For those of you who follow the ebbs and flows of mental health law and policy you will be only too aware of the call by all stakeholders to reduce the increasing number of compulsory admissions and to reduce the number of minority groups who are over represented in the psychiatric system (read Luke Sheridan Rains’ blog on the increase in detentions).
Recent NHS Digital figures revealed that not only was there a 2% increase in the number of detentions between 2018 and 2019, but Black people yet again were the group with the highest rate of detentions (NHS Digital, 2019).
Whilst a number of studies have been recently published as part of the Independent Review of the Mental Health Act (Department of Health & Social Care, 2018), few focused on the assessment that happens to decide if someone should be detained or not.
In order to better understand whether the Mental Health Act (MHA) Assessment process may play a role in these increasing figures, Alice Wickersham et al (2019) looked to explore the MHA assessors’ perspectives of these issues and to critically analyse the risk factors associated with compulsory hospital admissions during a MHA assessment.
Could the Mental Health Act Assessment process hold the key to the increasing numbers of compulsory admissions?
Methods
This study used mixed methods to collect both qualitative and quantitative data in one inner London NHS Trust employing 53 Approved Mental Health Professionals (AMHPs), (8 of which were non-social workers and 45 were social workers) and 99 section 12(2) doctors:
- Approved Mental Health Professionals (AMHPs) are mental health professionals who are approved by Local Authorities to carry out a variety of duties for the MHA. This includes making a decision about whether to make an application for someone to be detained or not
- Section 12(2) doctors are medical practitioners, usually psychiatrists, who are qualified to make recommendations about whether someone should be detained or not.
The quantitative data was drawn from routinely collected assessment records of 150 in-area community Mental Health Act assessments relating to 146 service users, of which 105 resulted in detention. The data relating to completed MHA assessments resulting in detention was collected for the period between October – December 2016. In contrast, the data relating to MHA not resulting in detention was collected for the period between September 2016 – February 2017 to allow for a greater number of assessments not resulting in detention to be captured and included in the study.
Qualitative data was also captured from 4 AMHPs and 4 Section 12(2) doctors who were recruited using purposive sampling and then interviewed one-to-one. Three AMHP service managers were opportunistically recruited and took part in a focus group. Of the 4 AMHPs and 3 AMHP service managers, 6 were social workers. These local assessors were interviewed to explore factors that might help or hinder detention minimisation.
Results
The results of this study I am sure will resonate with practitioner experiences of undertaking MHA work:
Qualitative
The participants suggested that detention minimisation is helped by:
- Thorough and rigorous referral processes, gate-keeping and the processes used to warrant of AMHPs.
- Utilising AMHPs (not on duty) within community mental health teams as a resource to discuss potential referrals based on actual knowledge of the person being assessed, before passing to an on-duty AMHP to consider assessing.
- The assessing team having informed, up-to-date current and background information from family, friends, professionals and other networks to base decisions upon, and involvement of the community team.
- Assessing the person as a team (with AMHP and both doctors present at the same time) rather than a split assessment, including where appropriate the referrer too, and the crisis team, as well to offer the least restrictive alternatives.
- The assessing practitioners having higher detention thresholds, supported by clear guidance in MHA, and assessors having confidence.
- Engaging and working in collaboration with service users minimises detention by intervening early and avoiding inappropriate referrals for a MHA assessment.
- More actual alternatives to admission such as day hospitals and crisis houses, support from third sector organisations and drug and alcohol services.
- Greater resources for multi-professional, multi-skilled community teams may reduce detentions by offering greater care coordination and crisis planning.
- Recognising that there are numerous social factors, such as marginalisation and widening inequalities, that can lead to detention.
Participants suggested that detention minimisation is hindered by:
- Concerns over culpability, which might lead assessors to be risk averse and therefore decide to detain.
- AMHPs may not have time or capacity to withhold making an application for detention and try other least restrictive options.
- Delays in undertaking MHA assessments can lead to greater detentions as those being assessed deteriorate in the meantime and cannot consent to alternatives to admission.
- Inappropriate use of community treatment orders, and using the MHA when deprivation of liberty safeguards would have been more appropriate, or assessing people who are under the influence of drugs or alcohol.
- Poor discharge planning, poor continuity of care (high staff turnover), premature discharge leading to repeat admissions, and bed scarcity hindering informal admissions.
Quantitative
The study found strong evidence that the probability of detention was higher when:
- There is an evident risk to others or themselves (this is a criteria of detention so is reassuring);
- Person being assessed lacked capacity or ‘insight’;
- Nearest relative was contacted;
- Difficulties identifying a bed.
The study found strong evidence that the probability of detention was lower when:
- There was a diagnosis of personality disorder or other mental illness, compared with serious mental illness;
- Other professionals attended, with the assessing team (this was the case in 18% of assessments in the study).
Greater coordination by different professionals can minimise detentions but this is impeded by low resources.
Conclusions
This study concludes as practitioners might anticipate by stating:
Mitigating wider societal risk factors for detention, equipping services to prevent and respond to crisis effectively and optimising implementation of existing legislation in MHA assessments may be of vital importance in minimising compulsory admission rates (p. 20).
In essence, arguing that greater resources are needed for mental health services to respond to crisis to minimise compulsory admissions.
The study recognises that other roles in MHA work also need to be explored to understand their impact on compulsory admissions, and I would suggest that this is really needed.
Perceived risk is the most salient factor in decisions to detain people under the mental health act.
Strengths and limitations
This is one of the few studies that have focused on the MHA Assessment process in trying to understand the rising rates of detentions. The study has provided an insight into the factors which impede and facilitate the minimisation of detention according to the mental health professionals involved in the MHA. By doing so, it has revealed a number of timepoints, from the time leading up to the crisis to the referral being made, at which interventions can be considered to minimise detentions. However, it should be noted there were a number of limitations:
- The key qualitative findings are drawn from a small sample of professionals from 3 groups (AMHPs, Sec 12(2) doctors and service managers) in just one Trust, which limits generalisability. Moreover, specific demographic characteristics of the participants were not reported.
- There was missing quantitative data in 33 out of the 150 routinely collected assessment records (40% in the not detained group, and 14% in the detained group) used in this study. This may suggest some sort of bias in the recording of assessments.
- Data collection time periods for non-detained and detained groups were different and this could be detrimental to the findings of the study if there were any changes to practice during this period.
- Service users and other stakeholder perspectives were not captured, and comparison between professional groups was not possible as the overall small sample constituted 7 participants across 3 professions.
- The authors also make a rather bold statement regarding institutional discrimination claiming there was no evidence of such discrimination in their findings. However, this study was conducted in one inner-London Trust which may not be truly representative of the wider national picture, as illustrated by the findings of NHS Digital (2019). Moreover, the current study included a small sample of MHA Assessments which may not have allowed for enough power to detect differences between ethnic groups and there was no further exploration of one interviewees acknowledgement of the role of unconscious bias in decision-making.
Implications for practice
The findings of this paper will resonate with mental health practitioners and those with lived experience.
Whilst it is encouraging that risk is the most salient factor in determining the decision to detain people under the mental health act, it is concerning that assessors are being risk averse due to concerns over culpability. This may indicate a need to better understand these concerns so services can address such concerns appropriately and change the culture of teams to encourage positive risk-taking and minimise detentions.
The findings also indicate a need for a wider pool of professionals to be involved in the decision-making process, with information gathered from a variety of sources such as care coordinators and carers to ensure the right decision is reached.
Under-resourced services were also thought to impact the decision to detain, highlighting the need to ensure services are well funded, to allow for coordinated responses to crises which enable alternative, less restrictive options to detention.
These findings add a great deal to the MHA literature and allow for a better picture to be constructed of the factors which may be at play in the rising rates of detention.
We cannot underestimate the importance of the wider mental health system in minimising compulsory admissions.
Conflicts of interest
No conflicts of interest.
Links
Primary paper
Wickersham, A., Nairi, S., Jones, R., & Lloyd-Evans, B. (2019). The Mental Health Act Assessment Process and Risk Factors for Compulsory Admission to Psychiatric Hospital: A Mixed Methods Study. The British Journal of Social Work.
Other references
NHS Digital (2019). Mental Health Act Statistics, Annual Figures 2018-19. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-act-statistics-annual-figures/2018-19-annual-figures
Department of Health and Social Care (2018). Modernising the Mental Health Act – final report from the independent review. https://www.gov.uk/government/publications/modernising-the-mental-health-act-final-report-from-the-independent-review
Photo credits
- Photo by Emily Morter on Unsplash
- Photo by Cristina Gottardi on Unsplash
- Photo by Perry Grone on Unsplash
- Photo by Riho Kroll on Unsplash
- Photo by Terry Vlisidis on Unsplash
So long as researchers restrict their investigations to other professionals, they won’t learn useful background from support workers and carers.
Why is that important? Because psychiatrists and AMHPs only dip into service users’ lives, whereas support workers and carers know far more about the person and their circumstances over the longer term.
Here’s how MHA assessments work in practice:
1) Support workers &/or carers reach the end of their resources in dealing with someone, so they call in those professionals who can access the next level of scarce resources i.e. the AMHP who can access in-patient care.
2) If the AMHP is willing to accept this referral, the assessment process begins. That means setting up an MHA assessment with two Section 12(2) doctors, typically two semi-retired psychiatrists whose understanding of current resource constraints is by definition out-of-date. Also they pick up a fee for attending, so there’s a more-than-usually strong institutional bias to go along with what the local professionals recommend.
3) When the meeting is finally set up for the convenience of the professionals, who may be travelling some distance in between their other commitments, the AMHP remembers to phone the carer (who, of course, has no commitments or travel constraints), typically to say “We’re meeting with your loved one in one hour’s time, can you make it?”
4) To fend off the “mental capacity” issues mentioned, MHA and MCA assessments are now combined in the same interview! This is not clearly explained to the service user and carer, who usually have only the haziest grasp of the process (never mind the legalities) and are offered no advocacy support.
5) So, three professionals who’ve never met the service user before try to assess whether s/he’s a risk to self &/or others. If so, admit as in-patient. If not, send her/him back to the exact same circumstances that led up to the assessment.
But – refer (2) above – no over-stretched AMHP is going to waste resources on an assessment that’s unlikely to admit someone to an available bed. Therefore, so long as there’s a bed available, the service user will almost certainly be admitted. It’s just a question of voluntary or compulsory.
(If the symptoms are very florid – enough to justify the effort of trying for an out-of-area bed – an assessment may be arranged even when a local bed is not available.)
I can’t see from the stats linked at the end of this piece that anyone is monitoring how many assessments end in admittance (voluntary or mandatory) to an in-patient ward.
The minimal research project reported here ends with recommendations for all the usual platitudes which I’m sure all those participating fully realise are pie in the sky for now.
For quicker and more practical improvements, better to ask why people are referred to MHA/MCA hearings in the first place. What can AMHPs do to help support services prevent referrals from “upstream” of their process, instead of forever swimming against the tide.
Except that AMHPs are paid more than equivalent grade social workers, so what institutional incentive is there to stem the flow of work?
So that’s my exerience of the process. Your experience may differ.
Perhaps a currently practising AMHP would like to reproduce here their (suitably redacted) log of a recent case?