Engagement and disengagement (mental health) policy – Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)

1 Policy summary

Rotherham, Doncaster and South Humber NHS Foundation trust provides a wide range of services including physical health, mental health, learning disability, and substance misuse services.

This policy aims to cover the process of intervention and both promotion of engagement and management of disengagement for children, young people, adults, and older adults. The purpose is to set out the arrangements for, and approach to, promoting engagement and the management of patients who are at risk of disengaging, or who have disengaged, with mental health services and those where there may be safeguarding children’s or vulnerable adults concerns.

This policy and procedure will apply to all mental health services and community directorate within Rotherham Doncaster and South Humber NHS Foundation Trust.

2 Introduction

The trust recognises that there could be numerous factors that influence whether patients decline treatment or disengage with services. We recognise the importance of listening to and understanding what is important to patients to meet their needs and reduce the likelihood of patients declining treatment or disengaging.

Any users of our services may choose to discontinue contact with some, or all of the services provided. In some cases, this may not be problematic; however, there may be occasions when the situation gives cause for concern.

Disengagement can be defined as when a patient avoids contact with services, either intentionally or unintentionally over a period of time. The period of time will be determined by the clinical judgement of the care team following their assessment of the risks that are identified around the patient.

Disengagement could manifest in a range of ways such as:

not attending for a community appointment
not attending for planned medicine administration or monitoring
not being at home when visited by a colleague when dates and times had been pre-arranged.
not attending community activities
having moved from usual places of residence and given no indication of new address
not completing agreed tasks such as scales, questionnaires and exercises between session

Reasons for disengagement are varied and may include difficulties beyond the control of the individual who may have a limited understanding of care plans. This may be due to mental capacity, language difficulties, sensory impairment and lifestyle, or due to poor communication by health care professionals. Other reasons may include:

Safeguarding, cuckooing, vulnerabilities to radicalisation and entrapment
travel or transport issues
childcare and caring responsibilities
physical illness and mobility
language spoken and understood
nature of mental health difficulties, for example, negative symptoms, insight, fear, paranoia
work and vocation commitments
limited or no access to digital equipment or mobile phones
culturally inappropriate course of treatment of care, which does not reflect or take into account the lifestyle, and beliefs of the individual.

Services may contribute to disengagement through poor communication such as sending appointment letters that do not provide clarity or guidance. Being insensitive to the stigma associated with services, services having long waiting times for, or inflexibility in, arranging appointments and individuals experiencing difficulties in contacting services.

For others disengagement may occur because they feel they have reached a stage in their recovery where they no longer feel that they need to engage with services. However, in some cases, disengagement with services will raise significant concerns relating to the health, safety and wellbeing of an individual or others.

Some patients may need additional support to engage with services, supporting individuals to engage with services and comply with their recommended treatment programmes is applicable to all services and a key part of our care delivery.

The report of the National Confidential Enquiry into Suicide and Homicide by People with a Mental Illness, found that:

“Non-attendance and loss of contact with mental health services are frequent findings in enquiries into suicide and homicide.”

In order to promote the health, safety and wellbeing of all patients and others, it is vital that disengagement from services is considered seriously and that responses from services are proportionate to any measured or perceived risk. Disengagement from services may be an indication that action is required to safeguard the patient or potentially others that the patient has contact with.

It must be recognised that any person who has capacity and who’s mental health does not warrant detention under the Mental Health Act (1983) has the right to refuse treatment or services.

The trust has a responsibility to ensure that it delivers safe and effective services and attempts to engage patients in treatment and care. It must also consider the complex mental health needs of its patients and the impact that disengagement from services may have on them and their families.

Patients referred to adult community mental health services attend, in the main, on a voluntary basis. Exceptions to this are those individuals who are subject to Mental Health Act (1983) (MHA) community treatment orders, other sections of the Mental Health Act, those who need to be treated under the Mental Capacity Act 2005 (MCA) and treatment orders directed by the courts.

In child and adolescent mental health services (CAMHS), disengagement is often more complex than simple non-attendance. It may include:

a young person refusing to attend sessions
carers or family members failing to bring the child to appointments
inconsistent engagement with planned therapeutic tasks
family not responding to contact attempts or repeated cancellations.
important contextual considerations include:
- the child’s stage of development and ability to engage independently
- dynamics within the family or caregiving system (for example, parental mental health, domestic abuse)
- environmental barriers (for example, transport, childcare for siblings, conflicting priorities)
- cultural stigma, lack of trust in services, or misunderstanding of the role of the child and adolescent mental health services

Non-attendance in these circumstances should not be viewed as service refusal without further exploration. Clinicians must consider whether disengagement could indicate unmet need, disguised compliance, or safeguarding risks.

3 Scope

This guidance applies to all clinical colleagues working within community mental health services and arrangements to safeguard children and vulnerable adults.

For further information about responsibilities, accountabilities and duties of all employees, please see appendix A.

4 Engagement

Clinical teams and practitioners should ensure that every effort is made to engage patients who are in need of services. Steps to be taken to promote engagement include

Care planning and treatment:

patients must be part of decision making and co-produce their care plans
information should be clear and delivered in a way that meets individual needs
reasons for clinical decisions should be clearly communicated, explained, and discussed with the patients
when a patient does not choose to engage with services, every effort must be made to find out why and the reasons given recorded in the patients notes
clinical teams and practitioners should consider whether there are alternative interventions or ways of delivering and accessing services
understand what is important to the person who uses our services
explore the person’s current understanding of the situation and options
discuss the various different care and treatment options and the pros and cons of declining or accepting any or all of them, these may include any possible side effects, detrimental effects and benefits
care plans should support effective collaboration with social care and other care providers and include details of how to access services in times of crisis
it is known that some patients disengage and re-engage with services a number of times before reaching a stage where they are ready to complete the treatment pathway. In view of this, any risk of disengagement should be discussed and planned for jointly with the patient before they enter into an episode of treatment

Accessibility:

services should appreciate that there may be barriers preventing patients from accessing services such as transport difficulty, lack of digital access and carer responsibilities which should be explored
children may be reliant on parents or carers to bring them to appointments which may create barriers. Options to increase accessibility such as offering school based appointments or digital appointments should be considered. Parental barriers to children attending appointments such as parental poor mental health, substance misuse or safeguarding concerns should be explored

Involving carers and families:

for patients in secondary services communication involving the support network of family or carers is extremely important. For patients receiving taking therapies or primary care interventions only, they will likely have lower levels of risk and may have different confidentiality expectations. However, family and carer involvement should always be encouraged where appropriate
ensuring families and carers are supported can help promote the engagement of patients with services
colleagues need to make contact with families and carers as early as possible in the treatment process, so that their concerns and the information they have can be shared
if the patient does not consent to their involvement, family or carers should still be provided an opportunity for their views and concerns to be listened to and considered within the care planning process. The family or carers’ own choices and circumstances in caring must be considered. They may find it more comfortable to discuss this with the health professional in a separate meeting

Managing service transitions:

anticipate that withdrawal and ending of treatments or services, and transition from one service to another, may evoke strong emotions and reactions in people using mental health services. Such changes, especially discharge, are discussed and planned carefully beforehand with the service user and are structured and phased
when referring a service user for an assessment in other services (including for psychological treatment), they are supported during the referral period and arrangements for support are agreed beforehand with them

5 Disengagement

For the purpose of this policy the trust has separated patients who disengaged into three groups:

patients referred to, but not yet assessed by services
patients in receipt of services who subsequently disengage
patients referred to primary care and talking therapy services

Colleagues should follow the guidance below that most appropriately describes their patient. Where there is uncertainty, colleagues should discuss the patient with their multidisciplinary team, team manager or clinical lead and agree which pathway to follow.

When a patient disengages, the steps below must be followed and all actions appropriately recorded in the electronic patient record (EPR).

6 Methods of communication

Communication methods should meet the needs of the patients and various methods of communication should be considered including:

telephone calls
text messages (including text reminders for appointments)
letters
cold call home visits or ad-hoc visits that are planned to common places of attendance, religious venues, places of frequent visiting
communication with family, carers or support networks.

7 Patients referred to, but not yet assessed by services

7.1 Urgent or emergency referral

In advance of a scheduled appointment attempts should be made to confirm appointment attendance.

If the patient misses an initial appointment following referral, then the allocated assessor must:

ensure that all the necessary information including risk factors are obtained from the referrer and others who may be involved in their care
attempt to contact the patient at the point of their scheduled appointment to identify reasons for non-attendance
agree an alternative appointment if possible
attempt to contact any identified family members or carers where appropriate.
consider undertaking a cold call home visit, if there is no answer, a calling card must be left asking the patient to contact the service
where there are concerns regarding a real and immediate risk to life, or of significant harm to others, the assessor must consider informing the police, taking into account the right care, right person guidance (staff access only). Where possible this should be discussed with a team manager or senior clinician to inform right care right person approach
if there is immediate significant risk to the patient or others, then a mental health act assessment should also be considered. It will often be appropriate to have tried to see the patient first prior to attempting any Mental Health Act assessment but there may be circumstances such as concerns about patients absconding where a practitioner visit beforehand would be inappropriate. The Mental Health Act can also afford powers of entry under section 135 if a patient is not allowing access to their property. The practitioner should consider calling the police if the patient can’t be located. There maybe recall powers that can be used such as community treatment orders or conditional discharges
check the patient record to identify any other agencies involved in the patients care and contact these agencies as appropriate
no discharge decision should be made unless agreed in an multidisciplinary team (MDT) meeting as outlined in section 12
consider whether any steps need to be taken under safeguarding children or adults as set out in section 11
unless contact is re-established the case should be discussed in an multidisciplinary or with a senior team clinician within 24 hours of the missed appointment to agree appropriate actions and timescales for those actions

This list is not intended to be exhaustive and clinical judgement about appropriate action to take should also be used.

7.2 Routine referral

The referrer will determine the urgency of the referral and determine whether it is urgent or routine. If on triage there is disagreement about the urgency or immediacy of risk then the patient should be managed under the relevant part of this policy.

For routine patients where no immediate risks have been identified:

attempt to contact by the patient by telephone, all attempts to contact the patient must be documented in the clinical record with the time and outcome
the record should include if indicated the plan for further contact and by whom
check the record to identify any other people and agencies involved in the patients care, contact should be made with these agencies and people in order to clarify reasons why the patient may not be engaging but also to inform discussions about any potential discharge
if contact is unsuccessful there should be an multidisciplinary team meeting as outlined in section 12 to discuss potential next steps including whether the patient would be suitable for discharge
consider whether any steps need to be taken under safeguarding children or adults as set out in section 11
unless contact is re-established the case should be discussed in an multidisciplinary or with a senior team clinician (consultants, clinical leads or team managers would typically fulfil this role) within 7 days of the missed appointment to agree appropriate actions and timescales for those actions

This list is not intended to be exhaustive and clinical judgement about appropriate action to take should also be used.

8 Patients who are already in receipt of secondary care services

For patients already in receipt of secondary care services there should be personalised risk assessments and formulations that will indicate what actions will be necessary and proportionate to take. It should be noted that risk assessment is dynamic and that if a patient has disengaged this may indicate an increasing level of risk.

8.1 No immediate risk to self and others identified

For patients where no immediate risk to self or others has been identified the team should take the following actions (consultants, clinical leads or team managers would typically fulfil this role).

Attempt to contact the patient by phone, or another appropriate method, to identify the reasons for non-attendance and to offer a further appointment, all attempts to contact the patient must be documented in the clinical record with the time and outcome.
The record should include if indicated the plan for further contact and by whom.
The option of an alternative venue and time most suited to the needs of the patient concerned should be offered.
Contacting family, carers or known associates.
Contacting other providers involved in the patients care including voluntary sector providers.
If contact is successful and there is a suspected or confirmed deterioration in the patients mental health, then the patient should be considered for transfer to a more appropriate community treatment team, for example, Assertive Outreach team (if the patient has a psychotic disorder) or Home Treatment team.
If contact is successful and the patient is well and wishes to be discharged this should be managed in line with the discharge process.
Consider whether any steps need to be taken under safeguarding concerns as set out in section 11.
If there continues to be no engagement then a there should be an multidisciplinary team (MDT) meeting as outlined in section 12 to discuss potential next steps including discharge.
Unless contact is re-established the case should be discussed in an multidisciplinary team or with a senior team clinician (consultants, clinical leads or team managers would typically fulfil this role) within 7 days of the missed appointment to agree appropriate actions and timescales for those actions.

Taking into account the patient’s personalised risk assessment and formulation the team should also consider the following actions.

Cold call home visits (if unsuccessful colleagues must leave a calling card asking the patient to make contact).
Consider support from home treatment (with a clear remit of clinical interventions for short term engagement) or assertive outreach (if the patient has a psychotic disorder) who may be able to offer a more flexible or intensive approach to engagement.
Consider whether it is appropriate to undertake a Mental Health Act assessment. It will often be appropriate to have tried to see the patient first prior to attempting any Mental Health Act assessment but there may be circumstances such as concerns about patients absconding where a practitioner visit beforehand would be inappropriate. The Mental Health Act can also afford powers of entry under section 135 if a patient is not allowing access to their property. The practitioner should consider calling the police if the patient can’t be located. There maybe recall powers that can be used such as community treatment orders or conditional discharges.

Consultants, clinical leads or team managers would typically fulfil this role

This list is not intended to be exhaustive and clinical judgement about appropriate action to take should also be used.

8.2 Immediate risk to self and others identified

For patients where there is an immediate risk to self or others identified the following steps should be taken.

Attempt to contact the patient by phone, or another appropriate method, to identify the reasons for non-attendance and to offer a further appointment. All attempts to contact the patient must be documented in the clinical record with the time and outcome.
The record should include if indicated the plan for further contact and by whom.
Contacting family, carers or known associates.
Contacting other providers involved in the patients care including voluntary sector providers.
Where there are concerns regarding a real and immediate risk to life, or of significant harm to others, the assessor must consider informing the police taking into account the right care, right person guidance (staff access only). Where possible this should be discussed with a team manager or senior clinician to inform right care right person approach.
If there is immediate significant risk to the patient or others, then a Mental Health Act assessment should also be considered. It will often be appropriate to have tried to see the patient first prior to attempting any Mental Health Act assessment but there may be circumstances such as concerns about patients absconding where a practitioner visit beforehand would be inappropriate. The Mental Health Act can also afford powers of entry under section 135 if a patient is not allowing access to their property. The practitioner should consider calling the police if the patient can’t be located. There maybe recall powers that can be used such as community treatment orders or conditional discharges.
If contact is successful and there is a suspected or confirmed deterioration in the patients mental health, then the patient should be considered for additional support from the Home Treatment team or referral to a more appropriate community treatment team, for example, Assertive Outreach team.
If contact is successful and the patient is well and wishes to be discharged this should be managed in line with the discharge process.
If contact is unsuccessful there should be an multidisciplinary team meeting as outlined in section 12 to discuss potential next steps including discharge.
Consider whether any steps need to be taken under safeguarding concerns as set out in section 11.
Unless contact is re-established the case should be discussed in an multidisciplinary team or with a senior team clinician (clinical leads or team managers would typically fulfil this role) within 24 hours of the missed appointment to agree appropriate actions and timescales for those actions.

This list is not intended to be exhaustive and clinical judgement about appropriate action to take should also be used.

9 Primary care services (including talking therapies)

These are services where patients would either present themselves without immediate risk and only those people who are able to engage with a therapist or individual practitioner and GP alone.

Next of kin would very rarely be involved in a patients care due to the confidential nature of patients seeking therapy and would only be considered for involving when there is a immediate concern about risk.

9.1 During the first assessment and appointment

Allocated staff member contacts the patient by telephone at the time of appointment.
Text message sent to request to contact or advise of discharge (service dependent).
If a request to contact is sent, there is a 2-week timescale to re-book an appointment.
If there are any risk or safeguarding concerns, then clinician to seek advice from their clinical lead or multi-disciplinary team before discharging. Cases requiring escalation should be done so within a week.
Discharge letter sent to the patient and copied to the GP.

This list is not intended to be exhaustive and clinical judgement about appropriate action to take should also be used.

9.2 During treatment

Allocated staff member contacts the patient by telephone at the time of appointment.
Did not attend (DNA) text message and voicemail is sent to the patient requesting contact and the opportunity to opt back into the service. For talking therapies this is within 48 hours and if no contact a discharge letter is sent to the patient and GP (timescale for other primary care services differs).
If there are any risk or safeguarding concerns, then clinician to seek advice from their clinical lead or multi-disciplinary team before discharging. Cases requiring escalation should be done so within a week.
If a patient cancels an appointment, they will be given the option to rebook. If a patient cancels via a phone call, then admin will advise the clinician of the cancellation. The clinician is responsible for managing any risk concerns from cancellations. For psychological therapy intervention multiple missed appointments during treatment will be managed by clinicians and their supervisors, for example three missed appointments may indicate a need for discharge, as for therapy to be effective regular attendance and engagement is required. If there are repeated cancellations then please refer to the local working instruction.

This list is not intended to be exhaustive and clinical judgement about appropriate action to take should also be used.

Please note that patients can re-refer themselves to talking therapies at any time, however, should a patient be continually referring themselves to the service and not engaging with their initial appointment offer, admin will seek advice from their manager or clinical lead.

10 Cases where there are children or adult safeguarding concerns

It must be made clear at the commencement of any intervention or offer of a service, that all colleagues have a responsibility to safeguard children and vulnerable adults and this may include sharing information and breaching an individuals confidentiality with other agencies. This will include a professional’s assessment of the impact that failing to attend or engage may have on the ability of an adult to parent or provide care to a child or children.

When a patient disengages it can also mean that the patient may be more vulnerable themselves and at an increased risk of exploitation. There equally may be safeguarding issues that are preventing a patient from accessing services. It is essential colleagues have professional curiosity when considering patients that have or who are disengaging. Home visits can be an essential part of assessments as it may identify situations such as cuckooing.

In addition to the actions listed in the relevant disengagement section colleagues should also consider:

whether the disengagement could affect the parenting capacity and therefore place any child or children at risk or indeed create any other child safeguarding concern, the clinical colleague must discuss the case with their team manager, line manager, safeguarding supervisor or the safeguarding team as to what action should be taken
determine whether the disengagement could affect the caring ability and put vulnerable adults at risk or whether there are any other adult safeguarding concerns. The clinical colleague must discuss the case with the team manager, line manager, safeguarding supervisor or the safeguarding team as to what action should be taken
whether the disengagement itself may be being caused by a safeguarding issue affecting the patient
whether disengagement may lead to an increased vulnerability which may give risk to safeguarding
inform the referrer by telephone and in writing if the patient does not respond to re-engagement requests and the assessed impact that disengagement may have on their ability to parent or provide care to others
inform any services known to be engaged with the children or vulnerable adults as part of any ongoing intervention, for example, health visitors, school nurses, GP’s, other partner agencies, community support services, third sector organisations
act in accordance with the trust safeguarding children policy
act in accordance with the trust safeguarding adults policy

10.1 Safeguarding children

10.1.1 Where an adult is the patient

In a small number of cases failures to attend or disengaging with services raises serious concerns relating to safeguarding children. In order to promote the safety and well-being of all children it is vital that failure of an adult to attend their appointment is considered factoring in the impact that compliance or lack of engagement will have on the adult’s ability to provide good enough and consistent care to a child.

The overriding principles of the Children Act (1989) and Children Act (2004) place a clear and absolute requirement for all organisations and their services to have a clear emphasis on:

“The importance of keeping the focus on the child and his or her safety and welfare, understanding the daily life experience of the child, seeing the child alone where appropriate and using information about the family’s history and functioning to inform decision making.”

This awareness of the child’s needs can help those services working with adults to recognise the potential impact of non-attendance or disengagement from services by adults and the impact this could have on the safety and well-being of a child or children whether they live with the child or have contact with a child or children. The clinical decision tree is a key tool in this process and provides a tool where risk and impact can be considered.

If a carer has expressed concern about the risk to the patient or others, then a multidisciplinary case review should be held at the earliest possible opportunity to address these concerns. Wherever possible, given the permission of the patient, the carer should be invited.

10.1.2 Where a child is the patient

For any children or young people who do not engage with their own scheduled appointment with child and adolescent mental health services (CAMHS), this must be considered as “was not brought” rather than “did not attend” and clinicians should be curious regarding lack of engagement, considering potential safeguarding factors. Clinicians should ensure they make all reasonable attempts to contact children and young people, and their families or carers as appropriate as soon as they are aware of a “was not brough” situation to ascertain reasons for non-engagement. Further appointments should be offered at a location and time to suit the child or young person.

The process regarding contact and communication detailed in sections 8 and 9 should also apply to children and young people, with family or carers and other agencies (such as schools) being contacted following any “was not brought” appointments to establish any safeguarding concerns related to the child or young person.

11 Multidisciplinary team meeting and discharge in secondary care

If the team are unable to make meaningful contact with the patient, then they must arrange a multidisciplinary team meeting (MDT) to discuss and plan future care.

The urgency of the multidisciplinary team meeting will be determined by the information available to the practitioner at the time. The multidisciplinary team meeting must include as a minimum a senior clinician or team manager, however, may include a number of professionals across agencies. All parts of the multidisciplinary team meeting and support network are to be empowered to influence decision making. It is a critical and expected part of any multidisciplinary team meeting that feedback will have been obtained from any sources such as family, carers and other agencies etc to allow a better understanding of the patients current difficulties and risks.

A decision to discharge for failing to keep appointments may not be deemed clinically appropriate, and therefore the multidisciplinary team meeting should consider the appropriate course of action keeping the patients general practitioner informed of any changes in care. Consideration should be given to whether patients would benefit from an assertive outreach approach where there are identified difficulties with engagement.

For those patients that are under assertive outreach services where there is continued disengagement it must be made clear that disengagement in of itself is not a reason to discharge a patient. Risks must be considered and if appropriate use of the Mental Health Act also considered.

The multidisciplinary team may conclude that is appropriate to discharge a patient after the patient has been notified in writing of the plan to discharge but it should be noted that some patients may struggle with letters due to language barriers and disabilities and so consideration needs to be given to whether this is appropriate.

The plan agreed by the multidisciplinary team meeting must be shared with the GP, other relevant agencies and family or carers where appropriate.

Any decision to discharge should be informed by the multidisciplinary team meeting and must be discussed and agreed with the team manager. When making a decision to discharge consideration needs to be given to how not engaging or refusing treatment may alter the patient’s risk profile. For example a patient may present with low immediate risks at a point where discharge is being considered but it may be possible to predict that risks will significantly increase if a patient is discharged. As a result risk at the time of discharge not only needs to be considered but also what can be reasonably predicted and mitigated in the future when making these decisions. Where a decision is made to discharge the GP, other relevant agencies and family or carers where appropriate must also be informed of discharge and the rationale for this.

Notification of discharge must be sent to the patient in writing and must include a crisis contingency plan, which, as a minimum supports the patient to access services should they experience any future deterioration in their mental health. Good practice would be to include community led support services that the patient may be able to access. For most patients being discharged due to disengagement it would not be appropriate to have as part of the care plan that the patient needs to be re-referred via primary care should they re-engage. Unless there are exceptional circumstances it would be expected that a patient discharged for reasons of non-engagement could reengage with the team without a further referral from primary care unless the patient has been discharged from the team more than 2 years ago. This is distinct from where a patient has been discharged from a team for clinical reasons such as completing treatment where reassessment from primary care before re-referral may be appropriate.

Summary for multidisciplinary team meetings:

the urgency at which an multidisciplinary team meeting is held will depend on clinical information and risks as known at the time
risk assessment is dynamic and disengagement can indicate an increasing level of risk, any decision to discharge someone from services and care plan should consider risks that could be reasonably predicted that may happen in the future
attempts should be made to obtain information from other people and agencies that can feed into the multidisciplinary team discussion such as family, carers, known associates, other care providers and voluntary sector organisations
consideration should be given to transferring the patient to another team such as the Assertive Outreach team that may be able to engage the patient
for patients already under the Assertive Outreach team a failure to engage is not a reason alone to discharge the patient
where discharge is being planned for a patient, the multidisciplinary team should consider if it is appropriate to notify the patient of this in writing and give them an opportunity to make contact
where a patient is disengaging this should always prompt consideration for any safeguarding concerns, these may be safeguarding concerns about the patient themselves, vulnerable adults or children
when a patient is discharged they must be notified in writing and sent a care plan, information should also be sent to the referrer, GP and other relevant agencies informing them of the discharge

12 Training implications

12.1 All clinical staff groups receive safeguarding training as part of the safeguarding training offer

How often should this be undertaken: the policy links to safeguarding children training requirements.
Training delivered by whom: named nurses, safeguarding children.
Where are the records of attendance held: electronic staff record system (ESR).

As a trust policy, all colleagues need to be aware of the key points that the policy covers. Colleagues can be made aware through a variety of means such as:

all user emails for urgent messages
one to one meetings supervision
continuous professional or development sessions
posters
practice development days
group supervision
special meetings
team meetings
local induction

13 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

13.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

13.1.1 How this will be met

No issues have been identified in relation to this policy.

13.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

13.2.1 How this will be met

This policy will be implemented in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1).

14 Links to any other associated documents

15 Appendices

15.1 Appendix A responsibilities, accountabilities and duties

15.1.1 Service managers or team managers

Service managers or team managers are responsible for:

making their colleagues aware of the contents of this policy
monitoring the compliance of their colleagues with the contents of this policy
facilitating multi-disciplinary team discussions to assist decision making and communication of assessments and plans

15.1.2 Care coordinators or lead professionals

Following the appropriate steps in this policy and informing the team manager, or nominated deputy, where necessary.

15.1.3 All other clinical colleagues

It is the responsibility of every member of the care team to alert the care coordinator or lead professional if they are concerned that a patient is at risk of disengaging from services.

15.2 Appendix B monitoring arrangement

15.2.1 Management of patients who do not attend appointments

How: dip sample of patients with recorded did not attend.
Who by: matron and or service manager.
Reported to: care group quality meeting.
Frequency: quarterly.

15.2.2 Management of patients who are discharged for reasons of disengagement

How: dip sample of patients with recorded as discharge due to disengagement.
Who by: matron and or service manager.
Reported to: care group quality meeting.
Frequency: quarterly.

15.2.3 Number of patients who are discharged due to disengagement

How: report on re-portal
Who by: Mental Health Act manager
Reported to: Quality Committee
Frequency: quarterly.

15.2.4 Number of patients who did not attend appointments

How: report on re-portal
Who by: Mental Health Act manager
Reported to: Quality Committee
Frequency: quarterly.

Document control

Version: 2.
Unique reference number: 562.
Ratified by: clinical leadership executive.
Date ratified: 16 September 2025.
Name of originator or author: chief medical officer.
Name of responsible individual: chief medical officer.
Date issued: 12 December 2025
Review date: September 2028.

Page last reviewed: December 12, 2025
Next review due: December 12, 2026

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