The Mental Health Act 1983

What is the Mental Health Act?  The Mental Health Act is the legislation by which people diagnosed with a mental disorder can be detained in hospital and be treated, if required this can be against their wishes.

When people are detained this is often known as being sectioned.

The use of the Mental Health Act (MHA) is regulated by the Care Quality Commission (CQC).

The MHA has been in its current form since 1983 and was updated (amended) in 2007.

The Madhouses Act 1774 stated …

Whereas many great and dangerous abuses arose from the present state of houses kept for the reception of lunatics, for want of regulations with respect to the persons keeping such houses, the admission of patients into them and the visitation of the said houses and patients: and whereas the law, as it now stands, is insufficient for preventing or discovering such abuses.

This is very similar to the role of the CQC undertake today monitoring the MHA, this is explained by section 120 of the MHA…

The regulatory authority must keep under review and, where appropriate, investigate the exercise of the powers and the discharge of the duties conferred or imposed by this Act [the MHA 1983] so far as relating to the detention of patients or their reception into guardianship or to relevant patients.

(2) Relevant patients are:

(a) patients liable to be detained under this Act

(b) community patients, and

(c) patients subject to guardianship

(3) The regulatory authority must make arrangements for persons authorised by it to visit and interview relevant patients in private:

(a) in the case of relevant patients detained under this Act, in the place where they are detained, and

(b) in the case of other relevant patients, in hospitals and regulated establishments and, if access is granted, other placesI work for the CQC in the team that monitors the use of the MHA. This blog is not an official CQC blog nor are the opinions expressed those of the CQC these are my own musings. This is not a technical blog more of a one sided chat, I will try and write in plan English so that it is accessible and understandable to everyone. In the work pages of the blog I will share the work that we are doing and some of the things that we find when visiting and meeting detained patients.

To start with I will share the reason why I do the work. A job that I would have thought was not required in a modern society. Why should we need to regulate the care of our most vulnerable members of society, surely no one would want to harm these people?

Sadly often we are not always very good at looking out for these people and at times we are abuse towards them. This is the reason I and the people I work with will be out and about visiting hospitals and asking people who are caring for people detained under sections of the MHA to justify why they are doing things and checking that the safeguards provided by the MHA are always afforded to the people who are detained under the act. I will also spend time with those people who are detained and listen to their experiences of being detained.

The CQC and the Mental Health Act Commission (who had the responsibility for monitoring before the CQC was formed in 2009), produce a report for Parliament into the findings made whilst monitoring the use of the mental health act, some of these are truly shocking.

In the twelfth biennial report published by the Mental Health Act Commission – Risk, Rights, Recovery (a PDF can be found HERE)

Pages 19 and 20 of this report list the most disturbing findings during 2007. These included the following;

• Older people consulting a list of when they were able to have a bath in the week, (according to staff available).

• Six patients sharing a poorly decorated room; and one of them refusing to go out on leave for fear of losing this bed – because when she came back she could be in an even worse room with a high risk of violence.

• A patient being nursed by four nurses in a bare room, with a mask on her face to stop her spitting; three nurses holding her.

• Three members of staff restraining a patient in a way that involved holding a towel across his mouth and holding it from behind so that the patient had difficulty breathing.

• A dying man nursed in a dining room of an elderly unit whilst other patients having their lunch (lack of staff to nurse him appropriately).

• Vulnerable women housed with predatory men – alleging physical / sexual abuse – unwilling to take complaint forward due to fear of what would happen and lack of control over the process. Had told male member of staff who had laughed it off.

• Observation blinds to patients’ rooms kept permanently in the open position for staff convenience.

• Seclusion room with no privacy to use the toilet – only disposable bedpans.

• Visit to rehab/assess unit. Female patient from black minority ethnic group, frequently verbally abused by male patient of a racist nature and during the past month physically abused.

• Three new acute wards with 135% bed occupancy.

• Finding detained patients sleeping on mattresses on floors on wards, doctor’s office, quiet room, etc., due to bed over occupancy levels.

• CCTV in patient bedrooms supposedly switched off following complaints by male and female patients, but reported to come back on randomly.

• Of six women who are members of the service user reference panel who responding to project on women in detention, four described personal experience of serious abuse or serious sexual harassment.

• An all male Psychiatric Intensive Care Unit (PICU) located in an extremely cramped upstairs ward with no secure access to outside.

• Patients without section 17 leave never have access to fresh air or outdoor exercise.

• Patient on one to one observation, able to hang himself in his room with door open and nurse sat outside.

• A woman in seclusion who was deprived of sanitary protection whilst menstruating.

• A male member of staff using his mobile phone to photograph a female patient naked in a bathroom (she was in the bathroom being supervised by other staff members).

• A Hindu woman offered Halal meat.

• Mice and cockroaches on the wards.

• A detained young man with learning disability with a double fracture of his arm as a result of ‘restraint’.

• A bedroom on a Psychiatric Intensive Care Unit (PICU) with no door and the inhabitant frightened.

• A hospital where due to staff shortages, patients had to collect their belongings in a bin bag each morning, take them to another ward where they would spend the day then only return to their ward each night.

• A detained patient being kept in seclusion for about two weeks due to financial closure of PICU.

I have been out this month and discovered that patients who are not able to consent to or refuse to agree to taking medication are being given medication that has not been correctly authorised.

What do I mean by this? The MHA allows a person who is able to make a decision about his or her treatment, to decide that they do not want to have medication. The team caring for the individual may feel that the illness is having an adverse affect on this decision and the individual needs the medication to aid their recovery. To safeguard the individual another doctor makes the decision on whether this treatment is necessary, suitable or appropriate. This doctor is independent to the hospital that is detaining the patient. Only the medication approved by this second doctor who is known as a SOAD or a second opinion appointed doctor, can be given to treat the individual for their mental disorder.

So since 1983 these safeguards have been in place yet in the last week of July 2013 I reviewed the medication records for all four detained patients on a ward and found each of these records that medication not approved was being given.

What this means is a series of safeguards had been ignored and those people who are charged with caring for them were not protecting the patient. An external doctor (SOAD) had met the patient discussed the care and treatment with the patient, their doctor, a ward nurse and one other member of staff. They had written a report and provided a certificate that identified what medication could be used to treat the patient.

Despite all of this;

• The hospital doctors had prescribed medication not approved.
• The pharmacist had dispensed medication not approved.
• The nurses had administered medication not approved.
• The manager had not audited any of the documentation to check only authorised medication is used to treat the patient..

But a simple check of the documents, that took less than a minute identified that the medication that was not authorised had been administered to the patient for the previous 10 days.

It is not all doom and gloom in the twelfth biennial report pages 21 and 22 identifies the changes made following visits during 2007.

• The introduction of a protocol for ensuring that consent to treatment (s.58) process is properly applied rather than simply having lip-service paid to it.

• Much improved and well recorded representation of rights information to patients – patients clearly better informed and more aware of their rights.

• A joint visit with Healthcare Commission to a womens’ secure unit at 7 p.m. one night found appalling conditions, practices and care. Joint letter to managers, notice served by HCC, followed by changes and improvements.

• A man in a medium secure unit for more than a year had been told that he was to move to a rehabilitation unit the next day. He was upset about this because he wanted to say goodbye to friends (other patients) by cooking a meal for them. Negotiated with ward for move to be delayed for a few days for him to be able to do this.

• Persuading a hospital to introduce independent advocacy services for the first time.

• Improved partnership working between agencies on a ward where substance misuse was having a negative and dangerous impact on patient care and experience, and staff safety and morale.

• Seeing improvement in level and quality of activities on one particular ward, following sustained feedback.

• The introduction of a new policy for to ensure that patients are informed of their right whilst detained and the application of an audit on the implementation of this.

• A learning disability patient living in a ‘cell’ with a commode chained to a radiator being properly assessed and provided with more appropriate and humane living facilities.

• Cutting the over-occupancy rates in one trust from 12 wards at 115% to only one ward going over 100% in one year.

• An independent unit where I questioned whether they were able to provide patient care – no nurse call; no attack alarms; ligature points throughout; staff not Care Programme Approach trained; provision inadequate for disabled patient etc. Next visit, the unit had been renovated, addressing all environmental issues. A new manager and clinical lead had been appointed, and staff training had dramatically improved. All contributed to better patient care.

• Persuading a multi-disciplinary team to change their minds about transferring a patient back to prison four months before the end of his sentence, after four years in hospital. In prison he would have received no resettlement plan. In hospital plans were put in place for a structured discharge with family support and involvement.

In the most recent report ‘Monitoring the Mental Health Act in 2011/12’ the CQC identified the following key messages;

The number of people subject to the Act (sectioned) is rising (those detained as inpatients and those subject to community treatment orders).

Services are under pressure.(for example issues relating to provision of Approved Mental Health Professionals and transport to hospital, high bed occupancy, increased workloads, access to psychological therapies).

The CQC found:

Some hospitals and wards are doing a very good job in treating patients with dignity and respect. The report highlights good practice, for the first time naming the relevant providers in order that they may share good practice and learning.

But the CQC also found some overall improvement but most of the concerns highlighted in previous reports remain, particularly in respect of care planning, patient involvement and consent to treatment. For example, 37% of care plans checked by CQC showed no evidence of patients’ views; there was no evidence that patients had been informed of their legal right to an Independent Mental Health Advocate (IMHA) in 21% of records reviewed; almost half (45%) of patient records reviewed still showed no evidence of consent to treatment discussions before the first administration of medication to a detained patient

There is a significant gap between the realities CQC is observing in practice and the ambitions of the national mental health policy – No Health without Mental Health.

The CQC is concerned that cultures may persist where control and containment are prioritised over the treatment and support of individuals. In this kind of culture, ‘blanket rules’ can become institutionalised. On one in five visits, CQC expressed concern about the de facto detention of patients who were voluntary rather than compulsory patients.

So despite legislation dating back 239 years to 1774 and a current act that has been in place since 1983 (30 years), we still are needed to go out, visit and talk with people who are detained and to report our findings as these is still room for improvement to the care being delivered by those charge with caring for people who are detained under sections of the MHA.