Consultations (2011)

NICE Draft Guidelines on the Longer-Term Management of Self-Harm

Wish welcomes the guidelines general approach including the emphasis on care plans rather than risk assessments, the advocacy of service-user involvement in treatment development, the individualised understanding of self-injury, the recommended use of psychological therapies and the recognition that the negative attitudes that currently prevail stigmatise and inhibit the recovering of people who self-injury. However we wish to raise some points where the draft guidelines could be strengthened.

The term ‘self-harm': Wish believes that the term self-injury is preferable to self-harm for two reasons. Firstly, it is less pejorative, in keeping with the guidelines focus on changing attitudes and reducing dismissive or ill-informed approaches. Secondly, the term more clearly excludes that which is outside the scope of the guidelines (eating disorders, excessive drinking of alcohol and risky sexual behaviour).

Harm-minimisation approaches: Whilst the guidelines draw attention to harm-minimisation approaches, Wish recommends fuller reference to the range issues that this approach addresses and its potential to benefit those who do not want to stop their self-injury. The guidelines could include greater explanation of the content of the harm-minimisation approach including education around safer cutting, the use of sterile blades and self-wound care.

Care Plan outcomes: The outcomes to be considered when creating care plans currently do not include harm minimisation. Although they include stopping or reducing self-harm this is not enough to encourage harm minimisation as a part of care plans. In Wish's experience of working with women who self-injure, harm minimisation is a key outcome for many women and is very beneficial. It is important as a goal in itself but also as a stepping stone towards desistence.

Gender and self-injury: From Wish's experience women's practice of self-injury has gender-specific factors. The guidelines recognise to a certain extent the links between experiencing abuse or domestic violence and practicing self-injury (section 1.1.21). However, there needs to be greater recognition of self-injury as a gendered practice, frequently associated with the experience of harm at the hands of others, particularly family members and intimate partners.

Self-injury by women in prison: The guidelines and evidence base have neglected the high rates of self-injury for women in prison. Women account for 52% of incidents of self-injury in prison in 2008 despite making up 5% of the total prison population (Ministry of Justice, 2009, Statistics on Women and the Criminal Justice System). In-reach mental health provision in prisons is varied and frequently of an inadequate standard. Women in prison who self-injure routinely face negative attitudes towards their behaviour and the belief it is ‘attention-seeking'. Much more needs to be done to improve the quality of mental health provision in general and self-injury treatment in particular within prisons. The guidelines should make specific reference to the needs of this high-risk and frequently neglected group.

Legal Aid Reform

All but one of the hundreds of women we have worked with have been granted legal aid, for reasons such as: regaining their independence from mental health sections, regaining custody of children, getting protection from domestic abuse in the civil courts and accessing benefits. Wish opposes the planned changes because they:

(i) Discriminate against women who are more likely to lack the resources to pay for their own legal costs
(ii) Discriminate against people with mental health problems who are more likely to need legal aid for cases relating to family law and debt
(iii) have not been subject to a gender impact assessment, as required by law
(iv) Breach the Human Rights Act 1998 - ‘the ability to access legal advice and representation is a vital part of the right to a fair trial, which is fundamental to the rule of law and protected under the HRA in Article 6 of the European Convention on Human Rights'; and, ‘a lack of access to legal advice and representation may lead to violations of other fundamental rights protected under the HRA, such as the right not to be subject to inhuman and degrading treatment (Article 3, ECHR) and the right to respect for a private and family life (Article 8, ECHR)'.

Disability Living Allowance Reform

Many of the women we work with claim DLA for their mental health and sometimes other disabilities. Most receive the higher care rate for DLA and the lower rate for mobility. Some with additional physical disabilities receive the higher mobility rate. For those receiving DLA, this is a vital benefit for their ability to live independent and full lives. Wish's mains concerns are that:
(i) Women with mental health problems should be able to choose to be assessed by a medical professional they know and trust. They should be able to request a female assessor and the right to an advocate.
(ii) The assessment needs to treat people with fluctuating conditions fairly. One day face-to-face assessment may not be the best method for gathering evidence about a person's condition.
(iii) The new method of assessment should be shorter, more transparent and treat people with respect.
(iv) Clearer information should be provided about the benefit, particularly if fines will be applied where claimants do not comply with requirements to update the DWP. We are very concerned that if this is not done more women with mental health needs may be fined and moved towards the criminal justice system.
(v) The reforms should be carried out with attention to the changes taking place in Local Authority service provision and wider benefit reform impacting on claimants.

Ministry of Justice Sentencing Green Paper

Our response focuses on the issues that are most important for the women we work with: mental health, housing, children and family, types of sentences and genuine resettlement and rehabilitation. We illustrate the value of Wish's intensive working and needs-based approach, and urge MoJ to continue and expand their funding of specialist Women's Organisations who carry out an integrated approach to offender management involving collaboration between statutory and voluntary sector

Sayce Review of Employment Support for Disabled People

We believe that gender-specific and mental-health-aware approaches are better able to meet the needs of women for increasing their access to employment and training. The evidence we provide for the Sayce Review is two case studies, based on interviews with women we work with, explaining their support needs and their concerns for finding training and work. They provide examples of the most important issues we encounter in our work with women with mental health needs: discrimination, low self-esteem, a lack of gender-specific community based support and the need for building relational security.

Health and Social Care Bill

As the Bill aims to devolve decision-making for health and social care commissioning, and bring in a wider range of health and social care providers, we wish to raise the issue of continuity of care and services. Women with mental health needs experience unacceptable variation in the quality of services, the approach used and fractured treatment. This is exacerbated by the failure to effectively divert women with mental health needs, who commit petty and non-violent crimes, away from the criminal justice system. Community mental health services are severely lacking and many women only receive treatment when their condition reaches crisis point, or results in offending behaviour. Secure settings are often inimical to recovery and regaining control over their lives. The geographical dispersion of secure provision for women disrupts family relationships, removes them from support networks and jeopardises their opportunity to have a say in the direction of their treatment and care. Local boards and government departments address the needs of this group of women differently, using different standards of care and differently prioritised outcomes. The reorganisation of the commissioning and provisioning structure provides the opportunity to implement oversight. Outcomes should be co-ordinated, and the importance of gender-specific approaches in this area reaffirmed, in line with policy recommendations.

Strengthening Women's Voice in Government

The key challenges facing Wish members:

• Continued paucity of services to meet the gender-specific needs of women experiencing mental distress
• Service cuts affecting women who rely on them for their wellbeing, to deal with poverty and to support them as mothers
• Lack of understanding and purchasing of gender-specific services for women despite evidence of their positive impact and cost effectiveness

Approaches we suggest for strengthening women’s voice in government:

Wish endorses the proposals put forward by the Women’s Resource Centre that a plurality of methods should be used. Our organisation and our members value face-to-face engagement. These can be complimented by an IT platform but not replaced by it, especially when women we work with have little access to the internet.  We hope these proposals will increase opportunities to meet others working and using services in the women’s sector to share our knowledge and represent it to policy-makers. The GEO’s role facilitating meetings between the women’s sector and ministers and policy-makers would be important. Ideally there should be a mix of policy-focussed, specialist events and less formal discussions suited to those not working in the sector but with experience of the issues. Events that cross policy areas to address the needs of specific groups of women without departmental boundaries would be useful for groups such as women with mental health needs. Without opportunities to consider mental health, the criminal justice system, housing, family and employment support services in a joined-up way progress for this group will be slowed.

Community Care Grant call for evidence

Wish is concerned that the Government's plans to localise the grants and loans programmes without a ring-fenced budget or specified service requirement risk patchy provision and unmet need. Women that Wish works with, particularly those completing custodial sentences, are often destitute and have an urgent need for small loans and grants. The money they receive usually goes towards buying basic furniture in the place where they live or paying bill to have heating or electricity. The proposals suggest there will be inconsistent and inadequate provision with the changes the Government is putting forward. We are concerned that small groups of high need people, facing emergencies and changes to their living status will be disadvantaged and left vulnerable. They may resort to drastic measures such as reoffending to return to a room that is furnished, even if this is in prison. Wish believes that The Community Care Grant and Crisis Loans should be maintained with a protected and adequate budget. There should be a consistent and national provision of the funds. In this way the need for urgent living costs for those without the funds will continue to be met.

NICE Draft Guidelines of service user experience of adult mental health services

Wish’s key points in response to the NICE Draft Guidelines:

1. Gender-specific ways of working should be within the capabilities of health and social care staff. Training should be provided to staff and staff with the greatest expertise around gender-specific working should be identified to mentor staff with less experience or understanding.

2. Service users’ gender-specific needs should be considered when assigning a professional to work with someone, when staff are involved in restraining service users and when considering the service-users practical needs such as addressing their caring responsibilities.

3. Relational security should be a named principle of working with service users.

4. Voluntary sector organisations that use gender-specific ways of working should be known about and signposted to. They could also be involved in supporting service users to provide training and to support them when they are discharged.

5. Clinical language should be avoided because women we work with attest to the role of clinical language and labels in disempowering and frightening them during discussions with medical professional. The over-use of clinical language and jargon inhibits them from sharing decision-making and putting their views forward.

6. Service-users should be actively supported to engage with community organisations.

7. Preferences about the gender of staff working with women should be respected, especially where compulsory treatment or restraint is being used.

8. When being discharge a service user should be actively supported to engage with community support services and they should have opportunities to discuss their housing and finance situation.

9. The risk of service users having experience domestic violence or sexual abuse should be considered when developing their care plan, when making an assessment, when involving family members and when they are discussing their home situation during discharge.