Thursday, 31 October 2013

Detentions under the Mental Health Act 1983: The Latest Statistics 2012-13

The latest statistics on inpatientsformally detained in hospitals under the Mental Health Act 1983, and patientssubject to supervised community treatment was published on 30th October 2013. This is an interesting and easy to understand report, and I would urge everyone with an interest in mental health and the use of the Mental Health Act to read it.

This is the third time I have reviewed these annual reports from the Health and Social Care Information Centre, which is part of the Government Statistical Service. The authors clearly love statistics as much as I do (my previous reviews are here and here).

Two years ago I wrote: “What is clear is that, after only two full years of its use, CTO’s are beginning to seriously impact on the overall use of the MHA. There appears to be an inexorable rise in the number of people in the community subject to CTO’s, as once made, CTO’s can be extended indefinitely.”

One year ago I wrote I quoted from last year’s report: ““The total number of people subject to detention or CTO restrictions under The Act has continued to rise. On the 31st March 2012, this figure stood at 22,267 people, representing a 6 per cent increase since the previous year… There were 4,220 CTOs made during 2011/12, an increase of 386 (10 per cent) since last year.”

So what do the statistics show this year?

The report notes that “there were 4,647 CTOs made during 2012/13, an increase of 427 (10 per cent) since last year”. The report also notes that “in spite of larger numbers of CTOs being ended each year, the number issued continually outweigh this, resulting in an increasing number in place at the end of each reporting period.”

Despite some (potentially flawed) evidence that CTO’s are ineffective in keeping people out of hospital, it appears that this is not deterring clinicians from using these orders.

Last year, I observed that, as an AMHP, I was “finding increasing amounts of my work relate to CTO’s. In the last 12 months, I have been involved in 4 new CTO’s (Sec.17A). But I have also been involved in the extension of CTO’s on 6 occasions (Sec.20A).”

And what of my own personal statistics for the last 12 months? Well, a significant amount of my time as an AMHP continues to be occupied in work relating to Supervised Community Treatment. I was involved in 3 new CTO’s, I extended 4 CTO’s, and was involved in revoking 3 CTO’s. These tasks involve an interview and assessment of the patient each time, involvement in S.117 planning meetings, written reports each time I am involved in a new CTO, or an extension, or a revocation, and frequently the necessity to prepare Managers and Tribunal reports and attend Tribunal hearings.

I’ve just calculated that I have spent 85 hours in the last year on work relating to CTO’s. That’s more than two working weeks. It amounts to a significant proportion of the overall time I spend discharging my statutory functions under the MHA.
Two years ago I posed the question: Are Community Treatment Orders taking over the Mental Health Act? The evidence is increasingly pointing in that direction.

Although of course I am ignoring the increasing time that formal assessments under the MHA are taking in general. What with problems in finding a bed, coupled with increasingly long delays in getting an ambulance, assessments can often take 6 hours or more, especially when you are covering a large, mainly rural area, with hospitals few and far between. However, these latest official statistics cannot cover this area.

The Report makes another, rather telling, statement:
“Detentions on admission to hospital increased in both independent and NHS services during 2012/13. For NHS hospitals there was an increase of 3 per cent since 2011/12 but for independent hospitals the increase was much larger at 13 per cent, although the numbers involved were smaller. A large proportion of this increase was attributable to a 31 per cent (313) increase in uses of Section 2 in independent hospitals.”

This is a continuing trend. The Report for 2011-12 noted: “Total detentions in independent sector hospitals increased by 21 per cent; a large proportion of this increase was attributable to a 45 per cent increase in uses of Section 2.”

Last year, I said that “over the last year it has become not unusual in my fairly rural area to have to travel 50 miles or more to admit a patient to hospital. There have been times when there have been no psychiatric beds at all in the entire region. When this happens, the only alternative is to use an independent hospital, at huge expense, of course. This has in any case tended to be the default for young people under the age of 18, and also for people with eating disorders, for whom there are no specialist Trust beds in the region at all.”

The continuing closures of NHS psychiatric beds nationwide is not surprisingly continuing to increase pressure on Mental Health Trusts to use private hospital beds.

I am finding it difficult to understand how the extensive and prolonged use of extremely expensive private beds does not outweigh the savings supposedly gained by the closure of NHS beds, and the reduction in the numbers of frontline clinical staff who might be able to provide alternatives to hospital admission.

Emergency detentions under Sec.4 (where it is not possible to obtain two medical recommendations) continue to reduce year on year. In 2008-9, over 727 people were detained under this section; last year the figure was less than 400, representing almost a 50% reduction overall.

And what about use of Sec.136 (police detentions for people in “a place to which the public have access”)? Well, there appears to have been a slight reduction in overall use of this power. However, outcomes have not changed: in 2012-13, 82% of the use of Sec.136 did not result in detention under Sec.2 or Sec.3.
Although there are no figures for the numbers of people detained under Sec.136 who are subsequently admitted informally, the overwhelming conclusion to be drawn from these figures is still that the police, who to be fair do not have the training in the identification of mental disorder that mental health professionals have, are still using Sec.136 inappropriately.

Saturday, 19 October 2013

Is the Concept of Informal Psychiatric Admission in Jeopardy? A Commentary on the Current Crisis in Mental Health Beds

"Well, they've finally located a bed. Just need to get an ambulance now."
There has been a gratifying media response to the excellent investigation conducted by Community Care and the BBC into the drastic shortage of acute psychiatric beds across the country. This investigation has confirmed what AMHP’s already know: the cuts in psychiatric beds are leading to unsafe and possibly illegal practices, which are often harming patients.

Around 1,700 mental health beds have been closed since April 2011, which amounts to an overall reduction of 9%. However, the changes to community mental health services which are occurring all over the country, which are often driven by the need to make drastic cuts in budgets, do not lend themselves to a reduction in demand for beds, but rather an increase in the demand for acute admissions.

It was reported that “three-quarters of the 1,711 bed closures were in acute adult wards, older people’s wards and psychiatric intensive care units. Average occupancy levels in acute adult and psychiatric beds are running at 100%, while half are over that and all are above the 85% limit recommended by the Royal College of Psychiatrists.”

Andy McNicoll reports in Community Care about the various ways in which this crisis is affecting service delivery and patient care. These include possibly avoidable patient deaths, the use of expensive private beds, and many examples of inherently poor practice, which can have a seriously adverse effect on patient care and outcomes.

Examples of poor practice include admitting people to a hospital when there is no bed for them, the use of leave beds, premature discharge which then leads to early readmission, and the use of inappropriate beds, such as placing people under 18 in adult wards.
In my own experience, one of my service users, who was a voluntary inpatient in her 40’s, went on home leave. The leave did not go well, and she needed to come back into hospital. However, her bed had been taken by an emergency admission, and she was placed overnight on a dementia ward.

Overcrowded wards lead to stressed staff and poor experiences for patients which in turn leads to slower recovery, and an increase in incidents of violence and exploitation.

It appears that one of the worrying consequences of bed shortages is that preference may be being given to patients detained under the Mental Health Act as opposed to informal admissions, presumably based on the assumption that informal admissions are less urgent.

A report in Community Care in August 2012 (Mental health detention rise amid ‘pressure on hospital beds’) quotes an anonymous AMHP as saying that detention under the MHA is “the only way to get a bed these days.” I have certainly had it said to me on more than one occasion that a bed is only available for patients detained under the MHA. I have had to argue the case forcefully in order to obtain the bed.
There is more than anecdotal evidence of this practice. Michael Knight committed suicide on 28th August 2012, at the age of 20. He was assessed under the MHA, and agreed to be admitted informally. However, there was no bed available anywhere in the county in which he lived. This led to an overnight delay in his admission, during which he killed himself.
The Coroner in the case stated: “The tragedy in this case is the fact that, after having gained Michael’s agreement to accept voluntary inpatient care, a bed was not then available. I am of the view that the situation was then exacerbated by the to-ing and fro-ing which then took place with regard to a bed becoming free, but only for a very short period of time before it was then unavailable.”
It was reported that “following Mr Knight’s death a serious investigation report was compiled, which found that staff followed the ‘right pathways’. It said an acute bed would have been found for Mr Knight if he had been sectioned.” (my italics)
The Mental Health Act is very clear in its views on informal admission. Sec.131 deals specifically with informal admission. Sec.131(1) states categorically:
“Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital or registered establishment in pursuance of arrangements made in that behalf and without any application, order or direction rendering him liable to be detained under this Act, or from remaining in any hospital or registered establishment in pursuance of such arrangements after he has ceased to be so liable to be detained.”
This essentially means that if a patient needs a bed, and they are agreeing to be admitted, then no requirement can be made that they should only be admitted if detained under a Section of the MHA. Any hospital imposing such a condition is therefore acting expressly in contravention of the MHA.
The Reference Guide to the Act devotes a chapter (Chapter 37) to informal admission, and begins by saying (37.2): “Nothing in the Act prevents people being admitted to hospital without being detained, and this is expressly stated in section 131. Compulsory admission under the Act has always been intended to be the exception, not the rule.”
The Code of Practice (Para 4.9) reinforces this: “When a patient needs to be in hospital, informal admission is usually appropriate when a patient who has the capacity to do so consents to admission.”
AMHP’s are legally required to satisfy themselves that detention in a hospital “is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need”, and informal admission is seen as a valid alternative to compulsory detention. Simply because an AMHP concludes that formal detention is not necessary, this does not necessarily mean that the patient does not need to be in hospital.
There is no doubt that hospital beds are expensive. Properly funded community based alternatives, such as Dementia Intensive Support Teams, may not only save money, but also provide patients with appropriate support in their own homes, and minimise disruption to them. Many Mental Health Trusts are relying on allegedly improved and enhanced community based crisis services to obviate the need for more hospital beds, and to justify a reduction in beds.
But there is a problem with this. I have been working in the mental health field for long enough to remember the plans in the 1970’s and 1980’s to close the long stay hospitals in which people with mental illness and learning difficulties would spend many years.
These plans were admirable. These asylums were mostly daunting and depressing Victorian edifices, deliberately built away from communities, and institutionalised the hapless inmates. Most of the inpatients didn’t need to be there, but there were few alternative community services. I was involved in a small way in moving some of these patients into the community myself when I started out as a social worker in the 1970’s.
The problem, however, was that community services were supposed to be funded with the money saved from closing the hospitals, but they had to close the hospitals first in order to get this money. It was like having a plan to buy a cow with the money raised from milking the cow. You had to have the cow first, but you couldn’t get the cow until you had sold the milk the cow would provide. Mental Health Trusts appear to be trying to pull off the same trick.
The now long defunct Mental Health Act Commission, in their Biennial Report for 2003/05 (p.204), advised:  “ In our view… the focus on establishing community interventions to keep patients from hospital admission must not blind us to the continuing need for inpatient care that patients will enter and reside in voluntarily”. That statement still holds today

Monday, 7 October 2013

The Sun and Mental Health -- That Front Page

The Sun’s full page headline today (7th October 2013) states baldly “1,200 killed by mental patients”. The number 1,200 is in red letters 2 ½ inches high. In tiny letters to the side of this headline is the admission that this figure was the total over a decade.

It’s hard to know where to start in a dissection of this report.

That huge red number is clearly intended to alarm. One has to conclude that the Sun wishes to suggest that its readers are all at risk of being murdered in their beds by homicidal maniacs.

The Sun’s use of the term “mental patients” is not only deliberate use of a term with pejorative implications, but also implies that there are two sorts of people: “normal” people (Sun readers perhaps?) and “mental” people, people who are unpredictable and potentially dangerous.

Having emblazoned its front page with this frightening statement, the Sun’s “full story” is buried on pages 6 and 7. It begins: “A Sun investigation today reveals disturbing failings in Britain’s mental health system that have allowed high-risk patients to kill 1,200 in a decade.”

The article is fringed by 12 brief accounts of people who have been murdered by “mental patients” over the last few years.

So where did the Sun obtain these figures? It mentions “a Manchester University study”. This can only be the Annual Report The National Confidential Inquiry into Suicideand Homicide by People with Mental Illness, published by the University of  Manchester in July 2013.

The Sun’s “probe” (their word), must have taken all of 30 seconds before finding this study, which was published 3 months previously in July. Community Care published a thoughtful article back on 5thJuly 2013, headlining their article with a quote from the Report saying: “The number of homicides committed by mental health patients has fallen ‘to its lowest level for a decade’.” The writer of this report, Julian Hendy, goes on to express skepticism of some of the figures.

The Sun reports that 122 people a year on average were killed by “mental patients”. This would appear to have been lifted from Community Care’s article.

The Sun goes on to lay the blame for these figures on “the slashing of budgets for mental health care”. They quote Marjorie Wallace of SANE as saying that “homicide figures may not have increased in decades – but significantly they have not declined either.”

So what does the University of Manchester report actually say?

Right at the beginning of the report, it is stated: “Homicide by mental health patients has fallen substantially since a peak in 2006, and the figures for the most recent confirmed years, 2009-2010, are the lowest since we began data collection in 1997”.

Although the report acknowledges that some of its statistics may be incomplete, it does say “it is likely that this is a true fall in patient homicide”.

Already, this seems to be factually at odds with the Sun’s report. While I do not wish to minimise the potential effects of recent cutbacks to spending on mental health, in this case, recent changes in mental health legislation and delivery are given as a possible explanation for this reduction, citing the use of CTO’s as a potential factor.

Another failing of the Sun’s “probe” is to place these figures in any sort of context. The Office of National Statistics provides illuminating statistics for overall numbers of homicides.

It gives statistics going back to 1960 for homicides initially recorded by the police. The long term graph shows a gradual increase in homicides from 282 in 1960 to a peak of 1047 in 2002-3. Since then, there has been a steep fall to around half of that peak.

Taking the ONS statistics, it can be seen that during the 10 year period from 2001-2011 on which the Sun bases its figures, there were a total of 7926 homicides. This compares with the figure of 1220 homicides committed by mental health patients quoted by the Sun and Julian Hendy. In other words, a little over 15% of homicides were committed by people who were known patients of mental health services. To put it another way, 85% of murders were committed by people who weren’t “mental patients”.

But I suppose the headline: “You’re 6 times more likely to be killed by a “normal” person than someone with mental health problems” doesn’t have quite the same ring to it.

Friday, 4 October 2013

What’s on Those Pink Section Forms?

If you’ve ever been detained under the Mental Health Act, or if you’ve ever been involved in an assessment, you will at some point have seen the Approved Mental Health Professional produce a set of pink forms, which the AMHP and the doctors then fill in.

The filling in process is usually done out of the sight of the patient (in the kitchen, or outside in the AMHP’s car). Once completed, the AMHP then informs the patient that they have been formally detained under the MHA and will have to go to hospital.

These forms are rarely shared with the patient. Once the patient has been admitted, the forms are filed away, either in the patient’s medical records or in the Mental Health Act Administrator’s office. After that, generally only the Care Quality Commission will see them when they conduct periodic hospital inspections.

So what’s actually on those forms?

The majority of detentions under the MHA are either under Sec.2 or Sec.3. Sec.2 is for assessment, while Sec.3 is for treatment. More rarely, a Sec.4 is used, which is an application for assessment in an emergency.

The Registered Medical Practitioners’ Forms
Registered Medical Practitioners are qualified doctors. The doctors fill in their own forms, which are actually only recommendations that a patient should be detained, as it is the AMHP who makes the final decision.

If the doctors see the patient at the same time, they can fill in a Joint Medical Recommendation. If they see the patient separately, they must fill in separate Medical Recommendations.

The doctors have to put their own name and office address, as well as the name and address as the patient.

On these forms, the doctors must say when they last examined the patient. Each doctor must also state if they had “previous acquaintance” with the patient – in other words, that they have had some contact with the patient in the past. They must also state if they are “approved under Sec.12 of the Act as having special experience in the diagnosis or treatment of mental disorder”. This means that they are either a practicing psychiatrist or that, being a GP for example, they have had extra training and have therefore been “approved”.

At least one of these doctors must be Sec.12 approved. It is desirable, but not essential, for at least one of the doctors to know the patient. However, if neither of them knew the patient, the AMHP must explain on their own form why it was not possible to get a doctor who did know the patient.

For Sec.2 and Sec.4, they have to state that “this patient is suffering from a mental disorder of a nature of degree which warrants the detention of the patient in hospital for assessment (or assessment followed by medical treatment) for at least a limited period.”

For Sec.3 they have to state that “this patient is suffering from mental disorder of a nature or degree which makes it appropriate for the patient to receive medical treatment in a hospital.”

For Sec.2, Sec.3 and Sec.4 they also have to state whether or not the patient ought to be detained in the interests of the patient’s own health, the patient’s own safety, and/or with a view to the protection of others. However, for Sec.3 they additionally have to state that the patient “should receive treatment in hospital” and that that treatment “cannot be provided unless the patient is detained under Sec.3”.

In all cases, the doctors then have to write down in detail the reasons why they have these opinions. For a Sec.3 they also have to state at which hospital or hospitals appropriate treatment is available.

Although often the two doctors assess the patient at the same time, this is not always the case. Where the doctors have not assessed the patient together, then there must not be more than five clear days between the two recommendations. This means, for example, that if the first doctor examined the patient on a Monday, then the second doctor’s examination should not be later than the following Sunday.

The doctors have to sign and date their recommendations. For a Sec.4, because it’s an emergency, and the detention only lasts for a maximum of 72 hours, they also have to put the time.

Sec.4 is a bit different from Sec.2 & Sec.3, as it is only used for emergencies. Only one medical recommendation is needed. However, the doctor has to state on the recommendation that “compliance with the provisions of Part 2 of the Act relating to applications under Sec.2 [ie having two medical recommendations] would involve undesirable delay” and must give the likely length of time of that delay and state what risk such a delay would pose to the patient or other people.

The AMHP’s Forms
The AMHP is making an Application for Admission, either for assessment or for treatment. The first thing that the AMHP has to fill in on any application form is the name and address of the hospital to which the patient is to be admitted. The AMHP therefore has to know where the patient is going to be admitted before he or she can complete the form. This can at times lead to a delay in completing the application, as it can often be hard to find a bed.

The AMHP then has to put his or her name and office address on the form as the applicant, as well as the name and address of the patient, and must also state that he or she is an Approved Mental Health Professional and give the name of the local social services authority who approved them.

For Sec.2 and Sec.3 the patient’s Nearest Relative needs to be identified if possible. For a Sec.2, the AMHP either has to identify the NR or another person who has been authorised to act as such, and to state whether or not they have informed that person of the application and the right of that person to order the patient’s discharge.

For a Sec.3, the AMHP has to state that the NR or proxy has been consulted by the AMHP, and state that that person has not objected to the application being made. If the AMHP has not consulted with the NR, they have to give reasons why it was impracticable to do so.

If the AMHP has either not been able to find out who the NR is, or believes that the patient has no NR, then in both cases, the AMHP has to state this on the form.

The AMHP has to explicitly state that they have interviewed the patient  and are satisfied that detention in hospital is “in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need.”

In all cases, if the assessment was undertaken by a doctor or doctors who did not know the patient prior to assessment, the AMHP has to give reasons why they were unable to get doctors who did know the patient.

The AMHP has to sign and date the Application. Only then, after all the forms have been fully completed, is the patient formally liable for detention.

General notes
The AMHP and the doctors have to give the date when they assessed the patient. In the case of Sec.4, they also have to give the precise time.

Both the medical practitioners’ forms and the AMHP’s forms have to have the name and address of the person being detained. These should be identical on both the doctors’ forms and the AMHP’s forms. However, the name does not have to be correct to be legal. For example, I once had to detain a person who was in Charwood police station but who was from another part of the country. He was therefore unknown to anyone in Charwood. The name he gave police was “Charlie Bangles”, so this was the name that we put on our section forms. He was then admitted to a hospital in his home area. When we arrived there, it was discovered that, as he was actually a professional entertainer, this was his stage name, not his real name. However, this made no difference to the legality of his detention.

The forms consist of a combination of written statements which the AMHP or doctors agree to by means of signing the form, statements that can be crossed out according to the circumstances, and spaces for free text.

The exact wording of the forms is laid down in a statutory document called “Mental Health Regulations 1983”. It is the wording of the forms that constitutes the legal document, not the form itself. This means that, although traditionally the forms are printed on pink paper, they can be on any colour of paper. They can even be handwritten. In a rare flash of humour, Richard Jones in the Mental Health Act Manual states that in an emergency, where the printed forms were not to hand: “an alternative course of action would be to remove the appropriate pages from this Manual.”