For the NHS, 2018 really does appear to be make or break time. The NHS is in a financial maelstrom – more than three-quarters of all providers are in deficit. Last year’s spending review provided upfront funding for the NHS in 2016-17, but this is short lived. Many in the NHS must be hoping that the tight financial squeeze expected later in this parliament is not really the government’s plan, and that the Treasury will be reopening the health service spending settlement in a year or two. The political argument would be that health is simply too important to be allowed to fail. Just as the government has in effect provided a bailout for the service in the spending review, so it will do the same in a couple of years’ time. And anyway, isn’t the chancellor being too pessimistic and money can always be found?
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Illustration: The Health Foundation
Taking account of the economic outlook Since the autumn, the economic outlook in the UK and globally has worsened, and delivering the economic and fiscal forecasts in the autumn statement looks tough. This is likely to stiffen the Treasury’s resolve that the anticipated overspend is not going to be funded by another raid on its fragile coffers but will come out of the extra cash earmarked for next year. This extra funding is going to have to stretch a long way – filing the existing financial black hole, meeting rising pension costs, funding demand pressures and supporting transformation. To rely on the Treasury riding to the rescue is only for those who like very high stakes poker – not really the way to run a vital public service. Against this backdrop, much of health policy looks perplexing. We cannot afford inefficiency or poor productivity. David Nicholson,former chief executive of NHS England, recognised this back in 2009 but progress has been woeful. All too often the focus has been on the one-off, short term and tactical. There has been little drive to address the fundamental barriers to a more efficient and productive service. The Five Year Forward View – Simon Stevens’ plan to make the NHS more sustainable – and Lord Carter’s review of NHS spending, offer hope for a different approach. But 15 months on from the launch of the Forward View, we still don’t have an efficiency plan for the NHS. Beyond the immediate backyard of NHS services the storm clouds are gathering. Delivering a sustainable health service requires action on social care and public health. Evidence suggests that around £1 in every £5 of NHS spending is the result of ill health attributable to the big five risk factors of smoking, alcohol, poor diet, obesity and inactivity. This, more than anything else, is why we perform so poorly compared with our European neighbours on health outcomes. Despite this, public health budgets are being cut in real terms by almost 4% a year.

The gap between the number needing social care support and the number receiving it

On social care, the government has recognised that the system can’t sustain a further round of cuts on the scale of the last parliament. Most estimates are that the additional funding for social care won’t bridge the funding gap. Social care is the dog that hasn’t barked – despite the reductions in access to social care service, demonstrating that this has had a direct impact on the NHS has been difficult. But recent data from the Health Survey for England shows that the lack of robust research evidence on the impact of social care cuts should not be a source of complacency. Providers are reporting that one of the reasons for their rising deficits is delayed transfers of care, partly related to issues of timely access to social care.
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The graph shows the gap between those who needed social care and the numbers who didn’t receive it in each income group. Illustration: The Health Foundation
There are increasing numbers of vulnerable older people living in silent misery with no help. The chart above shows the gap between need and provision (from any source, formal and informal, public and privately funded) for men and women in different income groups. The gap between need and receipt of help is greatest for those on low incomes and growing over time. Whatever the economics of that, it surely cannot be something we aspire to as a society in 2018
Ending ‘substituted decision making’ in crisis care: lessons from Northern Ireland Colin Caughey 15 March 2018 Northern Ireland law-makers have led where England and Wales may follow later this month. Addressing ‘paternal’ attitudes towards decision making capacity proved key in Belfast, writes Colin Caughey of the Northern Ireland Human Rights Commission. In England and Wales, you can be detained in hospital against your will if you are diagnosed with a mental health disorder and it’s deemed that your health would benefit from a stay in hospital. In 2007, the definition of ‘disorder’ in the Mental Health Act was expanded to even include people with learning disabilities, even though learning disabilities are not medically treatable illnesses. In Northern Ireland, in line with UK-UN agreements, a person’s decisions on care cannot be substituted merely on the basis of any condition that the person has. Prime Minister Theresa May has appointed psychiatrist Professor Simon Wessely to review the Mental Health Act, though not the Mental Capacity Act. That’s another piece of legislation. However, later this month we may see his team recommend that parliament introduce one new law to replace both. Capacity to make decisions is at the heart of many of the rights-based debates around what mental health care should like in the 21st Century.  Colin Caughey, of the Northern Ireland Human Rights Commission, provides an overview of how Belfast approached delivering legislation to support progressive mental health care provision…   Background In 2009 the UK signed up to a United Nations agreement that states deprivation of liberty cannot be justified by the existence of long-term physical, mental, intellectual or sensory impairments. Clearly, this challenges the role of ‘sectioning’ in mental health care. In September last year the United Nations (UN) called on the UK Government and devolved institutions to “abolish all forms of substituted decision-making [through] adopting new legislation and initiating new policies in both mental capacity and mental health laws.” • See also: In Our Right Mind England and Wales are currently playing catch up on the other home nations. The Mental Capacity (Northern Ireland) Act 2016 received Royal Ascent – a major milestone in the process towards becoming law – in May of that year.   The Northern Ireland Model One law In Northern Ireland there is now a single legislative framework governing situations where a decision needs to be made in relation to the care, treatment (for a physical or mental illness) or personal welfare of a person aged 16 or over, who lacks capacity to make the decision for themselves. The Mental Capacity (Northern Ireland) Act 2016 is the largest piece of legislation enacted by the NI Assembly and was scrutinised by a joint assembly committee composed of members of the Justice Committee and Health Committee. Presumption of capacity The 2016 Act introduces a presumption of capacity in all persons over the age of 16. It continues to make provision for substitute decision making, however an act done or decision made for or on behalf of a person lacking mental capacity must be done or made in their best interests and – innovatively – with special regard to their past and present wishes and feelings. The Act has been described by the Essex Autonomy Project as innovative in its emphasis on supported decision making. Throughout 2017 the Department of Health has been developing a Code of Practice required to ensure the effective implementation of the Act. • Join Mental Health Today Wales to get up to speed on how new legislation will affect England and Wales. The Act provides that a person is not to be treated as lacking capacity unless it is established that the person lacks capacity in relation to the matter. The Act makes clear that a determination of capacity is not to be made merely on the basis of any condition that the person has, or any other characteristic of the person, which might lead others to make unjustified assumptions about his or her ability to make a decision. It is hoped that this provision will go some way to addressing paternalistic assumptions regarding person’s with disabilities. The Act makes clear that a person should not be considered to lack capacity to make a decision unless: (a) is not able to understand the information relevant to the decision; (b) is not able to retain that information for the time required to make the decision; (c) is not able to appreciate the relevance of that information and to use and weigh that information as part of the process of making the decision; or (d) is not able to communicate his or her decision (whether by talking, using sign language or any other means); and references to enabling or helping a person to make a decision about a matter are to be read accordingly. The Act makes clear that a person is not to be treated as unable to make a decision for himself or herself about the matter unless all practicable help and support to enable the person to make a decision about the matter have been given without success. The Act at section 5 sets out the steps that should be taken in providing support to an individual who may have capacity issues. Duty to support It is hoped that the presumption of capacity combined with the duty to provide support to individuals who may have capacity issues will address paternalistic approaches to persons with capacity issues. The duty to provide support will be further elaborated by way of the Code of Conduct, which is currently under development. This element of the Act is somewhat unique to NI and there is limited guidance from other jurisdictions as to how an individual can discharge their duty to provide support. The Act at section 7 sets out the steps an individual must take when assessing an individual’s best interests. The Act makes clear that The person making the determination [of an individual’s best interests] must not make it merely on the basis of— (a)P’s age or appearance; or (b)any other characteristic of P’s, including any condition that P has, which might lead others to make unjustified assumptions about what might be in P’s best interests. This provision guards against assessors making determinations solely based on an individual’s condition. An assessor must consider all the relevant circumstances. The assessor must also consider whether the individual will at some time have capacity in relation to the matter in question. Respecting values and choices In terms of process, the assessor must ensure the individual participates as fully as possible in the determination of what would be in their best interests and must consult the relevant people about what would be in the individual’s best interests. The assessor also has an overriding obligation to ensure the proposed intervention or decision is proportionate, and must consider if the same purpose can be as effectively achieved in a way that is less restrictive of the individual’s rights and freedom of action. The Mental Capacity (NI) Act 2016 contains a rather unique obligation for an assessor to have special regard (so far as they are reasonably ascertainable) to — (a) [an individual’s] past and present wishes and feelings (and, in particular, any relevant written statement made when the individual had capacity); (b) the beliefs and values that would be likely to influence the individual’s decision if the individual had capacity; and (c) the other factors that the individual would be likely to consider if able to do so. The precise implications of the obligation for an assessor to have ‘special regard’ is currently unclear and whilst the Code of Conduct is likely to provide some clarity it is likely that jurisprudence will be required to ensure assessors have a full appreciation for the extent of their duty. However it is hoped that the introduction of this specific duty will go some way to addressing paternalistic approaches to best interest assessments. • See also: Can I go out for walks? What about my education?Exploring Scottish strides towards securing improved rights in mental health care. Children’s rights not yet legislated for During policy discussions regarding the development of the Bill the Department for Health committed to review how the current legal framework, principally the Children (NI) Order 1995, reflects the emerging capacity of children in a health and welfare context. However, during the Second Stage debate on the Bill the Minister for Health stated that there are ‘simply no available resources and arguably no time to undertake such a wide-ranging project at this moment’. In 2016 the UN raised concern that children under the age of 16 years are excluded from the protection under the Mental Capacity Act (2005) in England and Wales, as well as under the Mental Capacity Act (2016) in NI, including with regard to medical treatment without consent. The UN recommended that the UK review current legislation on mental health to ensure that the best interests and the views of the child are taken duly into account, in particular with regard to hospitalisation and treatment without consent. The Northern Ireland Commission on Human Rights has highlighted these recommendations to the Department of Health. However due to political disagreement the NI Assembly has not been sitting since January 2017 and political negotiations to restore the institutions have not yet led to a resolution. • Join the Mental Health Study Day in London to learn about supporting school children’s mental health. The Northern Ireland Commission on Human Rights remains concerned that children under the age of 16 are excluded from the application of the Act. To that end, the Commission continues to call on the Department of Health to conduct a review of current legislation on mental health to ensure that the best interests and the views of the child are taken duly into account, in particular with regard to hospitalisation and treatment without consent. Cultures changes required to keep up with legal progress The Northern Ireland Human Rights Commission looks forward to the enactment of the Mental Capacity (NI) Act 2016 and continues to engage with the Department of Health with respect to the Code of Conduct. The experience of reform in other jurisdictions has demonstrated the importance of ensuring changes to legal frameworks are accompanied by cultural changes. There needs to be emphasis placed on the autonomy of disabled people and the societal barriers around supporting disabled people to make decisions for themselves.
The Northern Area Mental Health Initiative (The Initiative) is an innovative and exciting new project led by Cookstown and Western Shores Area Network (CWSAN), in partnership with Action Mental Health (AMH) and Nexus NI, which will deliver mental health awareness and resilience training, and internet safety, sexual abuse and exploitation education to children and young people aged 8 to 25 years, and their key contacts. The Initiative is funded by the Northern Ireland Executive’s Social Investment Fund (SIF) until March 2019 and will be delivered across the Northern Social Investment Zone which broadly mirrors the Northern Health and Social Care Trust boundary. Training for young people: • Mental Health Awareness 8 – 25 years • Confidence Building & Self Esteem 11 – 25 years • Exam Stress 11 – 25 years • Body Image 11 – 25 years • Bullying Awareness 11 – 25 years • Internet Safety, Sexual Abuse & Exploitation Education 11 – 25 Training for key contacts: • Personal Resilience 18+ • Internet Safety, Sexual Abuse & Exploitation Education 18 + Target areas: • Antrim – Farranshane • Ballymena – Ballee • Carrickfergus – Northland • Coleraine – Ballysally 1, Central Coleraine, Cross Glebe • Larne – Ballyloran • Newtownabbey – Dunanney, Monstown 1, Valley 2 A4 FLYER NORTHERN AREA MENTAL HEALTH INITIATIVE If you’re interested in booking a workshop, download and complete a booking form and return to northernareamhi@amh.org.uk Community Booking Form Primary School Booking Form Young People 11+ Booking Form Key Contact Booking Form Follow us on Facebook,  Twitter and Instagram. Contact Details Northern Area Mental Health Initiative 4A Steeple Road Antrim BT41 1AF T: 028 9442 5356 E: northernareamhi@amh.org.uk
The recent announcement that everyone receiving Personal Independence Payments (PIP) will have their claim reviewed, was made by the Department for Work and Pensions. The issue is how those with mental health issues are being assessed, and proves just how vital a clear understanding of these conditions are. In the week when Elexxer Healthcare unveiled its plans for a new Training Academy which will focus on mental health the government statement underscores the real need for the training we are offering. A total of 1.6 million of the main disability benefit claims will be reviewed, with around 220,000 people expected to receive more money. The issue is an example of where law and healthcare meet and raises many of the points LEXXER Law use in advocacy for those suffering from mental health issues. It. comes after the DWP decided not to challenge a court ruling that said changes to PIP were unfair to people with mental health conditions. The review could cost £3.7bn by 2023, and without proper investment in training similar problems will arise. The minister for disabled people, Sarah Newton, said the DWP was embarking on a “complex exercise and of considerable scale”. She added: “Whilst we will be working at pace to complete this exercise it is important that we get it right.”
As a firm we believe research is vital to all we do in particular when tailoring solutions to the pressing needs of our healthcare sector.
Leading the field in this area of mental health research is the Mental Health Foundation whose report Fundamental Facts – Northern Ireland exposed the real need here.
Speaking at the launch they said “The first Fundamental Facts was produced in 2007 to mark the landmark Adult Psychiatric Morbidity Survey in England.i Since 2015, Fundamental Facts has become a regular publication by researchers in the Mental Health Foundation. In addition to the full UK report, we publish a Fundamental Facts for Northern Ireland, Scotland and Wales. With each publication, we aim to strengthen the range of statistics that we include and your suggestions for additions are welcome. As the UK’s leading public mental health charity we draw together not only illustrative statistics on conditions and services, but also gures relating to the social, political and economic factors that impact mental health. Further, the Foundation’s strong advocacy for equity grounded policy, research and practice means that we want those who use Fundamental Facts to access statistics that inform on protected characteristics and socio-economic status.”

Elexxer Healthcare Academy is pioneering a blended learning approach to Healthcare Education and Training with an exciting an innovative range of real time and on line courses and events.

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Blended learning programs are quickly becoming common place in educational settings, but also in the professional industry. Innovation in this area is being driven by a more personalized learning experience, engaging content, and collaboration.
If you are unfamiliar with blended learning, it is a format of education in which at least a portion of the learning content and instruction is delivered online. The main benefit with this approach being that the user gains control over the time, place, path, or pace of their learning experience.
A well-done blended learning program helps to build higher-order thinking skills. It takes the emphasis off of “remembering” and gets the learner “evaluating” and “creating”. This is one reason why blended learning is growing.
Accessibility to mobile devices is another reason why there is growth with blended learning. The typical student uses tablets and smartphones on a regular basis, making online learning a natural choice – almost an expectation.
One of the biggest advantages of having a portion of course content delivered through e-learning is that it allows the student to exert some control over how they learn and engage with the content. Students can focus on their trouble by repeating the content as needed, as well as at their own convenience.
Done correctly, the benefits of a blended learning approach to learning can really enhance learning retention. At Sterling Academy, our programs have been developed with both teacher and student input.  We lead the field in best-practice instructional design principles in regards to planning and program roll-out. We employ the right mix of real time and on line learning which is geared to create a culture of blended learning.
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