Health CommitteeSupplementary written evidence from the Mental Health Alliance (MHA 01)

1. Following our oral evidence session on 26 February 2013, representatives of the Mental Health Alliance would like to provide further information on questions asked by Members.

2. We also have a point of clarification. In Q30, Grahame M. Morris MP said, “A little earlier, Mr Lawton-Smith told us that we should not worry about the increasing cohort of patients who are sectioned under the Mental Health Act,…”. We think that this is a misunderstanding and that it does not represent what Mr Lawton-Smith said but in any case would like to clarify that the Mental Health Alliance’s view is one of concern about increasing rates of detention.

Readmissions of People who were Previously Detained

3. We do not have these statistics for England though it is possible that they could be obtained from the Health and Social Care Information Centre. In Scotland, the Health Secretary provided figures in response to a written question showing that in 2011 nearly 10% of mental health patients were readmitted within 28 days of discharge (1,331 people out of 14,647) (S4W-08246—Health and Social Care (11/07/2012)).

Thornicroft (1992) followed-up 357 psychiatric patients who had been in one of two large North London psychiatric hospitals hospital for over one year; 118 were “new” long stay and 239 “old” stay patients. Of all discharged patients, 97 (27%) were re-admitted at some time during the follow up period. (British Medical Journal, 1992 305:996.)

The CTO revocation rate is (as at 31 March 2012) 3,509 out of 14,295 CTOs made, ie 25%.

Advocacy in Wales

4. As indicated in our evidence, the Mental Health (Wales) Measure 2010 extends independent mental health advocacy to people admitted to hospital on a voluntary basis as well as all patients detained under the Act. This came into effect in April 2012—

Joint Crisis Care Planning

5. In our evidence we referred to the effectiveness of joint crisis care planning in reducing the use of compulsion. The research evidence for this is Henderson, C, Flood, C, Leese, M et al (2004), “Effect of joint crisis plans on use of compulsory treatment in psychiatry; single blind randomised controlled trial”, British Medical Journal, 17 July 2004, 329(7458):136. In this study 13% of those with a joint crisis plan were admitted compulsorily compared with 27% of the control group. A larger multi-site trial has been conducted but not yet reported.

IMHA Access

6. The UCLAN study, The right to be heard, found a strong consensus that those who need the IMHA service the most access it the least. The researchers thought that specific groups of people who may be under-served include: people from Black and minority ethnic communities, people with learning disabilities, older people and those with dementia, people who are hearing impaired or deaf, people on CTOs and people placed out of area (summarised on page 94 of the report).

One of their recommendations is that consideration be given to an opt out of, rather than opt in to, IMHA with consultation about how to take this forward. We think this would be well worth considering as a way of ensuring access.

Quality standards for commissioning set out by the researchers include equality analysis to ensure that provision is non-discriminatory and meets the diverse range of needs, and inclusion in IMHA contracts of measures to ensure that the diversity of qualifying patients are able to access appropriate IMHA services.

Deprivation of Liberty Safeguards (DOLS)

7. If the policy intention behind DOLS was to protect vulnerable people, the legislation is not achieving this adequately. Firstly, while recognising that more sophisticated data would be helpful, the great variability of applications suggests that citizens are not having equal access to these safeguards. The fact that care providers have to refer themselves to supervisory bodies is a significant consideration in this.

Secondly, we are concerned about lack of compliance with the requirements of ECHR Article 5(4). As the people concerned lack capacity they are likely to have to rely on a relevant person’s representative (RPR) who may be a relative with no knowledge of the DOLS system. Independent Mental Capacity Advocates are the very people who could help P and the RPR through the system, but the statutory right to be referred to as 39D IMCA is very poor and variable. The Court of Protection is the only option, which can be a lengthy and costly process and, unlike provisions under the Mental Health Act, there is no automatic referral.


8. The reasons for over-representation of people from some Black and minority ethnic (BME) communities in MHA detention and under CTOs are not fully understood and need more analysis. As mentioned in our evidence, when we referred to “circles of fear”, a key study in this area is Breaking the circles of fear (Centre for Mental Health, 2002)— Its findings included “There are circles of fear that stop Black people from engaging with services. Mainstream services are experienced as inhumane, unhelpful and inappropriate. Black service users are not treated with respect and their voices are not heard. Services are not accessible, welcoming, relevant or well integrated with the community. Black people come to services too late, when they are already in crisis, reinforcing the circles of fear.”

Substance Misuse

9. The following references may be helpful to Members’ consideration of substance issues in relation to mental health problems.

The 2010–11 British Crime Survey estimated that 8.8% of adults aged 16 to 59 had used illicit drugs (almost three million people) and that 3.0% had used a Class A drug in the last year (around a million people). Neither estimates were statistically significantly different from the 2009–10 survey

This includes the finding that “Adults from a White ethnic group had higher levels of any (9.4%) or Class A (3.2%) drug use than those from a non-White background (that is, ethnic groups other than White; 5.1%, any drug use; 1.0% Class A)”.

And see the box under 2.1 of this special BCS report on drugs and ethnicity

According to the Royal College of Psychiatrists, “Two million people in the UK smoke cannabis. Half of all 16 to 29 year olds have tried it at least once. In spite of government warnings about health risks, many people see it as a harmless substance that helps you to relax and ‘chill’—a drug that, unlike alcohol and cigarettes, might even be good for your physical and mental health. On the other hand, recent research has suggested that it can be a major cause of psychotic illnesses in those who are genetically vulnerable.”

Use of SCT Outside “Revolving Door” Patients

10. Care Quality Commission data (2009/10 Annual Report on the use of the Mental Health Act) suggests some 30% of people placed on a CTO have no history of non-compliance with treatment (so are not “revolving door” patients).

The Department of Health has stated in July 2012 (Post-legislative assessment of the Mental Health Act 2007, p. 12–13) that “One of the objectives of the CTO provisions was to help tackle the ‘revolving door’ syndrome”, implying there were others. It also stated that “The view was that SCT could be used wherever it was necessary. That could mean using it to prevent people getting into the ‘revolving door’ cycle”; and that criticism of SCT being used more widely than intended “may be a misunderstanding of the original intention of the Act”.

However at the time of the passage of the Bill in 2007, the Department of Health’s own explanatory leaflet on SCT (Mental Health Bill, Amending the Mental Health Act 1983, Supervised Community Treatment) stated “SCT will address the specific problem where patients leave hospital, do not continue with their treatment, their health deteriorates and they require detention again—the so-called ‘revolving door’.”

The same leaflet defended the Government’s position on not amending the SCT criteria to include a history of non-engagement thus: “The Government believes that these amendments excessively restrict SCT so that few patients could benefit. They exclude patients who are a risk to themselves, and make it difficult for SCT to succeed in its aim of tackling the ‘revolving door’.”

The leaflet is at:

At the same time, in a briefing for members of the House of Lords on 30 January 2007, Health Minister Philip Hunt stated “We have listened carefully to calls that the SCT criteria should be tighter. We have thought further about the arguments put forward, but we think that any further restrictions on the use of SCT would be misguided. We are concerned that we would risk neutralising SCT so that it could not address the very problem that it was developed to tackle—that of the revolving door”.

It is possible to argue that Parliament at the time was led by these statements to think that SCT would only be used for known revolving door patients, not for any patient that might, in a clinician’s view, become a revolving door patient—which significantly widens the scope of SCT powers, as has been shown by the subsequent clinical practice of placing many people on CTOs who do not have a history of disengagement from services. So the use of CTOs for this cohort is not inappropriate in that the Act does allow such use; but it could be considered inappropriate in terms of parliamentarians’ and others’ expectations of who might become subject to CTOs.

Savings from SCT

11. At the time (2007), the Bill’s Regulatory Impact Assessment (p.11) put to parliamentarians estimated the costs and savings to be made as a result of the new SCT arrangements. This suggested that there might be net savings to the NHS in England resulting from the introduction of SCT of £34 million pounds annually by 2014–15. However at this time, we have no idea whether these estimated savings have been met, or are on track for being met by the “steady state” year of 2014–15. It would be interesting to know if the Department of Health was keeping track of any savings made by the introduction of SCT.

The Regulatory Impact assessment is at:

Numbers of People on a Community Treatment Order (CTO)

12. There does seem to be a discrepancy in the data on the numbers of people under a CTO. The latest NHS Information Centre data (October 2012, p.22) give a figure of 4,764 people under a CTO as at 31 March 1012.

At the same time, the same report (p.20) gives the total number of CTOs made between November 2008 and 31 March 2012 as 14,295, of which 3,509 had been revoked (with a patient returning to a hospital bed) and 3,922 discharged—suggesting there were still some 6,964 people under a CTO. This may be simply a data quality issue (as the report acknowledges), or some patients may have been given over time more than one CTO, but an explanation of the discrepancy would be helpful.

March 2013

Prepared 9th August 2013