There is “no evidence” that professional misuse of the Mental Health Act (MHA) is a factor in the growth in detentions in recent years, the Care Quality Commission (CQC) has found.
The regulator’s review of detentions under the Act did find that staff in wards caring for older people, many of whom have dementia, had “turned increasingly” to using the MHA. This was due to long delays in visits from assessors to grant authorisation for hospital stays under the Deprivation of Liberty Safeguards (DoLS).
There had also been a “shift in culture to avoid de facto detention” in all services, the CQC said, and the 2014 Cheshire West Supreme Court ruling on deprivation “may have sharpened” a “steady decline” in informal patients – those who are in hospital voluntarily – in recent years.
The review said that every patient on some older people’s wards was detained, and some areas reported that 80% of patients on acute wards were now detained.
The number of detentions in England under the Mental Health Act increased by 40% from 2005-06 to 2015-16, to 63,622.
The CQC said this could be because more people with severe mental health problems were living outside of hospital settings as bed numbers have fallen, placing them at greater risk of being detained.
It also suggested that admissions, which could have been preventable in the past, are not being prevented because less restrictive alternatives in the community are not available.
No ‘gaming the system’
It found “no evidence that professionals had been misusing the Mental Health Act in any way”; such as attempting to “game the system” by detaining people who do not meet the criteria so that they could be guaranteed an overnight bed in hospital.
There would be a rise in the number of successful appeals against detention if people who did not meet the criteria were being detained just to obtain a bed, the regulator said, but data from the First-tier Tribunal (Mental Health) showed no such increase.
Why MHA detentions are increasing
The CQC grouped the causes of the rise in detention under four main themes:
- Changes in mental health service provision and bed management, including fewer alternatives to inpatient care in some parts of the country (such as support in the community);
- Demographic and social change, including growth in sections of the population that are more likely to be detained, such as older people with dementia and people who are homeless;
- Legal and policy developments, notably the broadened definition of a mental disorder in the revised Mental Health Act in 2007, plus greater awareness, for example among the police, of mental disorder; and
- Data reporting and data quality, including the potential for double-counting, such as when a detained patient moves between wards or from one hospital to another.
The report was based on a review of available data, visits to eight NHS trusts, two independent mental health service providers and 23 local authorities, and conversations with patients and representative bodies.
Patients attributed increases in detention to “a culture based on the level of risk the person poses to themselves and others, rather than a culture that focuses on their recovery”, as well as a lack of 24-hour practical, face-to-face help.
Some professionals “thought it likely that some of the increase in uses of the MHA reflect a trend towards repeated, short periods of detention for treatment for some patients, who in the past might have experienced fewer but longer hospital stays”. They said this could be due to “pressures on beds causing premature and inappropriate discharge”.
However, the CQC added, repeated admissions “might represent good practice” for some patients and “the less restrictive alternative to prolonged stays in hospital”.
The overall increase in detentions, and the fact that people from Black and minority ethnic groups are much more likely to be detained than those from White British groups, prompted the government to launch an independent review of the MHA last year.
It is chaired by Professor Sir Simon Wessely, a former president of the Royal College of Psychiatrists, and is due to report by autumn 2018.
Health system ‘under strain’
Dr Paul Lelliott, the CQC’s deputy chief inspector of hospitals (lead for mental health), said some of the factors behind the rise in detentions were “also signs of a healthcare system under considerable strain”.
“Detentions under the Act can be influenced by gaps in support and provision in the system,” he added.
“This includes limited hospital bed availability, which means that people cannot easily be admitted as voluntary patients early in the course of their illness. This is a particular problem if it is coupled with limited support for people in the community, which can prevent a person’s mental disorder from deteriorating to a point that detention under the Act is necessary.”
He added: “Changes to the law must happen alongside action to address the wider problems.”
Professor Wendy Burn, president of the Royal College of Psychiatrists, agreed there were “limitations” to relying on legislative change to reduce detentions under the MHA, and said the report was “further evidence that declining access to community services is leading to more people reaching mental health crises”.
She added: “The government is right to look at why detentions under the act have risen and why some ethnic groups are detained more often than others in the Mental Health Act Review. But they must remember that the best way to prevent someone being detained is to prevent them from falling into a crisis in the first place; to understand that poverty, poor housing and poor physical health impact on a person’s wellbeing and psyche.”