This week we have been working with Tees, Esk and Wear Valleys NHS Trust (TEWV), in one of our largest projects funded by the Health Foundation which is focused on supporting staff to embed a rights based approach in mental health recovery. Over the next 12 months we will be working with two teams; Children and Young People’s services and Older People’s services, supporting leadership and staff to use a human rights framework in decision making, policy and practice.

Our first session, at the end of April, was with a Children and Young People’s inpatient service in Middlesbrough.  The Service is keen to promote positive and safe practice and improve the quality of care.  As part of this overall aim, the Project offers opportunities to consider the ways in which embedding a human rights framework impacts on mental health service delivery and vice versa; the ways in which mental health services can impact the human rights of service users, families and staff. 

Over the next year we will be working alongside the Trust to develop and embed a culture which empowers those receiving services to know their rights and increases the ability and accountability of staff, who are responsible for protecting those rights.

The first step in this 15 month project, is empowerment and capacity building of all staff across these two pilot teams. By August we will have delivered human rights training to over 140 individuals, including nurses, health care assistants, approved mental health practitioners, therapists, psychologists, administrative support, ward managers, site managers and board members. This is huge. The Human Rights Act is the law and under section 6, all public authorities are bound by legal duty to respect, protect and fulfil human rights. In health and care settings, human rights reaches into so many area of service provision; do people have choice and control over treatment decisions? Can they participate in their communities or maintain contact with families? Are the actions of staff causing unlawful harm, for example in the use of restraint? Are people being discriminated against because of their health condition? And of course the rights of families, carers and staff must also be considered. This is about policies and protocols, as well as the everyday decisions that are made in health and social care.

Human Rights Act training is not mandatory for staff working in health and social care settings. Sadly, experience tells us that staff are more likely to have received food hygiene training than human rights training; so the commitment TEWV are making to this project is the exception, rather than the rule, with the Trust taking a proactive approach to service improvement grounded in human rights.

Human rights are often seen as a nice idea, a vague concept or an add-on. The conservatory if you will- something it’d be nice to have once the rest of the house has been done up. Human rights instead have to be the foundations, the base public services use to build upon for planning, commissioning and training and enabling staff to deliver services.

Human rights are not just fuzzy concepts or nice ideas but instead a legal framework which can support staff when it comes to making really difficult decisions about care, treatment and recovery. And in no project I’ve delivered so far has this been as apparent as it was working with the staff from the Children and Young Peoples service. These senior practitioners and managers, working in a mental health hospital for children and young people, many of whom suffer from eating disorders, are faced with incredibly difficult decisions every day.  Decisions about feeding someone with a nasogastric tube against their will, or risking further physical health deterioration due to refusal of food and fluids. Decisions which do not have a straightforward or correct answer and which many people will come at from different perspectives.  What human rights offers is a framework that sets out the duty to consider a range of specific rights factors, and a means for balancing these considerations, recognising when a service can and cannot interfere with these rights and when they have a duty to act . These rights include  the right to life (Article 2), freedom from inhuman and degrading treatment (Article 3), the right to Liberty (Article 5) and the right to respect for private and family life specifically wellbeing and autonomy (Article 8). Now of course, some aspects of these decisions are governed by the Mental Health Act but two points are clear. Firstly, staff should be implementing mental health legislation in a ways that is human rights-respecting. Secondly, just because the MHA applies, does not make daily enforced feeds any less distressing for the child or any less difficult for the staff members involved.

On Monday, we used a relevant and representative case study.  We started with baseline human rights training for all the staff present. Looking at their legal duties under the HRA, and specific human rights that were relevant to the situation.  We explored the absolute and non-absolute nature of each of the rights; the very limited circumstances under which non-absolute rights can be restricted and the subsequent 3 stage test which must be met- is the restriction lawful, legitimate and proportionate?

We then gave staff the task of working in multi-disciplinary teams to use a human rights approach in addressing the challenging and very realistic situation described. The FAIR model, a human rights framework developed by the Scottish Human Rights Commission. This model asks practitioners to think about;

 Facts: What is the experience of the individual? Are they being heard?

Analysis of rights at stake: What are the human rights at stake? Can the rights be restricted? What is justification for restricting the right? Is the restriction proportionate?

Identify shared responsibilities:What could be changed to make it more rights respecting? Who has responsibilities for making changes?

Review actions:How can the actions taken been recorded and reviewed and can the individual been involved?

The room was buzzing with discussion, passion and most importantly light-bulb moments. The team lead at West Lane told me at the end of the session, “This is the most constructive conversation we have had about this sort of situation, ever.” And another member of staff stated, “At my table we had the sudden realisation that we have been prioritising one right at the expense of so many others. We need to now go back and change things for patients.”

This was the first session of the project; and even though we do this work day in and day out, seeing those light-bulbs go off is always what sticks in our heads during the long train journeys home. The next year with TEWV is about turning those lightbulb moments into action. As the project progresses, we’ll be developing practice-based tools with the Trust to enable staff to make human rights-respecting decisions, as we have with other projects. You can see our toolkits, flowcharts, posters, etc. here.

Projects like this evidence how successful human rights are as a tool to open discussions, remove emotions and the personalised opinions that can become “the way we do things” and instead provide a concrete legal framework through which difficult decisions can be made. In using a human rights approach, staff are supported to make rights-respecting decisions, with people receiving health and care reassured that they are being treated with dignity and respect.

Every day staff in hospitals and care settings make decisions that determine another person’s quality of life, or sometimes their life itself; we need to make sure staff have the capacity and confidence to ensure human rights are at the heart of these decisions.