Monday, 23 August 2010

The Science Bit

A Brief Statistical Analysis of Outcomes of my Assessments under the Mental Health Act

A reader of this blog (hi, La-reve) recently asked how often in my experience admission to hospital was deemed necessary, and of those, how many resulted in formal detention under the Mental Health Act.

I thought this was an interesting question, so I had a trawl through my records. (Throughout my professional career I have kept meticulous records of assessments and outcomes. This is not [just] because I am obsessive-compulsive, but because AMHP’s have to be able to provide evidence of active practice in order to gain reapproval every 5 years.)

The total number of MHA assessments I have undertaken during my career so far that have resulted in either: no admission; informal admission; Sec.2; Sec.3; or Sec.4, is approaching 600. From these figures I have extracted the following statistics:

No admission: 35.8%
Informal admission: 15.6%
Sec.2: 18.5%

From this you will see that over a third of assessments did not result in an admission at all. Just under half of the assessments (48.6%) resulted in detention under Sections 2, 3 or 4.

There are a number of reasons why a formal assessment under the MHA may not result in an admission.

• The request may have been inappropriate or misguided.

• Detention under Sec.136 (when a police officer removes someone from a public place who appears to be mentally disordered) nearly always triggers a statutory duty for an AMHP and a doctor to assess under the MHA. However, many of these assessments do not result in a hospital admission. This is often because the person may have been under the influence of drugs or alcohol at the time of their initial detention, or because the detaining police officer misinterpreted the person’s behaviour (police have little formal training in mental disorder).

• An alternative to admission has been identified. This may be that the patient agrees to take medication, or that the Home Treatment team takes them on, or it is identified that a crisis is resolved, or an admission to a care home or respite has been arranged as an alternative.

• Increasingly I am getting requests for assessments under the MHA for older people with dementia who lack mental capacity who do not actually need admission to hospital but do need to be removed from a risky environment. In those cases, the powers under the Mental Capacity Act can, and should, be used.

There are of course quite a few people who find themselves being assessed on multiple occasions. I have written about some of them. There are several reasons for this.

• Some people with severe and enduring mental illness such as bipolar affective disorder or schizophrenia may have little insight into their illness and therefore can be prone to discontinuing medication and withdrawing from mental health services. This can then lead to an acute relapse. These people may require repeated admissions under Sections of the MHA.

• Some people, especially those with borderline or emotionally unstable personality disorders, may from time to time display alarming or disturbing behaviour that others may identify as “illness” and which may lead to formal assessments. Behaviours may include impulsive overdoses, self harming behaviour such as cutting or burning themselves, or making threats to harm themselves. However, it is generally recognised that admission to hospital for these people rarely achieves anything, and alternative strategies are usually preferable. I know that in my CMHT we try and work with people with personality disorder to reduce their risk behaviours as a response to stress or distress by helping them to devise alternative coping strategies.

The relationship you may have with an individual patient may also influence outcomes.

• It is more likely that someone with a history of mental health problems who is assessed by an AMHP and doctors who do not know the patient will be detained under the MHA, especially if the assessment is occurring outside normal working hours. Having worked in the past in an out of hours emergency social work service, I know that professionals are often less inclined to take risks when assessing in the middle of the night; they are also less likely to have access to information that may help them with their decision making, and may also have less access to support services and alternatives.

• If I know a person and have worked with them over a period of time (and possibly been in a situation in the past with them where I have had to undertake a formal assessment), it is sometimes possible to use the trust the patient may have to persuade them to take medication or to accept an informal admission.


  1. Good article.

    That breakdown "feels" about right for my practice too, though I don't keep quite as detailed records as you do, to check!

    With the changes to the Act when the amendments came into force, did you notice an upswing in 2s relative to 3? In a neighbouring county, I noticed that 2s became much more prevalent. In this county, it isn't nearly so pronounced a shift, but there's still a bit of a difference compared to pre the changes.

  2. I haven't particularly noticed an increase of 2's over 3's, certainly not as many as I would have expected, given the change in the law and guidance. However, some of the Responsible Clinicians do not seem to be aware of these changes, and I have at times had a run in with consultants who have gone for a Sec.3 straight away on inpatients admitted informally and who are not previously known to services.

  3. Thanks. this is interesting. So my 8 assesments and only one informal admission is not that unusual. If a little pointless. But then I did not what to say and when ;). In fact I used on of your quotes to get out of last assesments but thats another story.

    Anyway. thanks for breakdown. Its helpful o make sense of things other side now putting all behind me. x

  4. Hello I am finding your blog really intersting as i prepare for an interview next week returning to work as an AMHP after a year off work!!
    Really useful to think about what i would do in some of your cases as potential case studies! Can you offer any tips for preparing for my interview?

  5. Hello

    Your rate of declined admissions would be considered high in these parts. For a lot of staff 'doing a mental health act assessment' is virtually synonymous with 'admitting the person to hospital'. There may be good and bad reasons for this. The first is that staff have internalised the code of practice to such an extent that there's a high degree of informal consensus about thresholds for admission, staff don't do assessments out of idle curiousity and that pink forms only come out of the drawer when there is serious intent. The bad reasons are that resources to divert people from admissions are underdeveloped, that the AMHP's discretion to delay acting on medical recommendations are frequently neglected and staff play safe when considering admissions rather than taking calculated risks. What job you do also affects your strike rate, I was talking to an Emergency Duty Team colleague. She has a lower admission rate than daytime staff, partly because of dodgy s. 136 assessments that fizzle out in the small hours but also I'd imagine because most out of hours crises ultimately simmer down but might initially attract an emergency respone wheras CMHT staff know their clients well and would attempt to solve problems first before considering the use of MHA powers until such a time as they were considered unavoidable. The rate of negative assessments under the Deprivation of Liberties Safeguards is much higher. Because of the ever present example of the MHA it's difficult to convince people this is a good thing but I think it demonstrates that the assessment is an assessment, intended to find out an unknown outcome, not just an elaborate bureaucratic ritual to sanctify the decision we've all decided is inevitable.

  6. Thank you, Guilsfield, for all your thoughtful comments.