Tuesday, 19 March 2019

Section 3 and “appropriate medical treatment”


In my last blog I looked at S.2 and S.3 of the Mental Health Act. When an AMHP is considering use of S.3 of the Mental Health Act, which allows detention in hospital for treatment, two medical practitioners have to provide medical recommendations. These will be completed on Form 7 (joint medical recommendation) or Form 8 (single medical recommendation).

However, it is not enough merely for the doctors to say that the patient needs medical treatment in hospital. The wording of the medical recommendation forms states:

We are also of the opinion that, taking into account the nature and degree of the mental disorder from which the patient is suffering and all the other circumstances of the case, appropriate medical treatment is available to the patient at the following hospital (or one of the following hospitals)

The doctors then have to state the hospital or hospitals where this appropriate medical treatment is available.

The Code of Practice makes it clear that it is a requirement of the Act for the doctors to state this. The code goes on the say:

Preferably, they should know in advance of making the recommendation the name of the hospital to which the patient is to be admitted. If that is not possible, their recommendation may state that appropriate medical treatment will be available if the patient is admitted to one or more specific hospitals (or units within a hospital). (para14.76)

Chapter 23 of the Code goes into some detail relating to what “appropriate medical treatment” means.

It points out:

The appropriate medical treatment test must be applied to ensure that no one
is detained (or remains detained) for treatment... unless medical treatment for their mental disorder is both appropriate and available.(para23.8)

It goes on to state clearly that:

In order to be deemed appropriate, medical treatment must be for the purpose of alleviating or preventing a worsening of the patient’s mental disorder or its symptoms or manifestations. It must also be appropriate, having taken account of the nature and degree of the patient’s mental disorder and all their particular circumstances, including cultural, ethnic and religious or belief considerations. (para23.9)

The appropriate medical treatment test requires a judgement about whether an appropriate treatment or package of treatment for mental disorder is available for the individual in question. It is not consistent with the least ‘restrictive option and maximising independence’ and ‘purpose and effectiveness’ guiding principles’ to detain someone for treatment that is not actually available or may not become available until some future point in time.(para23.10)

Until the MHA 1983 was revised and amended by the MHA 2007, doctors only had to say that medical treatment was required. It was an important change for them to have to think about what sort of medical treatment was required for the specific patient, as well as where that treatment was actually able to be given.

It is clear that, in order to comply with the Human Rights Act, a detained patient should be able to be given the treatment they need, otherwise they could be incarcerated indefinitely, while receiving no treatment at all.

I recall many years ago attending a Mental Health Tribunal for a patient who had been diagnosed with a personality disorder. He had been detained under S.3 and placed in a hospital where the appropriate treatment that he was deemed to require was available. This consisted of psychological therapy.

The patient appealed on the grounds that, although the treatment was available, the patient did not wish to have that treatment, and since psychological therapy cannot be administered against the will of the patient, he ought to be discharged.

The Tribunal found this to be a compelling argument, and discharged him.

More recently, I found myself in an invidious position regarding the detention of a patient with treatment resistant depression.

The patient was in the community, but well known to services, and had been receiving home treatment without any alleviation of their symptoms. She had in the past been treated in hospital with ECT, which had been very effective, and she had made a full recovery. The doctors therefore concluded that the treatment she required was ECT, and named several hospitals in the Trust area where treatment was available.

A bed was found in one of these hospitals, so I completed my application for S.3 with the consent of the nearest relative, and arranged for her to be conveyed to the hospital. The NR was in full agreement that she required ECT, and accepted reluctantly that she could not stay at home for this.

This is where it all unraveled.

The section papers were accepted by the hospital, and she was duly admitted. However, as I was about to leave, I was informed by the ward manager that ECT was not actually available in the hospital. All patients requiring ECT had to go to one hospital in the area that administered ECT, but as all the available slots were taken by existing patients, she would have to go on a waiting list, and it could be several months before she would be able to have this treatment.

Para23.4 of the Code makes it clear that this situation was not consistent with the guiding principles of the Act. While I had acted in good faith (and it is not the role of the AMHP to question what treatment might be required) I had been placed in a position in which I had acted otherwise than in the best interests of the patient. Had I known that ECT was not available, I would not have made an application for detention, but since the section papers had been received, I had no power to withdraw my application.

What constitutes “appropriate medical treatment”?

Back in 2013, the Moors Murderer Ian Brady appealed to a Tribunal against his detention in Ashworth Special Hospital. I wrote in detail about it here.

A Tribunal is required to ensure that appropriate medical treatment is available to the patient in question. Among Brady’s arguments was the contention that appropriate medical treatment was not in fact available for him.

The Tribunal accepted that treatment would not include the use of medication, and that “Mr Brady is very unlikely to take part in any psychological treatment.” They therefore considered at length the definition of “treatment”.

The Tribunal concluded that the nursing care he was receiving, which included building a therapeutic relationship, and acting to minimise conflict within the hospital, did indeed constitute “treatment”, and that Brady was receiving some benefit from this, whether he thought so or not.

Tuesday, 19 February 2019

Section 2 or Section 3?



These are the sections of the Mental Health Act that are the most commonly used when compulsory detention in hospital is being considered.

S.2 Mental Health Act lasts for 28 days, and its main purpose is to assess a patient in hospital (although it does also permit treatment). S.3 MHA lasts for a maximum of 6 months, and is for the purpose of treatment.

Statistics show a general increase in the use of compulsory detention between 2016-17 and 2017-18. Detentions under both S.2 and S.3 have increased.

In the year 2016-17 there was a total of 34,137 admissions under S.2, while in the years 2017-18 there were 37,408. While this shows an increase of 9% over the previous year, it does not approach the peak in the year 2015-16, when detentions under S.2 amounted to 40,063.

In the year 2016-17 there were 21,361 detentions under S.3, while in the years 2017-18 there were 23,073. This shows an increase of 7.5% over the previous year, but still it does not approach the peak in the year 2015-16, when detentions under S.3 amounted to 28,147.

Digging deeper into these statistics, 11,296 of the S.3 detentions followed previous detention under S.2 This indicates that 30% of people detained under S.2 were subsequently detained under S.3 for a longer period of inpatient treatment.

The Code of Practice states that S.2:

should only be used if the full extent of the nature and degree of a patient’s condition is unclear, or there is a need to carry out an initial in-patient assessment in order to formulate a treatment plan, or to reach a judgement about whether the patient will accept treatment on a voluntary basis following admission, or there is a need to carry out a new in-patient assessment in order to re-formulate a treatment plan, or to reach a judgement about whether the patient will accept treatment on a voluntary basis. (14.27)

The Code goes on to say that Section 3 should be used:

if the patient is already detained under section 2, or the nature and current degree of the patient’s mental disorder, the essential elements of the treatment plan to be followed and the likelihood of the patient accepting treatment as an informal patient are already sufficiently established to make it unnecessary to undertake a new assessment under S.2. (14.28)

Despite this guidance, making a choice between S.2 or S.3 is a frequent source of discussion among AMHPs. There are a number of reasons for this.

Some are strictly to do with professional clinical decisions and the imperative to explore least restrictive options. It may be felt, for example, that the shorter detention period of a S.2 is felt to be less restrictive than the 6 months of a S.3.

Some may be more to do with expediency, or more, shall we say, complex issues.

What factors might influence use of S.2 or S.3?

Here are a couple of scenarios. They are fictitious, but describe situations that will be familiar to AMHPs.

Jason

It is 22:00 hrs on Friday evening: an out of hours AMHP is asked to assess a patient detained under S.136.Jason is in York, where he was detained by police attempting to climb onto the altar of York Minister claiming to be the Second Coming of Christ.

The Police have established that he normally lives in Cornwall, where he is well known to psychiatric services, has a diagnosis of paranoid schizophrenia, is subject to S.117 aftercare, and recently went missing from the mental health hostel in which he was living.

On assessment, it is clear that Jason is thought disordered, but is unable or unwilling to reveal any information about his medication or mental health care. It is clear that he needs to be in hospital. Unfortunately, the AMHP is unable to contact mental health services in Jason’s area to obtain more information.

Should Jason be detained under S.2 or S.3?

Applying the principles for decision making in the Code of Practice, the AMHP is aware that Jason is well known to his local mental health services, and has in the past been detained under S.3.

But at the same time, the AMHP is unable to confirm this and discuss the situation with Jason’s care team. Because he is so far from home, neither the AMHP nor the doctors assessing him have had any previous acquaintance with the patient.

The AMHP might in these circumstances consider that S.2 is preferable even though Jason’s diagnosis and presumably treatment is well known. It is just that these things are not well known to the assessing team.

Jonathon

Jonathan is a well known patient with a diagnosis of bipolar affective disorder. He has recently stopped taking his mood stabilising medication and his care coordinator reports that he is becoming increasingly manic, spending profligately, not sleeping, is harassing his neighbours, and becoming sexually disinhibited. These are all warning signs of relapse.

An AMHP and two S.12 doctors assess Jonathan at home and conclude that he needs to be detained in hospital for treatment.

The doctors have a dilemma. No hospital bed has been identified prior to the assessment, and the bed managers can give no indication as to how long it would be to identify a hospital.

What should the doctors do?

The difficulty here is that, unlike medical recommendations for S.2, the doctors have to state on a S.3 recommendation the name or names of hospitals where appropriate treatment would be available.

In the real world, where there is a national shortage of psychiatric beds, especially for children and people with learning disabilities, doctors will often make recommendations for S.2 and then leave them with the AMHP. These can then be used at any time within 14 days from the date of the recommendations. The doctors do not have to be involved in another assessment.

But the doctors in Jonathon’s case would not be able to complete their medical recommendations, because they could not name the hospital in which the patient could receive treatment. So they can’t just sign the document and go on their way.

Might they be tempted to find some pretext that might justify detention under S.2 for assessment, rather than S.3 for treatment?

And would that be ethical?

The Nearest Relative

The rights and powers of the Nearest Relative of a patient are important factors that AMHPs have to take into account when considering detention under the MHA.

For a S.2, the NR should at the least be informed that detention has taken place, and should be made aware of their rights to order the discharge of the patient from hospital.

However, for a S.3, it is a legal requirement for the NR to be consulted if at all possible, because if they object, detention under S.3 cannot take place. The only option then for an AMHP is to go to the Courts to have the NR displaced. This can be a time consuming process, and it can take weeks for the courts to make a final decision.

This is where some interesting decisions might be taken to avoid consulting the NR, especially if it is known that they are likely to object to detention under S.3.

There is a body of Case Law relating to the NR and failure to consult them. Sometimes, AMHPs (and ASWs in the past) have got into considerable trouble.

One example is GD v The Managers of the Dennis Scott Unit at Edgware Community Hospital and The London Borough of Barnet, Queen’s Bench Division (Administrative Court), 27th June 2008.

In this case, there were real fears that the patient’s father might hide the patient if it was known that an assessment under the MHA was going to take place. The ASW did not contact the NR before the assessment, and only let him know by leaving a message when the assessment was actually taking place. When the NR returned the call 20 minutes later, the paperwork had already been completed. He then indicated in no unclear terms his feelings about this and his objection.

But the ASW had by then filled in the section of the form indicating that it had been “impracticable” to consult with the NR.

The Judge in the case found that the patient had been illegally detained because the ASW had deliberately failed to make adequate attempts to consult with the NR as he knew that the NR would object.

So an AMHP may be confronted with a dilemma. The AMHP might be clear that a certain patient in the community, who is well known to services with a clear diagnosis, and where it is known what treatment the patient requires, needs to be detained for treatment under S.3.

But the AMHP is also aware that the NR may object, making it impossible to ensure their admission and treatment, at least without having to go to a Judge to have the NR displaced.

So does the AMHP bite the bullet, make efforts to consult, then go through the necessary legal processes if the NR objects?

Even if this might put the patient in danger?

Or does this hypothetical AMHP consider that just maybe they can find some justification for detention under S.2, for assessment, hence avoiding the need to obtain the NR’s consent, and at the same time ensuring the patient’s safety?

The Mental Health Act Review

The recently published review of the Mental Health Act makes many recommendations for changes to existing law. Some of these relate to the use of S.2 and S.3.

The Review is keen to reduce the length of time that a patient can be detained in hospital wherever possible.

For a start, the Review is keen to reduce the use of compulsory detention at all. It is suggesting that the bar for justification of detention should be raised, and even where a patient is detained under S.2, the detention should be reviewed after 14 days, and a decision should then be made to either discharge or detain under S.3: “section 2 should only be used where it is truly necessary to assess someone."

It goes on to say:

Where the AMHP is aware that a person has been subject to detention under section 3 within the last twelve months, an application for detention under section 2 can only be made where there has been a material change in the person’s circumstances since they were previously detained under a section 3. We are also recommending that the Code of Practice makes it clear that section 3, rather than section 2 should be used when a person has already been subject to section 2 within the last twelve months.

At the same time the Review is also recommending a reduction in the initial maximum detention period under S.3 to 3 months from the present 6 months. There would be a further extension period of 3 months, and only after that could a person be detained for 6 months.

I am inclined to the view that, even though the Review’s recommendations have a long way to go before a change in the law might take place, an AMHP should still heed the Review’s opinions, especially as the recommendations are backed up by people’s rights under the Human Rights Act.

Wednesday, 9 January 2019

When is it appropriate to use the MHA when someone is causing a public nuisance?


When I was working in a community mental health team, I was once asked to attend a public meeting regarding a Housing Association tenant. The meeting was arranged following a large number of complaints from tenants of one of the Charwood social housing estates.

It was to be chaired by the Housing Association, with representation from the local District Council and the police. They also wanted someone from the CMHT, as it was thought that the tenant who was the subject of the meeting might have mental health problems.

So I somewhat reluctantly attended as a representative of the CMHT. I was reluctant, because I was not sure what would be expected of me. Having checked the name of the person, who I will call John, on our records, I knew that he had no previous involvement with mental health services.

The hall in the local community centre where the meeting was to be held was packed. I was one of the panel members situated at the front. The others were the local chief inspector and a senior housing officer from the district council. Being faced by several dozen hostile tenants felt quite intimidating, to say the least.

John had not been invited to attend, and was not aware that the meeting was taking place. I only knew that John was male, single, and in his 30’s.

The chairman, the chief officer of the housing association, summarised the reason for the meeting. They had received many complaints about the conduct and behaviour of John in public areas of the estate.

Almost immediately, people started making allegations about him. It appeared that he was often to be seen naked to the waist, swaggering around near the estate shops, brandishing a pair of martial arts nunchuks, and that he often verbally threatened passers by.

Allegations started to be made that he was a paedophile. The chief inspector intervened.

“Could you tell me on what basis you are making these allegations?” he asked.

“Just a few weeks ago he was chasing a 15 year old girl down the street. It’s good job she got away from him. We told the police, but nothing happened,” one of the tenants said.

“Let me put this straight,” the chief inspector said. “I am aware of the incident you are referring to. The person in question was actually running away from the police, who were trying to arrest him. The girl just happened to be in front of him.”

The tenant who had made the allegation looked momentarily deflated. “Yeah, but he’s a menace. He needs to be sorted.”

A woman in the audience, whom I recognised as being a patient of the CMHT, looked at me.

“What’s he doing here?” she demanded. “He must be a nutter. What are you doing about it?”

Both the audience and the other panel members looked expectantly at me.

I was not actually anticipating having to say anything. I was suddenly concerned about breaching confidentiality. But was it a breach to say that someone was not a patient?

“I am just here as a representative of Charwood CMHT,” I said. “I can tell you that he is not one of our patients. I know nothing at all about him, other than what I’ve heard today.”

“Well why don’t you know about him? He obviously needs sectioning,” another of the tenants said.

“Look, we honestly don’t go round looking for people to admit to hospital under the Mental Health Act. In order to be seen by the CMHT, their GP has to make a referral. And that has to be with the consent of the person. We’ve never had a referral for John.”

While the tenants were clearly not satisfied by my response, the chairman steered the discussion to what the housing association could legally do about John in response to the concerns expressed by the tenants, and I was not asked to comment again.

After the meeting, the panel members had a private discussion. I discussed with the chief inspector the potential use of S.136 if John appeared to be mentally disordered and in a public place, which would facilitate a formal MHA assessment.

I was struck in this meeting by two things. One was how people can make assumptions based on misinformation and prejudice. The other was the assumption that someone behaving in an unusual or antisocial manner must by definition be mentally ill.

What happened next?

I’d like to be able to say that John was never heard of by mental health services again.

However.

A few months later John was arrested in a public place in Charwood during the evening. He was armed with a large knife, was stripped to the waist, and was threatening to kill anyone who came near him.

He was taken to Charwood police station and assessed under the MHA by the out of hours AMHP. He was reported to be floridly psychotic and too unwell to give any coherent account of himself. As a consequence of his dangerousness, he was detained under S.2 and admitted to a psychiatric intensive care unit (PICU).

I assessed him again a month later and detained him under S.3.

He remained a patient of the CMHT with a diagnosis of paranoid schizophrenia, and was detained under the MHA several times over the next few years, always after stopping his medication. On the last occasion, he was discharged on a Community Treatment Order.

After being made subject to a CTO, he remained well and did not require any further acute admissions. In fact, when the time came to consider extension of the CTO on two subsequent occasions, he made it clear to me that he liked the security of the CTO and wished to remain on it.

There’s no clear moral to this story. Even though John may have been mentally ill at the time of that public meeting, the anger of the local people did not in itself justify taking action to detain him under the MHA.

It’s often the role of the AMHP to unpick what’s really happening when complaints from members of the public are received. 

But people are allowed to be unusual or eccentric, or even mentally ill, as long as their behaviour is not putting themselves or others in danger.

It was only once John stepped over that line, from being a nuisance to posing a real danger, by possessing an offensive weapon in a public place, that it became appropriate to consider use of the MHA to protect John and the public from the consequences of his actions.

Saturday, 15 December 2018

The Mental Health Act Review

Professor Sir Simon Wessely, Chair of the MHA Review

The Mental Health Act Review, chaired by Professor Sir Simon Wessely, was finally published on 6th December 2018.

I naturally have a particular interest in the Mental Health Act 1983, because I have been working within the Act as an ASW and AMHP since 1983, as it happens.

It is immediately apparent that the Review is not proposing a new Mental Health Act; instead, it is proposing significant changes to the existing Act, as well as to Mental Capacity legislation, just as the MHA 2007 did. So, if the changes are enacted, we will still be referring to the MHA 1983 (as amended).

I don’t intend to criticise the Review per se, as it says a lot of good things, and is clearly and explicitly placing human rights at the forefront of decision making within the Act. It flags up a number of factors that are adversely affecting the effectiveness of the MHA.

But I have some misgivings, which I will go into in more detail later.

There isn't the space here to critique all the recommendations in the Review, as there are 154 in total, but I will concentrate on the proposed changes which are likely to have the most impact on AMHP practice.

[Aside: Approved Mental Health Professionals (AMHPs) are used to their official title being misunderstood. They are often referred to as Approved Mental Health Practitioners, and the abbreviation is often given as AMPH. I am afraid that even the MHA Review has got the title wrong in one place. In one of the headings we are referred to as Approved Mental Health Act Professionals. Sigh.]

The Four Principles

The Review begins by recommending that four principles should underlie all aspects of practice within the MHA, and that these should be inserted into the Act right at the beginning.

The existing Code of Practice already has guiding principles, which should be considered when acting with the Act. These are:

Least restrictive option and maximising independence
Empowerment and involvement
Respect and dignity
Purpose and effectiveness
Efficiency and equity

The Review, however, is proposing replacing these with 4 new statutory principles:

Choice and autonomy – ensuring service users’ views and choices are respected
Least restriction – ensuring the Act’s powers are used in the least restrictive way
Therapeutic Benefit – ensuring patients are supported to get better, so they can be discharged from the Act
The Person as an Individual – ensuring patients are viewed and treated as rounded individuals

Rather than as at present, where the principles are in the Code, and therefore do not have the same statutory force, the Review is recommending that they should be embedded into the Act, even suggesting the wording for the beginning of the Act, for example, replacing the current Section 1 with a new one:

1. The purpose of this Act is to confer and authorise the powers (including coercive powers) necessary for the treatment of mental disorder and to safeguard the dignity and rights of those who are made subject to the exercise of such powers and for related purposes.

A new Section 2 would then include a statement of these 4 principles, and how they should be followed.

From these principles there flows a range of new or radically refocused proposals. These include addressing the disproportionate use of the MHA with black and ethnic minority patients.

Here are some of the proposed changes to the legislation.

Abolition of the Nearest Relative

As expected, the Review is proposing the abolition of the “Nearest Relative”, replacing it with a Nominated Person, similar to the Scottish Mental Health legislation.

Our recommendations will allow the patient to choose their own Nominated Person (NP) either prior to detention, at the point of assessment for detention or whilst detained through a new nomination process.

Where a patient has not appointed a NP prior to detention, an AMHP would be able to appoint an Interim Nominated Person (INP), which would involve identifying a friend or relative who was most suitable to fulfill the role. This may involve the use of the existing hierarchy for identifying the Nearest Relative, but as soon as the patient has the capacity to do so, they would be able to choose their own NP.

The powers and rights of the NP would also be extended, to include the right to be consulted over renewal of detention, extension of a CTO and transfer from one hospital to another. They would also have the right to be consulted on care plans.

The concept of the Nearest Relative, and the importance in law for AMHPs to identify the correct Nearest Relative, is an issue that produces endless head scratching and discussions within AMHP circles. In our local AMHP hub, a day will rarely go by without a debate on how to identify a particular patient’s Nearest Relative. I have written about this in my blog, and have taught the intricacies of this at length on AMHP training courses. So anything that simplifies this process will by much welcomed.

Informal admission (S.131)

S.131 of the MHA has always been clear that informal admission should be the default for the care and treatment of inpatients. But this is frequently not the case. I have even come across gatekeepers of beds, both in the NHS and in private hospitals, informing me that they will only accept detained patients.

The Review recommends a higher stress on the primacy of informal admission over compulsory detention, to the extent of recommending that “section 131 of the MHA is moved so that it sits above sections 2 and 3 of the Act."

Changes to criteria for detention

The Review proposes that there should be new criteria for significant harm, with the intention of raising the bar for detention:

We believe the Act needs to be more explicit about how serious the harm has to be to justify detention and/or treatment, or how likely it is that the harm will occur. We are recommending that there must be a substantial likelihood of significant harm to the health, safety or welfare of the person, or the safety of any other person.

The Review observes:

The AMHP must clearly state on the application form what specific harm they have identified, and how detention will reduce this, including why alternatives are not available or suitable.

This is at least partly in response to the Review’s concerns about risk aversion among mental health professionals. In trying to identify the factors that have led to a marked rise in the use of detention under the MHA in recent years, the Review cites the culture of risk aversion, arising from fear of the consequences to the patient and others of errors in judgment. Wessely makes the point that, while risk used to focus on risk to the patient, there has been a shift to trying to protect the agency or professional from risk.

I would make the anecdotal observation that some mental health trusts are not encouraging clinical staff to take risks, through reluctance to pay staff at a high enough rate. Some Trusts have reduced the numbers of Band 7 nurses as a cost saving exercise; a consequence has been that less well paid and less experienced staff will be more likely to request an assessment under the MHA for a patient who is not wholly cooperating with their treatment plan, often relying on historic or purely hypothetical risk factors to justify this.

Length of detention and other time scales

The Review is keen to reduce the length of time that a patient can be detained in hospital wherever possible.

S.2 should be reviewed after 14 days, and a decision should then be made to either discharge or detain under S.3: “section 2 should only be used where it is truly necessary to assess someone."

The Review explains:

Where the AMHP is aware that a person has been subject to detention under section 3 within the last twelve months, an application for detention under section 2 can only be made where there has been a material change in the person’s circumstances since they were previously detained under a section 3. We are also recommending that the Code of Practice makes it clear that section 3, rather than section 2 should be used when a person has already been subject to section 2 within the last twelve months.

The Review is also recommending a reduction in the initial maximum detention period under S.3 to 3 months from the present 6 months. There would be a further extension period of 3 months, and only after that could a person be detained for 6 months.

I actually suggested this in my blog over 2 years ago. In the MHA 1959, the time scale for S.26, the predecessor of S.3, was 1 year, then 1 year, then 2 years. The MHA 1983 cut this in half. In view of changes to average detention times since 1983, it seems eminently reasonable to cut this in half yet again.

The Review is also suggesting that there should be a statutory time limit for finding a bed once a decision has been made to detain under the MHA. This is addressing the current dire problems in finding beds in an emergency. I have known it to take up to 4 weeks to find a bed for a patient. This problem also leads to a reluctance to go out and assess someone without there being a bed identified first.

The Review also proposes that there should be a minimum waiting time standard for the commencement of a MHA assessment.

Treatment

The Review recommends that the current criteria for treatment should be tightened up so that “not only must appropriate treatment be available that cannot be delivered unless the person is detained, but also that the treatment would benefit the patient.”

It is also recommending greater protection for people objecting to treatments such as ECT.

Community Treatment Orders

The Review had severe misgivings about CTO’s, especially in view of the dubious research evidence for their efficacy. The Review stated that “CTOs are in the “Last Chance Saloon”.

While not actually recommending that CTO’s should be abolished, there was a desire to seriously reduce their use.

One of the proposals is that two Approved Clinicians and an AMHP should makes decisions about placing a patient on a CTO. Additionally, an AMHP should interview the patient and consult with the NR/NP and CMHT. A CTO should end after 24 months unless there are exceptional circumstances.

Statutory Care and Treatment Plans

Following admission, a Statutory Care and Treatment Plan (CTP) should be in place within 7 days of admission, and should be reviewed within 14 days. This would also identify whether a patient detained under S.2 should be continued to be detained, or discharged from detention, facilitating an early challenge to compulsory treatment.

Advance Choices Documents

These are similar to Advance Directives under the Mental Capacity Act, in which a patient can express their views about future care and treatment. The Review states:

Where a person is recorded as having capacity at that time the choice is made, the presumption will be that it will be honoured unless there are compelling reasons why not. So in future a request for a treatment that might be less than optimal, but still possible, should be honoured.

In order to strengthen the authority of the ACD, the Review states:

Where a patient has capacity for advance decisions, ACDs should be authenticated where possible by a health professional, unless the patient objects to this. In other words, we think that a health professional should confirm that the patient has capacity to make the choices contained in the document. We make this recommendation to remove the potential for doubt later as to whether the person had capacity to make the choices contained in the documents.

This should make it less likely that a case such as Kerrie Wooltorton, who was allowed to die from ingestion of antifreeze because she had written a “living will” refusing treatment, could recur. Further information about this notorious case can be found on my blog.

Advocacy

The right to an Independent Mental Health Advocate (IMHA) would be extended to informal patients. Additionally:

We think that IMHAs should be able to challenge treatment decisions, and make applications for discharge, on behalf of the patient where the patient lacks capacity to do so.

Children and young people

One of the proposals relating to children and young people is that young people between the ages of 16 and 17 should not be admitted to hospital or treated purely on the basis of parental consent.

While I welcome this stance, I think that this occurrence is in any case fairly rare for this age group. My own view is that any child over the age of 13 is better served by using the MHA if appropriate, rather than relying on children’s legislation and parental rights.

Learning disabilities and autism

In view of the fact that the current Code of Practice tends to take a dim view of the use of hospital admission for people with learning disabilities and autism, and it was also intended that the MHA should only ever rarely be used for this group, I did wonder whether the Review would remove them entirely from the scope of the Act.

What the Review does do is affirm the general inappropriateness of the MHA for these people:

We are recommending changes to the detention criteria to establish a culture which is less risk adverse because it too easy for the behaviour of a person with a learning disability, autism or both to meet the current threshold of risk. When detention is being considered, professionals will need to focus on more than just a person’s presenting behaviour that is perceived to be challenging. There will need to be a ‘substantial risk’ of ‘significant harm’.

The Police and the MHA

The Review recommends that police cells should never be used as a place of safety, suggesting a cut off point of 2023/24. In fact, this is only an affirmation of the current policy of only using designated health based places of safety for detention under S.136.

A welcome suggestion is that S.136 should be amended so that a police officer can make the decision to end a detention, rather than an AMHP and a doctor. This would arise where it was clear that a full assessment under the MHA was not justified.

Section 140

S.140 states that those responsible for providing hospital beds should fulfill this duty.
The Review suggests:

The operation of this responsibility needs to be discharged more consistently and more effectively, in particular to address the fact that people who are arrested under the criminal law are staying in police cells for too long, often unlawfully, after it has been established that they need to be admitted to hospital following a Mental Health Act assessment.

Ambulance services

The Review has some interesting things to say about the provision of ambulances for the conveyance of mental health patients. The bane of AMHPs’ lives (or at least one of them) is delays in ambulances attending to convey a detained patient.The Review sates:

Ambulance services should establish formal standards for responses to section 136 conveyances and all other mental health crisis calls and ambulance commissioners and ambulance trusts should improve the ambulance fleet, including commissioning bespoke mental health vehicles.

Conclusions

I have only concentrated on some of the highlights of the Review, which is after all, over 300 pages long.

Were all the recommendations to be taken on board by Parliament, I do think we would have a much more robust and rights based legislation for people with mental health problems.

But I see a lot of problems.

Some of the recommendations fall short of changes to legislation, recommending instead government policy changes, or changes to the wording of the Code of Practice. Sometimes it is difficult to detect the difference between suggesting what might be better, and proposing actual changes to the Act.

Many, if not most, of the necessary changes would require a huge additional investment in mental health services, which may not be forthcoming (in fact, until now, the reverse has been the case). Had adequate funding remained in place since 2007, there may not even have been a need to review the MHA.

It was first proposed that the MHA 1983 should be reformed as long ago as the late 1990’s. Several draft Mental Health Bills were published before the MHA 2007 (amending the 1983 Act) eventually came into law nearly 10 years later. Even if Parliament had the will, I would not expect to see any of these changes happening within the next 2-3 years.

The recent review of the Mental Capacity Act has led to a new Mental Capacity Bill which was markedly different from the Law Commission’s detailed proposals.

A Government press release in response to publication of the MHA Review, while stating that it is committed to reforming the MHA, appears to go on to say that is only accepting 2 of the recommendations, these apparently being:

Those detained under the Act will be allowed to nominate a person of their choice to be involved in decisions about their care. Currently, they have no say on which relative is contacted. This can lead to distant or unknown relatives being called upon to make important decisions about their care when they are at their most vulnerable.

People will also be able to express their preferences for care and treatment and have these listed in statutory ‘advance choice’ documents.

So I’ll not be holding my breath.