Feature

Mental health: patients and service in crisis

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j1141 (Published 13 March 2017) Cite this as: BMJ 2017;356:j1141
  1. Jacqui Wise, freelance journalist, London, UK
  1. jacquiyoung1{at}gmail.com

Jacqui Wise examines why the numbers of people being detained under the Mental Health Act are increasing and how they are treated

The police broke down Emma McAllister’s front door, and she was later handcuffed in front of her neighbours, taken away in the back of a police van, and placed in a cell. She has never been violent or threatened anyone. But she does have a mental illness.

“When you are unwell being held in a police cell is very frightening and unhelpful. I was treated like a criminal and it can add to your feelings of paranoia,” she told The BMJ.

Emma, a professional with a steady job, has had mental health problems for 30 years including an eating disorder, depression, and psychotic episodes. The occasion she described came after she went to her general practitioner for help. However, according to Emma her GP couldn’t get hold of anyone in the crisis mental health team and as she was concerned for Emma’s safety she felt she had no option but to call the police.

“When I am well I am much more frightened about becoming unwell again,” says Emma. “I am worried about contacting anyone for help as I am frightened of the police coming to my home and taking me to a cell again.”

Emma’s experience is far from unique. In England the use of section 136 of the Mental Health Act, which allows police officers to remove someone they think is mentally disordered and “in immediate need of care or control” from a public place to a place of safety, increased by 18% last year to 22 965 cases. Data from NHS Digital show that there has been a more than fourfold increase in use of powers to detain people under section 136 over the past decade.1

Last resort

Emma was taken to a police cell because in some areas there aren’t enough health based “places of safety” for people awaiting assessment under the Mental Health Act. The good news is that the number of people ending up in cells has reduced substantially in recent years. This is partly the result of the crisis care concordat, an agreement between local NHS, the police, and other bodies and services to work together to improve crisis care. (www.crisiscareconcordat.org.uk)

Data from the National Police Chiefs’ Council show the number of times that police cells in England and Wales were used as a place of safety fell from 4537 in 2014-15 to 2100 in 2015-16—a 54% reduction.2 However, there is still wide geographical variation, with some areas reporting hardly any people ending up in cells and others reporting high numbers.

Last August the Department of Health announced £15m (€17m; $18m) to improve provision of mental health places of safety and reduce the use of police cells. The money will be spent in those parts of the country with the worst records on detaining mentally ill patients in police cells.3

Another piece of positive news is the Policing and Crime Act 2017, which received royal assent on 31 January.4 This will stop children and young people who are experiencing a mental health crisis from being held in police cells and restrict the circumstances when adults can be taken to police stations.

The home secretary, Amber Rudd, said at the time: “The police should never be the default response for someone experiencing a mental health crisis.”

Michael Brown, a police inspector who writes a blog called mental health cop (https://mentalhealthcop.wordpress.com/) told The BMJ: “The police to an extent have always been used as an emergency mental health service.”

Brown says the police receive little formal training in managing patients with mental health problems. “A highly agitated person may be experiencing serotonin syndrome due to the mismanagement of their antidepressant medications. The signs are subtle, and most police officers won’t be able to pick up on that. We need to have a proper debate about what is the role of the police in this area.”

Brown says the fact that the number of people being held in police cells has gone down may mean the problem has been shifted to hospital emergency departments. He adds that in many cases a health based place of safety is just a room with no quick access to mental health staff. “The police may have to remain there with the patient for six or seven hours waiting for mental health staff to arrive,” he says.

But Gary Wannan, consultant in child and adolescent psychiatry in London and chair of the BMA community care committee, says: “Even if the health based place of safety is not perfect at least the person does not have to go through the whole trauma of being arrested and placed in a police cell. And they should get the mental health assessment they need more rapidly.”

Human rights concern

The total number of people subject to the Mental Health Act 1983 continues to rise. In England, there were 63 622 detentions in hospital in 2015-16, a rise of 9% from the previous year. Overall the number of people subject to the act has risen by 47% since 2006.1

In Scotland, the Mental Welfare Commission warned last year that the rising use of compulsory treatment for mental ill health is a “human rights concern.” The commission said compulsory detention and treatment orders were issued 5008 times last year—a record high since the 2003 Mental Health Act was introduced in Scotland.5

The Care Quality Commission is carrying out an investigation into why increasing numbers of people are being detained under the Mental Health Act, with publication expected later this year. Paul Lelliott, deputy chief inspector of hospitals (lead for mental health), said: “We do not know, for example, the extent to which the rise is due to repeated detentions. It could signal a lack of support in the community for people with serious mental health problems or, if people are being detained repeatedly, it could be a sign that some services are operating ‘revolving door’ admissions.”

Community treatment

One important change in recent years is that more people who are subject to the Mental Health Act are being treated under community treatment orders (or compulsory treatment orders in Scotland) rather than in hospital. The latest figures in England show the use of community treatment orders has decreased slightly—down 4% from 4564 to 4361. This is the first decrease in the use of community treatment orders in four years. But in Scotland the total number of new compulsory treatment orders is 8% up on the previous year, at 1386.2

Community treatment orders were introduced in 2008 amid opposition from mental health charities. They were meant to deal with the “revolving door syndrome” in which patients with psychotic illnesses are repeatedly released and involuntary admitted to hospital. But a randomised controlled trial published in the Lancet showed that community treatment orders have not reduced rates of hospital readmission.6 7

Paul Farmer, chief executive of the mental health charity MIND, says: “Community treatment orders are being used far more than originally predicted and are used inappropriately in some cases. Research shows that they are no more effective than previously existing powers, yet they are far more restrictive and can last much longer.”

Earlier support

Last year an independent commission led by Nigel Crisp and set up by the Royal College of Psychiatrists warned that access to acute care for severely ill adults with mental health conditions was “inadequate nationally and, in some cases, potentially dangerous.” The commission recommended a maximum four hour wait for admission to an acute psychiatric ward or for home treatment.8 9

Wannan says: “Mental health is the Cinderella service, and despite government promises to increase funding there is good evidence that it is decreasing. If we have the help in place and readily available then it is much more likely that we can prevent patients from being detained.”

He added: “I have heard of families that have been forced to phone the police just because they couldn’t get the help they needed at the right time.”

Farmer commented: “We are worried that the rise in detentions could be because people aren’t getting the help they need early enough, meaning they are more likely to reach crisis point and may need to be detained under the Mental Health Act. We have also heard anecdotal reports that stretched services and bed shortages mean that, in some cases, professionals feel under pressure to ‘section’ someone as a way of ensuring they get the care they need. This is not acceptable.”

Liz England, clinical lead for mental health for the Royal College of General Practitioners, said: “The main problem is that patients appear to be discharged from the crisis care team earlier than maybe they should be as the team hasn’t the resources. They deteriorate quickly and need to go back again.”

She adds: “I think the crisis care teams are very good at dealing with people with severe mental health problems such as schizophrenia or psychosis, and there is a clear pathway for caring for them. But there are a whole group of people with behavioural disorders or personality disorders that they don’t know what to do with who seem to bounce around the system.”

Emma is clear why sectioning of mental health patients is increasing. “Even five years ago there was more routine mental healthcare available,” she says. “I used to have support from a community psychiatric nurse and a community psychiatrist who knew me well and could identify when things were starting to go wrong. Now, because of cuts to teams and an increase in case load, this help is just not there.”

Emma adds: “What would help me is having straightforward access to crisis care that I can self-refer to when things are really bad. Now the only way to get crisis care is to go to A&E or to be picked up by the police.”

Detention under the Mental Health Act

  • Section 2—Gives the power to detain someone believed to have a mental disorder for assessment and possibly treatment if it is necessary for the patient’s health or safety or for the protection of other people. The order lasts for 28 days and cannot be extended or renewed

  • Section 3—Gives the power to detain someone for treatment of a mental disorder. It is for patients who need to be detained for their own safety or for the protection of other people and if treatment can’t be given unless they are detained in hospital. This order lasts for six months and can be renewed

  • Section 4—The emergency power to detain someone for assessment for up to 72 hours

  • Section 136—Gives the police power to detain someone in immediate need of care or control and remove them to a place of safety. Power to detain lasts for 72 hours

  • Community Treatment Order—Allows a person who has been detained in hospital for treatment to leave hospital and get treatment in the community

Footnotes

  • Commentary, doi: 10.1136/bmj.j1165
  • Emma McAllister is a pseudonym.

  • Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

References

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