Following my recent glance at the statistics*, published by the Health and Social Care Information Centre (‘information centre’), showing use of the Mental Health Act (MHA83) during 2010-11, I now want to spend more time taking a look at some of the figures from both a front line and critical perspective.
General observation
The general observation I make is one which suggests the figures are inaccurate and an under-representation of the compulsory use of the Mental Health Act throughout England.
At present, I have no ‘hard data’ to substantiate this claim: I make my assertion primarily on the basis of personal experience. To support my view it is worth noting that Table 9, of the reference data tables compiled as part of the annual report, lists the organisations which submitted detention data to the Information Centre. What strikes me is the absence of certain hospitals/health providers where I know patients have been detained but such hospitals are not listed. This would be suggestive of an incomplete survey and support my view that the published data is an underestimation of the true use of the MHA83.
Where are the missing hospitals?
The absent hospitals appear to be acute medical hospitals, as opposed to mental health units, where a number of people can end up being ‘held’ under s5 MHA83, or where patients are detained under the MHA83 when they have significant physical health needs (eg. having caused themselves physical damage following a suicide attempt or when ill as a consequence of an eating disorder).
Many acute medical hospitals, unlike mental health trusts, do not tend to have a mental health act administration meaning there can often be a lack of data collection within the organisation itself. This inevitably means that when asked for MHA83 related data the hospitals don’t often know for themselves. Further, many acute trusts do not fully understand the ramifications of, and responsibilities imposed upon them by, the Mental Health Act meaning they see no need to collate data.
An even more vulnerable group of patients?
It is my view that patients subject to the MHA83 and who are detained within acute medical hospitals are a particularly vulnerable and un-represented cohort of patients even compared to those detained within mental health units.
It is further my opinion that such individuals are potentially being denied access to the statutory rights which are afforded to them. For example, most patients subject to the MHA83 have the right to appeal against their detention to hospital managers, and a tribunal. Whilst, I would think, there will be some acute medical hospitals with provisions and systems in place for this, I strongly suspect many (? most) do not. The consequence of this is that it runs a very real risk of patients being denied a key legal and human right – that to challenge their loss of liberty before a court. This subsequently places hospitals at risk of legal action by breaching Article 5(4) European Convention of Human Rights.
Trends in formal detentions under the Act
Section 1 of the information centre report provides statistics regarding the number of patients having been detained under the MHA83: detained being defined as those who were detained following a s136 arrest, all formal admissions (ie. s2, s3, s4, Part III orders and ‘other’ Acts) and ‘detentions subsequent to admission’ (ie. informal to formal).
The headline figure states that in 2010/11, the total number of formal detentions decreased by 0.1% compared to the previous year. The actual number of patients detained were 49,365 (whereas in 2009/10 the number of detentions was 49,417).
I again suggest that this figure is an under-estimation. This is not only based on my argument above but because it does not include patients who were subject to a Community Treatment Order (CTO) and whose order is revoked ie. who became detained again: the published figures only record the detention as one episode. Some will counter-claim this is because the patient’s original s3 order remains in the background as part of a CTO and is thus the correct way to collect data. However, whilst the s3 in the background is true, it is my view that a revocation should be counted as a new detention and be reflected as such in these figures. If a patient is detained under s3, discharged on a CTO but later revoked back to detention, I am sure the patient would argue they have been sectioned twice, and not regard it as one (as per current statistics).
NHS v independent hospitals
Section 2 of the report presents the number of detentions by service provider and use of different parts of the Act. Compared to the previous year, there had been a 0.1% decrease in the number of detentions in independent hospitals. There was also an increase in the use of s2 MHA83 but a decrease in the use of s3 MHA83. The report queries why this is the case and the hypothesis is suggested that the reduction in s3 numbers may be attributed to people being subject to a CTO. I would also suggest a possible reason for this is purely logistical: in order for a person to be detained under s3 MHA83, the medical recommendations provided by doctors must specify that appropriate medical treatment is available in the hospital(s) which they stipulate on their statutory forms. Given the difficulties in being able to access mental health beds, it can often take hours until a bed is located for the patient, by which point the doctor may no longer be available. This means that at the point in time when doctors write their recommendations, they are unable to specify where appropriate medical treatment is available for the patient – thus not being able to complete a recommendation for s3. Rather than having to ‘wait around’ I wonder whether it is easier to recommend s2 instead (as for a s2 there is not a need for doctors to specify a hospital).
A further possible reason for the reduction in use of s3 but increase in s2 may be because of an increased perception amongst many mental health professionals that patients, even if known to services, should usually be admitted in the first instance under the provisions of s2. The issue of whether to detain under s2 or s3 is a blog article in itself so watch this space for that!
A further statistic which I found interesting was that there was a higher proportion of patients detained under s3 MHA83 in independent hospitals, compared to NHS hospitals. 45.5% detentions in independent hospitals was under s3 MHA83, compared to 25.4% in NHS facilities. There may be genuine and quite valid clinical reasons for this but I remain sceptical. What I suspect, based on my own experience, is the insistence by many independent providers to only accept patients if under s3 MHA83. Coincidentally, this is very beneficial to independent hospitals: given it takes longer to get a Tribunal when under a s3 it is likely that those subject to s3 stay detained for longer meaning the hospital gets more money. To be fair, however, I may be wrong as to the reasoning and the limited experience I have with independent hospitals may skew my judgement. If I get any more data on it I will write it up. Nevertheless, I do think we need to question why there is such a difference.
I am awaiting the provision of information from the Care Quality Commission (CQC) which may help shed further light on the statistics and my theories… so watch this space for Part 3!!
* Information Centre for Health & Social Care, In-patients formally detained in hospitals under the Mental Health Act 1983 and patients subject to Supervised Community Treatment, annual figures, England 2010/11 (2011)
