Mental health: patients and service in crisis

We read with interest the recent article regarding the rise in detentions under the Mental Health Act (MHA), outlining the obvious human rights concerns.

Rarely discussed is what happens to people detained under the MHA once they enter hospital. Their human rights are protected by the Mental Health Review Tribunal appeal system, which involves a review of the detention by a panel consisting of a judge, independent doctor and lay member. For a Section 2, which allows assessment and treatment up to 28 days, the standard is that the tribunal is held within seven days of receiving the appeal. But does this process actually work?

We examined the outcomes of patients who had been detained under Section 2 at one London mental health trust serving a population of 1.2 million. Assessing 6 months of data in 2016, it was found that of 399 patients detained under Section 2, 96 (24%) appealed. Only four patients were discharged by the tribunal; 1.0% of the total number detained and 4.1% of those that appealed. This reflects the 2015/16 national data for Section 2 appeals where 4.3% resulted in absolute discharge and 2.1% in delayed discharge (1).

The outcome for just over half of the sample (201, 50.3%) was to be discharged from the Section 2 by their consultant psychiatrist. It could be argued that the real power of the appeal is to persuade the consultant to discharge the patient prior to the tribunal, if it is felt that defending the section is unlikely to succeed. In our study a patient appealing against detention was no more likely to be discharged from section by their consultant than one who had not appealed. However, they spent significantly shorter time detained, 18.4 (sd 8.3) days compared to 14.2 (sd 6.1) days (p<0.001, two tailed t-test).

The fact that so few patients are successful in their Section 2 appeal could be interpreted as evidence of the appropriate use of MHA powers at initial detention. A more sceptical view is that the tribunal system, and the weight it gives to professional opinion, makes it very difficult for a patient and their representative to make a persuasive case. It may be that the standard of holding the hearing within seven days, although intuitively in keeping with protection of human rights may paradoxically make discharge less likely so early in the patient journey. This merits further research.

In one study in 1991 (2) only 9% of people detained under section 2 appealed their detention compared to our figure of 24% in this data. However the proportion of all people discharged on appeal then was essentially the same as now; 1.5%. Encouraging more people to appeal may appear to be a worthy goal but seems to make little practical difference.

The tribunal system is expensive (3). If it acts as merely a theoretical challenge to professional authority but offers benefit to so few patients can the current system be justified? More profoundly, does it ease our conscience by giving the impression of an overarching impartial review, but in fact only serves to endorse the decisions already made by professionals?

References
1. Monitoring the Mental Health Act in 2015/16 Appendix B, Care Quality Commission
http://www.cqc.org.uk/sites/default/files/20161122_mhareport1516_web.pdf

2. O’Dwyer J and Neville P. Appeals against Section 2 of the Mental Health Act 1983. BJPsych Bulletin 1991 15.4.225

3. Blumenthal S and Wessely S. The cost of Mental Health Review Tribunals. Psychiatric Bulletin 1994 18:274-276.

I would like to support the comment by Emma, a patient quoted in this article, regarding the reductions in resources in mental health services over the last few years. Before I retired, 6 months ago, service reductions meant that I would often find myself the the only psychiatrist in a large community base containing 5 busy mental health teams struggling with large caseloads. If you look at in-patient services, 1 in 16 beds have been lost in general and acute medicine – but 1 in 5 beds in mental health. Given that mental health services had already, in the move to community-based care, lost the majority of their beds, this subsequent reduction looks particularly ill-judged. Those mental health beds that remain are consequently continually over-occupied.

The pressure on these beds has reached a level that too often renders impossible any efficient management of these expensive resources. Crisis admissions become the rule, not infrequently to distant beds, inaccessible to the community team involved. Discharges happen too quickly or with inadequate planning. It is hardly surprising that mental health crises multiply, with their consequent demands on police time. The government can make helpful noises about "parity of esteem" for mental health, but such statements ring hollow when the proportion of NHS expenditure on mental health remains around 12% against a total morbidity contribution by mental health problems of nearer 20%. So, for the moment, I suspect that searching for a specific part of the system to "blame" is probably not helpful - every component is stretched to ineffectiveness. And I fear that even plausible structural changes, such as moving community mental health teams to primary care, would be hamstrung by the inadequate resources available.