Human Rights in a Health Care Setting: Making it Work for Everyone

Title of guidance:

Human Rights in a Health Care Setting: Making it Work for Everyone: an evaluation of a human rights-based approach at The State Hospital

Author: Scottish Human Rights Commission

Human Rights in a Health Care Setting
Year published: 2009
Length: 77 pages
Format: PDF (689Kb)
Other formats: none indicated
Producer/ Publisher: Scottish Human Rights Commission
Type of organisation: Human rights commission in the UK
 

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Categories:

Health | All (cross-sector) | Evaluation of practice | Human Rights Act | European Convention on Human Rights | International Covenant on Civil and Political Rights | Convention on the Rights of Persons with Disabilities | GB wide | Case studies

Audience: Senior executives | Service management | Corporate management | Front-line service personnel | Elected councillors, board members, trustees | Policy managers and directors | Legal directors

Topics: Human rights | equality | assessing risk | transparency and accountability | proportionality | blanket policies / individual assessment | balancing competing rights | mental health | impact assessment | organisational change | involvement and participation

Summary

This is an evaluation of the experience of The State Hospital, the only high security forensic mental health hospital in Scotland and Northern Ireland, based in Lanark, which has, since 2000, sought to put human rights at the heart of its day-to-day operations. The report contains valuable lessons for any public authority seeking to effect thoroughgoing change in its organisational culture and / or to evaluate the extent to which its policy and practice meets human rights standards. It describes in detail how The State Hospital used human rights to shift from a punitive, custodial ethos to one which emphasised care and treatment of patients. It identifies the benefits that accrued to staff, patients, carers and relatives and the lessons learned with regards to process and implementation. It provides a set of human rights indicators that can be used to monitor over time the degree to which human rights principles are brought to life in day-to-day practice.

Key human rights messages in this guidance

  • Three key questions emerged in relation to policy and practice:
    • is it legal?
    • is there a legitimate aim?
    • is it proportionate? (does it use a sledgehammer to crack a nut?)
  • A human rights-based approach meant a reduction in 'blanket' policies and an increased focus on individual needs and risks.
  • By adopting a human rights-based approach, TSH reduced both human and organisational risk; for example, the risk of having to react to critical media comment, negative public perceptions or legal proceedings.

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Background

The State Hospital (TSH) in Lanarkshire provides psychiatric care for people who are compulsorily detained under mental health or criminal law.

In 2000, following a critical external report, a decision was taken to put the human rights of everyone - staff, patients, carers and relatives - at the heart of the hospital's policies and practices.

THS chose to use the Human Rights Act (HRA) as a 'vehicle for cultural change', rather than conducting a purely defensive audit in order to avoid litigation. In this way, human rights were both a means (a way of doing things and treating people), as well as an end to be achieved.

What did The State Hospital do?

TSH established a Human Rights Working Group led by senior management and involving clinical and non-clinical staff. With expert advice, it identified specific articles of the European Convention on Human Rights that were most relevant to their service. These were: the prohibition of torture, inhuman and degrading treatment or punishment; the right to liberty; the right to a fair hearing, and the right to respect for privacy and family life.

The group consulted staff and patients from every ward, identifying real scenarios which might have human rights dimensions. Three key questions emerged in relation to policy and practice:

  • is it legal?
  • is there a legitimate aim?
  • is it proportionate? (does it use a sledgehammer to crack a nut?)

Policies and practices were assessed using a 'traffic light' system. None was given a red light for non-compliance with human rights; however, some were given an amber light, such as those related to seclusion and restraint, mail vetting and searching. The audit highlighted areas where practice diverged significantly from policy, especially in relation to (potential) failure to achieve proportionality in interfering with patients' rights.

The group developed human rights training for staff and tools for the assessment of future policy and practice. It also created a forum for staff, patient, and carer involvement in decisions (based upon the right to participation) and a Best Practice Guide, which stated that:

The starting point now of a patient's journey through the Hospital is the recognition of the patient's human rights. Forfeiting all rights on admission and winning back privileges is no longer sustainable.

From 2005-9, driven largely by new legislation and public sector duties, TSH developed an integrated equality, diversity and rights approach, along with more forums for patient and public involvement in how the hospital is run.

What difference did human rights make?

Senior managers said many staff were initially sceptical as to what the human rights initiative would achieve; some feared it would give patients unwarranted power.

However, the evaluation cites a majority of staff, patients, carers and external commentators as saying that

The adoption of a [human rights-based approach] was successful in supporting a cultural change from an institution ... with a 'them and us' culture, towards an organisation with a more positive and constructive atmosphere with mutual respect between staff and patients.

Staff said the experience had reduced their 'fear' of human rights, and increased their understanding of how to take balanced and proportionate decisions, as well as understanding the meaning and benefit of their own rights. The initiative coincided with staff reporting a reduction in stress and anxiety, though causality is hard to establish.

The human rights-based approach saw a reduction in 'blanket' policies and an increased focus on individual needs and risks. Patients noted that the use of restraint had become 'more measured' and better explained. Seclusion was not routinely used as a punishment and patients actively engaged in decisions that affected them.

A carer who had been visiting TSH for 30 years said the previous culture had been 'pretty barbaric ... staff used to be prison officers, now they are nurses'.

The human rights 'mantra' of legality, necessity and proportionality had become common currency. Staff also believed that this 'solid rights foundation' paved the way for a smooth assimilation of new obligations, such as equality, freedom of information and mental health duties.

The report notes that, by adopting a human rights-based approach, TSH had reduced both human and organisational risk; for example, the risk of having to react to critical media comment, negative public perceptions or legal proceedings when human rights are breached.

Process and implementation lessons

The evaluation notes that several elements were crucial to the success of the human rights initiative at TSH. These included:

  • top level buy-in and vision from the Board, Chief Executive and senior management
  • clear executive leadership in implementation
  • dedicated human rights expertise applied in the hospital setting
  • a 'participatory diagnostic process', the human rights audit, involving staff and stakeholders
  • investment of appropriate time and resources, and
  • focusing on the rights of everyone affected - staff as well as patients and carers.

The report notes that newer staff do not always relate individualisation of care and treatment expressly to the human rights-based approach. This suggests that, once embedded, policy and practice may not always be signposted as being underpinned by human rights, especially where other external drivers are pointing in the same direction. This in turn has implications for the sustainability of the human rights-based approach.

The evaluation notes that human rights principles and practice need to be refreshed over time, to respond to changes in personnel or circumstances. This might be achieved through periodic training, as well as continual assessment of policy and practice. This is especially important, the report argues, in order to reinforce human rights as the framework within which equality and diversity naturally sit.

Using human rights indicators

The report recommends the use of human rights indicators to provide a structured human rights accountability mechanism for the purpose of internal monitoring over time. It provides such a framework and uses it to assess in detail the degree to which a range of human rights principles are brought to life in day-to-day practice at TSH. The indicators draw on several international human rights instruments and are designed to assess the structures and processes in the hospital and outcomes for all concerned.

The principles it explores are those of:

  • participation
  • accountability of duty-bearers to rights-holders
  • non-discrimination and equality
  • empowerment of rights holders (knowing your rights and being supported to be able to claim them)
  • legality (express application of the HRA and international and regional rights standards).

This framework would be of use to any public authority seeking to evaluate the extent to which its policy and practice meets human rights standards.

The report offers insights into how the impact of human rights practice can be measured and assessed most effectively. For example, this evaluation is primarily qualitative and based on perceived outcomes; a more robust approach would be to conduct a baseline study in order to measure 'before and after' changes.

Despite the acknowledged shortcomings in the evaluation methodology, this report is valuable because there is a dearth of evaluative work which demonstrates the impact (whether positive or negative) of adopting a human rights-based approach to public services.

Date of review

April 2011

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