Reversing reinstitutionalisation in a reformed Mental Health Act
Dear Editor
The government’s White paper proposals to reduce coercion by reforming the Mental Health Act (MHA) in England and Wales are welcome [1], but they do not go far enough. Open-door policies in traditional psychiatric hospitals led to England reducing its number of inpatients from 1954 before other European countries.[2] The 1959 MHA made informal admission rather than detention the usual method of admission. By 1963, 80% of English psychiatric patients were in open wards. The advantages were striking: tension reduced, violence declined, ‘escapes’ were no longer a problem and staff were able to give their attention more to therapy rather than custody. This therapeutic trend was reinforced by improving patients’ rights in the 1983 MHA. Many old long-stay patients grew old and died in hospital, and the number of new long-stay patients to replace them became much less. With the reduction in hospital bed space, there was a reduction in the average length of stay, although actual numbers of acute admissions increased, including so-called ‘revolving door’ patients. The traditional asylums went into decline and became increasingly irrelevant to the bulk of mental health problems.
There was resistance to the rundown of the psychiatric hospital, not least because it was seen as a challenge to the authority of psychiatrists. Polarised attitudes to community care only ended after the traditional hospitals were eventually closed. Fears about public safety due to homicide by psychiatric patients eventually led to the government’s controversial conclusion that community care had failed.[3]
Although the traditional asylums have closed, bureaucratic practices still exist in the network of community, including smaller residential, facilities that have replaced them. In fact, since the 1990s, there has been a reinstitutionalisation of services,[4] particularly evidenced by an increasing number of secure psychiatric beds both in the NHS and private sector. For example, the forensic services population rose by 45% in the 10 years between 1996 and 2006.[5] This resort to reinstitutionalisation reflects an overemphasis on the coercive management of risk rather than more appropriate measures. The number of detentions under the MHA continues to rise.[6] Alongside the increase in detentions, the proportion of involuntary admissions to private hospitals increased from 3% in 1984 to 15% in 2015/6. This shift was more pronounced for forensic (Part III) patients, although also occurred for civil (Part II) cases. Patients who are seen as difficult to manage and place have been shipped out of the NHS to private care and to low and even medium security, when they should be managed in a more open-door environment.
The new MHA needs to reverse reinstitutionalisation and do more to improve the process of deinstitutionalisation started by the 1959 and 1983 Acts. Community treatment orders introduced by the 2007 amendments to the Act need to be repealed. Any new admissions under civil detention arrangements (Part II MHA) should be prohibited to secure facilities, both for learning disability and mental illness. This will allow secure services to develop their proper function of providing a therapeutic alternative to prison. Proposals to improve advocacy in the White paper need to be taken further by creating an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts to provide opinions in the best interests of detained patients about medical, nursing and social matters. The White paper proposals to extend the role and powers of the Mental Health Tribunal (MHT) also need to be taken further, so that the MHT takes over the function of Second Opinion Approved Doctors (SOADs) in scrutinising treatment decisions of the Responsible Clinician (RC). The MHT can adjudicate in any conflict between the RC and the independent expert and if necessary require the RC to reconsider a specific treatment decision. SOADs could then be abolished and, anyway, seem anachronistic when treatment decisions should be more open to challenge in the MHT. Recommendations from MHTs should also become more routine, especially if discharge, leave, transfer or community services cannot be ordered within 5 weeks, and progress can be reviewed in any subsequent MHT hearing if needed. All these changes should reduce the frequency and length of MHA detentions, promoting the rights of detained people.
1. Beck, A., Farmer, P. & Wykes, T. Proposed reforms of the Mental Health Act. BMJ 2021;372:n727
2. Goodwin, S. Comparative mental health policy: From institutional to community care. London: Sage, 1997
3. Burns, T. & Priebe, S. Mental health care failure in England. Br J Psychiatry 1999; 174:191-2
4. Priebe, S. & Turner, T. Reinstitutionalisation in mental health care. BMJ 2003;326:175
5. Rutherford, M. & Duggan, S. Forensic mental health services: Facts and figures on current provision. British Journal of Forensic Practice 2008;10:4-10
6. Keown, P., Murphy, H., McKenna, D. & McKinnon, I. Changes in the use of the Mental Health Act 1983 in England 1984/85 to 2015/16. Br J Psychiat 2018;213:595-9
Rapid Response:
Reversing reinstitutionalisation in a reformed Mental Health Act
Dear Editor
The government’s White paper proposals to reduce coercion by reforming the Mental Health Act (MHA) in England and Wales are welcome [1], but they do not go far enough. Open-door policies in traditional psychiatric hospitals led to England reducing its number of inpatients from 1954 before other European countries.[2] The 1959 MHA made informal admission rather than detention the usual method of admission. By 1963, 80% of English psychiatric patients were in open wards. The advantages were striking: tension reduced, violence declined, ‘escapes’ were no longer a problem and staff were able to give their attention more to therapy rather than custody. This therapeutic trend was reinforced by improving patients’ rights in the 1983 MHA. Many old long-stay patients grew old and died in hospital, and the number of new long-stay patients to replace them became much less. With the reduction in hospital bed space, there was a reduction in the average length of stay, although actual numbers of acute admissions increased, including so-called ‘revolving door’ patients. The traditional asylums went into decline and became increasingly irrelevant to the bulk of mental health problems.
There was resistance to the rundown of the psychiatric hospital, not least because it was seen as a challenge to the authority of psychiatrists. Polarised attitudes to community care only ended after the traditional hospitals were eventually closed. Fears about public safety due to homicide by psychiatric patients eventually led to the government’s controversial conclusion that community care had failed.[3]
Although the traditional asylums have closed, bureaucratic practices still exist in the network of community, including smaller residential, facilities that have replaced them. In fact, since the 1990s, there has been a reinstitutionalisation of services,[4] particularly evidenced by an increasing number of secure psychiatric beds both in the NHS and private sector. For example, the forensic services population rose by 45% in the 10 years between 1996 and 2006.[5] This resort to reinstitutionalisation reflects an overemphasis on the coercive management of risk rather than more appropriate measures. The number of detentions under the MHA continues to rise.[6] Alongside the increase in detentions, the proportion of involuntary admissions to private hospitals increased from 3% in 1984 to 15% in 2015/6. This shift was more pronounced for forensic (Part III) patients, although also occurred for civil (Part II) cases. Patients who are seen as difficult to manage and place have been shipped out of the NHS to private care and to low and even medium security, when they should be managed in a more open-door environment.
The new MHA needs to reverse reinstitutionalisation and do more to improve the process of deinstitutionalisation started by the 1959 and 1983 Acts. Community treatment orders introduced by the 2007 amendments to the Act need to be repealed. Any new admissions under civil detention arrangements (Part II MHA) should be prohibited to secure facilities, both for learning disability and mental illness. This will allow secure services to develop their proper function of providing a therapeutic alternative to prison. Proposals to improve advocacy in the White paper need to be taken further by creating an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts to provide opinions in the best interests of detained patients about medical, nursing and social matters. The White paper proposals to extend the role and powers of the Mental Health Tribunal (MHT) also need to be taken further, so that the MHT takes over the function of Second Opinion Approved Doctors (SOADs) in scrutinising treatment decisions of the Responsible Clinician (RC). The MHT can adjudicate in any conflict between the RC and the independent expert and if necessary require the RC to reconsider a specific treatment decision. SOADs could then be abolished and, anyway, seem anachronistic when treatment decisions should be more open to challenge in the MHT. Recommendations from MHTs should also become more routine, especially if discharge, leave, transfer or community services cannot be ordered within 5 weeks, and progress can be reviewed in any subsequent MHT hearing if needed. All these changes should reduce the frequency and length of MHA detentions, promoting the rights of detained people.
1. Beck, A., Farmer, P. & Wykes, T. Proposed reforms of the Mental Health Act. BMJ 2021;372:n727
2. Goodwin, S. Comparative mental health policy: From institutional to community care. London: Sage, 1997
3. Burns, T. & Priebe, S. Mental health care failure in England. Br J Psychiatry 1999; 174:191-2
4. Priebe, S. & Turner, T. Reinstitutionalisation in mental health care. BMJ 2003;326:175
5. Rutherford, M. & Duggan, S. Forensic mental health services: Facts and figures on current provision. British Journal of Forensic Practice 2008;10:4-10
6. Keown, P., Murphy, H., McKenna, D. & McKinnon, I. Changes in the use of the Mental Health Act 1983 in England 1984/85 to 2015/16. Br J Psychiat 2018;213:595-9
Competing interests: No competing interests