Adults with Incapacity (Scotland) Act 2000: improving knowledge and compliance in acute

Dr Cesar Rodriguez Consultant Old Age Psychiatrist Associate Medical Director, Older People NHS Tayside, Scotland

27th Alzheimer Europe Conference 2nd October 2017, Berlin Introduction

• Adults with Incapacity (Scotland) Act 2000

• NHS Tayside acute hospitals

• Compliance with the law: external scrutiny

• Action plan and evaluation

• Lessons learnt Adults with Incapacity (Scotland) Act

Act of the Scottish Parliament to make provision as to the property, financial affairs and personal welfare of adults who are incapable by reason of mental disorder or inability to communicate.

• Principles: • Benefit the adult (>16) • Take into account adult’s past and present wishes • Take into account the views of relevant others • Minimise restriction of adult’s freedom while achieving benefit • Encourage adult to use existing skills or develop new ones

• Part 5: • Deals with Medical Treatment and Research • Assessment and certification of incapacity in relation to treatment: Section 47 Certificate and Treatment Plan • “Proxy decision-makers” welfare attorneys and guardians NHS Tayside Teaching Hospitals

• Medical School: Ninewells , and Hospital with1034 acute beds (excludes community hospitals and psychiatric beds).

• Serving a population of over 400,000 (plus regional services), NHS T employs 13,790 staff: 1258 doctors (including 554 trainees) and 4400 registered nurses.

• Main causes of incapacity in acute care (either permanent, fluctuating or temporary): • Delirium • Dementia • Learning Disabilities • Acquired Brain Injury and other physical causes • Severe and enduring mental disorders 2014 population estimate 2031 Total Under 65 Over 65 (%)* Over 65 Angus 116,660 91,027 25,633 (22%) 34,995 Dundee 148,260 122,464 25,796 (17.4%) 32,287 P&K 148,880 116,364 32,516 (21.8%) 44,355 Tayside 413,800 329,855 83,945 (20.3%) 111,367

* Scotland over 65 % = 18.11 Compliance with the Law: external scrutiny

• November 2012 report from Scottish Public Ombudsman Service: recommendations for NHS Tayside staff to be aware of responsibilities. Report on 24th September 2014, 3 cases chosen, the first one (NHS Highland) regarding failures in use of legislation and consultation on decisions on treatment.

• Further local information through feedback, complaints and Significant Clinical Event Analysis (SCEA) highlighted similar issues.

• Since 2011 (Mrs V), the Scottish Government has commissioned Healthcare Improvement Scotland to inspect the care of older people in acute hospitals. September 2014 HIS inspection to Older People’s Care in PRI: • NHST to ensure that current legislation….is fully and appropriately implemented. • When a certificate is required, assessment of capacity to consent to treatment is performed and documented.

• Further inspections in Ninewells H in June 2016 and in Stracathro H in February 2017. Action Plan and evaluation

• NHS Tayside’s on-line module on Capacity and Consent: 1007 staff completed it in first year (17-09-14 to 17-09-15) and over 3000 by now.

• Targeted training • Individual groups: Lead Clinicians, dermatologists, charge nurses, dementia champions (around 200 staff) • Consultant Nurse-led workshops (over 500 MDT staff)

• Inclusion in the six-monthly Junior Doctors Induction Programme/ NMP course

• Awareness Raising through email communications to medical staff and news letters

• Link to the delirium work: embedded in local delirium guidelines, rapid tranquilisation

• Documentation: changes to aid compliance Nursing documentation Nursing documentation Nursing documentation: traffic light Nursing documentation: traffic light

Evaluation and scrutiny

• Difficulties related to whole system practice (and cultural) change.

• Clinical, Care and Professional Governance reporting through the NHS Tayside Older People Clinical Board at organisational level but this needs each acute unit to own and scrutinise their own data to drive improvement.

• June 2015 HIS and NHS Scotland published : “Care of Older People in Hospital Standards”: • Specific standards for the care of Delirium, Dementia and Depression • Standard 3: “decision-making, consent and capacity” where staff are required to understand their roles and responsibilities in supporting patients to make decision and in assessing and documenting capacity to consent. Lessons learnt

• Awareness raising and build infrastructure

• Embed ethics and law in training, guidance and documentation

• Small tests for change: make compliance easy

• Select and support your champions

• Organisational culture changes take a long time. Capitalise on “lobbing” opportunities: Older People’s Week, Alzheimer Day...

• Embrace external and internal scrutiny as a tool for improvement Thank you! [email protected]