Supervised Discharge

This paper develops the Community Psychiatric Nurse’s Association’s (CPNA’s) position paper on Aftercare under Supervision (Supervised Discharge) issued in January 1996. Surveys conducted by the CPNA in Autumn 1996, and the National Association of Health Authorities and Trusts (NAHAT) in 1997, in addition to the experiences of CPNA members, have informed this updated summary paper. An outline of Aftercare Under Supervision as laid out in The Mental Health (Patients in the Community) Act 1995 will be followed by an analysis of the professional implications for the Community Mental Health Nurses (CMHN’s) involvement with those subject to Aftercare under Supervision.

Summary of the provisions of Aftercare under Supervision
The Mental Health (Patients in the Community) Act 1995 (HMSO 1995) makes provision for certain mentally ill patients who have been detained for treatment under the 1983 Mental Health Act to receive aftercare under supervision after leaving hospital. The provisions incorporate the key principles of the Care Programme Approach (HC(90)23/LASSL(90)11) and reflect the Guidance on the Discharge of Mentally Disordered People and their Continuing care in the Community.
(HSG(94)27). Aftercare under Supervision was implemented in April 1996, and has become known colloquially as Supervised Discharge.

Section 4 of the Act (1995, p.2) outlines to whom Aftercare under Supervision may apply:

A supervision application may be made in respect of a patient only on the grounds that:

a) he is suffering from mental disorder, being mental illness, severe mental impairment psychopathic disorder or mental impairment.
b) There would be a substantial risk of serious harm to the health or safety of other persons, or of the patient being seriously exploited, if he were not to receive the aftercare services to be provided for him under section 117 after he leaves hospital.
c) His being subject to aftercare under supervision is likely to help to secure that he receives the aftercare services to be so provided.

A supervision application may only be made by the responsible medical officer, in conjunction with an approved social worker, and in consultation with the patient, the patients next of kin or significant others, individuals who have been involved in the care of the patient prior to the application, the person likely to be responsible for the post discharge supervision, and other interested parties.

Paragraph 25 (p.7) of the Act outlines the requirements of Aftercare under Supervision:

a) that the patient reside at a specified place
b) that the patient attend at specific places and times for the purpose of medical treatment, occupation, education or training and
c) that access to the patient be given at any place where the patient is residing, to the supervisor, any registered medical practitioner or any approved social worker or to any other person authorised by the supervisor.

25D (4) A patient subject to aftercare under supervision may be taken and conveyed by, or by any person authorised by, the supervisor to any place where the patient is required to reside or to attend for the purpose of medical treatment, occupation, education aor training.

Aftercare under supervision begins when the patient leaves hospital and ends six months later.

A further period of 6 months, and a further period of one year may be imposed, and yearly periods thereafter. For a patient to cease to be subject to aftercare under supervision, the following parties must have been consulted: the patient, the patient’s next of kin or significant others, the supervisor, those involved in aftercare services, other non professional involved parties.

Aftercare under supervision will also cease if the patient is admitted to hospital, is received into guardianship or taken into custody.

The provision of Aftercare under supervision has been greeted with some criticism and concern, seen by some as an anti-therapeutic community health law (Eastman 1995). In common with the Care Programme Approach, the introduction of Aftercare under Supervision has not been accompanied by additional funding or resources, raising immediate concerns in light o the patchy and slow implementation of this earlier initiative (NAHAT 1997).

The impact on the role and responsibilities of mental health professionals must be debated, and it is this context that the CPNA outline their concerns.

The MHNA’s Position
The MHNA firmly believe that Supervised Discharge is coercive, and therefore antagonistic to the principles of client centred care, as advocated in the Review of Mental Health Nursing (Department of Health 1994). It is concerned that the rapport and collaboration developed between a CMHN and his/her client and carers may be irrevocably damaged on the imposition of the conditions of Supervised Discharge. The MHNA wishes to table a number of professional and employment concerns for the practitioners they represent, as CMHN’s are acknowledged to be central to the implementation of Supervised Discharge.

Utilising Supervised Discharge
Estimates of the number of clients to whom supervised discharge would be applied have bee found to be exaggerated (NAHAT 1997, CPNA 1996). This may be in part due to ideological objections, to scepticism about its value, as it does not allow for compulsory treatment, or that it is too early to assess its real impact (Royal College of Psychiatrists 1996). However, the CPNA remains concerned that a wider application, perhaps to avoid adverse publicity for services, or to include those with suicidal ideation or Alzheimer’s disease, for example, may develop over time.
There is also a concern that there may be increased used of Sections of the Mental Health Act (1983) in order to facilitate the use of Supervised Discharge following a period of impatient care. the potential for the wider and greater application of supervised discharge has a direct impact on community mental health service, and CMHNs in particular, as they predominate in the role of supervisor.
In Spring 1997, The Department of Health commissioned research to explore the ise of the provisions of Aftercare under Supervision and Guardianship which will shed greater light on these issues.

The CMHN as Supervisor
CMHN’s are very likely to be the named supervisor under the provision of Aftercare under Supervision. This may in part be due to health needs predominating over social need sin those clients with serious mental illness likely to be subject to Supervised Discharge. Whilst the Codes of Practice which accompany the Act assist in the development of protocols at local level, the input of CMHN’s is seen as critical. The role of supervisor is diverse and onerous, and the MHNA wishes to recommend a number of key pre-requisites before CMHN’s take on this role:

Education and Training
The formal recognition and training of designated supervisors is seen by the MHNA as a cornerstone of good practice. Education and training of CMHNs must be mandatory prior to accepting the role of supervisor, to ensure client safety and service quality.
Whilst the suitability of the SMHN for the role of Supervisor may be made on individual merit, the MHNA recommends that the CMHN should have specific, post basic qualification in Community mental health nursing (CPN Certificate or Diploma, or Specialist Practitioner Qualification). However, the impediment to this requirement is that the minority (37%) of CMHN’s hold such a qualification (White 1990). Furthermore, courses for CMHN both existing and planned, should incorporate education about the theory and practice of Aftercare under Supervision, to ensure that newly qualified CMHN’s are equipped to act in the capacity of supervisor, where other conditions detailed in this document can be met.

Seniority and Accountability
The MHNA recommends that only the most senior and experienced CMHN’s should act in the role of Supervisor under the Act. The minimum clinical grade at which CMHN’s might act as a supervisor for clients should be clinical grade G. this grade is the minimum to allow for the nurse to carry continuing overall responsibility for his/her caseload. Such accountability and responsibility seems commensurate with nurses at this level of seniority: it seems questionable whether a nurse graded E or F, operating under the supervision of another more senior nurse, could reasonably be expected to perform in the role of Supervisor. The creation of a new grade of CMHN, an “Approved Community Mental Health Nurse” may be an option for consideration, in preference to adding the responsibilities of Supervisor to all CHMN’s role without adequate preparation or recognition.

Support, Monitoring and Clinical Supervision
At this relatively early stage of development, there are likely to be local variations in the way in which the provision is being used, and in the selection of Supervisors. In addition to education and training, the MHNA believes that the provision of high quality Clinical Supervision for supervisors under the Act is essential.

Clinical Supervision
The MHNA welcomes the clear emphasis on supervision in recent publications (Department of Health 1994b: UKCC 1996; Department of Health 1993). The on going professional development and safe practice of supervisors will be contributed to by the provision of regular supervision.
The MHNA suggest that the creation of a statutory, national register of Supervisors would allow for identification of local networks, inform the provision of relevant supervision, and assist in the development of standardised protocols. Member of this register should be seen as “approved” to perform the role, similar to the Approved social worker status. Such a register would ensure that staff moving between wemployers could have their status recognised in their new post, and this in turn might contribute to the standardisation of competencies, quality and thus client safety.

The Potential for Scapegoating
The MHNA is concerned for CMHN’s in the face of the media’s attention on clients with serious mental illness, and the blame culture which has sometimes become a feature of other controversial high profile health issues (child protection for example). It wishes to ensure that CMHN’s are protected from scapegoating which may be a feature of failures within the new provisions to secure a safe, satisfactory outcome for clients and mental health professional alike, rather than professional misjudgement. The MHNA wishes to avoid situations where individual professionals are blamed for shortcomings outside of the sphere of professional conduct and accountability, and recommends that clear guidelines for good practice are established.

A checklist for action
Unless adequate steps are taken to address the deficiencies highlighted here, the MHNA has grave reservations about the CMHN accepting the responsibilities associated with the role of supervisor. The MHNA therefore strongly recommends that the following points are taken into consideration before CMHN’s take on the role of supervisor under the provision of Aftercare under Supervision. The CMHN should:

Be a qualified mental health nurse with a specific community mental health nursing postbasic qualifications
Be graded at G of the clinical grading structure or above
Ensure that they are educated to perform this role
Ensure that local protocols are developed, have involved CMHN’s in their development, are adhered to and evaluated
Establish and defineate their roles and responsibilities, and lines of accountability for the supervisor
Ensure that there are clear local guidelines for good practice
Insist on high quality appropriately focussed supervision.

If CMHN’s cannot be reassured of points above, they should detail their concerns in writing, as they are obliged to do under The Code of prfessional Conduct for Nurses, Midwives & Health Visitors (UKCC 1992) clauses 11,12, 13. They may be well advised to refuse the role of supervisor until the pre requisites laid out in this document are satisfied. Whereever possible, CMHN’s should act as part of a professional or multi professional group rather than as an individual. The MHNA representative will be willing to act in conjunction with them and in support of them in drawing attention to and rectifying their concerns.

Nonetheless, some eighteen months after the implementation of Aftercare under Supervision, the MHNA does see that there is potential in the provisions, particularly those elements which are akin to those of Guardianship, for CMHN to act as an advocate for the client, and to work in a way which allows the client and their significant others to shape the direction of service provision, and to empower them within the Supervisor/Supervisee relationship. This would enable a relationship of mutual learning and negotiation where the service user might feel a sense of ownership of the service, rather than being alienated from it. reshaping the complexion of Aftercare Under Supervision in this way requires an adequately trained, adequately remunerated, adequately supervised mental health worker, who can take their place in the development and delivery of a service which their clients have requested.

In conclusion, The NMC Code of Professional Conduct may be seen as a useful yardstick against which professional decisions in connection with Aftercare under Supervision may be measured:
Each registered nurse, midwife and health visitor shall act, at all times, in such a manner as to; safeguard and promote the interests of society justify public trust and confidence and uphold and enhance the good standing and reputation of the professionals.

Bibliography

Community Psychiatric Nurses’ Association (1996) Results of the CPNA survey in to CPNs Experiences of the Care Programme Approach and Supervised Discharge Bristol CPNA Publications

Department of Health (1990) The care Programme Approach for People with a mental illness referred to the Specialist psychiatric services HC(90)23/LASSL(90)11DH

Department of Health(1994a) Guidance on the discharge of mentally disordered people and their continued care in the community HSG (94)27/LASSL(94)4 DH

Department of mental health (1994b) Working in partnership: a collaborative approach to care: Report of the Mental Health Nursing review Team London HMSO

Department of Health (1995) Mental Health (Patients in the Community) Act 1995 London HMSO

Department of Health (1995) Building Bridges: A guide to arrangements for interagency working for the care and protection of severely mentally ill people London Department of Health

Eastman N (1995) Anti-therapeutic community mental health law in British Medical journal 310, 1081-2

NHS Management Executive (1993) A vision for the future London; Department of Health

NAHAT (1997) Mental Health Care: from problems to solutions: An NHS perspective NAHAT Research paper no.23 with the London Saisbury Centre for Mental Health Birmingham NAHAT

Royal College of Psychiatrists (1996) Report of the Confidential enquiry into Homicides and Suicides by mentally ill people London Royal College of Psychiatrists

United Kingdom Central Council (1992) Code of Professional Conduct for Nurses midwives and health visitors London UKCC

United Kingdom Central Council (1996) Position statement on clinical supervision for Nursing and health visiting London UKCC

White E (1990) the Third Quinquennial national Survey of Community Psychiatric Nursing: University of Manchester, Nursing Department