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THE level of scrutiny provided over Northern Ireland’s mental health services has been widely criticised, amid calls for the relevant legislation to be updated to address this “gap that currently exists”.
A person acutely affected by this issue has also reiterated the claim that the situation risks a “dereliction of duty”.
This is because the Regulation and Quality Improvement Authority (RQIA) – the independent body responsible for monitoring and inspecting health and social care services in Northern Ireland (NI) – has admitted to The Detail that it doesn’t regulate either community or inpatient mental health services.
In addition to not regulating such services, we can also reveal the RQIA doesn’t even inspect the community-based mental health services.
The Detail was alerted to these issues a few months ago, when a man contacted us about his concerns that mental health services in NI lack effective scrutiny.
He has since told us that while he was aware of the “regulatory deficit” within community mental health when he first got in touch with The Detail, he was surprised to recently learn that the RQIA also doesn’t regulate mental health inpatient services.
The man was also concerned about the standard of care that his close family relative has received from mental health service providers in NI over the course of almost 15 years.
His relative is in his thirties and is a vulnerable adult with complex needs.
Most of his treatment has been provided in the community but he has also spent time as an inpatient.
The vulnerable adult’s mother, and his close male relative who contacted The Detail, wished to go on the record about these issues.
However, neither wanted to be identified as they were concerned about how their loved one may react to media attention. We will therefore call their relative by the pseudonym, Charlie.
Charlie’s relative told The Detail: “Now we know the facts about the lack of regulation, it doesn’t come as a surprise that the necessary framework is not in place to ensure meaningful accountability of both community and inpatient mental health services.
“While it is unclear if the treatment would have been any different, I consider it reasonable to suggest if the proper legal framework and safeguards were in place, there may have been a better experience and outcome for Charlie.”
Charlie’s mother worked as a nurse for decades. During the Troubles she at times had to get police and army escorts, occasionally crossing barricades, to enable her to care for sick and injured people in areas of conflict
She said: “I don’t feel my son has been treated in a manner that’s been either sufficiently safe or in his best interests.”
Regarding the RQIA’s incapacity to regulate mental health services or even to inspect the community-based services, Charlie’s mother added: “It is possible some of the people we have dealt with felt empowered in circumstances where there was no-one for them to have to adequately answer to.
“I would not be surprised to learn that the sort of treatment our family has experienced has been endured by others and I fear it will just continue unless people overseeing the provision of mental health services are held to account.
“God knows how many lives are in their hands.”
Regulation versus inspection
Inpatient mental health services are those which are provided to people who have been admitted, to stay, in a hospital for care and treatment such as those provided at Muckamore Abbey Hospital where there have been widespread allegations of ill-treatment of patients by staff.
While the RQIA can, and does, inspect inpatient mental health services, it told us it doesn’t “inspect these in the manner we are required to inspect regulated services”.
The RQIA can make requirements of services it regulates which must be complied with and it has the power to, effectively, close such services.
However, the RQIA cannot shut down either community or inpatient mental health services as it regulates neither.
Of services which it inspects but doesn’t regulate, such as mental health inpatient services, the RQIA can only make recommendations for services to adhere to.
The RQIA does, however, have a duty to report inspected services to the Department of Health (DOH) if they are of an unacceptably poor quality or if there are significant failings in the way they are being run.
While the organisation maintains there is a “clear expectation” that these recommendations are complied with, these differ from requirements which must be complied with.
Mental health services provided in a person’s home or at a doctor’s surgery are considered community services, as are hospital outpatient services. These are neither regulated nor inspected by the RQIA.
The Chief Commissioner of the NI Human Rights Commission, Les Allamby, told The Detail: “At a time when community mental health services are under severe strain, ensuring sufficient provision and accountability is even more critical.
“The gap that currently exists in NI needs to be addressed and the RQIA empowered to inspect and regulate the service within a framework of law.”
Private hospitals and clinics, “some of which may provide mental health services” are regulated by the RQIA.
The Health and Personal Social Services (Quality, Improvement and Regulation) (NI) Order 2003, “extended regulation and quality improvement to a wider range of services” in NI.
This led to the establishment of the RQIA in April 2005, but it didn’t enable the organisation to regulate either community or inpatient mental health services, or even to inspect such services provided in a community setting.
Despite this, an RQIA document titled, About Us, states that undertaking a “range of responsibilities for people with mental ill-health and those with a learning disability” is one of the organisation’s three main areas of work.
Regulation review
DOH sign in Stormont.
A DOH spokesperson has said that it can request the RQIA to conduct an inspection of services provided or commissioned by health and social care trusts and that this could extend to mental health services provided in the community.
However, the RQIA has maintained it isn’t statutorily responsible for inspecting or monitoring these services.
The DOH spokesperson said: “The current legislation dealing with regulation and inspection of health and social care services dates back to 2003.
“Since that time there have been a wide range of developments in terms of what services are available and how services are delivered.
“The DOH is currently carrying out a fundamental review of regulation to ensure that the system of regulation of health and social care is appropriate.”
The Patient Client Council (PCC) is a public body that was set up in 2009 as part of the reform of health and social care in NI.
It acts as a “powerful, independent voice for patients, clients, carers and communities”.
The PCC’s chief executive, Vivian McConvey, told The Detail: “We welcome the review of regulation being carried out by the DOH.”
She also added that the PCC supports the need for “accountability and legal oversight over all mental health services in NI”.
There are certain organisations which aim to maintain standards within specific professions which work within mental healthcare in NI such as the Royal College of Psychiatrists, the British Association of Counselling and Psychotherapy and the Nursing and Midwifery Council.
However, the regulation and inspection of mental health services varies significantly throughout the UK.
England
The RQIA’s relative equivalent in England is called the Care Quality Commission (CQC).
The Health and Social Care Act 2008 established the CQC as the regulator of all health and social care services in England – including both community and inpatient mental health services – unlike the RQIA in NI.
The CQC discharges its responsibilities by regulating, inspecting and monitoring both community and inpatient mental health services in England.
Muckamore Abbey Hospital provides inpatient mental health services in NI and, as such, these services are not regulated by the RQIA.
If such services were provided in England, they would be regulated by the CQC.
Muckamore has been under the spotlight recently over allegations of widespread ill-treatment of inpatients by staff, which have been widely reported in the press.
As a result, dozens of staff members have been suspended from the hospital and the PSNI stated in August 2019 that CCTV footage of the psychiatric intensive care unit of Muckamore showed evidence of 1,500 crimes taking place there during a six-month period in 2017/18.
So far, two individuals have been arrested in connection with Muckamore.
Glynn Brown’s son is an inpatient at the hospital. He told The Detail he was astounded when he found out the RQIA couldn’t regulate mental health services provided in places such as Muckamore.
He said: “It’s only when something tragic happens that you start looking at these organisations, seeing what their powers are – what they can do and what they can’t do – and by then it’s too late.
“The RQIA is really a toothless tiger the way it’s set up, which is a waste of public money.”
When Mr Brown first got in contact with the RQIA, he felt the person he was dealing with was “very dismissive” of him.
He added: “I had to explain to them, I wasn’t making up what the Muckamore staff were telling me happened.
“I then got a lecture about how good the RQIA’s reporting system was, how efficient it was and how it would take bad apples out of the barrel.
“The RQIA employee then told me ‘I find what you’re saying so hard to believe and I’m going to ring Muckamore’.
“I then received a call back about 20 minutes later, saying ‘I couldn’t believe what you’re saying to me is right, but I called Muckamore and all you’ve said is correct’. It didn’t fill me with enthusiasm.”
Mr Brown continued: “The RQIA is meant to be a watchdog and to be alert to the failings in the system.
“But when a parent rings up alerting them to failings in the system, they are just so full of their own importance and full of their own self-belief in their own procedures and protocols that they don’t grasp what’s going on.
“That’s, I think, one of the big problems. Everybody has been so self-reliant on procedures and protocols they think are super and effective, which have turned out to be catastrophic and useless.”
Staff were first suspended from Muckamore in November 2017 while the PSNI carried out its investigation into the hospital.
It wasn’t until August 2019 that the RQIA issued three ‘enforcement notices’ on the hospital regarding staffing and nurse provision, adult safeguarding and patient finances, respectively.
However, because the mental health services which Muckamore provides are not regulated by the RQIA, the organisation can only recommend the hospital to make changes to its service delivery, it cannot make requirements which must be adhered to.
The lead investigating police officer into Muckamore is Detective Chief Inspector Jill Duffie.
She has called the Muckamore investigation the “largest adult safeguarding case” of its kind, that the PSNI has ever undertaken.
Mr Brown, whose son is an inpatient at Muckamore, was then asked about his views on the fact that the CQC in England can regulate inpatient mental health services but the RQIA can’t do so in NI.
He said: “That’s the crux of the problem. If you’re setting up a regulatory body, you have to give it authority – it has to be effective, it has to be robust.
“If not, inevitably down the road you’re going to reap what you’ve sowed, which has happened at Muckamore.”
Muckamore Abbey Hospital in July 2018. Credit: Jonathan Porter, Press Eye.
Wales and Scotland
Like the RQIA in NI, the Healthcare Inspectorate Wales (HIW) and Healthcare Improvement Scotland (HIS) don’t regulate community or inpatient mental health services in Wales or Scotland, respectively, unlike the CQC in England.
However, both the HIW and HIS have the powers to inspect community and inpatient mental health services in their respective jurisdictions whereas, in NI, the RQIA confirmed it only inspects inpatient services but not those provided in a community setting.
Foyle MLA, Mark H Durkan, is the former chair of an all-party Stormont group on mental health and is the SDLP’s health spokesperson.
He told The Detail he feels the current situation, in relation to how mental health services are scrutinised in NI, runs the risk of a “dereliction of duty”.
Regarding the differences in how mental health services are both inspected and regulated in other parts of the UK compared with NI, he said: “This is a considerable and indeed inexplicable oversight.
“The simple fact that mental health services here do not have the same protections and legal framework afforded elsewhere on these islands, is a disgrace.
“The failure to properly regulate the quality and standards of our mental health provisions is in effect, failing some of the most vulnerable people in our society.”
Mr Durkan continued by claiming the current legislation is failing and that there’s an “urgent need for a more comprehensive and modernised mental health strategy for NI”.
He added: “Whilst I welcome recent progress in relation to the Protect Life 2 suicide prevention strategy, it is clear this doesn’t go far enough.
“Unfortunately, in the absence of an Executive, the crucial decisions and updated legislation so desperately needed, cannot be delivered.
“All the while, an already sub-par system is falling further and further behind.”
The RQIA discharges the responsibilities it does possess, in relation to mental health services, under the Mental Health (NI) Order 1986, the Health and Personal Social Services (Quality, Improvement and Regulation) (NI) Order 2003 and the Health and Social Care Reform (NI) Act 2009.
Action Mental Health (AMH) is a mental health charity in NI. Its chief executive is David Babington.
Mr Babington told The Detail, AMH “wholeheartedly supports the need for legal oversight” of mental health services in NI.
He added: “Yet again, NI is found to be lagging behind the rest of the UK, as it does in all areas of mental health.
“This lack of parity with the rest of the UK comes on top of the raft of inequalities, in terms of funding and overarching strategies, despite NI’s greater incidence of mental ill-health.”
On this issue, Charlie’s male relative added: “It’s difficult to understand the circumstances in which service users of mental health in NI are not afforded the same legal protections as elsewhere in the UK.”
Charlie’s family moved from one NI health and social care trust area to another in 2015, due to a family bereavement.
His relative said the family “would never have envisaged the type of treatment by the current trust’s community mental health team”.
The man continued: “I was surprised that in these circumstances there was no-one to turn to for sufficient and adequate help.
“The whole experience, in all honesty, has been poor and it’s no longer acceptable
“I would have feared for Charlie and his mother, a lady now over pension age, who was only seeking the entitlement of appropriate care for her vulnerable son and to secure his future, had they not had close family support and the help of friends and the family minister.
“It’s been an unnecessary and painful episode in their lives, which promoted little in the way of hope for Charlie and his mother, who have both endured considerable loss in their lives.”
Charlie’s family’s minister was previously a senior nursing manager in the NHS in NI.
He told The Detail: “I’ve journeyed with this family for about three years. They are dignified and balanced in their dealings with the trust.
“They want nothing but the best for Charlie, but this is also a family that has been hurt by those who are meant to care for them.”
RQIA sign outside its office building in central Belfast.
Public inquiry
Charlie’s male relative wanted to go on the record about Muckamore, adding that he supports the affected families in their aim to have a public inquiry to “obtain all manner of truth regarding the treatment of their loved ones”.
Glynn Brown, whose son is an inpatient in Muckamore, reiterated this call.
He said: “The fact the RQIA doesn’t regulate Muckamore absolutely increases the need for a public inquiry about what went on there.
“The public has no understanding about what’s happened. It’s slowly being peeled back like an onion, layer by layer. Only a full public inquiry is going to get to the bottom of the failures.”
Mr Brown concluded that “root and branch reform” of mental health services in NI is vital and that a public inquiry into what happened at Muckamore is the best way to instigate this process.
The DUP’s Gavin Robinson is Mr Brown’s MP. Mr Robinson has previously called on the Secretary of State for NI, Julian Smith, to establish a public inquiry into Muckamore. Foyle MLA, Mark H Durkan, supports this too.
“It is imperative we get the truth,” he said.
“It is something (a public inquiry) which I have previously requested from the Permanent Secretary of Health, Richard Pengelly, the response to which alluded to the ongoing PSNI investigation taking precedence and the fact that, ultimately, any decision for such an inquiry would need to be taken by a minister.
“Yet many questions remain unanswered; how could the abuses of society’s most vulnerable go undetected and unchecked for so long and where would we have been without the extensive CCTV footage which subsequently came to light?
“These questions must be answered. The families of victims deserve those answers.
“The best way to do this is through a public inquiry. If it keeps being glossed over the learning can’t be done.”
The man who phoned The Detail’s office a few months ago, concerned about his loved one Charlie, finished by requesting politicians to act.
He said: “Over the years, lots of credible initiatives regarding mental health have been put forward by many respected bodies and individuals yet, the whole time, the critical foundation of appropriate regulation of mental health services was, and continues to be, absent.
“We would therefore, respectfully, call on all politicians in NI to make this issue of regulatory deficit within mental health a matter of priority to resolve.
“Not only is it deserving of our people but otherwise, we run the risk of a dereliction of duty.”