NPM monitoring from a mental health approach: the Portuguese experience João Portugal NPM Steering Committee
I. Mental health system overview II. NPM action III.Some findings IV.Challenges
I. Mental health system overview 1. Capacity installed Mental health care is centered in the local health care services, predominantly in general hospitals, regional services and psychiatric hospitals. The Portuguese National Mental Health Plan foresees a deinstitutionalization process and consequent progress to local community approach focused on rehabilitation. From 1386 beds in 2000 for mentally ill inpatient, to 874 in 2013. Plus 3000 in the social sector.
I. Mental health system overview 1. Capacity installed Concerning inpatient care of mentally ill: Civil system - 3 Psychiatric Hospitals (Lisboa, Porto and Coimbra) and further inpatient Psychiatric Units integrated in General Hospitals. Criminal system 2 Psychiatric Units: the Psychiatric Hospital of Santa Cruz do Bispo Prison, for long term care of non-responsable and the Psychiatric Clinic of the Prison Hospital, for short-term care. Children and youngster 3 Psychiatric Departments attached to the main Pediatric Hospitals (Lisboa, Coimbra and Porto) and paedopsychiatric services in general hospitals.
I. Mental health system overview 2. National Strategy: improvements in the living conditions in psychiatric hospitals; the development of community services; the integration of mental health care within primary care; the development of psychosocial care; the increasing participation of users and families in the improvement of policies and services; the protection of the human rights of people with mental disorders.
I. Mental health system overview 3. Legal framework on the rights of the persons with mental disorders Law 36/98 Involuntary placement of a person suffering from a serious mental disorder is necessarily a consequence of a judicial decision. Requirements: serious mental disorder and (a) endangerment of relevant legally protected rights or goods, either personal or patrimonial, from oneself or from others [danger inpatient treatment] or (b) possible serious deterioration of the mental state [guardian inpatient treatment]
I. Mental health system overview Judicial procedure to the psychiatric evaluation of the person concerned. It includes the hearing of the patient and family, the intervention of at least 2 psychiatrists and a final common session with the mandatory presence of the legal counsellor of the concerned individual. Final decision states the reasons on which is based, including the identification of the patient, the specification of the clinical reasons, the clinical diagnosis and the justification for the compulsory treatment. The right to appeal is an unrestricted guarantee. Mandatory revision after 2 months (of the final decision or of the maintenance decision ) or whenever requested by the patient/legal proxy.
II. NPM action Integration of Ombudsman and NPM functions Complaints on internment Positive Negative Visits (preventive or not) previously made (e. g. prisons, foreigners centers, youngsters centers) comprehending mental health issues
II. NPM action Importance of the OPCAT and NPM mission Openness to civil society Openness to other areas of knowledge Intervention within the scope of private entities
II. NPM action Programme of visits including Psychiatric hospitals Psychiatric services from general hospitals Establishments admitting psychiatric patients in the context of criminal proceedings Establishments for mentally disabled people Units of public or private and social nature Youngsters centers Foreigners detention centers The enforcement of supervision: the Monitoring Commission
II. NPM action Principles of Action Emphasize and promote the rights of the individuals suffering from mental disorders, especially of those deprived of liberty. Collaborate to the improvement of mental health facilities Build bridges between the clinical and legal worlds in favor of one of the most vulnerable groups of the society.
II. NPM action Visits to Psychiatric hospitals have only been gradually integrated: 2014 - Department of forensic patients of the Hospital Magalhães Lemos (Porto) 2016 - Psychiatric Department of the Hospital Montijo/Barreiro 2017 - Psychiatric and Paedopsychiatric Department of the Beja Hospital - Clinical S. José (social sector) Internal report and issue of a Recommendation. Results: procedure modifications
II. NPM action How to overcome the gap between the legal language and the medical discourse? the gap between visitors and patients?
II. NPM action Cooperation with external experts - psychiatrists The support of an external medical expert is a crucial feature. Promotes the overcoming of the language and skills gaps Facilitates the examination of medical files Increases credibility of the work and results achieved Enables the approach of the NPM to the patients and increases communication Training provided
II. NPM action Cooperation with external experts - psychiatrists Difficulties Additional financial burden Impartiality requirements
II. NPM action Legal framework International law and standards of specialized bodies and institutions. National law ( Mental Health Law - Law 36/98) and specific regulations such as Guidance 21/2011 of the General Directorate of Health concerning the use of means of restraint.
II. NPM action Aspects addressed with the help of a script Patients living conditions Safeguards in the context of involuntary placement Means of restraint and seclusion Medical treatment Preventions of ill-treatment Human resources
II. NPM action Structure of the Visit Initial talk with the Director and/or Clinical Director. Visit and questioning of the staff (doctors; nurses; clinical director). Interviews with the patients. Random observations of clinical files, especially focusing on the cases of patients subjected to restraint measures or in involuntary treatment.
II. NPM action Other features Unannounced visits NPM team of two or three members plus an external expert (psychiatrist) Particular focusing on two or three issues, the use of restraint measures being always specially addressed.
II. NPM action Prevention of ill treatment Assessment of the physical and organizational structure of the institution and type of patients (voluntary/involuntary- acute/chronic) Identification of involuntary inpatients or lacking civil capacity Admission procedure Contacts with the exterior (tv, mobile phone, access to internet and social media) Staff resources (qualifications, training and cooperative work) Internal supervision system External supervision entities (identification of visits or other interventions) Adequate exercise of the right to complaint (number and subject of complaints; complaint reply procedure and practices followed).
II. NPM action Patients living conditions Living space per patient/accommodation structure o o o Rooms or dormitories and capacity. Decoration of the rooms and common areas Do they assure visual stimulation? Bedside table and wardrobe per patient? Personal belongings allowed? Adequate lighting, heating and ventilation (natural light, air conditioner, ). Privacy (access to WC? Access to the rooms allowed during the day?). Food. Rules observed in the segregation of the patients.
II. NPM action Means of restraint/seclusion Means used. Frequency of incidents, overall and by patient, and duration. Recognition of the principle of last resort or exceptionality? Adequate comprehension of chemical restraint? Policies defined clearly? Internal norms? Procedure followed? Existence of a specific register, in addition to individual clinical files? Type of information provided in this register. Type of monitoring assured during the use of restraints? Seclusion rooms (security and appropriate human contact).
III. Some findings Most common recommendations appropriate drafting and dissemination of internal written instructions on the application of coercive measures in accordance with the guidelines of the Directorate-General for Health (in particular for psychiatric and emergency services). implementation of an autonomous register of incidents containing the relevant information (E.g., behavior that triggered the measure, attempted preventive measures, record of complications, physician who proposed or agreed to the measure, outcome of monitoring and, especially, duration of the measure). list of therapeutic solutions that should be considered measures of chemical restriction and, therefore, subject to the same use standards.
III. Some findings On the positive side: Facilities have generally good conditions of hygiene, lighting and of maintenance. The privacy of the patients is sufficiently safeguarded. Regarding the prevention of ill treatment, a focus on rehabilitation, social integration and community/family based care has been acknowledged.
IV. Challenges How to contest medical treatment issues, especially with regard to the pharmaceutical overdose. Is the NMP competent to examine the appropriateness of medical treatment? How to address the use of restraints in patients voluntary admitted; Identification of the facto detentions and procedure to follow. Do we suggest the immediate release of patients with mental disorders and consequently very vulnerable social and clinical situations when there is no legal base for a compulsory treatment and there are doubts on their informed consent? Mental health disorders among prisoners (relation between criminal health systems and the general health system).
joao.portugal@provedor-jus.pt