Can a person be detained under more than one section of the Mental Health Act at once?

This is by no means as straightforward an issue as it may seem, and can from time to time create difficulties and anomalies.

While as a general rule, a person cannot be subject to more than one section of the MHA simultaneously, there are exceptions to this rule. There are also implications regarding whether or not certain sections can continue once a decision has been made.

I’ll look at some examples.

S.5(2)

The Code of Practice states that S.5(2) cannot apply “to a patient who is already liable to be detained under section 2, 3 or 4 of the Act”(para18.7).

If an informal hospital patient is detained under S.5(2) an AMHP has up to 72 hours to arrange an assessment with a view to detaining under S.2 or S.3. Once a decision has been made, and an application completed for S.2 or S.3, the S.5(2) detention ends. This also applies if the decision is made not to detain.

The Code of Practice states: “Although the holding power lasts for a maximum of 72 hours, it should not be used to continue to detain patients after the doctor or approved clinician decides that, in fact, no assessment for a possible application needs to be carried out, or a decision is taken not to make an application for the patient’s detention.”(para18.20)

Additionally, it needs to be borne in mind that detention under S.5(2) does not permit the patient to be moved from one hospital to another. If they are moved, for example from a general hospital to a psychiatric hospital, or vice versa, then the S.5(2) would automatically end.

What about S.2 to S.3?

Ah. If an AMHP assesses a patient who is detained under S.2 for assessment with a view to detention under S.3 for treatment, and makes the decision not to detain them, then, although best practice would be for the Responsible Clinician to discharge them from S.2, there is no requirement to do so, so the S.2 could legally continue to the end of the 28 day period of detention.

There are situations in which this could be justified. An example that springs to mind is where a patient has been detained under S.2 and the request to detain under S.3 comes within the first couple of weeks of the original detention. The AMHP may consider that it is too premature to consider detention under S.3, which could last for up to 6 months, and may think that the patient’s condition could improve sufficiently over the remaining time of the S.2 to make further detention unnecessary.

S.136

A similar rule as that for S.5(2) applies for detention under S.136. If an AMHP and at least one doctor have assessed and decided that a patient detained under S.136 does not need to be detained under the MHA, the S.136 can remain in force only while any necessary arrangements are made for the disposal of the patient, such as arrangements for informal admission or transport home. The Code also points out that someone subject to S.135(1) or S.136 cannot be placed on S.5(2), since S.5(2) only applies to inpatients.

The S.136 will also remain in force while arrangements are being made for a hospital that is able to take the patient if it has been decided to detain under S.2 or S.3. Of course, this will only apply until the end of the maximum length of detention of 24 hours.

Assuming there is a bed, then the S.136 ends as soon as the relevant application has been made. As the patient is then liable to be detained, this authorises the AMHP, the police or any other relevant person to hold the patient in custody until they can be transferred to hospital.

The same will apply for a patient detained under S.135(1) who has either been taken to a place of safety for assessment, or assessed at the place where the warrant has been executed.

Guardianship (S.7)

No-one can be detained simultaneously under both Sec.3 and S.7, as the Reference Guide states: “Once a patient subject to guardianship is admitted for treatment, the guardianship ceases.” (para8.99)

However, a patient subject to Guardianship can be detained under S.2 (and S.4) (para30.36).

Community Treatment Orders

Possibly because Community Treatment Orders were added to the MHA 1983 by the 2007 MHA, many years after the original drafting, it gets rather more complicated.

Because people can only be subject to a CTO if they are detained under S.3, people on CTO’s can be regarded as still subject to the original, latent, S.3.

The Reference Guide states unequivocally that someone on a CTO cannot be made subject to S.5(2)(para8.72). It goes on to explain that “because patients on CTOs can be recalled to hospital for treatment if required, it should not be necessary to make applications for their detention.”(para8.96) The Code states that “where the person is known to be on a CTO and compulsory admission is indicated, the recall power should be used”(para18.17)

You might think therefore, that no other sections of the MHA can be used with people on CTOs, but that is not necessarily the case. The Reference Guide recognises that in practice patients may end up being detained under other sections “if the people making the application do not know that the patient is on a CTO"(para8.96). It goes on to state:

An application for admission for assessment under section 2 or 4 does not affect the patient’s CTO. Nor does an application for admission for treatment under section 3 if, before going onto a community treatment order (CTO), the patient had been detained on the basis of a hospital order, hospital direction or transfer direction under part 3 of the Act. (para8.97)

So this does mean that a police officer, not being aware of a person’s status as being subject to a CTO, may legitimately detain someone under S.136.

Consequently, an AMHP and a doctor would still need to assess in accordance with the requirements of S.136, but if they decided the person needed to be admitted to hospital, they could then make arrangements for their recall to hospital under the rules for a CTO.

An application for detention for treatment under S.3 would automatically end a CTO, in the same way that a S.3 would end a Guardianship Order. However, the Code says, “an application for detention should not be made in respect of a person who is known to be on a CTO” (para15.17), so the correct procedure would be recall to hospital, followed by revocation of the CTO if necessary. That action will then reactivate the latent S.3.

If in ignorance, perhaps because the person on a CTO has turned up in another part of the country, they are then detained under S.2 or S.4, the recall and revocation process can be initiated once the person’s true status is known, and once the S.3 had been restored, any other sections would cease to have effect.

I hope that’s cleared up any confusion.

Can Conditions Imposed Under Sec.37/41 Breach Article 8 Human Rights? Recent Case Law

Conditions can be imposed on patients subject to conditional discharge under Sec.37/41 MHA, as well as those subject to Community Treatment Orders under Sec.17A MHA. These can impose considerable limits on a patient’s freedom, such as stating where the patient must live, and what they can and can’t do. These conditions can include anything from stipulating whether or how a patient can access the internet, to prohibitions on drinking alcohol or taking illegal drugs.

Generally, patients do not object to these conditions, if it means that they can be released from hospital, so there is little case law relating to whether or not such requirements could breach an individual’s human rights. However, a recent Upper Tribunal appeal did address this issue.

The Upper Tribunal considered an appeal from the 1^st Tier Mental Health Tribunal concerning a conditionally discharged patient (RP v Dudley and Walsall Mental Health Partnership NHS Trust and the Secretary ofState for Justice, [2016]UKUT 204 (AAC) (26 April 2016).

RP had a diagnosis of paranoid schizophrenia, and had been made subject to hospital and restriction orders under Sec.37/41 following convictions for offences of violence.

He was conditionally discharged in September 2011, and had been living in the community since then. RP’s order and conditions were reviewed by a 1^st Tier Tribunal in February 2015, who decided the conditions should continue.

The appeal was based on the contention that there had been errors in law, the most significant being that the Tribunal had failed to comply with the patient’s right under Article 8, and it was this aspect that the Upper Tribunal had to consider.

Article 8 of the Human Rights Act is, of course, concerned with the right to respect for private and family life.

Specifically, Article 8 states:

1. Everyone has the right to respect for his private and family life, his home and his correspondence.

2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.

One of the conditions stated that “The patient shall abstain from using illicit drugs and steroids. He is also to refrain from the consumption of alcohol to excess.” It was the contention of the patient’s solicitors that this breached his human rights.

The Upper Tribunal gave this due consideration, stating:

 It is possible, for example, that the conditions imposed on a conditional discharge might represent an unjustified interference with private or family life. The tribunal is entitled to expect a representative to draw attention to any specific Article 8 issues that arise.

The Judge went on to state:

Most conditions that are imposed on conditional discharges are capable of being operated oppressively, but in practice they are not. It is understood when the conditions are imposed that they will be applied reasonably and according to the circumstances at the time. Intervention may be light-handed or heavy-handed as required. The application of Article 8 will be calibrated to the needs of the patient and the public. The tribunal is more likely to be concerned to ensure that the conditions are reasonable in principle.

Considering the condition relating to “excess alcohol consumption”, the Judge concluded:

It is, as the solicitors say, inherently vague. But it is reasonable for a tribunal to impose some kind of control over alcohol consumption and the difficulties of precise definition are capable of causing as many problems as they try to solve. What matters is how the conditions are operated and Article 8 operates to protect the patient at that stage.

The decision therefore was that the conditions of the discharge, even the contentious issue relating to drug and alcohol use, did not breach the patient’s Article 8 Human Rights.

CTO’s – Fit for Purpose?

Community Treatment Orders were introduced by the 2007 changes to the Mental Health Act 1983, and came into force in 2008.

The New Code of Practice states that the purpose of a CTO “is to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.” (Para.29.5)

It goes on to suggest that CTO’s could be regarded as fulfilling the principles of  treating patients using the least restrictive option and maximising their independence.

CTO’s have been very popular since their inception in 2008. This could be at least partly due to the process being initiated and managed by psychiatrists rather than AMHP’s, unlike with admission to hospital under Sec.2, 3, or 4, where an AMHP, as a non-medical professional, leads the process and makes the final decision.

But CTO’s have also been very contentious. Critics regard them as being excessively controlling and interfering with patients’ human rights, while supporters regard them as a way of enabling patients with severe and enduring mental disorder to live as normal and fulfilled a life as possible outside hospital.

Both views have their merits. It is one thing to argue that it is unreasonable to enforce treatment on a person who is not in a hospital, but there is also a point in arguing that it has to be better that someone remains out of hospital as long as there is a framework to ensure treatment for their mental disorder.

For compulsory treatment in the community to be justifiable, it has to be shown not only that it results in fewer admissions to hospital, but that is can also demonstrate a better quality of life for the patients involved.

So has there been a reduction in the numbers of admissions since 2008? It appears not. The Health and Social Care Information Centre (HSCIC) publish annual statistics for patients formally detained under the MHA, and for people subject to CTO’s. The figures for 2013-14 came out at the end of October 2014.

The Report states that since 2008 the number of people subject to CTO’s as of 31st March 2014 has more than doubled, an increase of 206% or 3,610. Over the same period there has indeed been a reduction in the number of people detained under Sec.3 for treatment, which must be linked to the increase in CTO’s, as patients can be recalled to hospital and their CTO’s revoked without the need for a fresh assessment under the MHA.

However, over the same period, overall detentions in hospital under the MHA have increased by a third, so that in the period 2013-14 “the Act was used 53,176 times to detain patients in hospital for longer than 72 hours” (ie. Under Sec.2 or Sec.3).

So, while there has been a reduction of people detained in hospital under Sec.3, mainly as a result of the introduction of CTO’s, overall detentions have increased to record levels.

While it may be tempting to reach the conclusion that CTO’s have not fulfilled their function of reducing admissions to hospital, the reality is far more complex, as it is likely that the nationwide cutbacks in services for people with mental health problems over the same period have contributed to this rise in acute admissions.

The only significant research into the link between CTO’s and hospital admissions is the OCTET Trial, published in 2013.

The object of this research was to see if CTO’s reduced readmission. They monitored the samples (a total of 333, of whom 166 were discharged on CTO’s and the rest on extended Sec.17 leave) for 12 months. Their conclusion was that “the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty.”

While the conclusion seemed unequivocal, I had some considerable misgivings about the usefulness of this piece of research, not least because of the miniscule size of the sample, which I wrote about on this blog back in April 2013. It is clear that much more research needs to be done in this area.

So what about the effectiveness of CTO’s in improving the quality of life of patients?

Unfortunately, there is again very little research into this, and it would appear that there is none at all in the UK. However, other countries have equivalent powers, including Australia, New Zealand, the USA and Israel, and there has been a recent review of available research, Compulsory community and involuntary outpatient treatment for people with severe mental disorders, by Steve Kisley and Leslie Campbell, which was published in December 2014.

The research looked at three trials consisting of a total of 752 people. The report concluded: “Results from the trials showed overall [compulsory community treatment] was no more likely to result in better service use, social functioning, mental state or quality of life compared with standard 'voluntary' care.”

It did note that “people receiving CCT were less likely to be victims of violent or non-violent crime.”

There are some provisos to these findings. For a start, the authors considered that the quality of evidence for the main outcomes was low to medium grade. They also noted that “other than feelings of coercion or being controlled, there were no other negative outcomes”

None of the available research satisfactorily provides evidence one way or another for the efficacy or otherwise of compulsory community treatment. All that is certain is that there should be much more research if such a potentially contentious form of intervention is to continue to be used at the current levels.

CTO’s and a dreadful case of unlawful imprisonment

Mistakes in law can come back to haunt you, even many years later.

A recent Court of Appeal  judgment on 10^th February 2015 ([2015] EWCA Civ 79) considered a request for compensation for unlawful imprisonment arising as a result of illegally imposing, then revoking, a Community Treatment Order which went as far back as 2009.

This related to a man called Lee Bostridge. He was lawfully detained under Sec.3 MHA in July 2008. In April 2009 a mental health tribunal reviewed his case and ordered his discharge, suggesting in the process that he should be discharged on a CTO.

But by so doing, the tribunal had committed an error in law. A CTO can only be imposed on a person who is "liable to be detained in a hospital in pursuance of an application for admission for treatment", but as the tribunal in their judgment no longer considered that that applied to Mr Bostridge, the subsequent CTO was by definition unlawful. (In essence, anyone on a CTO continues to be subject to detention under Sec.3, and when a CTO is revoked, the underlying Sec.3 detention comes back into force.)

After Mr Bostridge was discharged on this erroneous CTO in April 2009, he remained in the community until August, at which point his Responsible Clinician recalled him to hospital, under his powers of recall, and then revoked the CTO.

Despite having had two tribunals during this period of detention, it was not until 3^rd November 2010, when he attended another mental health tribunal, that it was realised that his initial discharge on a CTO back in 2009 was unlawful, and that he had therefore been unlawfully imprisoned for a grand total of 442 days!

As soon as this was discovered, Mr Bostridge was immediately released. However, I don’t think he can have enjoyed much time out of hospital, as he was assessed and lawfully detained under Sec.3 on the same day. This period of (lawful) detention lasted until 13^th September 2011.

Mr Bostridge received compensation for the 442 days that he was illegally deprived of his liberty. However, he appealed to the higher court on the basis that he ought to be entitled to a greater, and perhaps exemplary, compensation payment.

The Court of Appeal disagreed with the less than fortunate Mr Bostridge, concluding that “had the appellant been detained lawfully, he would have suffered the same unhappiness and distress that he suffered anyway”. He had therefore suffered no significant loss, and was not therefore entitled to any more than a nominal payment.

This sort of mistake was not unknown in the period following the introduction of CTO’s, which came into force as a result of the amendments to the MHA 1983 in the MHA 2007.

As well as having the power to discharge patients from detention under the MHA (generally Sec.2 & Sec.3), tribunals are allowed to make suggestions as to the disposal and aftercare of a detained patient and frequently do.

The tribunal regulations state that tribunals must discharge if certain things are concluded. One of these is if the tribunal is “not satisfied that the patient is then suffering from mental disorder of a nature or degree which makes it appropriate for the patient to be liable to be detained in hospital for medical treatment”.

Since Mr Bostridge’s tribunal had come to this conclusion, even though they were merely trying to be helpful in guiding the hospital towards a decision to use a CTO, the consequence of their decision was to make it illegal for the hospital to follow their suggestion.

Isn’t the law a wonderful thing?

The Case of QR: Capacity and Tenancy Agreements

This very recent judgment was published on 5thAugust 2014. It concerns tenancy agreements, and the issue of a person’s capacity to end, or indeed, to take out a tenancy agreement. It also highlights a situation which is covered by neither the Mental Health Act nor the Mental Capacity Act, but requires referral to the Court of Protection for a decision.

QR is a woman of 62. She has a diagnosis of paranoid schizophrenia. Her first serious episode was in 1995 at the age of 43, and she has had numerous detentions under both Sec.2 & Sec.3 MHA since then. She was discharged from hospital in December 2010, since when she has been subject to a CTO. Until her most recent admission to hospital, she lived in a local authority flat, and still has the tenancy of this property.

One of the conditions of the CTO is to reside in “ABC”, a residential treatment centre run by the local authority. The mental health team now consider that she no longer needs this level of support. However, the Judge records: “She must live in accommodation which provides 24 hour support and monitoring, so that QR will continue to be compliant with her medication and avoid the risk of a possibly fatal relapse.”

Her team now want her to live in a more independent living situation, but consider that there is too great a risk to her health and safety for her to return to her previous flat. However, QR will need to sign a tenancy agreement in order to move into a supported living flat, and must first surrender her existing tenancy.

In the words of the Judge the crux of the case is that “QR objects to the application on the grounds that she has capacity to decide whether to surrender the tenancy of her current flat and to sign a tenancy agreement for supported living accommodation.  She does not wish to surrender the secure tenancy of her council flat which is important to her and she does not wish to move to any of the proposed supported living options which have been proposed”.

The issue the Judge had to decide was whether or not QR has the capacity to decide where she should live, to surrender the tenancy of her flat and to sign a new tenancy agreement.

The issue of capacity is, of course, situation specific. A person may have the capacity to decide whether or not to have a cup of tea, but may lack the capacity to make a decision about where they should live.

In this particular case, the Judge concluded that “I am satisfied that QR is unable to make the decisions at stake in this case as a result of the nature of her mental illness.” He went on to say that “QR is not able to give weight to the issue of central importance in the arrangements which [the mental health team] propose, the reason why she needs to take her medication.”

This particular case has not yet reached a conclusion. Still to be decided is “what further evidence if any is required in order that a best interests decision on the issues before the court can be made.”

The implications of this case relate to the issue of the ability of someone with a mental disorder of any sort to either take on a tenancy or to relinquish a tenancy.

This has often not been considered when making arrangements for people who may lack capacity in certain areas because of learning difficulties, dementia or mental illness.

From time to time, and for the best possible reasons, professionals working with such people assist them in obtaining accommodation for which that individual will need to make decisions regarding signing or relinquishing a tenancy, and professionals may not consider the issue of whether or not they actually have the capacity to make those decisions.

While a person can be made subject to conditions in a Community Treatment Order, such as a condition to reside in a certain place, this power does not extend to either terminating a tenancy or taking out a tenancy on their behalf.

If the person  subject to such conditions does not have capacity in that area, then any legal decisions they make may be invalid. In such cases, referral to the Court of Protection appears to be the only remedy.

Review: Approved Mental Health Practice, edited by Sarah Matthews, Philip O’Hare & Jill Hemmington

 

The subtitle of this new book is “Essential Themes of Students and Practitioners”, and I would certainly endorse this. This is the only serious text of which I am aware that focuses entirely on professional practice under the Mental Heath Acts of the United Kingdom.

The authors grapple with the conflict between the social work role of empowerment and the AMHP powers that can lead to coercion and the imposition of social and medical control, and this book provides an excellent examination of the tensions existing in the role of the approved mental health practitioner, allowing the student and practitioner to reflect on the role in the context of the wider social perspective.

As the book is directed at an examination of practice under all the UK’s mental health legislation, they generally describe the professional as an “approved mental health practitioner”, so I will continue to use this terminology in this review, and the abbreviation of “AMHP” should be read in this way.

Sarah Matthews starts by posing the question, “Do social workers as approved mental health practitioners struggle to promote a model that views the manifestations of mental health in any way other than the dominant and, some argue, pathological one?” She goes on to outline the fundamental aspects of approved mental health practice. These include the social perspective as being central, as well as the independent nature of the role. She also stresses the importance of emotional engagement, containment and the concept of “dirty work” as contributing to the unique role of the AMHP. She states: “The mother, it is suggested, contains others’ distress without appearing to be affected by it herself and it is this which an approved mental health practitioner might also accomplish.”

I was particularly intrigued by her discussion of work under the MHA as being “dirty work”. Dirty work “describes the notion that people are compelled to play a role in work about which they ought to be a little ashamed, morally… A profession embraces unpleasant tasks as a means of establishing its credibility or undertakes such tasks as a necessary, albeit difficult, element.”

Tim Spencer-Lane provides an analysis of the legal and political factors in England and Wales that led to the revision of the 1983 Act and the creation of Approved Mental Health Professionals. Having practiced under Mental Health Acts since 1981, I have lived through these changes, and have been professionally associated with the issues which eventually led to the 2007 Act. He makes the interesting point that the MHA 2007 “was the result of a long and embittered battle between the Government and the major stakeholders about the fundamental purpose of mental health law”, whereas the Mental Capacity Act 2005 was developed in broad consensus and was the culmination of a long consultation process.

Jean Gordon and Roger Davis go on to compare and contrast mental health law in Scotland and Northern Ireland (although omits the Isle of Man Mental health Act 1998, which, like Northern Ireland, retains the Approved Social Worker).

David Pilgrim makes interesting points about the way in which mental health professionals can make basic assumptions about mental health practice which may be at odds with reality. He makes the point that "third-party interests constantly shape professional decision making and action. Indeed, at its most coercive, mental health work considers the needs of the identified patients only after others are protected from their prospective presence and actions... It is soon evident that public safety and institutional order can dominate staff decision making."

He argues, with some justification, that the MHA in England and Wales is more concerned with controlling mental disorder than with the promotion of mental health. This makes the AMHP role innately coercive, and he poses some challenging questions about the validity of enforcing compulsory treatment with drugs which are at best only moderately effective, and at worst can cause serious harm or even death.

Helen Spandler tackles problems around psychiatric diagnosis, wishing to "equip approved mental health practitioners with the knowledge to question, challenge and understand the broader meaning of mental disorder and diagnosis," in order for us to be "more cautious and thoughtful about the language we use to describe mental health crises."

She reviews the different approaches to diagnosis, from psychiatric, psychological and service user perspectives, often using as examples the ways in which the long term effects of childhood trauma can be interpreted as either normal reactions to extreme life events, or pathology indicating mental illness or disorder.

She suggests that a more useful, and service user centred approach for an AMHP to take is to assess levels of impairment and functioning, rather than diagnosis, to determine access to services and using mental health legislation. While expressing scepticism about the use of diagnosis, she states that "it is important not to let the endorsement or criticism of diagnosis get in the way of decision-making." Any alternative to conventional diagnosis "must result in better consequences for people in terms of gaining the more appropriate support and assistance."

Daisy Bogg examines ethics and values in the context of approved mental health practice, tackling in the process some of the ethical dilemmas inherent in the use of Community Treatment Orders, observing that "approved mental health practitioners serve as a counterbalance to a single dominant medical perspective and are required to provide a more holistic view, and account for the whole circumstances of an individual's situation before making a decision to apply for compulsory admission."

Amanda Taylor and Jill Hemmington's chapter on Diversity in Mental Health sets out to "challenge notions of diversity being simply and solely located within traditional, fixed dimensions and to alternatively view it as being unique to the individual, group and community." They warn that approved mental health practitioners need to be aware that they "belong to a 'dominant social group' that 'maintain systems of privilege and oppression'".

They give as an illustration an in depth analysis of Deafness, including specific case studies, using these to show that "it is vital that as practitioners we can seek that which is outside of the self and consider not only the diversity relating to the other but go some way to working within their 'internal frame of reference' to understand the layers that exist."

They conclude: "Empathy, 'tuning in' and constantly asking oneself questions are the starting points to a thorough, effective assessment that has honesty and collaborative work at its core."

I was particularly intrigued by Anthea Murr and Tamsin Waterhouse's chapter on "The Impact of Time and Place", as it focused on assessments in rural areas. Readers of this blog will be aware that I work predominantly in a rural area; even the towns in my area have populations of less than 30,000. They outline the special factors that can impact on the mental health of people living in rural areas, such as physical, social, cultural, psychological and geographical isolation, as well as the problems of rural poverty, and conclude that practitioners working in rural areas need to have special training and acclimatisation to prepare them for these particular challenges.

Julie Ridley outlines a study of service users’ experiences of mental health legislation in Scotland. Although specific to Scotland, this study is also of relevance to professionals working throughout the UK.

Experiences of compulsion varied from the positive to the negative, perhaps not unexpectedly. Some service users welcomed having “‘responsibility taken away’ and a structure to daily life imposed”, while others described it as a “nightmare” experience.

Philip O’Hare and Gavin Davidson devote a chapter to the role of the Nearest Relative, tracing the history of this role in mental health legislation going back to the 18^th century, and its evolution in more recent Mental Health Acts. They make the point that improvements in social work training and the changes to practice brought about by the Seebohm in the 1970’s added to pressure to replace the 1959 Mental Health Act with legislation that recognised the professional competence of social workers. This led to the 1983 Act, where the Approved Social Worker became the preferred applicant in applications for detention.

I was intrigued by the statistic that in the early years following the introduction of the 1983 Act only 1.6% of application were made by Nearest Relatives. I suspect that this figure is now even lower.

Practicing exclusively in England, I did not realise that legislation in Scotland had ended the Nearest Relative role as applicant for detention. I was interested to read that the other parts of this role have been replaced by a “named person”, who is nominated by the patient. Although this seems like an admirable idea, and would obviate the current difficulties that AMHP’s can find in identifying and consulting with the Nearest Relative, this idea was unfortunately not taken up when drafting the 2007 Act.

Philip O’Hare discusses to what extent evidence-based practice can inform approved mental health practice. There is a paucity of evidence on which to base evidence-based practice within mental health legislation,; evidence-based practice is essentially based on the medical model, which can be hard to replicate in a social care context.

O’Hare asks the question “How to AMHP’s make sense of their legal roles being informed by practice, and looks at making decisions based on least restrictive concepts, applying this in particular to the AMHP role in Community Treatment Orders: “how does an AMHP make a distinction between justified and unjustified CTO’s?”

Unfortunately, despite rather sketchy research into the efficacy of CTO’s, it is very difficult to assess the likely beneficial impact of a CTO on any particular individual, other than anecdotal evidence relating to length of time without a hospital admission. How can you test whether the conditions of a CTO have positively influenced a specific patient?

Jill Hemmington examines how AMHP’s have to manage uncertainty, and how one can develop practice wisdom. She makes the point that approved mental health practice “has been described as ‘crisis, mess and muddle’ where Mental Health Act assessments often arise from and within situations where there is ‘panic and confusion’”. She makes an interesting attempt to apply crisis theory to AMHP work, and also points out that “because something is lawful, it is not automatically ethical”.

She poses a number of pertinent questions for an AMHP to consider relating to their practice, for example, “How did I influence the situation through: my presence, my actions, my preconceptions or assumptions, other people’s perceptions of me, my physical well-being on the day?”

The editors conclude that “for an AMHP the focus is on how to interpret and analyse appropriately and avoid any illusion that there can be certainty.”

Each chapter contains reflective questions, which are designed to provoke stimulating discussions in student seminars, and which would also be useful for AMHP’s who are preparing reapproval portfolios to evidence reflective practice and to elicit learning points from professional experience.

I found the book as a whole stimulating and thought-provoking. It was a pleasure to read a book that directly addresses the dilemmas with which I am faced every day of my professional life.

I wholeheartedly recommend this book to anyone interested in the AMHP role, including those undergoing AMHP training, AMHP’s preparing for reapproval, and social work and mental health nursing students who seek to obtain a deeper understanding of the moral and legal complexities of the role.

Approved Mental Health Practice: Essential Themes for Students and Practitioners
Edited By Sarah Matthews, Philip O'Hare and Jill Hemmington
Palgrave Macmillan, April 2014
ISBN: 1-137-00013-9, 978-1-137-00013-2

Ask the AMHP – a new occasional column

Ask The Masked AMHP for the answers to your thorny MHA related problems. He might know the answer. Or not.

Here’s a question I recently received from a rather stressed and anxious AMHP (but then they all are, aren’t they?)

I’ve got 2 medical recommendations for Sec.3 on a patient who is in the medical assessment unit of our local hospital, but lives outside our area. The other area is currently trying to find a bed. Can I complete this application?

The Masked AMHP replies:

No, I’m afraid you can’t. You have to have the name and address of a hospital prepared to take the patient on your application form before you can sign it and therefore complete the application. But it’s even worse – your two doctors can’t make a recommendation for Sec.3 unless they can state the name of a hospital where appropriate treatment can be provided. And if they start giving a very long list of possible hospitals, in the hope that one of them might become available for the patient, that sort of defeats the object of suitable treatment being available.

The only thing I can suggest is that your two doctors make a recommendation for Sec.2. then they won’t have to name a hospital, and they can then leave. Since your patient is actually currently an inpatient on a general ward, you could see if you can detain the patient on that ward under Sec.2. You can then complete your application and the patient will be formally detained. The patient can then be transferred under the usual transfer arrangements once the other area has found a bed.

Here’s a question I had emailed to me by a student AMHP.

I am a student AMHP and a recent dilemma in the office has prompted me to write to you. If a person is on a CTO and the conditions of this are that they receive treatment in supported living should the living cost ie rent be paid through S117, local policy says not but I wanted to check.

Also, the local policy says that the person does not legally have to accept the S117 aftercare, however how does this fit in with aftercare that is a requirement of the CTO?

The Masked AMHP replies:

There is quite a bit of case law about S117 and housing costs, which I have covered on my blog. Normal living expenses, eg food, electricity, housing, are universal needs and are not arising from a mental health need. Therefore they are not covered by S117.

If the S117 aftercare is explicitly covered by the conditions of the CTO, eg that the patient resides in a certain place, then a failure to do so breaches his CTO. In such a situation, the patient would have to accept S117 aftercare.

Here’s a question from the blog:

Have you ever known a situation where one doctor disagrees and will not furnish a recommendation so a third doctor is sought in order to detain?

The Masked AMHP replies:

I have certainly had situations where one doctor has furnished a recommendation, but a second Sec.12 doctor has disagreed and refused. This is not uncommon for someone who is an inpatient, and the hospital Responsible Clinician has left a medical recommendation on the ward. I have to say that in these situations, I have been satisfied to go along with this and not therefore proceed with an application. However, theoretically, if as an AMHP you feel the dissenting doctor is acting perversely, and you are very concerned about risks to the patient if they are not detained, I do not regard it an unethical of obtain a further medical opinion. However, there’d have to be a limit to the number of doctors you could consult.

And here’s a final question from another stressed and anxious AMHP:

I’ve got a 16 year old girl on a Sec.2 in a private hospital. We do not feel she needs to be in hospital, and we have arranged for an alternative placement. The Community Responsible Clinician backs this plan. However, the hospital Responsible Clinician refuses to discharge her from hospital, and will not discharge the Sec.2. What can we do?

The Masked AMHP replies:

Crumbs! What a peculiar situation. The hospital RC has the final say in this, regardless of what the community RC thinks, and even if the community RC provided one of the recommendations. The patient can appeal against the decision, and as it’s a Sec.2 the Tribunal would generally be within 3 working days. In the meantime, you as the AMHP could make it clear that you would be recommending discharge, which might concentrate the mind of the hospital RC.

Keep your questions coming in! The Masked AMHP is always happy to try to assist.

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 30^th 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.

Are CTO’s Any Good? Observations on the OCTET Trial

 

I recently read the abstract of the OCTET research into the use of Community Treatment Orders for patients with psychosis published in the Lancet on 26^th March 2013. I’ve only read the abstract because, despite the research being funded from public money via the National Institute of Health Research, the full report is only available behind a paywall. So I apologise now if I’ve missed something important.

 

The burgeoning use of CTO’s since 2008 to manage mentally disordered people in the community is something I have written about on a number of occasions, if only because it has become an increasingly large part of an AMHP’s work – the AMHP has to endorse an application for a CTO, an extension of a CTO and the revocation of a CTO. All these require assessments, reports on the assessments, and these actions also often precipitate a Managers Hearing or a Mental Health Tribunal, both of which require the writing of a report and attendance at the hearing.

 

The trial selected detained patients with a diagnosis of psychosis. The total sample consisted of 333. Half the sample (166) were discharged on a CTO and the other half (167) were made subject to extended Sec.17 leave. Sec.17 leave is a process whereby a patient is not formally discharged from detention under Sec.3 Mental Health Act, but allowed out of the hospital on leave. They can be recalled at any time, with little formality.

 

The object of the research was to see if CTO’s reduced readmission. They monitored the samples for 12 months. Their conclusion was that “the imposition of compulsory supervision does not reduce the rate of readmission of psychotic patients. We found no support in terms of any reduction in overall hospital admission to justify the significant curtailment of patients' personal liberty.”

 

The message from this research seems to be unequivocal: CTO’s don’t work, and therefore shouldn’t be used.

 

AMHP’s and Psychiatrists clearly do not want to be engaging in practices which could be regarded as oppressive and/or counter productive: we’d all much prefer that patients should stay out of hospital and to use the least restrictive means to achieve that. The initial response to these conclusions would therefore appear to be a reluctance to subject anyone else to a CTO.

 

But how much credence can we give to this research?

 

A number of things strike me as making the results not as unequivocal as they at first seem.

 

The first is the size of the sample. They looked at 166 patients who were subject to Supervised Community Treatment. However, since 2008, when CTO’s were introduced, until March 2012, which is the most recent date for which figures are available, a total of 14,295 people have been placed on CTO’s. This means that their sample accounts for less than 1.2% of the total up to March 2012. This, to me, seems to be a very small sample on which to be base such serious and potentially far reaching conclusions.

 

The second is the selection of only people with a diagnosis of psychosis, which according to the abstract were those with schizophrenia. In my experience, CTO’s are not only used for people with schizophrenia, but are also often used for people with bipolar affective disorder, eating disorders, and other diagnoses. Would outcomes have been different if bipolar affective disorder had been selected, or if there had not been a restriction on diagnosis at all? We can’t possibly know without further research.

 

The third is the comparisons used. The two samples were people on CTO’s versus people subject to Sec.17 leave.

 

The Code of Practice does not exactly encourage the use of extended Sec.17 leave. In fact, the CoP (21.9-10) states:

“When considering whether to grant leave of absence for more than seven consecutive days, or extending leave so that the total period is more than seven consecutive days, responsible clinicians must first consider whether the patient should go onto supervised community treatment (SCT) instead… The requirement to consider SCT does not mean that the responsible clinician cannot use longer-term leave if that is the more suitable option, but the responsible clinician will need to be able to show that both options have been duly considered."

 

In practice, extended Sec.17 leave should only be used sparingly, and only for very good reasons. Yet, it appears that for the purposes of the study, patients “were randomly assigned to be discharged from hospital either on CTO (167 patients) or Section 17 leave (169 patients)”. Is this within the spirit of the MHA and the Code of Practice?

 

In the real day to day world of working within the MHA, Sec.17 leave is not an alternative to discharge on a CTO. It does not therefore seem to be a valid comparison. It might have been more useful to compare outcomes for patients discharged on a CTO with patients discharged with no CTO at all. What would the figures have shown with these two samples? We can’t possibly know without further research, but they may have shown a more positive result for CTO’s.

 

I have been working with people on CTO’s for several years now. These have been people with diagnoses of psychosis, bipolar affective disorder, and anorexia. While my own sample is tiny, and I would not want to draw any firm conclusions from my experience, I would say that overall, CTO’s have helped to keep patients out of hospital who otherwise would have been “revolving-door” patients.

 

I recently looked for research into the numbers and efficacy of the use of CTO’s for people with eating disorders. There was hardly anything to be found. In fact, this trial appears to be the first significant piece of research into CTO’s in this country.

 

That is why I would like to see much more research into the use of CTO’s, on much larger samples, using more realistic comparators, and looking at other diagnostic groups, before making a blanket decision to stop endorsing new CTO’s.



When Do You Stop Extending a Community Treatment Order?

Patients subject to CTOs at 31 March 2012, by gender and by year

Community Treatment Orders were introduced into the MHA 1983 by the 2007 amendments. The Code of Practice (25.2) states that: “The purpose of SCT is to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.”

The intention of Parliament was for CTO’s (or Supervised Community Treatment) to prevent “revolving door” patients – that is, people with severe and enduring mental illness such as schizophrenia or bipolar affective disorder who would tend to become unwell, require hospital admission , recover and be discharged on medication, which they would then stop taking, leading to relapse and further acute admission.

Since this part of the Act came into force in 2008, CTO’s have become increasingly popular. The report on use of the MHA for 2010-11 reported: “The number of people on CTOs at the end of the year rose, even though the number of new CTOs made during the year reduced. This was due to the number of new orders made being greater than the number of orders from which people were discharged: 3,834 new CTOs were made in 2010/11 and 2,185 orders were closed.”

The data for 2011-12 shows that “there were a total of 4,220 uses of community treatment orders (CTOs) across the NHS and independent sector. This represents a 10 per cent increase from 3,834 in 2010/11.” The latest report said that the statistic suggest “that there were 6,964 CTOs in place at the end of the 2011/12”.

The main reason for this would appear to be that people on CTO’s frequently get them extended.

Typically, what happens is this: a patient is detained in hospital under Sec.3 MHA for treatment. When they are ready for discharge, consideration is given for them to be discharged under Supervised Community Treatment (SCT) and they would then be on a CTO. Although the patient’s psychiatrist is responsible for making an Order, an AMHP has to endorse this.

The first period of SCT lasts for 6 months. Towards the end of this period, the patient’s psychiatrist reviews the effectiveness of the CTO in keeping the patient well and out of hospital, and considers the need to extend it. An AMHP also has to endorse any extension. The first period of extension lasts for another 6 months. If the CTO is extended again, the period lasts for 1 year, and each subsequent extension will be for 1 year.

Patients on CTO’s rarely appeal against either the initial CTO, or subsequent extensions. In fact, in my experience, they often want nothing to do with the Tribunal or Manager’s Hearing which can be automatically triggered by a discharge of a CTO or an extension. Some of them have even told me that they feel safer knowing that they are on a CTO. I guess they feel that they are less likely to be abandoned by mental health services.

This often leads to strange Tribunals, where only the Community Responsible Clinician and an AMHP or care coordinator are present.

The difficulty with this system is that it is much easier to make a decision to extend the CTO, than to discharge it or let it lapse. After all, if the patient has complied with the conditions of the CTO, which are generally that they should see their care coordinator and community responsible clinician and that they should take their prescribed medication, and they have remained out of hospital, then that is surely evidence that the CTO is working, and therefore should continue. Isn’t it?

Andy is a man with bipolar affective disorder. I have been his care coordinator for over 4 years. Andy does not like taking medication, and has little insight into his mental illness. His view is that if he is well, then he obviously does not need to take medication, as that is only for people who are unwell. Consequently, when he is discharged from hospital well, he will very quickly stop taking his medication. He then becomes acutely unwell, and is soon detained under Sec.3 MHA again.

Not only does he become acutely and distressingly unwell, but his behaviour becomes very reckless and dangerous, and he invariably comes to the attention of the police. In the past, he has hijacked vehicles, threatened people with knives, and damaged property.

In the year prior to his being placed on a CTO, Andy had three acute hospital admissions, all via the police, and all under the MHA. His behaviour was often so unmanageable on an acute ward that he would need a period of time in a Psychiatric Intensive Care Unit (PICU). His wife was at the end of her tether and was considering leaving him. It was decided that he would be given depot medication by injection once a fortnight and was discharged under a CTO.

Towards the end of the first 6 months we reviewed him. During that time, Andy had complied with all the conditions of the CTO, especially the condition that he attended for his fortnightly injection. During that time, he had committed no offences and had not had any relapses. His wife said that she was pleased with his stability overall, but expressed concern about his sedation. However, Andy said he was completely satisfied with the medication regime and did not want any changes. Nevertheless, in view of the serious consequences not treating his mental illness in the past, we decided that it was appropriate to extend his CTO for a further 6 months.

We reviewed the CTO again a few weeks before it was due to lapse. There had been no problems or any evidence of relapse during that period, and Andy again said he was happy with his medication. However, his wife said that she was still concerned by his lack of motivation, complaining that he spent most of the day in bad and was reluctant to leave the house or socialize.

It was decided to change his depot medication to see if that improved these side effects. In view of this change, it was also decided to extend the CTO again, this time for 12 months.

We reviewed Alan a few days ago. Things were much the same – he was still happily attending for his injection, he had not been in any trouble, and he appeared to be free of the grandiose and aggressive symptoms that had troubled him in the past. However, his wife was still complaining about his lethargy and complete lack of any motivation.

I was concerned about this situation. What was the best thing to do? Should we stop his medication altogether? Should we stop the injection, but try him on oral medication, which could not be given by injection? By now, he had been out of hospital and mentally stable for 2 years. Should we discharge the CTO? Should we allow the risk of relapse, on the basis that his quality of life appeared to be seriously impaired?

We knew that he would still be unlikely to take oral medication, and if it was his sole medication, he would be at almost inevitable risk of relapse. In the end, it was decided that he would be prescribed an oral mood stabiliser in addition to the injection to see if that had an effect on his overall presentation.

Because of this further change in medication, it was also decided to extend the CTO, the consequence of which was that by the time of the next review, he would have been on a CTO continually for 3 years. I didn’t feel very comfortable about this decision, but was reluctant to disagree with the recommendation of his psychiatrist, and equally reluctant to risk a repetition of his behaviour when unwell.

The question remains: when could it be considered worth risking the relapse of a patient who has remained stable on a CTO?

I don’t have an answer to that.

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.