I’m appalled by some of the things I see. There are still places where quality of care is not of a 21st century standard,” says Chris Heginbotham, chief executive of the Mental Health Act Commission.
His comments come in the wake of calls by the MHAC not to water down its role of visiting detained patients under the merger of the Commission for Social Care Inspection, the Healthcare Commission and the MHAC into the Care Quality Commission.
Last month the MHAC gave evidence to MPs scrutinising the Health and Social Care Bill, which will introduce the new commission. It wants to ensure that its work in visiting every ward at least every 18 months and interviewing around 6,000 detained patients a year is maintained by the new organisation. In addition, it has called for the introduction of a duty for all mental health providers to regularly inform the Care Quality Commission of serious and untoward incidents, as well as all admissions, discharges and deaths of patients.
Its chair, Lord Patel, told the committee: “The fear is that we will get lost in a larger organisation. If there is a health scare of some kind, then you might stop visiting.”
The biannual MHAC report, published last month, revealed that incidents of abuse of patients detained in mental health institutions are far from eradicated. Some of the most disturbing incidents seen in the last six months by commissioners include a member of staff taking photos of a female patient in the bath, patients having to sleep on mattresses on ward or office floors and a dying patient being nursed in a dining room while patients had lunch. Of particular concern is the ongoing issue of sexual abuse and harassment in mixed sex wards. The report found that 60% are not fully separated and vulnerable women are still being housed with predatory men.
“Our concern is that dilution of the way in which we visit on a regular basis would be detrimental to patients,” Heginbotham says.
While it is uncertain how the new body will operate, there has been some speculation that there will be more reliance on self-assessment to inform the need for visits. But Heginbotham has reservations over applying these methods to mental health institutions.
“We have been concerned that the Healthcare Commission’s self-assessment method hasn’t always picked up on providers where there are problems and no doubt some trusts do turn a blind eye to the worst excesses. If you don’t visit regularly scandals will occur. We believe that our commissioners have nipped some serious scandals in the bud.”
Programme of visits
However, there have been discussions about possible amendments to stipulate a minimum programme of visits. Another possible way forward is to ringfence the MHAC visiting function as a separate arrangement within the Care Quality Commission on the basis that it works with a vulnerable group that needs extra safeguards.
This approach has echoes of the disability committee within the Equality and Human Rights Commission. It was set up following concerns from the Disability Rights Commission that its role in defending the rights of people with disabilities would be overshadowed when it merged with the Commission for Racial Equality and the Equal Opportunities Commission to form the EHRC last year.
“The ringfence model looks as if it could be the most likely solution and would have the advantages of being part of a larger organisation with more teeth,” concludes Heginbotham.
Other mental health organisations are backing the commission’s calls and also believe the visiting role should be better defined in legislation. Jane Harris, head of campaigns and policy at mental health charity Rethink, says: “The Mental Health Act Commission is a really good force and we need to ensure that inspections stay at the same level or increase.”
She adds that community treatment orders are likely to result in an increased need for visits. “There is evidence that where these have been introduced overseas the number of sections has increased, so greater numbers of people could be detained, which makes the mental health role in the legislation even more important,” she says.
And Moira Fraser, head of policy at the Mental Health Foundation, agrees: “We are concerned that the monitoring function could be watered down. The proposals as they stand do include monitoring, but this could be downgraded as time goes on.”
She is worried that the visiting role may be passed on to inspectors without specialist knowledge of the rights of patients detained under the Mental Health Act. “Our concern is that in the future it will become a tiny part of the Care Quality Commission’s work and not prioritised in the way that it needs to be.
“Although we have been reassured now that there will be a visiting function, what happens in two to five years’ time if there are cuts in resources or if general staff are asked to carry out the monitoring job? Over time you might not get the same level of tenacity and expertise.”
While some managers at mental healthcare providers may secretly welcome fewer visits, Robert McLean, head of forensic social care at Mersey Care NHS Trust, which includes Ashworth high security hospital, is not one.
“We have a very good relationship with the current commissioners and it will be a shame to see this go. They make recommendations on ward policy and this has been beneficial,” he says.
McLean is also sceptical as to how well-served patients will be under new arrangements. “I can’t see how monitoring under the new commission can be as vigorous as we have at present, which is a vital function, particularly for patients who don’t have advocates or friends and family that have an interest in their care.”
He adds: “My concern is that a lot of providers will let their standards slip if they don’t have to provide as much information. If the emphasis is on self-assessment this gives an opportunity to be inaccurate in their reporting and leaves things open to interpretation.”
Kevin Murray, associate medical director of West London Mental Health Trust, within which is Broadmoor hospital, shares positive experiences of working with the commissioners. “The Mental Health Act Commission has very good knowledge of the institution and the patients know and trust them. I think the commissioners can pick up on issues where a larger, more general inspectorate may not. If it isn’t broke, don’t fix it in my view,” he says.
Jackie Wilkinson, who has been a mental health service user (although not a detained patient) and is a Mental Health Act hospital manager, explains why visits are important to patients. “People who are detained are often unwilling to speak out. If there is abuse, they fear if they tell staff that it will affect their treatment. They need someone independent who can look at things objectively without there being any comeback.”
Patients who have experienced abuse are much more likely to disengage from mental health services and develop secondary problems, which can “create more problems for mental health services”, she adds.
The MHAC is still waiting to learn whether its calls will be met. But Heginbotham concedes it is unlikely the same level of visits will be written into legislation.
“It is very difficult to lay down in statute the frequency and level of resources because this may differ in the future,” he says.
This article appeared in the 21 February issue under the headline “Thrown into the mix”