Memorandum by SANE
MENTAL HEALTH SERVICES (MH 70)
SANE
SANE was established in 1986, following the Forgotten
Illness campaign in The Times, and is now one of the
most prominent charities concerned with schizophrenia and other
mental illness. Its three main objectives are:
— to raise awareness and combat ignorance
about mental illness, and to improve mental health services;
— to initiate and fund research into
the causes, treatments and potential cures for schizophrenia and
depression through its work at the SANE Research Centre in Oxford;
— to provide care and support through
SANELINE, the only national, out-of-hours mental health telephone
helpline open from 12 noon to 2 am every day of the year.
SANE'S EVIDENCE
BASE
The following evidence is derived largely from
the experiences of people suffering from mental illness or disorder,
their families or other carers, and professionals who telephone
SANE's national telephone helpline SANELINE. Trained volunteers
handle on average 700 to 1,000 calls a week, spending 870 hours
a month listening to callers' problems as well as offering options
for action. The calls are logged (anonymously unless otherwise
requested) and analysed to find trends and patterns, eg unmet
needs and reasons for seeking help. In some cases, callers are
referred to SANELINE's Caller Care service where experienced mental
health workers, using counselling skills, ring them back and give
more intensive help over a crisis or until they are prepared to
accept help in their own area and those services are available.
Currently, Caller Care provides callers with 52 hours a month
of one-to-one contact.
Whilst SANE accepts that callers to the helpline
are not a statistically definitive sample, it believes that since
they come from all parts of the United Kingdom and reflect a wide
range of serious problems, they provide significant information
on current weaknesses in mental health legislation and services
to protect and support them. Their cases are in effect like a
series of thousands of "snapshots" which individually
are particular to one case and therefore not necessarily representative,
but taken together over the eight years SANELINE has been operating,
form powerful and repeating images of a system that is failing.
EXECUTIVE SUMMARY
SANE has long campaigned for a radical look
at mental health policies and care in the community. For some
years it has called for modernisation of mental health law to
reflect the fact that care of mentally ill people has moved substantially
from institutional and hospital based care to care in the community.
In 1996 SANE launched a campaign to secure a
Balance of Rights for patients, families, carers and the
public, consulting widely and identifying areas for change in
the Mental Health Act 1983.
Drawing on this consultation, on calls to SANELINE
and on reports and other evidence, SANE believes that services
for mentally ill people in the community and in hospitals are
often falling short of acceptable standards of access, protection
and care in a therapeutic environment. This has serious consequences
for patients, families and carers, and professional staff.
SANE has analysed a sample of 33 inquiries into
homicides involving a person suffering from mental illness. This
reveals that in 39 per cent of cases there was a multiple failure
of care. In almost one in three cases the patient had sought help
with unsatisfactory results, and in over half carers' direct concerns
were not taken seriously. In about one in three cases the inquiry
had regarded the homicide as predictable or preventable.
SANE's priorities for mental health services
are more psychiatric beds and 24 hour nursed units; recruitment
and training of mental health professionals; a new legal framework
for mental health care; and fuller involvement of families and
carers.
SANE hopes that the Government's proposals on
mental health law and services will be resourced to bring about
a true revolution. If this does not happen, mentally ill people
and their carers will be left little better off.
EVIDENCE
CURRENT GOVERNMENT
DEFINITIONS AND
CATEGORISATION OF
MENTAL ILLNESS
1. SANE has for some years sought an overhaul
of the Mental Health Act 1983 (MHA), believing that it no longer
meets the needs of mentally ill people, whose care has moved substantially
from institutional and hospital based care to care in the community.
SANE believes that a modern framework is needed in which law and
services work together rather than in conflict, ensuring positive
rights to care and treatment and greater recognition of the role
of carers and families.
2. In 1996 SANE launched a campaign to secure
a Balance of Rights for patients, families, carers and
the public, consulting service users, carers and families, mental
health professionals and many others. The consultation looked
at the MHA and identified the following key areas where it was
considered that change was needed:
— there should be a positive right
to care and treatment for people suffering from mental illness—currently
one in three are being turned away from services;
— families, partners and other carers
should have their own needs assessed—now granted in the
Mental Health National Service Framework—be given sufficient
information, and be involved where appropriate in key decisions,
including care plans;
— the treatability test in the MHA
for those diagnosed as suffering from personality disorder should
be removed—this has been an excuse for services not to treat
people, and not to relegate them to the criminal justice system.
3. SANE welcomed the Government's root and
branch review of the MHA. Responding to the proposals for consultation
issued in November 1999 Marjorie Wallace, SANE's Chief Executive,
said:
"The Government is right to tackle the two
most contentious issues in mental health care, without which any
new monies or reforms would founder:
— people who without medication and
other treatments deteriorate to the point that they are at risk
of harming themselves;
— people who have a personality disorder
deemed untreatable who fall between mental health services and
the criminal justice system.
"However, we are concerned that the very
people who could benefit from these proposals might be deterred
from seeking treatment, and that the increased resources will
not be sufficient to meet the new powers. The monies being proposed
will hardly meet the current need, let alone reduce the strain
on a system crumbling under the pressure.
"On the issue of compulsory treatment, we
continue to believe that it should only be used as a last resort,
with full safeguards, in a clinical setting, and wherever possible
as part of a "contract" between the patient and services.
Compulsion should not just be imposed on the few patients for
whom it might be necessary but on the mental health services to
provide more holistic, individually tailored treatments whether
in hospital or the community. We hope these reforms will bring
this about."
4. SANE supports the recommendations on
the scope of a new mental health act, and the definition of mental
disorder to be included in a new act, set out in the consultation
proposals referred to above.
THE ABILITY
OF CARE
IN THE
COMMUNITY TO
CATER FOR
PEOPLE WITH
ACUTE MENTAL
ILLNESS
5. SANE believes that whilst care in the
community was a good concept and a true liberation for many people,
it was ruined by underfunding and a refusal to recognise that
sometimes mentally ill people need more than community-based care.
SANE has campaigned for a radical look at mental health policies
and care in the community for well over 10 years.
Beds
6. In the last 15 years, 50,000 psychiatric
beds have been lost. Acute admission wards in every big city are
grossly overcrowded, with occupancy rates running consistently
between 110 per cent and 120 per cent, against a recommended rate
of 87 per cent. The number of patients who have to be compulsorily
detained in hospital has trebled since 1980, and in London and
other cities only patients referred from the courts or under a
section of the MHA secure a bed. In the last 10 years there has
been a nine-fold increase in private psychiatric care, often requiring
patients to be treated far away from home.
7. Commenting on its Eighth Biennial Report
issued in August 1999, the Mental Health Act Commission (MHAC)
stated: "The high pressure on beds causes serious problems
for both patients and staff and can result in delays for urgent
admissions while beds are sought, patients frequently moving in
and between hospitals, staff spending a disproportionate amount
of time finding alternative placements and patients being discharged
early or held in settings inappropriate to their care."
8. Bed pressures mean that hospitals are
all too often not therapeutic. Further MHAC comment on the above-mentioned
report stated: "The shift in the provision of mental health
care from hospital to the community has resulted in hospital admission
wards providing care for patients with more acute symptoms and
high levels of disturbance. There are indications that problem
behaviour on wards, such as threatening language and behaviour,
racial and sexual harassment and abuse of alcohol and drugs, is
a growing concern. Under such circumstances there is a need for
highly skilled and well motivated staff. However, there is an
acute shortage of nurses and a heavy reliance on temporary staff.
Where this is the case, and where there is an impoverishment of
the ward skill mix, therapeutic regimes are likely to suffer,
resulting in the provision of little more than custodial care."
9. For families and carers, premature discharge
from hospital because of bed pressures, or inability to obtain
a bed, mean unsupported home care. For professionals, there is
the constant dilemma whether to discharge someone who is still
acutely disturbed or turn away another patient who may be just
as much at risk.
Professional staff
10. Currently there are approximately 400
vacancies for consultant psychiatrists in England. Community psychiatric
nurses can have caseloads of 80 to 90 people against a recommended
35, and many authorities cannot staff 24-hour crisis teams. This
results in a lack of risk management at all levels, a high rate
of professional burn-out, and low morale.
Calls to SANELINE
11. Analysis of calls to SANELINE shows
that:
— 52 per cent of callers think services
are not available locally;
— 20 per cent of callers say that they
are unable to access services (they are either unable to locate
services, or due to waiting lists are unable to access them for
some time);
— 47 per cent of callers are not satisfied
with services, frequently commenting that GPs and psychiatrists
are unsympathetic and at worst dismissive;
— 8 per cent of callers think services
are not available when they are needed, particularly support out
of hours and at weekends.
SANE suicide survey
12. A survey of 10,359 people who contacted
SANELINE between January 1996 and June 1998 reporting a history
of mental illness and suicidal intentions showed that half of
the callers had attempted suicide in the past, and that almost
one-fifth were planning it at the time of the call. The calls
were made mostly to obtain information. Other callers described
problems of social isolation, stigma, poor social networks, or
difficulty in daily living. The survey found that:
— more than three quarters of the suicidal
callers had been in contact with a health professional in the
month preceding the call;
— almost three-fifths of suicidal callers
were under 35 years of age, with 37 per cent belonging to the
25 to 34 age group;
— more than half of all calls related
to people suffering from depression, and about a third were from
people with severe mental illness (psychosis).
13. SANE has also carried out a pilot study
of 21 cases of suicide based on information provided by bereaved
carers. This showed that:
— one in three of those who had previously
attempted suicide had received little or no follow-up care after
contact with services;
— two in three of all cases had attempted
suicide in the past.
Care in the community not working
14. There is substantial circumstantial
evidence that care in the community is not working:
— many seriously ill people living
independently cannot get access to day support:
— over seven out of 10 prisoners in
England and Wales have been assessed as having more than one of
the main types of mental disorder; 39 per cent of male sentenced
prisoners and 75 per cent of female remand prisoners as having
significant neurotic symptoms; and 14 per cent of women, 10 per
cent of men on remand and 7 per cent of sentenced men as having
a functional psychosis;
— homeless people are more than four
times more likely than others to be mentally ill; almost half
of those sleeping rough or using night shelters have a significant
psychiatric disorder, and 20 per cent have severe problems;
— 15 per cent of those with manic depression
or severe depression, and 12 per cent of those with schizophrenia,
commit suicide; 24 per cent of all people committing suicide had
been in contact with mental health services in the previous year;
— a 1997 report on London's mental
health care described "a service in inner London that cannot
be sustained because it is unable to meet the demands imposed
upon it".
SANE's priorities
15. SANE endorses much of what the Government
is proposing in the Mental Health National Service Framework,
but it considers it essential that the new measures target not
only the politically visible minority who hit the headlines but
provide a revolution in mental health care for everyone. SANE's
priorities are:
— more psychiatric beds and 24-hour
nursed units;
— recruitment and training of mental
health professionals;
— effective service delivery and accountability;
— a new legal framework for mental
health care;
— involvement of families and carers.
16. Care in the community can only cater
for people with acute mental illness if there are in place in
each locality:
— properly supported and supervised
living accommodation in the community for people who are not living
with their families or carers;
— adequately supported, trained and
experienced mental health professionals able to provide risk assessment,
care and supervision in the community, if necessary on a 24-hour
basis;
— access to a bed in a 24-hour nursed
unit or hospital if the patient's condition requires that. Such
beds should be provided in small, modern centres of excellence
able to provide assessment, diagnosis and high quality care in
a therapeutic environment.
17. Until supported accommodation in the
community, trained mental health professionals, and beds in 24-hour
nursed units and hospitals are made available in sufficient numbers,
care in the community will not be able to cater properly for people
with acute mental illness. Resources need to be backed by a recognition
that acute mental illness needs to be taken seriously at all times.
Everyone concerned—the patient, the family or carer, as
well as the professional—needs to be aware of the possible
manifestations of acute mental illness, of the possible need for
ongoing treatment and support, and of the possibility of relapse.
SANE review of homicide inquiries
18. SANE has analysed a sample of 33 inquiries
into homicides involving a person suffering from mental illness,
the sample including all but two of the total number of inquiries
reporting between January 1997 and April 1998. The analysis reveals
that in 39 per cent of cases there was a multiple failure of care
through simultaneous breakdown of five major aspects: communication
at all levels; inadequate or non-existent care plans; poor or
non-existent record keeping and inadequate case histories; lack
of risk assessment and poor risk management; and poor multidisciplinary
team work. In almost one in three cases, the patient had sought
help with unsatisfactory results, and in over half of them carers'
direct concerns regarding the patient's safety were not taken
seriously. In about one in three cases, the inquiry had regarded
the homicide as predictable or preventable.
THE TRANSITION
BETWEEN THE
ACUTE AND
SECURE MENTAL
HEALTH SECTORS
19. Just as access to an acute bed is necessary
if care in the community is to cater for people with acute mental
illness, access to a secure bed is a prerequisite for providing
care and management to patients whose condition may require a
higher level of security. Speed of access where someone is deteriorating
or presenting a danger to himself or others can be critical in
preventing a tragedy.
20. In its strategy document "Modernising
Mental Health Services", the Government acknowledge that
there are "too many cases where people who need secure care
cannot be found a bed. Some remain inappropriately placed on acute
wards or in prison for far too long." SANE's experience of
individual cases and of homicide inquiries bears this out. As
well as the gridlock in acute beds—leaving those needing
them inappropriately in the community—those in secure beds
are often far away from home, putting extra pressure on patients,
their families and carers, Welcome as the extra resources for
secure beds are, there is still unacceptable and unsafe pressure
on both the secure and acute systems.
THE TRANSITION
BETWEEN ADOLESCENT
AND ADULT
MENTAL HEALTH
SERVICES
21. SANE believes that child and adolescent
mental health services have been a neglected area, with a pressing
need to build up services. SANELINE receives calls concerning
children suffering from ADD, depression and other potential serious
illness, indicating a reluctance to diagnose and unmet need for
help.
22. Scientists working with SANE's Research
Centre in Oxford have found that warning symptoms of latent schizophrenia
can show up as early as the age of 11. Early results indicate
that those subsequently diagnosed as suffering from schizophrenia
may have had more developmental problems, less acceptable behaviour,
lower reading ability and poorer co-ordination. Some of these
differences can be traced back to the age of five or younger.
CONCLUSION
23. The Government's review of mental health
law and services provides a long overdue opportunity to bring
about a revolution in care for mentally ill people, and to give
the wider community greater confidence that they will receive
this. SANE hopes that the proposals announced by the Government
will prove to be a true revolution, given the right supplies of
skilled staff and 24-hour care. If this does not happen, there
will be only tame and temporary reform, and mentally ill people
and their carers will be left little better off.
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