Raising the Bar

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.


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.

IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


5 thoughts on “Raising the Bar

  1. “we subject citizens to inpatient detention less readily today than we did ten, twenty or fifty years ago?”

    I don’t agree and speak from personal experience in Scotland, having supported family members in psychiatric settings here since 1970, 5 health board areas, in every decade, and as a mental patient myself in 1978, 1984 and 2002. I think the state of affairs for mad or mentally ill people today is more risky and more coercive than might appear from the stats and statutory reports. Or that’s been our experience as a non-conformist family who don’t believe in the labels and resist forced psych drug treatment when we can. It makes sense to me not to swallow antipsychotics voluntarily for they depress me. The venlafaxine gave me suicidal thoughts, bone loss, and the lithium did nothing whatsoever apart from raise my blood pressure in 2002/3. I had to take charge of my own mental health to taper the drugs and recover. And so I did but the schizoaffective disorder label remains.

    Our experience from 2010 to 2013 has been of the mental health act not being implemented properly or monitored effectively in 2 Scottish health board areas. We had to call the police so as to get crisis support. They took family members into psychiatric settings otherwise, despite even having a CPN, we just couldn’t get help. The delay in appropriate support and having to call the police meant that the locked psychiatric ward was the outcome. Dehumanising treatment in one setting with forcible drug cocktails in the other, 5 psych drugs, including 2 antipsychotics in 2013. Overkill. I raised complaints with the Scottish Mental Welfare Commission and they sent a psychiatrist to visit. By that time I had sorted it out anyway.

    I think in Scotland that the focus on “targets” is to blame. The military style government maneouvres that require health boards to hit this, that and the other percentage, keep people alive and kicking in house, making sure that any suicides are NIMBY. Call me cynical. But I did hear this from local health board managers about the constraints put on them. Where I live they have taken a lot of resources out of psych wards and focused services “in the community”. Getting patients out as quick as possible. Problem is that mentally distressed people often can’t get in when needed and are pushed out before ready. Revolving door scenario resulting in no time for recovery focused practice, leading so easily to “mental illness” and chronicity.

    I agree that early intervention is the key and the right sort of intervention would be even better, particularly for people in altered mind states or psychoses eg a choice of talking therapies and not just psychiatric drugs/medication, coercively given if “non-compliant”. When my family members experienced psychoses I got them help when I could. It’s got much harder and more risky. I’ve been glad of the police even when they were in need of better mental health training which I hope they are now getting.

  2. To add and to qualify why I don’t agree. It may be more difficult to “get in” but there is more detaining and use of detention because of this. It’s a vicious circle. Trying to keep people out of care makes them more likely to need inpatient treatment and to need more intensive treatment, hence in Scotland the rise in more specialised and more expensive low and medium secure hospitals for male patients.

  3. There probably is less inpatient detention but there is a lot more community treatment orders and people not on treatment orders who use psychiatric services and who are on so called anti-psychotic drugs. These severely restrict people’s quality and length of life. They also reduce the chance of recovery as people find it much harder to think things through and engage with things that raise their self esteem when they are tranquilized to the degree that they are sleeping half the day or suffering the bad effects of these drugs such as akathesia.

    Lots of people live in their bedsits, isolated and drugged up.

    A proper service would not do this, it would address peoples problems and help them recover.

    So inpatient commitment has been replaced with community mass tranquilisation

  4. I think this is a fantastic thing that Inspector Brown is doing to raise awareness. I have experienced first hand what being arrested and put in a cell is like. I on arrest made the custody officers fully aware of my situation, medication etc after answering set questions that are put to you. However that was where the interest in my well being ended. I firstly must point out i was not arrested for violence or anything. I was ushered to a cell and left there for the night terrified apart from the odd person looking through a spy hole. I wasnt given a blanket and i was freezing cold bit too scared to ask for one. Ive never felt so alone in my life my 12 years a soldier a distant memory and no one cared. At 5am the next morning i suffered chest pains and had to shout for someone to help as i couldnt reach the alarm through pain. Eventually someone came and looked at me and called an ambulance. I was taken to hospital where i was escorted by 2 officers in full view of the public. I felt like the worst scum in the world and the nursing staff treated me like a criminal. Ex Soldier no one cared. However i spent 3 months in hospital and im fully recovered mentally and physically thanks to the dedication of the hospital i was in. Am i bitter yeah maybe a little because ive always supported the police and the law. I wouldnt of hesitated to help a police officer before and now i have no confidence in them.

  5. I am not totally sure but I think some of the drugs discovered were not developed with psychiatric uses in mind; perhaps it doesn’t matter but I am not sure it was a massive leap forward in insight, as if the drugs were designed to fulfil a well defined problem.

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