Debate: COVID crisis, natural capital and clinical care - 'building back better' for a new values-based CAMHS.

The COVID-19 pandemic has meant upheaval for child and adolescent mental health services and for children, young people and their families. We look at this disruption through the lens of values-based practice. We also briefly examine the concept of natural capital and the opportunity for 'Building Back Better' post-COVID. We suggest that as well as losses, there are also opportunities to rethink and reshape our practices to make them more value-based.

Shared decision making and consent post-Montgomery, UK Supreme Court judgement supporting best practice.

The UK Supreme Court Montgomery judgement marks a decisive shift in the legal test of duty of care in the context of consent to treatment from the perspective of the clinician (as represented by Bolam rules) to that of the patient. This has important implications in the surgical field worldwide, where informed consent is critical. This paper aims to explain the ruling and how it impacts the consent process. The case and ruling are outlined and summarised as pertaining to consent and requirements for validity; a shift from the clinician's interpretation about what would be best for patients to the values of the particular patient concerned in the decision in question. A sample of recent commentaries is reviewed. Four examples illustrate some of the practical applications of the Montgomery ruling on consent and how the ruling can empower doctors and patients to make mutually beneficial shared decisions. Future consent should be obtained using a Montgomery compliant strategy in accordance with the principles of shared decision making.

Values-based interprofessional education: how interprofessional education and values- based practice interrelate and are vehicles for the benefit of patients and health and social care professionals.

The 2016 All Together Better Health VIII Oxford conference brought together interprofessional education (IPE) and values-based practice (VBP) communities. As there is a paucity of research and publications in the area, following the event a working party consisting of representatives from both communities continued to meet and has developed a joint community of practice. This report describes the work achieved by the group so far and is intended for those involved in the planning and implementation of IPE and collaborative working. The authors consider that incorporating principles of VBP within a framework of IPE can provide a different perspective and understanding of the complexities involved in delivering realistic, student centered learning for collaborative practice, relevant in the 21st century workplace. In particular the authors suggest that using the principles of values and VBP in this way can inform the transition between IPE and collaborative practice facilitating effective person centered collaborative care. This process will require not only the incorporation of these principles within IPE sessions, but also incorporation within the training and support of new and established teachers involved in IPE.

Shared decision making in chronic medication use: Scenarios depicting exemplary care.

Patient-centred care includes patients and their values in the healthcare decision-making process. Shared decision-making is essential for patient satisfaction, medication adherence, and positive clinical outcomes. It also empowers patients to play an active role in managing their health condition by improving their sense of agency, allowing them to personalise their care. Long-term prescriptions are an unexplored area where shared decision-making could be impactful. This paper provides 5 common clinical prescription scenarios pertaining to route of administration, medication timing, side effects, and length of prescription. Minor tailoring of treatment plans could significantly improve clinical outcomes. These serve as exemplars as to how to personalise prescriptions through shared decision making in accordance with patient values.

The History of Mental Health Services in Modern England: Practitioner Memories and the Direction of Future Research.

Writing the recent history of mental health services requires a conscious departure from the historiographical tropes of the nineteenth and twentieth centuries which have emphasised the experience of those identified (and legally defined) as lunatics and the social, cultural, political, medical and institutional context of their treatment. A historical narrative structured around rights (to health and liberty) is now complicated by the rise of new organising categories such as 'costs', 'risks', 'needs' and 'values'. This paper, drawing on insights from a series of witness seminars attended by historians, clinicians and policymakers, proposes a programme of research to place modern mental health services in England and Wales in a richer historical context. Historians should recognise the fragmentation of the concepts of mental illness and mental health need, acknowledge the relationship between critiques of psychiatry and developments in other intellectual spheres, place the experience of the service user in the context of wider socio-economic and political change, understand the impacts of the social perception of 'risk' and of moral panic on mental health policy, relate the politics of mental health policy and resources to the general determinants of institutional change in British central and local government, and explore the sociological and institutional complexity of the evolving mental health professions and their relationships with each other and with their clients. While this is no small challenge, it is perhaps the only way to avoid the perpetuation of 'single-issue mythologies' in describing and accounting for change.

A pilot study of the early implementation of the Mental Capacity Act 2005 in England and Wales: the experience of consultants in old age psychiatry.

BACKGROUND: The Mental Capacity Act 2005 (MCA) was fully implemented in October 2007 in England and Wales. METHODS: A pilot qualitative study using thematic analysis examined the experience of consultants in old age psychiatry in the early implementation of the MCA using a questionnaire designed to ascertain the experienced difficulties and the positive experiences of implementing the MCA, and its impact on their workload and associated changes in staffing levels. RESULTS: Fifty-two (27%) of the 196 consultants in old age psychiatry returned usable questionnaires. Eleven categories of difficulties and nine categories of positive experiences in the implementation of the MCA were reported. Two-thirds of respondents reported an increase in their workload, but over 90% reported no associated changes in staffing levels. CONCLUSIONS: The factors contributing to the experienced difficulties and positive experiences in the implementation of the MCA require careful identification because strategies to lessen the difficulties and to maintain positive experiences need to be developed. The definitions of restraint and deprivation of liberty used in clinical practice and the overlap between these definitions requires careful study. The workload of clinicians in the context of implementing the MCA requires ongoing monitoring.

The early experience of Old Age Psychiatrists in the application of the Mental Capacity Act 2005: a pilot study.

BACKGROUND: The Mental Capacity Act 2005 (MCA) was fully implemented in October 2007 in England and Wales. METHODS: A pilot questionnaire study examined the experience of consultants in Old Age Psychiatry in the early implementation of the MCA pertaining to local policy and training in the application of the MCA, the assessment of decision-making capacity, the determination of best interests, and the use of the least restrictive option and restraint. RESULTS: Fifty-two (27%) of the 196 consultants in Old Age Psychiatry returned useable questionnaires. Seventy-five percent of them reported that local training on the application of the MCA was available, but less than 50% reported that training was mandatory. The vast majority of assessments of decision-making capacity were conducted by consultants in Old Age Psychiatry. Almost all of them reported using the four-fold specific test of decision-making capacity (DMC) described in the MCA. Restraint was reported to be rarely used. CONCLUSIONS: Consultants in Old Age Psychiatry generally reported using the criteria for the assessment of DMC, the determination of best interests and restraint described in the MCA. The findings highlight concern about the workload of clinicians in implementing the MCA and this requires careful monitoring. Consideration should be given to statutory provision of training in the application of the MCA by all healthcare and social care providers for all their healthcare and social care staff.

The application of the Mental Capacity Act 2005 among geriatric psychiatry patients: a pilot study.

BACKGROUND: The Mental Capacity Act 2005 (MCA) was fully implemented in October 2007 in England and Wales. The experience of clinicians working in Old Age Psychiatry, who are likely to have greater experience in the use of MCA, in the early implementation of the MCA was examined. METHODS: Case-notes of 37 patients in seven different Old Age Psychiatry services in two mental health trusts in west London, who had received at least one assessment of decision-making capacity (DMC) for a specific issue, were examined. A qualitative thematic analysis pertaining to the criteria used for the assessment of DMC, determination of best interests, least restrictive option and unwise decision was used for data analysis. RESULTS: The main findings were: the criteria used for the assessment of DMC and the determination of best interests were those described in the MCA and the accompanying Code of Practice; and clinicians were developing the concepts of least restrictive option and unwise decision with face validity despite the absence of their definitions in the MCA. CONCLUSION: Caution should be exercised in extrapolating the findings of this study, which is confined to two Mental Health Trusts in one geographical area and the speciality of Old Age Psychiatry, to other localities and other specialties. Nevertheless, there was evidence that clinicians were following the basic principles of the MCA correctly.

Psychiatry for the person and its conceptual bases.

The 2005 General Assembly of the World Psychiatric Association (WPA) established the Institutional Program on Psychiatry for the Person (IPPP) in response both to a recognition of our profession's historical aspirations and to recent international developments in clinical care and public health. These considerations point to the relevance of a comprehensive understanding of health and the centrality of the person in the delivery and the planning of healthcare. The IPPP's goals can be summarised as the promotion of a psychiatry of the person (of the totality of the person's health, both ill and positive), by the person (with clinicians extending themselves as full human beings), for the person (assisting the fulfilment of the person's life project) and with the person (in respectful collaboration with the person who consults). Operationally, the IPPP has four components: conceptual bases, clinical diagnosis, clinical care, and public health. What follows is an initial review of the IPPP's conceptual bases and an outline of its emerging activities.

Values-based practice in primary care: easing the tensions between individual values, ethical principles and best evidence.

BACKGROUND: The provision of health care is inseparable from universal values such as caring, helping and compassion. Consideration for individual values, particularly those of the patient, has also been increasing. However, such consideration is difficult within the context of modern health care, where complex and conflicting values are often in play. This is particularly so when a patient's values seem to be at odds with evidence-based practice or widely shared ethical principles, or when a health professional's personal values may compromise the care provided. SUGGESTED NEW FRAMEWORK: Values-based practice, a framework developed originally in the domain of mental health, maintains that values are pervasive and powerful parameters influencing decisions about health, clinical practice and research, and that their impact is often underestimated. Although it shares starting points with other approaches to values, it suggests that our current approaches lead us to ignore some important manifestations of values at both the general level, as relevant in legal, policy and research contexts, as well as at the individual level, as relevant in clinical practice. Drawing on ideas from philosophy, values-based practice significantly extends the range of phenomena that may be regarded as value-laden. It suggests that one of the reasons for overlooking values is that they are presumed to be shared when not apparently conflicting. Values-based practice is an approach to supporting clinical decision-making, which provides practical skills and tools for eliciting individual values and negotiating these with respect to best available evidence.

Normative warrant in diagnostic criteria: the case of DSM-IV-TR personality disorders.

This article focuses on the kinds of evaluative judgments made when applying DSM-IV-TR diagnostic criteria within the diagnostic interview between clinician and patient. The authors name these kinds of value judgments in diagnosis "normative warrant" because they involve one or more justifications (warrants) for standard-bearing (normative) elements involved in applying diagnostic criteria to actual patients. Seven types of normative warrant judgments are described (Type 1, Semantic-Phenomenal Matching; Type 2, Solicitation Choice; Type 3, Sociocultural Context; Type 4, Performance-Context Matching; Type 5, Deviance Threshold; Type 6, Threshold Characterization; Type 7, Disvalue characterization) and the typology is illustrated by applying it to various DSM-IV-TR personality disorder criteria. A research and clinical understanding of normative warrant may well contribute to the refinement of criteria sets as well as the refinement of the clinical use of criteria sets.

Should patients and their families contribute to the DSM-V process?

The authors consider arguments for and against the formal inclusion of mentally ill patients and their families in the deliberative processes leading to DSM-V. These discussions involve six key issues: the scientific status of psychiatric classifications; public policy and political considerations; the practical implications of widening the review process; the capacities of lay members of the workgroups; freedom of expression and the openness of the review process; and the uniqueness of consumer perspectives. The authors conclude that involving patients and families in the DSM review process is supportable on both scientific and public policy grounds.