by Angus Cadwallader
On 13 January 2021, the government unveiled its long-overdue plan to reform the Mental Health Act, which pledges to give individuals more control over their care and treatment and tackle racial disparities. Ministers intend to publish a Mental Health Bill in 2022, following a consultation on their plans.
While these reforms are a welcome step toward creating a fairer mental health system that respects people’s rights and dignity, we feel there are still several key issues that the government has failed to deliver on.
In this blog, we give our take on the government’s reforms and argue that any plan to modernise the mental health system must also address the underlying causes of mental health crises in the UK and provide more support for preventative interventions.
What is the Mental Health Act?
The Mental Health Act 1983 is a piece of that legislation that allows a mental health professional to detain and assess someone without their consent (this is also known as sectioning). A person can only be detained under the Act if they need urgent treatment and if their mental condition causes them to become a risk of harm to themselves or others.
When a person is detained under the Mental Health Act, authorities are permitted to transport them to a “safe place” where a mental health assessment can be carried out. This “safe place” should be a specialist mental health facility or hospital, but can also be a community-support building, depending on the availability of beds. After the assessment is completed, the patient is required to remain in hospital until cleared to leave by a doctor.
Why were these reforms needed?
The government’s proposed reforms come as a response to an Independent Review of the Mental Health Act, which was published in 2018. The Review highlighted several problems with the way involuntary detentions are implemented in England and Wales, with many patients experiencing poor, sometimes appalling, treatment, which can have a lasting impact on their mental health.
In particular, the Review found that patients were often denied the ability to express their autonomy and contribute to decisions about their care plan, which resulted in feelings of powerlessness and marginalisation that severely hindered their recovery.
Additionally, while some patients spoke of the use of coercive measures such as restraint, seclusion and forced medication as “sometimes necessary”, many patients experienced these types of coercion as “disempowering”, “frightening” and “distressing”, and as “reminders of traumatic events from their past, including sexual abuse”.
The Review also shone a spotlight on the rising number of involuntary detentions over the past few decades, which increased by 40% between 2006 and 2016, and continue to rise every year. A disproportionate number of those being detained are Black and Minority Ethnic (BAME) people, who are four times more likely to be detained, relative to the population.
What changes are the government proposing?
The government’s plan to reform the Mental Health Act builds on many of the recommendations put forward in the Independent Review. It’s disappointing that it’s taken so long to get to this stage – especially as these issues have been common knowledge for over two years now – but it’s better late than never!
Some of the main reforms involve minimising the use of coercive measures and giving people greater autonomy and control over their treatment (providing they have the relevant capacity to do so). This includes the introduction of Advance Choice Documents that allow a person to express their preferred course of treatment before they reach a crisis and need hospitalisation. During the patient’s stay in hospital, they will also receive more assessments to check whether their detention continues to be appropriate.
The proposed strategy to tackle the rising rates of detention, and its disproportionate use among certain ethnic groups, is to tighten the criteria for detention to prevent unnecessary admissions. There are also plans to further develop a Patient and Carer Race Equality Framework, which is designed to improve mental health trusts’ response to BAME communities.
A particularly welcome change is a commitment to stop using prison cells as “places of safety” for defendants with acute mental illnesses. Hammersley Homes has long campaigned to end this practice and it’s a great relief that judges will now be working with medical professionals to ensure defendants can always be taken directly to a healthcare setting from court.
What changes do Hammersley Homes want to see?
While we are very pleased to finally see these reforms, there are five more areas that we believe the government should be focusing on in the coming year:
1. Expanding NHS services to meet rising demand
One area that the government needs to give more attention to is the expansion of mental health services to meet rising demand. As the number of involuntary admissions has risen over the past three decades, the resources to meet this demand have been continually cut.
Mental health trusts in England have suffered budget cuts in real terms of just over 8% year on year since 2011. In addition, these trusts have lost almost a third of all NHS mental health beds over the past decade and 6800 (15%) mental health nurse posts have gone. The White Paper speaks vaguely about building new hospitals and renovating old ones, but we need to see a more solid commitment to improve capacity while demand continues to rise.
2. Improving communication lines between families and care services
While we welcome plans to give patients greater autonomy and control over their treatment, we also want to see better communication links between mental health services and patients’ families. These links are especially important when service users do not possess the capacity to make decisions about their treatment.
3. Doing more research into underlying issues
Something else we need to see is a greater understanding of the underlying issues that have led to increases in the number of involuntary detentions. We need to understand why more and more people are reaching a crisis and need hospitalisation every year. And we need to know what factors make BAME people four times as likely to have the Mental Health Act used against them.
A lack of research meant that The Independent Review (2018) was unable to find a clear-cut reason for these developments. Several studies have pointed to a reduction in spending on community services and adult social care as likely factors. Moreover, the government’s austerity measures, including welfare and benefits cuts, have been continuously linked to poorer mental health in the UK, and have severely impacted vulnerable people suffering with long-term mental illness.
If the government is serious about tackling these rising numbers, then tightening the criteria for involuntary detention will not be enough – we need to understand and deal with the underlying causes as well.
4. Investing more in crisis prevention
As said above, several studies have pointed to a lack of community support services as a likely cause for increasing numbers of involuntary detention. After the White Paper was announced, local government and NHS leaders called for greater investment in community services to be added to the government’s plan.
NHS Providers deputy chief executive Saffron Cordery said: “There must be increased support for public health and social care given the crucial role these services play in providing people with the care they need at an early stage, before they reach a crisis. Community-based specialist mental health care capacity must increase if the need to detain under the act is to decrease.”
We also hope that NHS’s commitment to providing consistent care for service users in the next 10 years will mean more investment in long-term supported housing options for sufferers of enduring mental illness. It is crucial that this type of supported housing is recognised as an effective intervention for preventing mental health crises.
5. Improving support for ex-prisoners
Finally, in order to reduce the impact of mental illness on our criminal justice, the government needs to commit to improving mental health support for ex-prisoners. When a person with a mental condition leaves prison, they are all too often unable to access mental health services and are handled by probation officers who do not possess the relevant training. Without the proper support, these people are liable to reoffend and end up in prison once again. In order to end this vicious cycle, we need to ensure that ex-prisoners are immediately referred to mental health services where they can be properly rehabilitated.
