Has the Mental Health Act had its day?

Factors associated with involuntary mental healthcare in New South Wales, Australia

BACKGROUND

There is uncertainty about factors associated with involuntary in-patient psychiatric care. Understanding these factors would help in reducing coercion in psychiatry.

AIMS

To explore variables associated with involuntary care in the largest database of involuntary admissions published.

METHOD

We identified 166 102 public mental health hospital admissions over 5 years in New South Wales, Australia. Demographic, clinical and episode-of-care variables were examined in an exploratory, multivariable logistic regression.

RESULTS

A total of 54% of eligible admissions included involuntary care. The strongest associations with involuntary care were referral from the legal system (odds ratio 4.98, 95% CI 4.61-5.38), and psychosis (odds ratio 4.48, 95% CI 4.31-4.64) or organic mental disorder (odds ratio 4.40, 95% CI 3.85-5.03). There were moderately strong associations between involuntary treatment and substance use disorder (odds ratio 2.68, 95% CI 2.56-2.81) or affective disorder (odds ratio 2.06, 95% CI 1.99-2.14); comorbid cannabis and amphetamine use disorders (odds ratio 1.65, 95% CI 1.57-1.74); unmarried status (odds ratio 1.62, 95% CI 1.49-1.76) and being born in Asia (odds ratio 1.42, 95% CI 1.35-1.50), Africa or the Middle East (odds ratio 1.32, 95% CI 1.24-1.40). Involuntary care was less likely for people aged >75 years (odds ratio 0.68, 95% CI 0.62-0.74), with comorbid personality disorder (odds ratio 0.90, 95% CI 0.87-0.94) or with private health insurance (odds ratio 0.89, 95% CI 0.86-0.93).

CONCLUSIONS

This research strengthens the evidence linking diagnostic, socioeconomic and cultural factors to involuntary treatment. Targeted interventions are needed to reduce involuntary admissions in disadvantaged groups.

Openness in the NHS: a secondary longitudinal analysis of national staff and patient surveys

Background

Improving openness—including candour when things go wrong, and willingness to learn from mistakes—is increasingly seen as a priority in many healthcare systems. This study explores perceptions of openness in England before and after the publication of the Francis report (2013), which examined failings of openness at one English hospital. We examine whether staff and patients’ views on openness, and experiences of giving voice to concerns, have changed since the report’s publication for better or worse.

Methods

Organisational-level data was collated for all trusts from the NHS National Staff Survey (2007–2017), NHS Acute Inpatient Survey (2004–2016) and NHS Community Mental Health Service User Survey (2007–2017). Survey items related to openness were identified and longitudinal statistical analysis conducted (piecewise growth curve and interrupted latent growth curve analysis) to determine whether there was evidence of a shift in the rate or direction of change following publication of the Francis report.

Results

For some variables there was a discernible change in trajectory after the publication of the Francis report. Staff survey variables continued to rise after 2013, with a statistically significant increase in rate for “fairness and effectiveness of incident reporting procedures” (from + 0.02 to + 0.06 per year; p < .001). For the patient surveys, the picture was more mixed: patient views about information provided by accident and emergency staff rose from a 0.3% increase per year before 2013 to 0.8% per year afterwards (p < .01), and inpatients being involved in decision making increased from a 0.4% rise per year before 2013 to 0.8% per year afterwards (p < .01); however, there were not rises in the other questions. Mental health patients reported a decrease after 2013 in being listened to (decreasing at a rate of 1.9% per year, p < .001).

Conclusions

Data suggest that the Francis inquiry may have had a positive impact on staff and acute inpatients’ perceptions and experiences of openness in the NHS. However such improvements have not transpired in mental health. How best to create an environment in which patients can discuss their care and raise concerns openly in mental health settings may require further consideration.

Current appeal system for those detained in England and Wales under the Mental Health Act needs reform

The approach to managing the involuntary detention of people suffering from psychiatric conditions can be divided into those with clinicians at the forefront of decision-making and those who rely heavily on the judiciary. The system in England and Wales takes a clinical approach where doctors have widespread powers to detain and treat patients involuntarily. A protection in this system is the right of the individual to challenge a decision to deprive them of their liberty or treat them against their will. This protection is provided by the First-tier Tribunal; however, the number of successful appeals is low. In this paper, the system of appeal in England and Wales is outlined. This is followed by a discussion of why so few patients successfully appeal their detention with the conclusion that the current system is flawed. A number of recommendations about how the system might be reformed are offered.

The construction of people with mental health problems as risk objects: Findings of a case study inquiry

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and management in mental health services are contested and perceived as problematic by both professionals and service users. There is substantial emphasis on risk as a core component of professional practice. However, recovery for people with mental health problems emphasizes self-determination which seems to conflict with risk management. A critique is emerging of risk assessment and management. However, there is a lack of empirical evidence which seeks to explore how professionals manage the conflicts between recovery orientated practice and risk management. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper reports on qualitative research which highlights people with mental health problems are objectified and frequently associated with the potential for harm. Risk dominates the work of mental health professionals and undermines individualized care. Service users are subject to increased surveillance and medication as a result. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Service users' subjective experiences need to be prioritized in mental health care by renewed focus on the relationship between professionals and service users. Mental health professionals should question the centrality of risk to their practice. ABSTRACT: Introduction The emergence of recovery, alongside significant focus on risk management, creates potential for conflicting influences in mental health care. Although evidence has critiqued risk assessment, there is a lack of research that seeks to explore how professionals make decisions within these apparently incompatible agendas. Aim To explore how practitioners, experience potential tensions arising from delivering recovery-orientated care and enforcing containment. Method This paper reports on a case study inquiry, using interviews with mental health professionals and observations in an acute ward and an assertive outreach team. Results Risk governed the practice of mental health professionals to such an extent it defined how service users were understood and treated. Service users were constructed as objects of risk, first by being objectified and secondly by creating a link between that object and harm. Discussion Hilgartner's (1992, Organizations, uncertainties and risk (pp. 39-53). Boulder, CO: Westview Press) theory of risk explains how risk dominates the identity of people with mental health problems at the cost of recovery. This results in increased monitoring, surveillance and medication to enact control. Implications for practice To undermine the dominance of risk, professionals should reconnect with the subjective experiences of people with mental health problems and challenge the acceptance of risk as central to their role.