Mental Health Act Review - Mind's influencing work
Mental Health Act Review
Mind's engagement and influence
Influencing the review
Being sectioned and detained in hospital to receive mental health treatment is one of the most serious things that can happen to somebody experiencing a mental health problem. The Mental Health Act 1983 (‘the Act’) is the legislation in England and Wales that sets out when people can be detained and treated for their mental health in hospital against their wishes.
It is only when we put those lived experiences at the forefront of change that we can start to create a system which is better for everyone.
In October 2017, the Government commissioned an independent review of the Mental Health Act. Here at Mind, we saw this as an important opportunity to influence how people are treated when they are at their most unwell and to draw attention to some of the wider problems in mental health service provision.
We knew that the best people to direct our work to in this area are the people who have lived experience of the Act itself. It is only when we put those lived experiences at the forefront of change that we can start to create a system which is better for everyone.
To do this we engaged with people in England between April and June 2018 who had experienced the Mental Health Act so their voices formed the cornerstone of our input into the Review.
We worked directly with over 50 people through various activities including:
A steering group made up of people with relevant experience of the Act and/or from Black and Minority Ethnic (BME) communities
A workshop with people from BME communities with experience of the Act
Three focus groups with people with experiences of the Act, one specifically with users of a homelessness service
10 telephone interviews with people with experience of the Act including current inpatients
Minority groups disproportionately impacted
We know that people’s race and ethnic background impacts on their experiences of mental health services and being sectioned. Black people are four times more likely than their white counterparts to be detained under the Act and are more likely to be subjected to coercive treatment.
The reasons for this are complex, but evidence suggests that the over-representation of BME groups under the Act is the result of mainstream mental health services often failing to understand or provide services that meet their particular cultural needs, alongside a lack of staff diversity at senior levels, negative stereotyping and institutional racism.
I could not identify with a white, middle-class psychiatrist. I couldn't sit down friendly and talk about the issues that were affecting me, my rape, my beating up etc. that I'd gone through. I couldn't sit there and talk to this strange white, middle-class man. For a long time, I couldn't talk to any of them. Maybe one or two of the Black nurses…but they weren't the ones documenting and dealing with my case.
Speaking to people with experience of homelessness also identified a lack of joined-up services and the failure to understand multiple needs. People were not being taken seriously by services and they were not being given priority.
Lack of access to services
A recurring theme from our engagement work is that it is not until someone reaches crisis point that they are able to access the services they need, and even then, not always. People aired their frustrations of desperately needing help but being unable to access it because of the lack of services. One of our participants told us that they felt lost in the system because they were being transferred from place to place without getting the help they needed.
While others spoke about their mental health deteriorating because of the delays in getting help, especially during the night and on weekends when many crisis services are closed.
"When you're homeless and you ask to be sectioned they just think you want a roof over your head. When you ask to be sectioned it's because you really need it. We're on the streets for months, we're used to it."
We heard an overwhelming view that earlier support from mental health services would often remove the need for detaining someone under the Act.
Many people we spoke with questioned the need to involve the police in order to access mental health services when they reach crisis point.
African Caribbean people are more likely than the general population to access mental health services through contact with the Police rather than through the health system, which is the main route to treatment for most people. Participants from our focus groups pointed to the lack of trust in the police from BME communities being related to previous incidents of institutionalised racism and discrimination towards Black people; this distrust is transferred when being detained.
Some people told us that contact with the police was found to be intrusive and unpleasant, for example one participant shared her experiences of several Police Officers invading her home to detain her son and entering his bedroom after they were asked to leave.
"When they come to take me to the hospital, they bring the police. Why?"
Poor experiences in hospital
Many of the people that we engaged with had very poor experiences of being in hospital. This ranged from an unsatisfactory physical environment through to racism on the part of staff. Some felt unsafe in closed environments, having been shouted at and intimidated by staff. Others had experienced physical restraint, seclusion or forced medication. People told us that ward environments did the bare minimum to ensure the wellbeing of patients.
"The support you get once you’re sectioned – you’re observed by someone pulling back a shutter half way through the night to make sure you’re asleep, and make sure you’re eating, making sure you’re taking medication. In terms of any talking therapy, trying to understand, and doing it in a holistic and joined up way, none of that exists."
Discharge from hospital was difficult for people in a number of ways with many feeling both unsupported and unprepared. From our engagement with people, recurrent issues were highlighted with aftercare – many felt they did not get enough support after they left hospital. This was especially true for people with multiple needs such as homeless people, who faced the double-edged sword of needing housing provision in addition to support with maintaining their mental health.
People told us there was a lack of communication around leaving hospital. Some felt that they were discharged too soon and in select cases that this decision was made unfairly, whereas others believed that they stayed in hospital too long.
"The Mental Health Act is all about crisis. Not about prevention and recovery. I shouldn’t be allowed to be discharged from hospital without a care plan."
Experiences with care planning differed among the people we engaged with. Some people had very positive experiences with care plans, but most people did not. While we did hear about some good examples of care plans which helped to facilitate recovery, it was disheartening to hear that many of our participants did not have care plans and those that did had very little involvement in writing their care plan. One of the participants shared that it was almost inevitable to slip back into the ‘system’ when there is no care plan and no co-ordination between hospitals and community services.
""If something was to change in the Mental Health Act, I would like it so that psychiatrist doesn’t have the final say.""
Patient Choice and Advocacy
Participants from our telephone interviews told us they felt ignored and misunderstood by staff while in hospital, with little opportunity to have a say about their care. Some suggested that greater access to advocacy (getting support from another person to help you express your views and wishes, and help you stand up for your rights) would be helpful when speaking to professionals, so they could have more meaningful involvement in their care. Additional suggestions for improvement were for staff to be better equipped to provide more culturally and religiously sensitive care.
Community Treatment Orders (CTOs)
A CTO is an order made by a clinician which allows someone to be treated in the community for their mental health, instead of staying in hospital. But they can be called back to hospital and given immediate treatment if necessary.
Black and Black British people are over eight times more likely to be on a CTO than White people . Black participants in our engagement suggested the reason for this disproportionate use was that Black people were not trusted to adhere to treatment and take medication, so clinicians used CTOs as a form of surveillance.
We engage with people to ensure that our influencing is driven by the views and experiences of people who have lived experience. Our various engagement activities gave us the opportunity to understand more about the perspectives of people with direct experience of being detained in hospital to be treated for their mental health.
As well as specific issues with the Act, what they told us made it clear that there are very serious issues in how people are treated when they are at their most unwell, including around institutionalised racism and disadvantage, lack of mental health services and poor discharge from hospital. This is why we need reform to the law, but also transformative changes to mental health services.
What does the review recommend?
The changes recommended by the Review set out to give much greater legal weight to people's wishes and preferences and to require stronger, transparent justification for using compulsory powers. They address the needs of particular groups affected by the Act including people from minority ethnic communities, and they call for improvements in services.
Read the full report and recommendations.
We welcome the Review’s recommendations to increase people’s choice and dignity when they are subject to the Mental Health Act, and for promoting race equality in mental health services and the use of the Act.
However, we were disappointed that the Review has not recommended getting rid of Community Treatment Orders (CTOs). These have not reduced hospital re-admissions and are often experienced as coercive, especially by people from Black or Black British backgrounds, who are more likely to be subjected to CTOs.
"These recommended changes are much needed but detentions will only reduce when people have access to quality, culturally relevant and timely care, so that fewer people end up in a mental health crisis."
Paul Farmer, Mind CEO
We will be pushing the Government to formally adopt and act on the review's recommendations as a whole, and will continue to hold it to account on its promises to reform mental health care.
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