How do people experience avoidable harm in mental health social care?

It is crucial that mental health social care services prioritise implementing measures that prevent avoidable harm, which can be defined as harm caused to service users by unsafe interventions and practices which could have been mitigated (Carr et al., 2023).

Some examples of avoidable harm are:

• demonstrating abusive and/or disrespectful behaviours toward service users,
• unjustified discharge from services, and
• failure to promote independence (Department of Health and Social Care, 2022).

Statistics have shown that a large proportion of service users do not feel they are provided adequate mental health social care:

• 28% feel they do not have a choice in their care plans, and
• 65% are overall, dissatisfied with support from services (NHS Digital, 2022).

It is important to gain further understanding of this, as it appears avoidable harm is widespread across services. Therefore, Sarah Carr and colleagues (2023) aimed to review results from various studies to assess service users’ experiences of psychological avoidable harm in mental health social care within England.

Avoidable harm, such as unjustified discharge from social care services, appears to be a widespread experience across service users.

Methods

A scoping review, guided by an Advisory Group of seven individuals with lived experiential and/or practitioner experience, was undertaken for this research study. The review was conducted based on the research question: What is known from peer-reviewed literature about mental health service user experiences of social and psychological harm in social care in England?

The search was done on PsycINFO, ASSIA, Social Care Online, Web of Science, SSCI and Social Policy and Practice. They also got in touch with various experts and Advisory Group members for further research recommendations.

Research using any methodological design exploring adult service users’ experience of accessing community-based social care or social work for their mental health could be included in the review. However, studies were excluded if they had any of the following characteristics: (1) conducted in, or before, 2007, (2) not written in English, (3) participants were aged below fifteen, (4) not in a community setting, (5) participants were not service users, (6) participants were not accessing support for their mental health and (6) the paper was not in a peer-reviewed journal.

The initial selection of articles was done by looking through 3,529 titles and abstracts, followed by selecting and reviewing 84 full-text articles and narrowing them down to 22 for the analysis. Thematic analysis was used to identify emerging themes from each study, that relate to the research aim.

Results

The researchers identified six themes that captured service users’ experience of social and psychological harm in social care.

1. Poor relationships and communication with practitioners

• Practitioners adhering strictly to assessment protocols, rather than having a natural flowing conversation, led to feelings of stress and disempowerment for the service user.
• Service users often felt ‘distant’ or disengaged with their assigned practitioner, for example, clinicians often made decisions about their care without discussing with the client.
• Practitioners who displayed signs of judgement and discrimination led to feelings of distress for the service user.

2. Information, involvement, and decision-making

• Service users often felt disempowered when they were not involved in their care-planning, for example, defining vulnerability, risk, and harm, without consulting with the service user.
• Practitioners not informing the clients of how personal budgets worked and what they could be used for created a sense of lack of control and choice for the service user.

3. Lack of support or support that fails to meet needs

• The lack of service user involvement in care planning often resulted in social care not meeting their needs, thus leading to deteriorating mental health, disrupted family life, increased exposure to external harms and fears around disclosing needs.
• Specific groups felt crucial aspects of themselves were not taken into account during care planning which led to feeling ‘let down’, for example, not considering religious beliefs and learning disabilities.
• Lack of funding and staffing, lengthy wait lists and delayed adult safeguarding responses all meant service users’ needs were not met and led to increased exposure to domestic violence and worsening mental distress.

4. Inflexible, bureaucratic systems

• Organisational systems and administrative requirements, such as complex, bureaucratic, and lengthy assessment and care planning processes, caused harm and distress to service users. For example, some service users felt overwhelmed by paperwork and had to rely on family members for administrative support.

5. Fragmented services and discontinuity

• Lack of integration and poor communication between mental health services led to fragmented and incoherent care pathways.
• Service users often felt that practitioners were ‘passing the buck’ to other agencies, which resulted in heightened risk and a delay in care.

6. ‘Power over’ and discriminatory organisational cultures

• Wider organisational structures such as social care services operating in the context of the Mental Health Act 1983 and 2007, can lead to service users feeling that others have ‘power over’ them, which can lead to emotional and social harm.
• Some service users found supported accommodation to be overly restrictive.
• Parents with mental health distress reported systematic discrimination as they were viewed as ‘unfit’ parents and a risk to their children, which led to worsening mental health and damage to family life.

Most service users discussed that lack of communication with practitioners and discriminatory organisational cultures led to feelings of distress.

Conclusions

Overall, this review provides the first step to understanding ways in which social care within England can be improved as it highlights various reasons that service users have felt distressed and disempowered whilst accessing social care.

For example, effort should be placed on communicating clearly and developing strong therapeutic relationships, with service users. Also, wider structural systems need to be addressed, such as there being clearer communication, and more integration between services.

This scoping review provides a good starting point to identify what’s needed to minimise avoidable harm within mental health social care settings.

Strengths and limitations

This scoping review provided insight into an incredibly important research topic, as it highlights ways in which mental health care engages in avoidable harm practices. Gaining more of an understanding of this topic allows services to learn how to improve their practices. Crucially, this helps health and social care services come closer to meeting the Care Quality Commission (CQC) requirements for good care, where services should be safe, effective, caring, responsive to people’s needs and well-led (CQC, 2022).

One of the main strengths of this study is the use of an Advisory Group of individuals with lived experiential and/or practitioner experience. It has been suggested that 85% of health research is ‘wasted’ (Glasziou & Chalmbers, 2018), largely due to research questions having limited relevance to clinicians and patients (Minogue et al., 2018). Therefore, having people with lived experience play a central role in this study, reduces the possibility of this research going to ‘waste’, thus creating useful mental health research that makes a difference.

A major disadvantage to this research study, and most scoping reviews, is that there is a high risk of bias due to high heterogeneity among studies, and no risk of bias assessment tool used throughout the review. However, a scoping review appears to be the most appropriate methodological design for this research question as it is an emerging topic, with a lack of sufficient literature to carry out a well-evidenced, reasoned analysis (e.g., a systematic review). Hopefully, this review inspires more studies to be carried out on this topic, leading to more rigorous research in the future.

This study may have benefited from also exploring positive mental health social care practices, as this could have further increased our understanding of what services need to do to optimise care for service users. However, this provides an avenue for future research to explore.

Researchers have brought awareness to a neglected research area that can help in enhancing support for adult service users.

Implications for practice

This study offers a valuable understanding of the harmful practices taking place in mental health community-based social care. This helps reveal what we need to do to provide better support within services. Importantly, practitioners must maintain communication with service users so they are aware of their care plans, this could potentially involve providing clients with copies of their notes and carrying out follow-up calls to ensure they are satisfied with the outlined plan.

As discussed previously, having an Advisory Group of individuals with lived experiential and/or practitioner experience was fundamental in making this research meaningful. This approach should extend in improving practice; it is important to advocate for service user involvement in service development, provision, and evaluation to ensure we are minimising harm and delivering effective support.

In line with the results of this research, in my role as a Psychological Wellbeing Practitioner for IAPT, I am aware of the lack of integration of services. Attempts have been made within the NHS Trust I work for to integrate services, for instance, we run monthly supervision meetings with three other IAPT services to gain more knowledge of how other services work so we can draw inspiration from one another. This could be extended by also having meetings with secondary care and other mental health services. However, it is important to recognise that more integration will only succeed if we have sufficient staffing. Currently, mental health services are severely under-staffed, and the government needs to develop a long-term plan to address this. Overall, efforts need to be made to integrate services that work hand-in-hand and support each other, as well as prevent potential harm to the people in our care.

As practitioners, we need to communicate more with service users and ensure they are involved in their care planning to enhance empowerment.

Statement of interests

None.

Links

Primary paper

Carr, S., Hudson, G., Amson, N., Hisham, I. N., Coldham, T., Gould, D., … & Sweeney, A. (2023). Service users’ experiences of social and psychological avoidable harm in mental health social care in England: Findings of a scoping review. The British Journal of Social Work, 53(3), 1303-1324.

Other references

CQC. (2022, August 25). The five key questions we ask. Care Quality Commission. https://www.cqc.org.uk/about-us/how-we-do-our-job/five-key-questions-we-ask

Department of Health and Social Care (2022). Care and support statutory guidance. GOV.UK https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance#safeguarding-1

Glasziou, P., & Chalmers, I. (2018). Research waste is still a scandal—an essay by Paul Glasziou and Iain Chalmers. Bmj, 363.

Minogue, V., Cooke, M., Donskoy, A. L., Vicary, P., & Wells, B. (2018). Patient and public involvement in reducing health and care research waste. Research Involvement and Engagement, 4(1), 1-8.

NHS Digital (2022, November 17). Adult Social Care Statistics in England: An Overview. NHS Digital https://digital.nhs.uk/data-and-information/publications/statistical/adult-social-care-statistics-in-england/an-overview