By Michael Bonnet
It won’t have come as a surprise to anybody working in mental health to learn that the Care Quality Commission’s (CQC) latest Monitoring the Mental Health Act report, published last month, showed that the use of the Mental Health Act 1983 (MHA) continues to rise. Just shy of 50,000 detentions to psychiatric hospital were made under the MHA last year (2018-19).
This trend is well established. Statistics show that detentions under the MHA have risen considerably in recent years and that the rate of that rise has been increasing. An earlier report by the CQC found that from 2014-16, for example, the number of detentions increased by close to 20%.
Theresa May’s government had been sufficiently concerned by this increase to commission an independent review into uses of the MHA, which reported in December 2018. The final report made a number of recommendations for changes to mental health policy and practice, and the current government is committed to reforming the MHA.
Investment in hospital alternatives would alleviate pressures
In a research project, recently published by the British Journal of Social Work, Dr Nicola Moran (University of York and Think Ahead) and I sought to obtain the views of approved mental health professionals (AMHPs) – the professional group, predominantly comprised of social workers, who carry out assessments under the MHA – on this trend.
In a series of face-to-face interviews with six AMHPs and via a national online survey completed by 160 AMHPs, participants were asked to draw on their unique experience in administering the MHA to consider why they feel detentions are rising and what they believe could be done to reverse this trend. Whilst extensive research looking at compulsory admissions under the MHA exists, the majority of this tends to be psychiatric in origin and focus.
AMHPs – whose involvement in assessments made under the MHA is intended to counter-balance more restrictive tendencies within the medical profession – have traditionally been an under-represented and under-consulted resource.
A majority of interviewed AMHPs commented that a lack of a ‘third place’ sitting between hospital and the community – such as a well-resourced crisis house – led to hospital being used as a ‘last resort’ for those posing a risk to themselves.
More investment in these resources would not only enable AMHPs to better align their practice with the MHA principle of least restriction and the duty to maximise patients’ independence, but would also give AMHPs more viable options other than a hospital admission to consider during MHA assessments. Such investment would reduce the chances of people being detained.
News: £200m announced for crisis services
All crisis teams will be able to offer round-the-clock support to people in mental health distress by next year under an investment of over £200m in crisis services announced by NHS England yesterday (5 March 2020).
The money, available over the next two years, will also go towards expanding the number of crisis houses and similar services that can support people in distress so that they are available in every region.
People will be able to self-refer to crisis services – whether by phone, online or by dropping in – in the same way as they would for urgent physical care, said NHS England chief executive Simon Stevens.
The money is part of the investment in mental health allocated under the NHS Long Term Plan, which amounts to an additional £2.3bn by 2023-24 over 2019-20 levels.
Under the MHA, people deemed to be suffering from a mental disorder that requires admission to hospital in the “interests of their own health or safety or with a view to the protection of other persons” can be detained and treated against their wishes. Some have suggested that greater use of compulsory powers is not necessarily a bad thing and could be indicative of more people getting the care and support they require.
However, more frequent use of the MHA also means more people are experiencing crises that require the use of compulsory powers. A wealth of evidence documents the disproportionate use of the MHA on black and ethnic minority communities and the profoundly negative and sometimes traumatising impact that being detained can have on people.
AMHPs favour investment over legal changes
Our study found the vast majority of AMHPs not only recognised and were worried about the trend of increasing detentions under the MHA, but they also agreed that the government was right to try and do something about this.
However, whilst AMHPs supported the intention, they generally disagreed with the government over the solution. They felt that greater investment in resources would be more effective in reducing detention rates from current levels than changes to the law. AMHPs also felt that the issue of rising detention rates was just one of many equally important problems currently facing mental health services.
In considering why the number of people admitted to hospital against their will was increasing, AMHPs in this study believed that the following inter-related issues may have contributed:
- A significant increase in demand for mental health services which has vastly outstripped supply.
- A lack of resources and investment within mental health services at both ends of the spectrum. AMHPs felt there were fewer preventative services, such as day centres and support workers, which help people with mental health problems to stay well, but also inadequate provision at the acute end of the spectrum, such as well-resourced crisis services.
- An increase in the social stresses faced by people – such as difficulty accessing benefits and problems associated with housing, addiction and social isolation – which is felt to be having a considerable negative impact on the mental health of the population and consequently increasing demand on mental health services.
- A lack of viable alternatives to hospitals to serve as ‘places of safety’ for people experiencing mental health crises.
MHA now ‘an overused last resort’
Our research has found that AMHPs share the government’s concerns about growing numbers of people being detained under the MHA. They do not, however, believe that the best way to address this problem is to change mental health legislation.
Instead they view the problem of rising detention rates as symptomatic of a bigger issue: an unprecedented and unsustainable demand for mental health services, caused in part by a deterioration in the social structures that help people to stay well, leaving services perilously stretched at precisely the point they are most needed.
Our research concluded that, within this context, use of the MHA has become an overused last resort, not by design, but by necessity. Rather than make changes to the law, the AMHPs involved in our study favour investment in resources. This investment should be directed at both preventative services, such as promoting greater social inclusion and interaction to help reduce the number of people experiencing mental health crises, and acute services, such as increasing the numbers of non-medical and crisis houses, to offer an alternative to hospital admission for those in crisis.
It is hoped the combined impact of these changes would lead to a reduction in detentions under the MHA.
Michael Bonnet is a social worker and graduate of Think Ahead