Supervision registers for mentally ill peopleBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6957.809 (Published 24 September 1994) Cite this as: BMJ 1994;309:809
- G R Glover,
- A W McCulloch,
- R Jenkins
EDITOR, - Glynn Harrison and Peter Bartlett set out several anxieties concerning the implementation of supervision registers for mentally ill people.1 In particular, they question the clarity of the Department of Health's guidance about which patients should be included on the registers. Registers are being introduced, in line with recommendations made after the Spokes inquiry into the care of Sharon Campbell,2 to ensure that patients most at risk of committing serious violence or suicide or of severe self neglect are identified by services so that their care needs can receive appropriate priority with the care programme approach in both the planning and delivery of care. The decision on whether a patient should be placed on or taken off the register must always be a clinical one; the role of guidance is to define the questions that should be asked to determine this. Harrison and Bartlett's argument that the guidance is loose and will be open to overinclusive interpretation rests on clauses quoted out of context.
The main statement is set out in paragraph 4 of the guidance note requiring the implementation of registers.3 This describes a set of increasingly narrow requirements, all of which must be met. Inclusion on the register is appropriate (a) if a person is a patient under the care of the specialist psychiatric services and (b) if a meeting of staff to review the patient's care programme concludes (c) that he or she is suffering from a severe mental illness and (d) is, or is liable to be, at appreciable risk of one of the three adverse outcomes (e) in some foreseeable circumstances (the specific circumstance should be specified) which (f) it is thought might arise in the particular case.
Hence the criteria excludes several groups. People who are not patients or have not been thoroughly reviewed fall at criteria (a) and (b). This does not imply that clinicians have no responsibility for these people; the supervision register is not, however, the appropriate tool. People who have deliberately taken a drug overdose and are thus at greater statistical risk of suicide may reach criterion (d) but may fall at criterion (e) or (f). Supervision of patients with dementia usually has a clear structure, and appropriate care plans should mean that these patients' potential risk of self neglect is not likely to be realised. These patients would thus usually fall at criterion (f).
Patients with personality disorders (including psychopathic disorder) were considered carefully during the development of the guidelines. Not all of them should be included on supervision registers: some offending behaviour is more appropriately considered within the criminal justice system. Some patients, however, are treated by the psychiatric services. Implicitly the services thus accept some responsibility for them, and their needs must be weighed when priorities are set and services planned. A third group of patients is those for whom the differentiation between psychosis and personality disorder is unclear for a time; this was the case with Sharon Campbell. The guidelines adopt the pragmatic approach that the test of whether a person who is not considered to be suffering from any other sort of mental illness might be considered to satisfy criterion (c) is the judgment by the local psychiatric services that he or she need to be the subject of continuing care.
Thus the Department of Health does not accept that the guidelines are ambiguous. It welcomes Harrison and Bartlett's advice to both purchasers and providers of health care that the task of prioritising the allocation of resources to those most at risk and in need of most care is important and pressing.