Estimated reading time at 200 wpm: 22 minutes
Standards is a big issue in medical practice. Standards therefore apply in psychiatry as a medical discipline. Psychiatrists are medical doctors; *not psychologists. This article is an aggregate of the key standards the author uses regularly, and visits about once per week. This was originally in a MS Word document. Now it is here for everyone who may be interested. Some links are being updated. [Last updated 2025-02-05]
This document was constructed over several months of experience in working with adults who had learning disabilities of various kinds and co-existent acquired cognitive impairment in many cases. There were many ‘forensic’ issues in that population. Once or twice per week I updated this document with new information and links. The standards and references gathered in this document to learning disability patients and other groups of patients.
Whether or not you agree our Fat Disclaimer applies
I regularly read the references, whenever I am considering a case and when generating correspondence to involved parties. Often times the shortened links are pasted into correspondence as evidence of a point of reference to standards and principles. I have had no negative or positive feedback for doing that.
Due to particular layouts this article is designed for viewing only on tablets, laptops and desktops.
Context
Building upon the insights shared in the previous blog, “Challenges of the Modern Psychiatric Consultation (June 2024),” it is essential to explore specific quality standards that guide psychiatric practice today. These standards, established by various regulatory bodies and professional organisations, are designed to ensure that psychiatrists provide safe, effective, and compassionate care to their patients. Understanding and adhering to these standards not only enhances patient outcomes but also helps practitioners navigate the complex and demanding landscape of modern psychiatry.
In the evolving field of mental health care, quality standards encompass a wide range of practices, from prescribing medications and protecting patient rights, to adhering to new legal precedents, and ensuring continuous professional development. This blog will explore these standards in detail, providing a comprehensive overview for psychiatrists seeking to meet the high expectations set by entities like the General Medical Council (GMC), the Care Quality Commission (CQC), the National Institute for Health and Care Excellence (NICE), and the Royal College of Psychiatrists. By adhering to these guidelines, psychiatrists can strive to overcome the challenges highlighted previously and deliver the highest quality of care to their patients.
Patients, their loved ones and advocates can use these quality standards as a valuable framework to understand the level of care they should expect from psychiatric services. By familiarising themselves with guidelines and standards from organisations like the General Medical Council (GMC), the National Institute for Health and Care Excellence (NICE), and the Royal College of Psychiatrists, they can better advocate for comprehensive, evidence-based treatment. These standards empower patients and their families to ask informed questions about their care, ensure their rights are protected, and actively participate in decision-making processes. Additionally, awareness of these standards can help identify and address any gaps in care, facilitating a collaborative approach to achieving the best possible outcomes in mental health treatment. I have no particular affection for the GMC, but I do find their standards very easy to read and helpful in maintaining good standards of medical practice.
The information herein applies to all doctors registered with a licence to practice medicine. In other words, the materials apply to adult patients in any mental health service. Some parts may be more relevant to learning disabled and dementia patients.
The objectives are:
- to provide the highest quality care for often very disadvantaged people (and their loved ones). Many of them do not have access to an independent advocate or will be unable to call for help of an advocate. I am their main advocate.
- To provide compassionate holistic care.
The list of standards can be accessed by clicking on each tab on the left. [The list may be updated at any time]
General Medical Council (GMC) Standards:
Good medical practice: This is a framework document that stands on its own but in many parts it is linked to other standards in the list below. It sets out the principles of good practice which all doctors must be familiar with. It is the foundation on which the rest of our guidance is built.
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Confidentiality: good practice in handling patient information: Know when you can make disclosures and when to respect confidentiality. This guidance will help you manage and protect patient information in practice.
Confidentiality: disclosing information for education and training purposes: What to share with medical students, doctors in training and others. This also covers writing case studies and training records.
Confidentiality: disclosing information for employment, insurance and similar purposes: Understand what to include in a report and know what you can and can’t leave out. This also covers the principle of ‘no surprises’ for patients.
Confidentiality: disclosing information about serious communicable diseases: How to balance privacy with keeping others safe. This guidance covers yours, and your colleagues’ health, as well as your patients’.
Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA: Know what to discuss with patients whose health makes them unfit to drive. Understand when it is their responsibility to report this and when it is yours.
Confidentiality: reporting gunshot and knife wounds: What to tell the police and when to share information without your patient’s consent.
Confidentiality: responding to criticism in the media: Understand what you can and can’t say in response to others’ comments. This covers criticism of you personally and your practice or the health service.
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Maintaining personal and professional boundaries: Understand how to keep a suitable doctor patient relationship.
Using social media as a medical professional: Our guidance on social media, apps and other online tools. This covers professional boundaries, confidentiality and respect for colleagues.
Intimate examinations and chaperones: Examinations can be embarrassing or distressing for patients. This guidance covers examinations of a patient’s intimate areas. It can also apply to any examination where it is necessary to touch or be close to the patient.
Ending your professional relationship with a patient: In rare circumstances the trust between you and a patient may break down. This guidance covers when you should and shouldn’t end the relationship and what to do. This includes closing or relocating your practice.
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Protecting children and young people: the responsibilities of all doctors: How to identify and protect children and young people who are at risk. This includes if they are living with their families or living away from home.
0–18 years: Understand how to provide care to young patients. Including young people who have the capacity to consent. This also covers assessing best interests and discussing sexual activity.
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Decision making and consent: Shared decision making and consent are fundamental to good medical practice. This guidance explains that the exchange of information between doctor and patient is essential to good decision making.
Making and using visual and audio recordings of patients: Know what you can record and when consent is needed. This covers making covert recordings and recording telephone calls. Understand how to store and delete recordings.
Consent to research: Understand how the principles of decision making and seeking consent apply to research.
Good practice in research: Research involving people can be key in improving the care and health of the population as a whole. This guidance will help you to protect patients and maintain public confidence.
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Good practice in prescribing and managing medicines and devices: This guidance gives best practice about prescribing to patients. It includes remote prescribing, unlicenced medicines and shared care.
Guidance for doctors who offer cosmetic interventions: This covers any procedure or treatment aiming to change the way someone looks. Including surgical and non-surgical procedures. These may be invasive or non-invasive.
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Treatment and care towards the end of life: good practice in decision making: Understand decision-making for patients of all ages at the end of their lives. The guidance also covers clinically assisted hydration and nutrition and CPR.
When a patient seeks advice or information about assistance to die: Responding to patients’ who want advice about assisted dying can be difficult. Recognise how you can respect and listen to patients without conflict with the law.
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Leadership and management for all doctors: Some doctors are formal leaders, accountable for the performance of a team or teams. But all doctors are responsible for identifying problems and solving them. This guidance covers what we mean by shared leadership.
Raising and acting on concerns about patient safety: If you believe patient care and/or safety is at risk, it is important you know how to take the appropriate action.
Delegation and referral: You will often work with colleagues to provide care for your patients. Know where your responsibility stops and where it continues.
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Identifying and managing conflicts of interest: Understand how to manage potential conflicts of interest and mitigating the impact of them when you can’t avoid them.
Personal beliefs and medical practice: Peoples’ beliefs and cultural practices can be different from each other’s . Know how to treat all patients with respect, whatever their choices or beliefs.
Providing witness statements or expert evidence as part of legal proceedings: You may be asked to give evidence to courts and tribunals. Our guidance applies when you appear in a professional or non-professional capacity.
Reporting criminal and regulatory proceedings: What you do and don’t need to tell us when you’re subject to criminal or civil proceedings anywhere in the world.
Duty of candour: Understand your duty to be open and honest with patients, or those close to them, if something goes wrong. This covers when to apologise to patients and sharing mistakes with colleagues.
Raising and acting on concerns about patient safety: If you believe patient care and/or safety is at risk, it is important you know how to take the appropriate action.
| Nice Quality Standards | Nice Guidance |
| QS8 – Depression in Adults: Outlines priority areas for quality improvement in the care of adults with depression. | NG222- Depression in Adults (June 2022): Offers recommendations on the identification and management of depression in adults, including both pharmacological and psychological interventions. |
| QS14 – Service User Experience in Adult Mental Health Services: Provides a framework for delivering high-quality, patient-centred care in adult mental health services. | CG178 – Psychosis and Schizophrenia in Adults: Provides recommendations on the treatment and management of psychosis and schizophrenia in adults. |
| QS34 – Self-Harm: Offers quality standards for the care and management of people who self-harm. | CG185 – Bipolar Disorder: Assessment and Management: Covers the diagnosis and management of bipolar disorder in children, young people, and adults. |
| QS80 – Psychosis and Schizophrenia in Adults (2015): Sets out the quality standards for the care of adults with psychosis and schizophrenia. | CG192 – Antenatal and Postnatal Mental Health(Feb 2020): Focuses on the clinical management and service guidance for mental health conditions during pregnancy and the postnatal period. |
| QS102 – Bipolar Disorder in Adults (2023): Focuses on the quality standards for the diagnosis and management of bipolar disorder in adults. | CG113 – Generalised Anxiety Disorder and Panic Disorder in Adults: Covers the management of generalised anxiety disorder (GAD) and panic disorder in adults in primary, secondary, and community care. |
| QS115 – Antenatal and Postnatal Mental Health: Provides quality standards for the care of women with mental health conditions during pregnancy and the postnatal period. | CG136 – Service User Experience in Adult Mental Health: Provides guidance on improving the experience of care for people using adult NHS mental health services. |
| QS53 – Anxiety Disorders: Sets out the quality standards for the care and treatment of people with anxiety disorders. | CG78 – Treatment of personality disorders |
Legal Standards and Precedents
- Montgomery v Lanarkshire Health Board (2015): This legal precedent emphasises the importance of informed consent and the necessity for doctors to disclose all material risks to patients.
- General Medical Council (GMC) Standards: A frame work document to 34 other standsards which covers all aspects of medical professionalism and ethical practice. GMC standards create duties of care.
- Duty of Candour: Legal obligation for doctors to be open and honest with patients when things go wrong, including providing a truthful account of what happened and offering an apology.
- Equality Act 2010: Ensuring that all patients receive equal treatment and that there is no discrimination based on protected characteristics such as age, gender, race, disability, etc.
- Safeguarding Vulnerable Adults and Children: Adhering to safeguarding protocols to protect vulnerable individuals from abuse or neglect.
- Mental Capacity Act 2015
CR180 – Vulnerable Patients, Safe Doctors: Good Practice in our Clinical Relationships (2007)
CR193 – Responsibilities of psychiatrists who provide expert evidence to courts and tribunals (2023)
CR148 – Good Psychiatric Practice: Relationships with Pharmaceutical and Other Commercial Organisations (2017)
CR154 – Good Psychiatric Practice 2019 (3rd Edition):
CR222 – Standards for the Use of Section 136 of the Mental Health Act 1983 (England and Wales) (2011): Provides guidance on the use of Section 136 for detaining individuals in need of immediate care.
CR209 – Good Psychiatric Practice: Confidentiality and Information Sharing (2006)
CR205 – Sexual Boundary Issues in Psychiatric Settings(2017)
OP98 – Continuing Professional Development (2015)
Quality Network for Forensic Mental Health Services (QNFMHS): Standards, publications and resources
Memory Services National Accreditation Programme (MSNAP): Standards for Memory Services: Guidelines for the care and management of patients with memory problems, including dementia.
Standards for Psychiatric Intensive Care (2022)
Standards for Acute Inpatient Services for Working Age Adults, 8th Edition (2022)
Standards for Older People’s Mental Health Service Editors: Hannah Bolger and Eleanor Parker (2017)
Standards for Community Mental Health Services (2019): Outlines the standards for community-based mental health services.
Mental Health Act Code of Practice 2015.
Reference Guide to the Mental Health Act 1983.
Mental Capacity Act Code of Practice
Any other standards found may go into this space.
NHS Constitution
https://bit.ly/nhsconstitution
- Working together for patients.
- Respect and dignity.
- Commitment to quality of care.
- Compassion.
- Improving lives.
- Everyone counts.
NHS Constitution (includes relatives and carers). https://bit.ly/NHS-Constitn-include-relatives-and-carers
Discharge of inpatients
- Discharges from S3 especially in complex cases ought to be done after extensive consultation with a MDT, consultation with peers, and other professionals.
- S117 meetings ought to be set up in advance of any agreed discharge from S3.
- The consequences of discharge ought to be carefully considered by a MDT.
- The absence of expression of patterns of behaviour does not take the nature of a mental disorder outside the legal criteria for detention, unless the absence exists without ‘protective factors’ for a considerable duration, which in complex cases would normally be more than 3 months.
Screening & Assessments
The PTSD Checker: https://rb.gy/zbm7x6
The ADHD Checker: https://rb.gy/q1qbgn
GMC related.
GMP https://bit.ly/GMP-2024 – a framework document that cuts to 31 other GMC standards.
GMC standards create legal duties of care where the word ‘must’ appears.
GMC requirement to act within the law (para 1 & 12 of GMP) https://bit.ly/GMC-para1-12-ActingWithinTheLaw
GMC: openness, honesty and candour https://bit.ly/GMC-candour
GMC (GMP) keeping records: https://bit.ly/GMC-keeping-records
GMC: on consent (GMP Para 17 – linking to 3 other guidance docs):
You must be satisfied that you have consent or other valid authority before you carry out any examination or investigation, provide treatment or involve patients or volunteers in teaching or research.
GMC Dialogue leading to decision https://bit.ly/GMC-dialogue-and-material-risk
The GMCs guidance on capacity and consent: https://bit.ly/GMC-dec-and-consent
Paragraph 52: “You must help to create a culture that is respectful, fair, supportive, and compassionate by role modelling behaviours consistent with these values.”
Paragraph 59: “If you have a formal leadership or management role, you must act on behaviours.”
Paragraph 60: “You must follow the detailed guidance on ‘Leadership and management for all doctors.'”
Paragraph 65: “Continuity of care is important for all patients. You must promptly share all relevant information about patients with others involved in their care, within and across teams, as required.”
Paragraph 75: “You must act promptly if you think that patient safety or dignity is, or may be, seriously compromised.”
Prescribing
GMC Prescribing Guidance (full): https://bit.ly/GMCRxFullGuidance.
Deciding if it is safe to prescribe: https://bit.ly/GMCRxGuidancePara34-50.
Note para 35,
Together with the patient, you should assess their condition before deciding to prescribe a medicine. You must have or take an adequate history, which includes:
- any previous adverse reactions to medicines
- current and recent use of other medicines, including non-prescription and herbal medicines, illegal drugs and medicines purchased online or face to face
- other medical conditions.
Para 48: Sharing information when you prescribe: https://bit.ly/GMCRxPara48
Para 97 – consult with pharmacist where necessary.
GMC – Prescribing unlicenced medications: https://bit.ly/GMC-UnlicencedRx
Note also RCPsych guidelines on unlicenced medications: https://bit.ly/RCPsych-unlicencedRx
GMC reviewing meds para 96 and 97 – pharmacists: https://bit.ly/GMC-Rx-reviewing-meds
Para 93: Whether you prescribe with repeats or on a one-off basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review. You should take account of the patients’ needs and any risks arising from the medicines.
Para 94: When you review a patient’s medicines, you should reassess their need for any unlicenced medicines (see paragraph 103 to 106) they may be taking, for example antipsychotics used for the treatment of behavioural and psychological symptoms in dementia.
GMC clear guidance on prescribing and repeat prescribing (para 98) https://bit.ly/GMCguidance-repeat-rx
98 You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate.
GMC: requirement to relieve pain or distress para 16(c) [Applying knowledge and experience to practice] – “in providing clinical care you must” – take all possible steps to alleviate pain and distress whether or not a cure may be possible.
Mental Capacity related law
S1 MCA 2005 https://bit.ly/MCA2005-S1
S3 MCA 2005 https://bit.ly/MCA2005-S3-capacity – capacity criteria.
S4 MCA 2005 https://bit.ly/MCA2005-S4-best-interests – best interests and what is to be considered and done.
S5 MCA 2005 https://bit.ly/MCA2005-S5 – necessity.
S37 MCA 2005 (SMT): https://bit.ly/MCA2005-S37-SMT – rules surrounding ‘Serious Medical Treatment’.
Serious Medical Treatment: https://bit.ly/smt-mca-imca is defined under The Mental Capacity Act 2005 (Independent Mental Capacity Advocates) (General) Regulations 2006.
MCA Code of Practice: https://bit.ly/MCA2005-COP
Legal duties under S11, 22, 23 – The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – https://bit.ly/hsca-2008-14-s11
Materiality in consent:
- Montgomery 2015 UKSC https://bit.ly/MontgomeryUKSC.
- Materiality explored: Materiality – Investigative Psychiatry
Other related capacity/consent issues
MDU on Montgomery and informed consent: https://bit.ly/MDU-informed-consent
CQC slaps £8000 fine on University Hospitals Birmingham NHS for failure on consent procedures. Link: https://bit.ly/CQC-fines-on-consent-failure – CQC said:
- “Although this gentleman had complex health needs, he wasn’t given the opportunity to make decisions about his own care, every time, in the way that everyone should be able to expect. The trust assumed he didn’t have the capacity to make decisions or be consulted on consent to three of his medical treatments.
- “The trust should have made much more effort to communicate with him in a way that he understood, every time, such as via a British sign language interpreter, or via a familiar face such as his family or power of attorney who he could lip read.
- “For the failures to obtain consent we have issued fines to the trust of £8,000 which they have paid. We’re also aware that CQC’s focus on this, has already led to the trust making improvements in the processes that all staff should follow.
S11, 22, 23 – The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: https://bit.ly/hsca-2008-14-s11 – up to £50,000 fine.
NICE GUIDANCE
Rapid tranquilisation: https://bit.ly/NICE-NG10-rapid-tranq
Guidance (CG78) on treatment of Borderline Personality Disorder: https://bit.ly/NICE-CG78-treating-borderline-pd
Guidance (QS88) – quality statement on treating Borderline and Antisocial PD: https://bit.ly/NICE-QS88-quality-in-treating-borderline-and-aspd
CG185 Guidance on managing bipolar disorders: https://bit.ly/NICE-CG185-managing-bipolar
ICD-11
Clinical descriptions and diagnostic requirements for ICD-11 mental, behavioural and neurodevelopmental disorders (CDDR): https://bit.ly/icd-11-cddr
Neurodevelopmental Disorders: https://bit.ly/icd-11-nd-criteria
DOID: https://bit.ly/icd-11-doid
Bipolar Type 1: https://bit.ly/bipolar-type1
MEDICATION
Later-life and LD patients
The Government’s STOMP agenda and guidance from 2016 https://bit.ly/NHS-England-STOMP – and noting that NHS Digital has found that people with learning disabilities are 15 times more likely to be prescribed antipsychotics and almost 3 times more likely to be prescribed antidepressants (without a diagnosis of depression), over their contemporaries without a learning disability diagnosis https://bit.ly/NHSDigitalStatsRx2020 .
NHS England’s STOPP: Screening Tool of Older People’s Potentially Inappropriate Prescriptions as “potentially inappropriate in persons aged >65 years of age.” See: https://www.england.nhs.uk/wp-content/uploads/2017/03/toolkit-general-practice-frailty-1.pdf Whilst the document is probably aimed more at General Practitioners, I found it useful in the cognitively impaired developmentally for those over 65. [This does not mean that I am suggesting stopping the risperidone in all such patients. Any such decision will need to be taken very cautiously by a consultant psychiatrist in full collaboration with all interested parties.]
Unlicenced medications
Very informative is the Mental Health Services Prescribing Management Group (Glasgow) [2021] https://bit.ly/Rx-off-label-and-unlicenced [Note this part of the guidance is well outdated and wrong where it states, “There is no legal requirement to disclose the off-label use of a drug to a patient but such disclosure is advocated strongly and the GMC advice on prescribing states that sufficient information must be given to enable informed consent to be made to any treatment, including explaining the off-label nature of prescribing to the patient (or carer as appropriate) and the reasons for doing so.”
[Note that the GMC has merged off-label and off-licence prescribing into ‘unlicenced prescribing’.]Key points from https://bit.ly/Rx-off-label-and-unlicenced
- Off-label prescribing occurs when medication use falls outside the scope of the marketing authorisation with respect to one of five key domains:
- Demographic: The age of the patient may lie outwith the recommended range e.g. the use of sertraline for depression in a 16 year old.
- Disorder: Prescribing for a condition which is outwith the marketing authorisation e.g. the use of hyoscine hydrobromide for clozapine-related hypersalivation.
- Dosage: Prescribing at a dose that is higher than recommended e.g. olanzapine prescribed at 30mg daily.
- Duration: Prescribing for a longer period of time than is recommended e.g. a benzodiazepine prescribed for longer than 4 weeks.
- Domain. Where a drug is licenced for a particular indication in one country and not another e.g. in some EU member states, valproate salts have a licence for prevention of migraine.
- Consent:
- Prescribers must now ensure that patients (or their carers if the patient lacks legal capacity) are aware of any ‘material risks’ involved in a proposed treatment, and of reasonable alternatives, following the judgment in the Montgomery case (Montgomery v Lanarkshire Health Board 2015). ‘The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.’
- Robust record-keeping and documentation is fundamental to all prescribing practice. When commencing new treatments, patients should be provided with sufficient information to allow them to make an informed decision.
- Remember to RECoRD……
- Rationale
- Evidence-base
- Consent
- Review
- Document
- Remember to RECoRD……
Choice and medication (NHS leaflet) https://bit.ly/factsheet-ul-medication
Advice from MHRA: https://bit.ly/unlicenced-meds-mhra-guidance
“The responsibility that falls on healthcare professionals when prescribing an unlicenced medicine or a medicine off-label may be greater than when prescribing a licenced medicine within the terms of its licence. Prescribers should pay particular attention to the risks associated with using unlicenced medicines or using a licenced medicine off-label. These risks may include: adverse reactions; product quality; or discrepant product information or labelling (eg, absence of information for some unlicenced medicines, information in a foreign language for unlicenced imports, and potential confusion for patients or carers when the Patient Information Leaflet is inconsistent with a medicine’s off-label use).”
Advice for prescribers says you should:
- be satisfied that an alternative, licenced medicine would not meet the patient’s needs before prescribing an unlicenced medicine.
- be satisfied that such use would better serve the patient’s needs than an appropriately licenced alternative before prescribing a medicine off-label,
- before prescribing an unlicenced medicine or using a medicine off-label you should:
- be satisfied that there is a sufficient evidence base and/or experience of using the medicine to show its safety and efficacy.
- take responsibility for prescribing the medicine and for overseeing the patient’s care, including monitoring and follow-up.
- record the medicine prescribed and, where common practice is not being followed, the reasons for prescribing this medicine; you may wish to record that you have discussed the issue with the patient.
SMPc – medications
Summary of product characteristics are important because they set out more accurately the information from manufacturers, compared to the BNF. See https://www.rpharms.com/development/trainee-pharmacists/product-characteristics-summary
Aripiprazole: https://bit.ly/smpc-aripiprazole
Citalopram: https://bit.ly/smpc-citalopram
Keppra (levetiracetam): https://bit.ly/smpc-keppra
Lamotrigine: https://bit.ly/smpc-lamotrigine
Melatonin (Circadin) https://bit.ly/smpc-melatonin-circadin
Methylphenidate (BNF): https://bnf.nice.org.uk/drugs/methylphenidate-hydrochloride/ SMPC:
Olanzapine: https://bit.ly/smpc-olanzapine
Paroxetine: https://bit.ly/smpc-paroxetine
Pregabalin: https://bit.ly/smpc-pregabalin
Promethazine: https://bit.ly/smpc-promethazine
Quetiapine: https://bit.ly/smpc-quetiapine-hemifumarate
Risperidone: https://bit.ly/smpc-risperidone
Sertraline: https://bit.ly/smpc-sertraline
Scopoderm (hyoscine patch): https://bit.ly/smpc-scopoderm
Valproate: https://bit.ly/smpc-valproate
Zuclopenthixol: https://bit.ly/smpc-zuclopenthixol
