Reforming our Mental Health Act

The Mental Health Act is not perfect. Since 1959, when it first came into being, it has been gradually reformed and refined until we have something which works reasonably well, but still with flaws. What piece of legislation doesn’t?

The Royal College of Psychiatrists was among the major mental health organisations to call for a review of the Act – something that should be done at intervals anyway – to iron out inconsistences between it and the Mental Capacity Act, which protects individuals who lack capacity to make their own decisions about their care, and also look into the problem of increasing numbers of people being sectioned. According to statistics, 63,000 people were detained in England and Wales in 2014-2015, a 43 per cent increase compared with 2005-2006. And 56.9 per 100 individuals who are sectioned come from Black and Minority Ethnic (BME) groups, compared to 37.5 per 100 who do not.

The Royal College of Psychiatrists is very aware of these and indeed other problems with current legislation. That’s why we joined with the leading mental health charities and called for just that in the run up to the election campaign.

The Royal College of Psychiatrists is very aware of these and indeed other problems with current legislation. That’s why we joined with the leading mental health charities and called for just that in the run up to the election campaign.

We know that we need to respond to those who are indeed legitimately concerned that the statistics could reveal unacceptable discrimination towards certain groups, including those from BME backgrounds. It is important that we understand why the Act disproportionately affects the most vulnerable, including those from BME backgrounds.
There is good evidence that people from BME groups are less likely to be seen by what we call early interventions services, which have been shown in many trials to improve the outcomes and reduce subsequent admissions of those in the early stages of severe mental illness. That unfortunately means that they are more likely to present late, and in more severe stages of illness. Which also means they may be more likely to come to the attention of the police and spend time in police custody

Nobody wants that. Not the police, not the health service, not families and most important of all, not the patients themselves.
But one solution might be improving early intervention services, and making them more acceptable and accessible to those from BME backgrounds, rather than assuming that changing the Act will of itself sort out the problem. I am afraid that all the mental health organisations, including my own, are of the opinion that eventually the matter of adequate resources and funding is going to raise its ugly head.

Much the same applies to alternative to hospitalisation. No one can deny the current crisis in social care. But the consequences are that for example access to supported housing has declined. The mental health system is complicated – but pull away any of the different supports available, and you see an effect across the system.

The mental health system is complicated – but pull away any of the different supports available, and you see an effect across the system.

 And that is exactly what we are seeing – fewer alternatives to hospital admission. Yes, there has been welcome investment in crisis services, which is very much what is needed, and a commitment to ending the unacceptable practice of sending people to beds that might be hundreds of miles away from where the patient and family live. But overall, whoever wins the election is still going have to make good these promises as well as ensuring that this investment gets to where it is needed, which ever since the 2012 Health and Social Care Act is not quite as simple as it might sound.

I think everyone agrees that this is a delicate area, and one in which language is important. So for that reason I do hope that we can avoid terms such as “unnecessary detentions”. No one could ever support unnecessary use of the Mental Health Act, but in practice how often does that happen? Given the continued bed crisis, and of course the costs involve, in my experience everyone involved in the system – which includes but is very much not just, psychiatrists, do everything they possibly can to avoid admission, and instead will always go for what we call the “least restrictive option”. But sometimes the situation is simply that there is no alternative. I would much prefer that we talk about “avoidable” as opposed to “unnecessary”. Because I believe a programme of sustained investment in early intervention and alternatives to admission is the best way of stopping the steady rise in the numbers of people detained in hospital against their wishes.

We should also remember that the modern Mental Health Act involves a very clear system of checks and balances that are specifically designed to protect the rights of those with the severest mental illnesses.

So yes, this is a good time to review mental health legislation. That’s why we and others have asked for this. Not just because of the rise in detentions, but also to try and resolve some of the complexities that have arisen from the fact that we actually have two mental health acts – the Mental Health Act itself, and the Mental Capacity Act. Recent court judgments have made it clear that these two Acts don’t always work well together, and some inconsistencies need to be resolved. We also need to have a look at what is happening elsewhere – Northern Ireland for example has instituted a rather different way of dealing with these issues, opting for a single act based around issues of mental capacity rather than mental illness. It might be sensible to see how that works before rushing to judgements here.

But whatever the end result, I know two things. First, these things take time. We know that reforming the mental health acts has usually taken up to two years, but patience has always been rewarded in improved legislation. Second, we will never do away with some form of mental health legislation, intended to ensure that the rights of those with the most serious mental illness are respected, whilst also enabling people to receive treatment in a proportionate way. I have been to parts of the world where there is no such legislation, and those are definitely places where I would not want to experience severe mental illness in either myself or within my family.

Professor Sir Simon Wessely

Sir Simon Wessely is Regius Professor of Psychiatry and Co-Director, King’s Centre for Military Health Research and Academic Department of Military Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London.He is a clinical liaison psychiatrist, with a particular interest in unexplained symptoms and syndromes.He has responsibility for undergraduate and postgraduate psychiatry training, and is particularly committed to sharing his enthusiasm for clinical psychiatry with medical students. He also remains research active, continuing to publish on many areas of psychiatry, psychological treatments, epidemiology and military health.
Professor Sir Simon Wessely is also President of the Royal Society of Medicine.
Professor Sir Simon Wessely
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