Preventing falls at home among people with intellectual disabilities: A scoping review.

BACKGROUND: Falls are common among people with intellectual disabilities. Many falls happen within the home. Our scoping review aimed to identify evidence for falls-risk factors and falls-prevention interventions for this population. METHOD: We conducted a multi-database search to identify any type of published study that explored falls-risk factors or falls-prevention interventions for people with intellectual disabilities. Following a process of (i) title & abstract and (ii) full-text screening, data was extracted from the included studies and described narratively. RESULTS: Forty-one studies were included. Risks are multifactorial. There was limited evidence of medical, behavioural/psychological, or environmental interventions to address modifiable risk factors, and no evidence of the interventions' cost-effectiveness. CONCLUSIONS: Clinically and cost effective, acceptable and accessible falls-prevention pathways should be available for people with intellectual disabilities who are at risk of falls from an earlier age than the general population.

Community-Enhanced Social Prescribing: Integrating Community in Policy and Practice.

The NHS Plan is introducing social prescribing link workers into GP surgeries in England. The link workers connect people to non-health resources in the community and voluntary sector, with the aim of meeting individual needs beyond the capacity of the NHS. Social prescribing models focus on enhancing individual wellbeing, guided by the policy of universal personalised care. However, they largely neglect the capacity of communities to meet individual need, particularly in the wake of a decade of austerity. We propose a model of community enhanced social prescribing (CESP) which has the potential to improve both individual and community wellbeing. CESP combines two evidence-informed models - Connected Communities and Connecting People - to address both community capacity and individual need. CESP requires a literacy of community which recognises the importance of communities to individuals and the importance of engaging with, and investing in, communities. When fully implemented the theory of change for CESP is hypothesised to improve both individual and community wellbeing.

Epistemic struggles: The role of advocacy in promoting epistemic justice and rights in mental health.

Advocacy for people using health and social care services is widely promoted but its theoretical foundation is under-developed and its impact poorly conceptualised. This paper explores the liberatory potential of independent advocacy, using Fricker's concept of 'epistemic injustice' as a framework. People experiencing mental distress are particularly vulnerable to epistemic injustices as a consequence of deeply embedded social stigma resulting in a priori assumptions of irrationality and unreliability such that their knowledge is often discounted or downgraded. The mental health service user/survivor movement is at the forefront of validating personal experience and narrative to secure a different ontological and epistemological basis for mental distress. A foundational strand of this is advocacy to enable people to give voice to their experience. The case of independent mental health advocacy (IMHA) services under mental health legislation in England, provides an opportunity to critically examine whether advocacy can promote epistemic justice as a result of the legally sanctioned encounter between clinical assessment and subjective experience, pivoting on judgements about risk. This paper draws on empirical data from a national evaluation of IMHA services, which included 90 individual interviews with people subject to detention and three focus groups with mental health service users. Fricker's concept of epistemic injustice is used as a lens to investigate how this type of advocacy might mitigate forms of epistemic injustice, and thereby promote greater social justice in mental health. The concept of epistemic injustice provides a valuable theoretical basis for understanding the worth of advocacy in addressing testimonial injustice as well as its relative weakness in overcoming hermeneutical injustice. The challenge of independent advocacy to the dominant discourse within mental health is considered and questions raised about the place of advocacy in modern democratic mental health systems.

Rethinking place and the social work office in the delivery of children's social work services.

Limited attention has been given to the concept of place in social work research and practice. This paper draws on the national evaluation of social work practices (SWPs) in England undertaken between 2009 and 2012. SWPs were pilot organisations providing independent social work services for children in out-of-home care in five sites. One factor distinguishing some of these pilots was their attention to place. The evaluation employed a mixed methods approach and we use data from interviews with 121 children and young people in out-of-home care, 19 birth parents and 31 interviews with SWP staff which explored their views and experiences of the SWP offices. Children and young people were alert to the stigma which could attach to social work premises and appreciated offices which were planned and furnished to appear less institutional and more 'normal'. Daily interactions with staff which conveyed a sense of recognition and value to service users also contributed to a view of some SWP offices as accessible and welcoming places. Both children and parents appreciated offices that provided fun activities that positioned them as active rather than passive. Staff valued opportunities for influencing planning decisions about offices and place was seen to confer a value on them as well as on service users. However, not all the SWPs were able to achieve these aspects of place, and engaging children and families in place was less likely when the service user population was widely dispersed. Recognising the importance of place and how place is constructed through relationships between people as well as through the physical environment appeared to be key to creating offices that combated the stigma attached to out-of-home care. Those leading and managing children's services should explore ways of involving local communities in planning social work offices and turn attention to making these offices accessible, welcoming, places.

'When you haven't got much of a voice': an evaluation of the quality of Independent Mental Health Advocate (IMHA) services in England.

Advocacy serves to promote the voice of service users, represent their interests and enable participation in decision-making. Given the context of increasing numbers of people detained under the Mental Health Act and heightened awareness of the potential for neglect and abuse in human services, statutory advocacy is an important safeguard supporting human rights and democratising the social relationships of care. This article reports findings from a national review of Independent Mental Health Advocate (IMHA) provision in England. A qualitative study used a two-stage design to define quality and assess the experience and impact of IMHA provision in eight study sites. A sample of 289 participants - 75 focus group participants and 214 individuals interviewed - including 90 people eligible for IMHA services, as well as advocates, a range of hospital and community-based mental health professionals, and commissioners. The research team included people with experience of compulsion. Findings indicate that the experience of compulsion can be profoundly disempowering, confirming the need for IMHA. However, access was highly variable and more problematic for people with specific needs relating to ethnicity, age and disability. Uptake of IMHA services was influenced by available resources, attitude and understanding of mental health professionals, as well as the organisation of IMHA provision. Access could be improved through a system of opt-out as opposed to opt-in. Service user satisfaction was most frequently reported in terms of positive experiences of the process of advocacy rather than tangible impacts on care and treatment under the Mental Health Act. IMHA services have the potential to significantly shift the dynamic so that service users have more of a voice in their care and treatment. However, a shift is needed from a narrow conception of statutory advocacy as safeguarding rights to one emphasising self-determination and participation in decisions about care and treatment.

Conflict of roles: a conflict of ideas? The unsettled relations between care team staff and independent mental health advocates.

Drawing on a national study of independent mental health advocacy, we explored the social relations of independent advocacy. The study was commissioned by the Department of Health (England), and involved a case study design covering eight different geographies and service configurations, and interviews or focus groups with a total of 289 stakeholders across two phases of inquiry. This paper focused on the analysis of qualitative data relevant to the relationship between mental health-care services and independent advocacy services, drawn from interviews with 214 participants in phase two of the study. Discussion of these particular findings affords insights into the working relations of independent advocacy within mental health services beset by reorganizational change and funding cuts, and increasing levels of legally-sanctioned compulsion and coercion. We offer a matrix, which accounts for the different types of working relationships that can arise, and how these are associated with various levels of understanding of independent advocacy and appreciation for the value of advocacy. The discussion is framed by the wider literature on advocacy and the claims by practitioners, such as nurses, for an advocacy role as part of their professional repertoire.

Subjective experiences of compulsory treatment from a qualitative study of early implementation of the Mental Health (Care & Treatment) (Scotland) Act 2003.

Compulsory psychiatric treatment is highly contested, and little research has focused specifically on direct experiences. The Mental Health (Care & Treatment) (Scotland) Act, 2003 introduced new roles and provisions including community treatment orders, and was designed to increase participation, ensure treatment was beneficial and was the 'least restrictive' alternative. This article draws on findings from semi-structured interviews with 49 individuals, who had experienced compulsion under this new legislation during 2007-2008, that were part of a broader cohort study. Interviews with service users were conducted at two stages with 80% agreeing to be interviewed twice. The sample included people on a variety of compulsory orders from four Health Board areas, some of whom had been detained for the first time, while others reported 'revolving door' experiences. Peer researchers who were mental health service users carried out the interviews in partnership with professional researchers. The findings suggest that legislation had a limited impact on participation in the process of compulsion. Consensus was that although service users felt there was increased opportunity for their voices to be heard, this was not matched by having increased influence over professional decision-making, especially in relation to drug treatments. According to people's direct experiences, the passing of the legislation in itself had done little to change the dominant psychiatric paradigm. While providing a foundation for improving the process of compulsion, the findings suggest that as well as legislative reform, fundamental shifts in practice are needed both in terms of the nature of therapeutic relationships, and in embracing more holistic and recovery perspectives.

Partners in care?: views and experiences of carers from a cohort study of the early implementation of the Mental Health (Care & Treatment) (Scotland) Act 2003.

Carers are seen as legitimate stakeholders in wider policy processes and increasingly as 'co-producers' and key providers of care. Mental health carers, however, especially those caring for relatives subject to compulsory care and treatment, often feel overlooked and marginalised, caring in complex circumstances with little or no professional support. The Mental Health (Care & Treatment) (Scotland) Act 2003 (MHCT Act) implemented in 2005 aspired to change this for the better. This article focuses specifically on findings from seven focus groups and 10 individual interviews with 33 carers from three Health Board areas and the State Hospital in Scotland. Interviews were conducted at two stages during 2007 and 2008 as part of a wider study. Participating carers were supporting relatives who were under different compulsory measures and so had experience of new procedures under the MHCT Act. The data were gathered as part of a cohort study exploring service users', carers' and professionals' early experiences of the Act's implementation. A topic guide was used to explore the impact of compulsion on carers; the 'Named Person' role; Mental Health Tribunals; the principles underpinning the MHCT Act; and suggestions for improving the law. The study found that new provisions, in particular the Named Person role and Mental Health Tribunals, had resulted in positive change. However, many carers still felt isolated and unsupported. They remained critical of the lack of consultation and involvement at both individual and collective levels. Few were aware of their right to a carer's assessment and many were sceptical that this would make any difference. Acknowledging the study's limitations, we discuss the implications for practice in light of broader policy agendas of personalisation, recovery, recognition for carers and promotion of more community-based mental health services.