LENGTH OF DELAYED DISCHARGE CAUSED BY GUARDIANSHIP AUDIT Dr Roger Cable Speciality Registrar Old age psychiatry

Purpose of the Adults with Incapacity (AWI) Act (2000) The purpose of the Adults with incapacity (AWI) act is to make provision for the finances and welfare of adults who are incapable by reason of mental disorder or inability to communicate. The AWI act is governed by the following principles

Principles of the AWI act (2000) An intervention should benefit the adult and the benefit cannot reasonably be achieved without the intervention The intervention should be the least restrictive option in relation to the freedom of the adult In determining if an intervention is to be made, account should be taken of the present and past wishes of the adult, views of the nearest relative, primary carer, guardian, welfare or continuing power of attorney

When is legislation used Patient fit for discharge, requires 24 hour care Patient lacks capacity Patient and all interested parties agree on placement Section 13ZA of the social work act Patient disagrees with placement Welfare guardianship procedures Patient has a welfare power of attorney Welfare attorney makes the decision Patient has capacity Patients decision upheld

Guardianship process Clinical team assess patient to require 24 hour care and lacking capacityReferral to social work department for social work assessment MHO Appointed and case conference called to decide on the need for guardianship Private application Two medical reports and MHO report required (Legal aid) and prepared for court Papers lodged at court and case heard within 28 days Council application Two medical reports and MHO report, and preparation by legal department Papers lodged in court and heard within 28 days

Extent of the problem within Scotland ISD (Information Services Division) Scotland reports suggest a significant problem with an average of 204 patients being affected according to the quarterly ISD census between October 2005 and April % of these patients were over 65, an average of 180 patients

AUDIT Patients delayed in Greater Glasgow and Clyde health board in the July 2008 census were selected Case notes were requested and information gathered about the process including: – Length of hospital stay – Date of referral to social work – Length of delay – Case conference date

Audit limitations Poor record keeping of the process – Case conferences not documented – Undated social work reports – No record of assessment of capacity – No record of medical assessments Official statistics and case notes inconsistent Some patients incorrectly coded

Preliminary findings for patients proceeding to guardianship Delayed discharge 290 days/9.5 months (n=20) Delay to case conference 114 days/3.7 months (n=17) Case conference to guardianship order 172 days/5,7 months (n=17)

Comments Alarming delays (Expensive!) Suggestion of harm (falls, deaths, infections) Clinicians resigned to lengthy delays Weekly entries “awaiting AWI” Lack of knowledge regarding the legislation evident (Good practice guidelines) Clinical harm (patient on the waiting list committed suicide)

Preliminary findings for those not proceeding to guardianship Average delay under code 51X 150 days/4.9 months (n=11) Reasons for not proceeding – Agreed to move (2) – Died (2) – Section 13 ZA used (2) – Patient went home (1) – Relative with power of attorney discovered (1) – Legislation appears to have been ignored (5)

Reasons for delays Social work driven process – Social worker allocation in acute setting not a significant problem – Social work assessment takes the bulk of the time pre case conference – MHO report take bulk of the time post case conference – Court generally reach decision in a single sitting

Discussions with social workers Statutory work takes precedence Lack of MHO’s – No incentives to train as an MHO – More work – More responsibility – Same remuneration

Discussions with social workers Local social work department carries 300 cases on the duty system (Not allocated) Vulnerable patients in the community take precedence AWI is important but low priority

Power of attorney Greater awareness among solicitors Avoid need for guardianship in most cases Advice in memory clinics

Role of the good practice guidelines Improved clinician knowledge – Least restrictive option – Most appropriate route – Correct information given to patient Monitor guardianship process easily Clinical audit standards Reduced opportunity costs

Conclusion Alarming delays Massive financial cost Massive human cost Most vulnerable affected ? causes significant harm Guidelines a step in the right direction Further research