: it is all too often also the source of the most insidious danger to their physical and spiritual wellbeing. We acknowledge this unhappy fact and accordingly speak of "battered" children, spouses, parents, and grandparents. In the conflicts that often arise between adults living together as married couples or lovers, legal separation, divorce, and the so called protection order exemplify the legal system's acknowledgment of the problem and the need for legally sanctioned and enforceable mechanisms to remedy it. A protection order mandates physical separation between the parties and makes it a criminal offence for the denominated threatener to impose their mere presence on the threatened person. I suggest that we similarly acknowledge the unhappy fact of "battered mental patients" and the need to protect them from their batterers. In the absence of a protection order the power relations between psychiatrist and involuntary patient will continue to generate "psychiatric abuse," rationalised as protection and treatment. Indeed, it is precisely because psychiatrists reject advance psychiatric directives authorising abstinence from further treatment (a request that non-psychiatric doctors accept) that makes a legal mechanism such as the psychiatric protection order necessary.
Legalise "divorce" between psychiatrists and patients
Psychiatrists object to efforts to treat patients as responsible moral agents and cite the prevention of harm as a basic social mandate of psychiatry. Typically, they argue that people who would have committed suicide but for their involuntary detention would thereby have been deprived of the option of changing their minds once they had recovered from depression. A similar argument could be made against last wills or, indeed, any decision that profoundly affects one's future, such as marriage or having children. The standard psychiatric justification for "therapeutic" coercion either ignores the familiar conflict between liberty and security or, more often, equates (involuntary) psychiatric treatment with ("true") freedom. Elsewhere I have examined and discussed this and related problems in great detail and proposed reconciling psychiatry with liberty.
Human memory is notoriously short and selective. We have forgotten that until recently -- even in the United Kingdom and the United States -- people could not divorce.
In some countries women still cannot divorce their husbands. For a long time the law, supported by religion, ranked the sanctity of marriage more highly than the need to protect the wife from her abusive husband and so prohibited divorce. To make matters worse, the law deprived her of her voice.
The history of the "marriage" between mad people and their doctors shows a similar pattern. Since the beginning of mad doctoring in the 18th century, the law, supported by medicine (psychiatry), has ranked the "health" of mad people more highly than the need to protect them from the abusive psychiatrist and prohibited them from divorcing their psychiatrist. This is still the case. (The psychiatrist is free to leave the patient, typically by forcibly "marrying" the patient to another psychiatrist.) And again the law deprived, and still deprives, the victim of his or her voice. Only writers were, and are, willing to face the realities of psychiatry, illustrated for example by James Thurber's miniature masterpiece, The Unicorn in the Garden.
Many psychiatric patients are denied the right to refuse treatment they don't want
"Psychiatric wills" are recognised by courts only when patients use them to authorise treatment, not when they use them to reject the possibility of treatment
Like protection orders that protect wives from abusive husbands, "psychiatric protection orders" would protect patients from coercive psychiatric interventions
Doctors, politicians, and journalists assert that mental illnesses are real diseases and that psychiatrists are regular doctors. If that were true there would be no need for psychiatric protective orders.
Your rights as a service user
This is a very brief introduction to your rights as someone who uses mental health services, including those under the Mental Health Act 1983. You should always get detailed advice. The best way to try to ensure you get your full rights is to get the help of an advocate.
You and your GP
You have the right to
- be registered with a GP
- an interpreter, if you need one, when you visit your GP
- take a friend, relative or an advocate with you
- a clear explanation of any treatment proposed, including risks and possible side effects, and any available alternatives
- to be referred by your GP to a specialist (such as a psychiatrist) where necessary, as judged by the GP
- have a second opinion from another specialist, if you are uncertain about agreeing to the treatment proposed, provided your doctor agrees
- advice and help from your GP in applying for help from Social Services.
You and your medical records
You have a legal right to see your health records made by a GP, hospital staff or other health professionals on or after 1st November 1991 (Health Records Act 1990). Social Services and other agencies also have agreements under which you have access to your records. You may have to pay a fee of up to £10 to see the records, unless they have been added to within the last 40 days. You can have a copy of your records, but you may be charged the cost of copying.
If you believe a record is incorrect, you can have an amendment attached, though you cannot insist that the record itself is changed. Parts of your records may be withheld (without you being told) on the grounds that seeing them would damage your physical or mental health.
Community Care Assessment
If you contact Social Services for help you are entitled to an assessment, which can lead to an agreement between you, your carer (if appropriate), and Social Services, about the help you need.
Consent to treatment
You must give consent before you are given any treatment (except in the circumstances described below under Treatment Without Consent).
If you are over 18 and have the mental capacity to make decisions for yourself nobody else can give consent on your behalf.
You have the right to be given, and to understand, all necessary information about the proposed treatment:-
- what it is for, and what it is likely to achieve
- what the treatment consists of
- what is likely to happen if you don't have the treatment
- any risks or possible side effects
- any alternative treatments
For talking treatments like counselling and psychotherapy you have a right to know
- what the treatment will consist of, and how long it is likely to last
- what qualifications the counsellor/therapist has
- what code of professional ethics s/he follows
- whether they receive regular supervision from a qualified supervisor
Treatment without consent
Treatment can be given against your will in these circumstances:
- in an emergency: if you are acting in a way which is causing serious immediate danger to yourself or others you can be given limited treatment to alleviate the immediate situation.
- loss of capacity - if you do not have the mental capacity to make decisions for yourself.
- compulsory/detention treatment under the Mental Health Act (see below)
Your rights if you go into hospital
If you chose to go into hospital
You are an 'informal patient'. You are free to leave the ward or the hospital as you choose. (See also Preventing you from Leaving Hospital below) You have the right to refuse any treatment.
If you were taken into hospital against your will
You are a 'formal patient'. You can only leave when you are discharged (see below). In some circumstances you can be given treatment against your will.
Care and Treatment in Hospital
You are entitled to:
- ask for a relative, friend or advocate to be told that you have been admitted to hospital
- be allocated a named (key)nurse whose job it is to make sure that your needs are met
- be given information about independent advocacy
- have a say in your care plan to make sure it meets your needs
- have a relative, friend or advocate present at ward round or care programme meetings
- ask to see the consultant alone (or with a relative, friend or advocate) if the ward round or care programme meetings are too large or public.
You have a general right to dignity, respect, choice of diet, choice of a single-sex environment, access to religious or spiritual advisers, security of possessions, and meaningful or therapeutic activities.
Preventing you from leaving hospital
If you are an informal patient, and you decide to leave hospital, you can be kept against your will.
- for up to 6 hours by a nurse in order to be assessed by a doctor
- for up to 72 hours by a doctor while an application for detention under another section of the Mental Health Act is made.
The Mental Health Act 1983
The Mental Health Act and the Code of Practice give safeguards and procedures which must be followed by psychiatrists and other staff.
You can be detained against your will (often known as 'being sectioned') if:
- your condition is deemed to pose a threat to your health or safety, or that of others, and
- if you are suffering from a 'mental disorder'
You can then be detained for:
- up to 28 days, for Assessment (Section 2 of the Act)
- up to 6 months (renewable), for Treatment (Section 3)
- up to 72 hours, for Emergency Assessment (Section 4)
- up to 72 hours, if a police constable removes you from a place to which the public have access to a place of safety (police station or hospital) (Section 136).
For Sections 2 and 3 you can be discharged by:
- your 'nearest relative' ‑ who must give 72 hours notice to the Hospital Managers, who may overrule the request.
- the Responsible Medical Officer, or the Hospital Managers
You have a right to appeal to the Mental Health Review Tribunal
- within 14 days of detention under Section 2 or
- once within a 6 month period under Section 3
You can also appeal to the Hospital Managers.
If you are a formal patient the Hospital Managers have a duty to give you information on:
- the section under which you are detained
- your right to apply to a Mental Health Review Tribunal and/or appeal to the hospital managers
- your right to be discharged
- consent to treatment rules
- correspondence rules
- the duties of The Mental Health Act Commission