We started deinstitutionalising our mental health care in the 1960s, not long after the beginning of a psycho-pharmacological revolution which suggested we had found effective drug treatments for psychotic diseases. In fairness, it wasn’t just pharmacology that drove us: there were also concerns about the ethics of mass incarceration of those of us who were not just mentally unwell, but deemed socially inept for a variety of non-medical reasons – vagrants and single mothers included. Post World War II, the sheer cost of mass incarceration was a concern and we sought to implement alternatives for all these reasons and more besides. It was a complex socio-medical movement and overtime, it has become ‘harder’ to become a mental health inpatient.
So what, over time, has been the consequence of rising thresholds to inpatient psychiatric care?
I assume we all accept the principle that we subject citizens to inpatient detention less readily today than we did ten, twenty or fifty years ago? If you don’t think we have, please leave a comment below outlining why – I’d love to hear your view. I think – for what it’s worth! – that this is a good thing as long as it doesn’t got too far. However various mental health professionals have suggested to me that this is what has been going on in our NHS over the last few years, building on that reform over decades. The threshold for inpatient admission has risen and is still rising for as we have fewer inpatient mental health beds to use, so must they be targeted on those who need them most. Although the 2012/13 CQC report indicated that use of MHA had exceeded 50,000 for the first time in a single year, it is also safe to report that average lengths of detention have reduced over time. So the Mental Health Act in the United Kingdom is being used more frequently but for fewer days each time it is used.
So what evidence that the ‘bar’ is rising?
Aside from the anecdotal evidence that professionals keep offering up, the inference that could be drawn from the increased usage of the MHA, but for fewer days each time, there is also the views of GPs that we have seen voiced. They are less able to make referrals to secondary care than they previously were. And most importantly for this post – why am I banging on about it?!
It is because of the relationship to the use of section 136 MHA.
It’s a view frequently expressed – not least by Professor Louis APPLEBY on this blog – that the threshold for use of section 136 is falling. The main argument for this is the proportion of people assessed under s136 who are subsequently admitted to hospital: it has reduced over time. Whereas once, most people were admitted as inpatients, most people are now discharged from it. The current figure is 17% of s136 detainees are admitted to hospital under the Act, down from 20% the previous year. Of course, other factors contribute to how usage has changed and how outcomes have altered: improved police training and awareness, the effects of mass deinstitutionalisation combined with a community mental health system that almost everyone acknowledges is underfunded.
But what of that initial barometer – that AMHPs and medics admit fewer patients now than they previously did? Are we assuming that the medical ‘bar’ has remained constant when there is every reason to think otherwise? We know that people are spending less time in hospital because of bed restrictions; we know that more and more admissions are occurring but that the rise in admission numbers is not accounted for by more people becoming unwell. Some patients are in a cycle of short admissions and early discharge before being placed on Community Treatment Orders, the effectiveness in breaking the admission-discharge-relapse cycle has been questioned. May it be the case that a partial explanation for rising use of s136 nationally is that people detained by the police are less likely to be admitted by mental health professionals who are obliged to exercise greater caution about admissions?
Community mental health teams have commented that many patients now on the books of CMHTs or Assertive Outreach teams are patients who would have been inpatients only a few years ago if they were that unwell. With far fewer beds available to serve the population, it now means a combination of three things:
- Some patients who previously would have been admitted now being supported in the community;
- Some patients who are admitted remain in hospital for a shorter period before being discharged to community treatment.
- Community mental health teams are also under massive pressure of workload and GPs are reporting that fewer referrals to secondary mental health care are accepted.
So it’s harder for GPs to get patients into specialist mental health services; it’s harder to achieve an inpatient admission amidst reports that inpatient admission is unlikely on a voluntary basis. If you want evidence that this has gone too far to cope with predictable levels of demand, just look at the recent announcement that NHS England have order to commissioning of more CAMHS beds, because this sector of our mental health system in particular has been squeezed too far with stories of children being transported hundreds of miles, sometimes in the middle of the night, to achieve an inpatient admission.
SIGNIFICANCE OF 136 CONVERSION
So we need to look again at s136 conversion as a proxy for effective use of the power by the police. No doubt, some forces overuse and some officers will from time to time abuse what section 136 is for. But simply looking at the percentage figure of those detained by the police who are subsequently admitted to hospital is not an examination that tests police decision-making against a constant feature. Threshold decisions for the use of the MHA by AMHPs and DRs is a moving target so all other things being equal, we would still expect to see fewer patients being admitted, having been subject to section 136.
The rising use of section 136 nationally and the declining admission or conversion rate have been used to suggest that police officers are becoming too quick to use this legal power and that more training is required. Maybe – and in some areas of England, I don’t rule it out at all. But we do know that some areas use section 136 very responsibly and always did have far better conversion rates: as high as 45% in Birmingham. All of these things need careful deconstruction to ensure we’re not leaping to conclusions about what is going on in an area of business that is little researched and where data is notoriously unreliable. Meanwhile, it’s harder and harder for patients to access secondary or inpatient mental health care amidst many reports from professionals that some patients are spending too little time in hospital, waiting too long for specialist support in the community and being increasingly cared for by GPs who are anxious about their own training and capacity in dealing with complex mental health problems.
Whatever is going on in policing and section 136 — it is a symptom of broader problems with our social responses to mental health issues and a reaction to a mental health system which is increasingly focused on late intervention.
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