Memoranda submitted by The Sainsbury Centre for Mental Health (MH 39)
1.1 The Sainsbury Centre for Mental Health (SCMH) is an independent charity working to improve the quality of life of people with mental health problems. Our priorities are to tackle the high level of unemployment among people with mental health problems and to improve the quality of mental health care offered to prisoners in the UK. We are deeply concerned about the impact of the Mental Health Bill on the lives of the people who will be affected by it.
1.2 SCMH is a core member of the Mental Health Alliance. We endorse in full the views expressed in the Alliance's submission to the Committee. This submission focuses on additional evidence relating to our specific knowledge based on research and analysis we have carried out.
2. The Mental Health Bill
2.1 Reform of the Mental Health Act is overdue. However, we believe the Government's approach represents a missed opportunity for England and Wales to introduce legislation that would support twenty-first century mental health care in the model of the Scottish Mental Health Act 2003.
2.2 The impact of mental illness on a person's employment prospects is considerable. Less than one quarter of working age adults with severe and enduring mental health problems are in employment, yet we know from local and national surveys that the majority of people with a mental illness would like some sort of work (Grove, Secker and Seebohm, 2006). Many employers say they would not consider hiring a person with schizophrenia (SEU 2004).
2.3 The impact of detention is less well researched. One local study suggested employers would not be distracted by a person's previous detention under the Mental Health Act when recruiting (Fenton et al 2003). Yet a different survey, of 18 Black men previously detained under the Act, found that none were in work despite the fact that 13 of them had been in employment and/or higher education prior to being detained (ELCMHT 2006).
2.4 It is not yet clear what impact the new regime of supervised community treatment (SCT) will have on a person's ability to gain and keep work or on their education. The Institute of Psychiatry's review of the impact of community treatment orders found: "contradictory evidence from only one study prevents any conclusions about the effects of CTOs on employment" (Churchill et al 2007).
2.5 Despite the limited evidence, we would argue that the use and scope of compulsory powers should be kept to a minimum to support individuals to get their lives back. On this basis, the amendments made by the House of Lords bring some improvement to the Bill: they place sensible limits on the exercise of compulsory powers in line with the principle of using the least possible restriction. There remain, however, important areas of unfinished business, which we discuss below.
3. Race equality
3.1 It is clear from a great deal of research that African and Caribbean people are more likely to be detained under the Mental Health Act. In London, Black people are twice as likely as white people to be referred to mental health services by the police or the courts, while white patients are four times more likely to have been referred by their GP (SCMH 2006).
3.2 Some of the over-representation of Black people in hospital may be explained by higher prevalence of severe mental illness. But the experience of Black people within services is also quite different: in London, they are twice as likely to have been secluded while in hospital and are more likely to have been restrained physically by staff (SCMH 2006).
3.3 The impact of these inequalities on individuals and their families is considerable. Research has shown that there are 'circles of fear' between Black communities and mental health services. Staff see Black patients as 'big and dangerous' while Black people fear seeking help for mental health problems because of the excessive use of coercion (SCMH 2002).
3.4 The Government has acknowledged the need for action and begun a five year programme, Delivering Race Equality (DRE). The Mental Health Bill could help to support DRE by minimising the use of coercive powers (in keeping with the amendments achieved in the House of Lords), by providing all detained patients with an advocate throughout their time under compulsory powers and by tackling the use of police stations as 'places of safety'.
3.5 The Mental Health Act Commission, and its successor within the proposed new regulatory health and social care body, should be empowered to require all hospitals at which people are detained under the Act to provide regular data about admissions, deaths and other adverse incidents by ethnicity and religion. In the House of Lords, ministers gave assurances this would be tackled in regulations: we need to see further commitment to ensuring this is indeed the case.
4. Care planning
4.1 Under current government guidance, all detained patients should receive an 'enhanced care plan' when they are discharged from hospital as part of the Care Programme Approach (CPA). Research evidence suggests that implementation of CPA is still patchy, some 15 years after it was introduced. Where CPA is carried out properly it is highly effective, but in many areas this is not the case. A study carried out jointly by SCMH and the Mental Health Act Commission among people detained more than once over three years found:
- One third did not have a care plan relating to their previous discharge in their hospital case notes;
- Only a quarter were involved in writing their care plans, and less than one fifth had a copy;
- One fifth were readmitted within three months of their previous discharge;
- Less than half of care plans included anything about a service user's cultural, physical health, vocational or financial needs;
- Black and Asian people, women and those over 40 fared worse than others in some aspects of their assessment and care. (SCMH & MHAC 2005)
4.2 The Healthcare Commission's 2006 survey of community mental health service users found that 53% had been given or offered a copy of their care plan and that only 40% of people who wanted to be involved in writing their care plan had been involved (HCC 2006).
4.3 In the House of Lords, SCMH and the MHAC championed an amendment (supported by the Alliance) to require that all patients discharged from detention or placed on SCT would receive a comprehensive care plan. We believe it is important that a commitment to CPA is maintained and that people subject to the revised Act are no longer left without a full care plan.
5. Criminal justice
5.1 The mental health and criminal justice systems frequently work with the same people; very often with poor outcomes. The relationship between the health and criminal justice systems still too frequently breaks down at crucial points.
5.2 The first major pressure point occurs when a person is first brought into police custody in relation to an offence. Research by Nacro found serious shortcomings in court liaison services, which aim to divert people with severe mental health problems from the criminal justice system to mental health services. They found that one-third of schemes had only one member of staff, 41% reported difficulties in obtaining psychiatric reports and 72% were hindered by a lack of beds (Nacro 2005).
5.3 The Mental Health Act alone will not solve this problem. However, we support the Mental Health Alliance proposal that the Bill includes a measure to allow magistrates' courts and the Crown Court to remand a person on bail pending a psychiatric report in addition to the current options of remanding in hospital or custody.
5.4 The other pressure point occurs when a prisoner experiences severe mental health problems. Where the person requires specialist or compulsory care and they need to be moved to hospital, delays in transfer are commonplace. The 2002/03 annual report of Her Majesty's Inspector of Prisons calculated that some 41% of prison hospital beds were being used by people awaiting a transfer to the NHS (HMPS 2004).
5.5 Government guidance has begun to address the time taken to obtain a hospital transfer. There remain concerns, however, about the potential for more reductions if services continue to rely upon the limited supply of secure beds to effect transfers. The Alliance proposal for the Secretary of State to have a duty to order a hospital transfer once a responsible clinician has identified a need for this would help to speed up the process further.
6. Duty to assess needs
6.1 Unlike in Scotland, mental health law in England and Wales gives no reciprocal right for people to seek help when they need it. We agree with the Alliance that the Bill should include a duty on health and social services to assess the needs of people who come forward for help. Such a duty would have particular application in prison, where the current, albeit very limited, right to seek a Community Care Act (1990) assessment does not apply.
7. Resource issues
7.1 In addition to our concerns about the impact of the Bill on individuals, we have concerns about the impact of the Bill on services more widely. The introduction of supervised community treatment is a cause for particular concern. There is some international evidence that CTOs can lead to resources being pulled away from community services for other people (Churchill et al 2007). With many community services in England and Wales still at an early stage of their development, the impact of SCT on, for example, assertive outreach teams in major cities, could be considerable.
7.2 This is yet another reason why the use of compulsion should be kept to a minimum. It also requires constant vigilance to monitor the impact of CTOs on all service users, not just those brought within them.
Churchill R, Owen G, Hotopf M and Singh S 2007, International experiences of using community treatment orders, London: IoP
East London and The City Mental Health NHS Trust 2006, Alternative Pathways Project, London: ELCMHT
Fenton J, O'Hanlon D and Allen D 2003, Does having been on a 'section' reduce your chances of getting a job? Psychiatric Bulletin 27, 177-178
Healthcare Commission 2006, Survey of users of services 2006: community mental health services, London: HCC
HM Prison Service 2004, Annual Report of HM Chief Inspector of Prisons for England and Wales 2002/03, London: Home Office
New Thinking about Mental Health and Employment; Grove, Secker and Seebohm 2006, Radcliffe Publishing
Nacro 2005, Findings of the 2004 survey of Court Diversion/Criminal Justice
Mental Health Liaison Schemes for mentally disordered offenders in England and Wales, London: Nacro
SCMH 2002, Breaking the Circles of Fear, London: SCMH
SCMH and MHAC 2005, Back on Track, London: SCMH
SCMH 2006, The Costs of Race Inequality, London: SCMH
Social Exclusion Unit 2004, Social Exclusion and Mental Health, London: Cabinet Office