Tuesday, 27 November 2012

On Inappropriate Mental Health Act Requests

All AMHP’s will be familiar with being asked to do assessments under the Mental Health Act when it is not appropriate, but is motivated by the desire on the part of the caller to pass the buck. They might, for example, receive a request to assess an elderly person who actually just needs residential care, not a hospital admission, or to assess someone who is in emotional distress, where the professional involved with them is uneasy about leaving them over the weekend and just wants to relieve themselves of the responsibility.

Sometimes, it is possible to avoid a formal assessment. But at other times, you soon realise that, whatever the likely outcome, you’re going to have to go out and do a face to face assessment.

Back in the days when I did out of hours social work sessions, I was on duty one Saturday evening when I received a rather agitated call from the police.

They had a “situation”. They were asking for a MHA assessment to deal with it. They had earlier taken a call from Mike, the partner of Bella, because Bella had threatened to cut her wrists if he left the house. Mike was on police bail having assaulted Bella, but had been to see their six week old baby. The problem was that he would be in breach of his bail conditions if he did not leave, and stayed overnight.

When the police attended, they became embroiled in a domestic situation which did not seem to have an immediate solution. Mike wanted to leave, but Bella wouldn’t let him.

The police could not arrest Mike, as he had so far done nothing warranting arrest, and neither could they arrest Bella.

Bella had a considerable history of involvement with mental health services with depression, having had a couple of inpatient spells following suicide attempts, and had been receiving considerable support from mental health services, which in the past had included periods of 24 hour domiciliary care. She currently had regular visits from a domiciliary support worker in connection with the baby.

However, they could not detain Bella under Sec.136, as she was not in a public place. So they requested a formal assessment under the MHA.

It was further complicated by the presence in the house of a three year old child as well as the six week old baby. Removing the mother would raise considerable difficulties about who was to care for the children, especially the baby. In the circumstances, Mike was not an appropriate person to care for the baby, and the three year old was not in any case his child.

It became apparent that the only appropriate response as an on call social worker was to attend to make my own assessment.

The police were relieved to see me. So relieved, that they left almost immediately, despite me asking them to stay while I attempted to find a solution to the problem.

I decided to try to interview the two of them separately, but Bella was very reluctant to do this.

“He’ll leave the house if I let him out of my sight,” she said. “And then I’ll kill myself.”

“But I’ve got to go, or I’ll get arrested,” Mike pleaded.

“But you can’t leave me. I can’t live without you.”

Bella threw herself at Mike, who pushed her away and raised his fist. Bella seemed to be provoking him to hit her, but to his credit, he turned away, obviously distressed.

“I have to make a proper assessment,” I said. “I need to speak to both of you, but not together. Otherwise, we’ll just go round and round in circles and get nowhere. I have to be sure that both you and the children are going to be safe.”

“Leave the children out of this!” she screamed. “You’ll take them over my dead body!”

“I’m not proposing to take your children away, that’s the last thing I want to do, but I do need to make a proper assessment.”

I did eventually get them to agree to go into different rooms, and Mike promised he wouldn’t leave until I had completed my assessment.

With Mike out of the room, Bella slowly began to calmed down. She told me something of her mental health history, and talked about her fears that she would lose Mike because she had not been feeling like sex since her depression. I saw that she had cut her forearm, although it was only superficial.

She spoke to me of her feelings of inadequacy with looking after her new baby, feeling that she wasn’t a good enough mother. It became clear that this was at the root of her unwillingness to let Mike go, despite his violence towards her. I tried to reassure her, and gradually she relaxed and became less anxious.

I then talked to Mike on his own. He was in turmoil. He wanted to leave, but feared that Bella would harm herself. She had cut herself in front of him, and he had never encountered anyone deliberately self harming before. He couldn’t understand it, and that made him afraid – both for Bella and for his baby.

“Look, Mike,” I said. “Bella’s much calmer now, I suggest you leave now, while you’ve got the chance. I’ll see to Bella.”

I saw him out of the house, and heard him drive away.

Bella also heard him, but by the time she came out of the room she was in, he had gone. I persuaded her to make a cup of tea, and as we talked together, her anxiety subsided again. It became clear that she had a good relationship with her baby and older child, who were both blissfully asleep upstairs, and oblivious to the drama going on downstairs.

As we talked, Bella recovered some of her own confidence in herself, and began to make plans for both the immediate and the longer term future. I encouraged her to do this, and her mood began to brighten. She even managed a couple of smiles when talking about her children.

I was feeling increasingly confident that not only did Bella not require hospital admission, but that she was capable of caring for her children. Additionally, I was aware she was having a visit from a domiciliary care worker the following day, which would provide monitoring until normal office hours on the Monday.

I began to inwardly congratulate myself on having averted not only a detention to hospital under the MHA, but also the prospect of having to find a foster placement for a three year old toddler and a six week old baby late on a Saturday evening.

Then I heard a car pull up outside. Was it the police, coming back to check how things were going?

I went outside to investigate, and to my horror saw that Mike had returned. As he got out of the car, I asked him incredulously, “Why have you come back?”

“I wanted to make sure Bella and the kids were OK,” he said.

I found this hard to believe. I could only think he was somehow trying to stir things up some more. Perhaps he did not like feeling that Bella wasn’t, after all, entirely reliant on him.

At this point, Bella came out of the house. All her insecurities became reactivated.

“Don’t go, Mike, stay with me. I need you,” she pleaded.

“No, I can’t stay, I’ve got to go,” Mike replied, making a move to get back into the car.

Bella flung herself onto the bonnet of the car as he revved the engine.

“Don’t go, don’t go,” she repeated.

“I’ve got to go, I’ve got to go,” he yelled out of his window.

This was rapidly turning from pathos to bathos. I had to take control of the situation. Desperate measures were required

“Right,” I said, “It’s becoming apparent to me that you’re both clearly unable to look after your children. I’m going to have to get the police back, and they can make a Police Protection Order and take them to a place of safety.”

Bella was horror struck. She removed herself from the car bonnet and came towards me, pleading with me not to get the police. This gave Mike an opportunity to leave again, which thankfully he did.

 “Come on, Bella,” I said firmly but gently, “Let’s get back inside and check that the children are OK.”

 I stayed another half hour or so, mainly to make sure Mike did not decide to “check up” on Bella again, and when I was convinced that Bella was again calm and composed, I left.

Neither Bella nor the children came to any harm.

Thursday, 15 November 2012

The Abandoned Illness – the Schizophrenia Commission’s Report

The Schizophrenia Commission published their report on Schizophrenia and psychosis yesterday (14th November 2012). You can find the full report here.
It's a pretty scathing report. It lays bare the devastating effects on individuals experiencing this illness in the social, health and economic spheres. It finds that “people with severe mental illness such as schizophrenia still die 15-20 years earlier than other citizens”. It notes that “only 8% of people with schizophrenia are in employment”. Despite schizophrenia and psychosis costing society £11.8 billion a year the commission found “a broken and demoralised system that does not deliver the quality of treatment that is needed for people to recover.”  The report notes that “mental illness accounts for 23% of the disease burden in England, but gets only 13% of NHS resources.”
None of this comes as a surprise to professionals working in the mental health field. The report comes at a time when many mental health trusts are having to “reconfigure” services (a euphemism for devastating cuts in staff and resources, which have been necessary because of the year on year reductions in the budgets being doled out by central government.). One of the innovations the report praises are the creation of early intervention teams, specialist teams who focus on treating emerging psychosis at the earliest signs – but at the same time it observes that these same teams are being cut back in these trust “reconfigurations”.
The report also expresses concern about the increasing numbers of people treated under section, “partly because they delay seeking help until they are at crisis point. Levels of coercion are on the increase too, with a 5% increase in detentions under the Mental Health Act in 2010/2011 over the previous year.” (And it’s not getting better -- for the year 2011-12 there was a 6% increase.)
It notes too that “too much is spent on secure care – £1.2 billion or 19% of the mental health budget last year – with many people staying too long in expensive units when they are well enough to start back on the route to the community”. These people will be of course inevitably be detained under various sections of the MHA.
The commission unfortunately sees current and future changes in legislation continuing to adversely affect the prospects of people with serious mental illness. I have written here and elsewhere about my concerns about the suitability of the Work Capability Assessment when applied to people with mental illness. The commission makes it very clear that it is “not fit for purpose for people affected by mental illness and is in need of reform. The design of the assessment does not accurately identify the barriers they face in a working environment. There is also a low level of mental health expertise amongst assessors. Schizophrenia and psychosis can make it more difficult to complete the application and assessment process. Sadly, therefore, some of the most vulnerable claimants are potentially being excluded from the support they are entitled to.”
I wrote in the Guardian some months ago about my own experiences of accompanying people to these assessments, where it was quite apparent that the assessors often had no knowledge or understanding of mental illness. I found myself having to explain that paroxetine was an antidepressant, and the assessor only showed any interest in the assessment when the service user mentioned that he had a bad back – within seconds they had him on an examination table, manipulating his spine to see if he was experiencing any pain. But this was not the disabling condition.
The commission recommends “that the Work Capability Assessment process is amended for people with schizophrenia and psychosis to require the Department for Work and Pensions to seek information from health professionals to guide decisions rather than requiring potentially vulnerable people to navigate complex systems in order to provide it. The same principle should be built into plans relating to any qualifying assessment for the new Personal Independence Payment.”
Other changes affecting people with schizophrenia include the changes to eligibility criteria for personal budgets (the system whereby local authorities provide people with disabilities with money to help them with the problems they encounter in their lives in relation to their disability). To counter inconsistencies in the way this is administered, the Government is currently setting a national eligibility threshold through the Care and Support Bill regulations. The report expresses concern “that the social care eligibility threshold will be increased so that people with schizophrenia who are deemed to have ‘moderate’ needs (often due to their condition fluctuating) will lose support. Without this, a person’s mental health condition may deteriorate, resulting in a crisis and requiring access to more costly health or social care interventions, and possibly use of compulsory powers of the Mental Health Act.
The report makes many recommendations, designed to counter and resolve the indentified problems. The report is hopeful “that outcomes can be improved for everyone affected by severe mental illness. But it will require a radical overhaul of the system including an integrated approach with health and social services working together, a greater emphasis on patient preferences and a widespread application of flexible and innovative solutions. We do know what works – let’s apply it.”
I’d like to feel as optimistic as the Schizophrenia Commission appears to be, but I fear that “knowing what works” is not sufficient, when evidence based policy seems to be being replaced by political dogma.

Friday, 2 November 2012

Detentions under the Mental Health Act 1983: The Latest Statistics

What a tasty graph!
The latest statistics for people detained in hospital or on Community Treatment Orders has just come out. These cover the period from 1st April 2011 – 31st March 2012.

I always get a little moist looking at these statistics. I guess some people might think that’s just wrong, but what these statistics do is to lay bare some curious and perhaps unexpected consequences of law and policy, and they can provide insights into how the trends and changes in the real world impact on the use of the MHA with people with mental disorders.

So what do these latest statistics reveal? Well, last year, when the statistics for 2010-2011 came out, I wrote a post about what these statistics revealed about Community Treatment Orders (AreCommunity Treatment Orders Taking Over the Mental Health Act?).

I noted back then: “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.”

So what do the latest statistics show about CTO’s? Guess what, the report finds:

“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.”

Hand in hand with this is a reduction in the overall numbers of people admitted under Section 3. The report notes:

“In the 2011 publication of these statistics, we suggested that the decrease in the number of admissions via Part II Section 3 may be linked to the rise in the number of people on CTOs... Before the advent of CTOs, patients with a particular type of case would have been repeatedly admitted to hospital for treatment under this Section. What we may now be seeing is these patients are instead placed on CTOs and are seen in hospitals under recall instead. The underlying Section will only be reinstated if the CTO is revoked.”

As an AMHP, I am certainly 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). These CTO’s and CTO extensions also result in the necessity to write Tribunal and Managers Reports, and to attend Tribunals and Managers Hearings.

And what else do these statistics reveal?

“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.”

What exactly does this mean? Although the total numbers of people detained in independent hospitals is small compared to detentions in NHS hospitals (3,045 compared to 27,855) there is a very strange discrepancy between Sec.2 admissions to independent hospitals in 2010-11 (696) and in 2011-12 (1,011) – an increase of 45% year on year.

I have a theory about this, based on my and my local AMHP colleagues’ experience. While I cannot comment on AMHP’s experiences in other parts of the country (although I would welcome feedback from other AMHP’s) what I do know is that my colleagues have been finding it increasingly difficult to find beds in local NHS hospitals.

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.

And how has this shortage arisen in the first place? Could it be anything to do with the year on year cutbacks to NHS and mental health funding, which has resulted in reductions in beds, and in the numbers of community staff, who might be able to avoid admissions in the first place (and with more to come as the cuts continue to bite)? I couldn’t possibly comment.

I have noticed some other intriguing trends in these figures. One relates to the use of Sec.4. The report says:

“Section 4 is used to detain a person when emergency assessment is required and compliance with the usual Section 2 requirements would involve an ‘undesirable delay’. Uses of this power have decreased by 14 per cent since 2010/11 (from 535 to 458), continuing a downward trend in its use over the last five years (in the 2007/08 reporting year, there were 851 uses of Section 4).”

Although the use of Sec.4 is comparatively rare, it is good to see that its use is declining year on year, as it is frequently only used when it has been impossible to obtain a Sec.12 approved doctor, who has particular experience and knowledge of mental disorder. I would like to think that this is because it is becoming easier to obtain Sec.12 doctors for assessments.

Then there are the statistics for the use of Sec.136. Sec.136 is used by the police when they find someone in a public place who appears to be mentally disordered and in need of care or control. This seems to have increased year on year at the same rate that Sec.4 detentions have decreased over the same time (not that I can see a connection, mind). Also the numbers are hugely different: in 2011-12 a total of 23,569 people were detained by police under Sec.136.

The report comments:

“During 2011/12 the majority (11,567 out of 14,149) of Section 136 uses in a hospital setting did not result in formal detention (under Section 2 or 3). Following use of Section 136, a patient who is not detained is either discharged or remains in hospital voluntarily, but data on these outcomes is not collected separately. The proportion of Section 136 uses not resulting in detention has increased from 71 per cent in 2007/08 to 82 per cent in the most recent reporting year.”

I think these figures are troubling. Since the latest figures show that 82% of people on Sec.136 are not then formally detained (there are unfortunately no statistics to differentiate between people who then remained in hospital informally and those who were not subsequently admitted to hospital at all), it seems to be intimating that the police are frequently using their powers under Sec.136 inappropriately.

Some of these detentions might be due to intoxication by drugs or alcohol, which would not tend to result in eventual hospital admission, but which could provide a police officer with sufficient grounds to use Sec.136. However, it may also indicate a need for more training for police officers in identifying mental disorder in the first place.

There’s a lot more to be gleaned from this report. Those sufficiently interested can study them in full here.