DMH 292 College of Occupational Therapists
Submission to the Pre-legislative Scrutiny Committee
on the Draft Mental Health Bill (2004)
Response from the College of Occupational Therapists
Introduction
- The College of Occupational Therapists (COT)
is the national professional body representing over 27,000 occupational
therapists and support staff across the UK. This response to
the Submission to the Pre-legislative Scrutiny Committee on the
Draft Mental Health Bill (2004) consultation document has been
developed in collaboration with the College's specialist section
in mental health (AOTMH).
- Occupational Therapists are one of the main professions
whose core skills and knowledge are applied to the purpose of
rehabilitation, habilitation and occupation, and it is within
this context that occupational therapists work with people with
mental health and substance abuse problems throughout the United
Kingdom.
- The College has had significant involvement with
NICE and produced evidence for guidelines on a range of Mental
Health Disorders.
- The College of Occupational Therapists is a core
member of the Mental Health Alliance. This response aims to complement
the points made by the Alliance and pays particular attention
to the impact of the draft bill to occupational therapists working
in mental health.
Comments particularly requested
for the legislative scrutiny committee are:
1. Is the Draft Mental
Health Bill rooted in a set of unambiguous basic principles? Are
these principles appropriate and desirable?
1.1 Principles and values in mental health practice
are identified as essential for sound mental health practice (Woodbridge
and Fulford 2004). However, it is important that these are transparent
and therefore need to be placed in legislation rather than Code
of Practice that could be over-ridden under certain circumstances.
The College has concerns that the bill is rooted in the principles
of compulsion rather than provision of quality care for vulnerable
people.
2. Is the definition
of Mental Disorder appropriate and unambiguous? Are the conditions
for treatment and care under compulsion sufficiently stringent?
Are the provisions for assessment and treatment in the Community
adequate and sufficient?
2.1 Definition of Mental Disorder: some explicit
exclusion criteria are required within the proposed definition
in the Bill for those people that abuse substances or who have
Aspbergers Syndrome, or learning disabilities.
2.2 Conditions for treatment: Clause 7 suggests
that where a person is at a substantial risk of causing serious
harm to other persons can be in itself a defining criteria for
the condition of mental disorder (Clause 2). Risk assessment and
management are not precise and can be determined by the resources
available and culture of the organisation that practitioners work
in. This proposal could lead to an overly cautious approach, and
leave little opportunity to demonstrate any change in relation
to risk where Treatment orders are ongoing.
2.3 Provisions for assessment and treatment in
the Community: The determinants for this process need to be much
clearer in relation to the conditions for compulsion (Ch1 Clause
9).
2.4 Non-resident orders must only be applied where
there is evidence that it would reduce compulsory admissions to
hospital. This is favourable compared to a compulsory resident
order as it can enable people to maintain their routine and social
network as a non-resident. These factors need to be made explicit
within determinations for a Non- resident order in the Code of
Practice.
2.5 If a person is a subject to either assessment
or treatment in the community one of the conditions is that treatment
is available. It is important that where it is available is also
accessible in terms of travel, time, language and physical access.
What obligation is there on service providers for this? This will
have resource implications.
3. Does the draft bill
achieve the right balance between protecting the personal and
human rights of the mentally ill on one hand, and concerns for
public and personal safety on the other?
3.1 We are concerned that the proposals within
the draft bill are not balanced. The draft Bill may discourage
people from seeking help from the mental health services for fear
of hospitalisation. The draft bill is contradictory to what the
Government is aiming towards in tackling stigma, discrimination
and social exclusion of people with mental health problems. The
Bill is based on the principle of compulsory care to protect the
public from risk, rather than any attempts to manage risk through
adequate community services.
4. Are the proposals
contained in the Draft Mental Health Bill necessary, workable,
efficient, and clear? Are there any important omissions in the
Bill?
4.1 Primary care
4.1.1 There is little comment about the role of
primary care within the draft bill. It is not clear whether it
has any role at all in regard to compulsory assessment or treatment
in the community. Primary care also has an important role in access
to physical health care and therefore must be included where care
in the community is considered.
4.2 Aftercare
4.2.1 Free aftercare arrangements are available
for people currently held under Sections 3, 37, 47 and 48 of the
Mental Health Act under Section 117 until it is agreed by the
local authority and health provider that it is no longer required.
The proposals to curtail this to a maximum of six weeks represents
a major loss of service for people who may have been treated compulsorily
for many months.
4.2.2 The suggestion that services need only be
provided free for six weeks does not reflect delivery of care
based on the needs of service users. Where a person has to be
placed on a waiting list for interventions, they may need to pay
for it if they have to wait beyond six weeks. It is important
that the objective of mental health services is to provide the
appropriate treatment for the individual to return to a satisfactory
socially inclusive life.
4.2.3 It is also of concern that if people do
not attend aftercare following the six week period, they may then
become subject to a non-resident treatment order to ensure attendance.
4.2.4 It is important that specific considerations
of aftercare are extended for longer than six weeks where a person
has an organic condition, such as dementia. The resource is significant
to support this Bill and as such the College would wish to see
inclusion of a duty to provide sufficient numbers of approved
doctors and AMHP's including occupational therapists.
4.3 Reviewing of status
4.3.1 It is suggested that at all times the clinical
supervisor must review the status of a person subject to compulsory
powers. This review needs to be explicit about frequency and representation.
5. Is the proposed
institutional framework appropriate and sufficient for the enforcement
of measures contained in the draft bill?
5.1 Expert panel
5.1.1 Where an expert panel is consulted it is
important that they can address all aspects of "treatment"
as defined in Chapter 1, clause 2, section 7. This is an important
safeguard to ensure that all areas are under consideration for
the benefit of the service user.
5.1.2 Expert panel must provide a balance of medical
and social opinion in regard to someone's care.
7. Is the balance struck
between what has been included on the face of the draft bill,
and what goes into Regulations and the Code of Practices right?
7.1 No: see comments in 1:1 and 2:1.
8. Is the Draft Mental
Health Bill adequately integrated with the Mental Capacity Bill
(as introduced in the House of Commons on 17 July 2004)?
8.1 There do not appear to be clear links between
the two Bills (or the Scottish Mental Act or Incapacity Bill).
The incapacity measures previously included in the Mental Health
Bill for informal patients lacking capacity to consent to treatment
have not been represented in the Mental Capacity Bill. These
positive measures should be reinstated in full if the human rights
contraventions they were designed to prevent are likely to continue.
The College has concerns that the greater use of compulsion and
lack of incapacity measures for informal patients lacking capacity
to consent to treatment may contravene human rights legislation.
9. Is the Draft Mental
Health Bill in full compliance with the Human Rights Act?
9.1 See above.
10. What are likely to be
the human and financial resource implications of the draft bill?
What will be the effect on the roles of professionals? Has the
Government analysed the effects of the Bill adequately, and will
sufficient resources be available to cover any costs arising from
implementation of the Bill?
10.1 There are a number of concerns about the human
resource implications for occupational therapists in regard to
the draft bill. The Bill's Regulatory Impact Assessment (RIA)
workforce implications are underestimated and will lead to recurring
problems.
Approved Mental Health Professional
10.2.1 If occupational therapists take on the new
AMHP role it is important that the performance of the role is
recognised and approved by the HPC, the statutory regulator.
10.2.2 The role of AHMP must be performed by professionals
with sufficient experience and expertise in mental health practice.
Ideally, this should be an optional rather than compulsory responsibility
but that will have resource implications. The service capacity
required for AHMP functions must be considered alongside the impact
of diverting resources from other aspects of patient care.
10.2.3 Recruitment and retention for occupational
therapists in mental health has become a concern. Within London
in particular the turnover can range from 24% to 45% and the vacancy
rate from 0-57%(Genkeer 2003). There is evidence to suggest that
some occupational therapists find that their professional skills
are not being fully utilised in community mental health teams
(Northern Centre for Mental Health 2004). This in turn has been
noted as a concern for recruitment and retention of staff in mental
health (Sainsbury Centre for Mental Health 2002). It is important
to be aware that if occupational therapists are dissatisfied with
their role that they are able to work away from mental health
in other parts of the health and social care economy.
10.2.4 Within a large number of Community Mental
Health Teams (CMHTs) (Onyett, Hepplestone and Bushnell 1994) it
is frequently the case that there is only one occupational therapist.
This professional isolation is difficult for some occupational
therapists to deal with (Mentality 2003). Where an occupational
therapist takes on the AMHP role, this could mean that there will
be no occupational therapy input to other areas of patient care
while they undertake this role. It is imperative that the occupational
therapy role is available to all service users and not reduced
as a consequence of the AMHP role.
10.2.5 The AMHP role could be seen as either an opportunity
or distraction for occupational therapists. This could be in the
form of changed status, perhaps financial reward and further opportunity
for consultant grading on one hand and digression from the occupational
therapy focus on the other.
10.2.6 The recent publication from the Social Exclusion
Unit brings with it many opportunities for occupational therapists
to focus on working with service users on leisure, vocation and
work. This agenda is one that is essential for positive outcomes
for service users and communities. Occupational therapy is concerned
with the fulfilment of socially valued roles in people's lives
through occupation and employment. Occupational therapists are
well placed to take a lead on social inclusion in services it
is essential that they are able to perform this role.
10.2.7 On the other hand occupational therapists
are able to consider the impact of physical, psychological social
and environmental components in a person's life. Therefore, with
satisfactory training and supervision for the AMHP role, they
would be able to achieve a balanced professional approach in this
new role.
Acute inpatient services
10.3.1 Under the proposals of the draft bill people
that are subject to compulsory admission for assessment will require
a care plan drawn up within five days. It is important that all
treatments (as defined in Part 1, Chapter 1, Section 7) are included
in this. Habilitation and rehabilitation fall within the remit
of occupational therapy and this is an important role that the
College supports.
10.3.2 Where a person has been admitted to hospital
over a weekend, it is important that such an assessment occurs
as early as is possible. This will require OT staff working extended
hours beyond the traditional Monday to Friday, 9-5 periods. There
are already OT staff working extended hours in some mental health
services and this is a flexibility the College would wish to encourage.
It is important that these added workforce implications are addressed
as part of the implementation of the bill. It is important that
occupational therapy is available at these early stages to prevent
any social exclusion or detriment to the service user.
10.3.3 Once a person has been assessed and the relevant
conditions are met there is a Mental Health Tribunal where occupational
therapy staff would be required to submit relevant reports or
attend. This will increase workload for this workforce and will
require administrative support.
10.3.4 Where an individual is subject to compulsion
there are implications if occupational therapy is not available.
There is currently no recommended remit for the number of occupational
therapy staff required per inpatient bed. The current funded establishment
of OT staff for acute care is currently being surveyed by the
Sainsbury Centre for Mental Health as part of commissioned research
about Acute Inpatient services by the National Institute of Mental
Health. This is due for publication in Spring 2005.
Non-resident treatment orders
10.4.1 People subject to compulsion in the community
will go through a similar process of drawing up a care plan, tribunal
and ongoing review.
This has similar implications for occupational therapy
staff in terms of availability for assessment and treatment availability.
Conclusions
In summary, the College has real concerns in respect
of the workforce required to deliver the Mental Health Bill's
intentions. The proposals combining community orders with a wide
definition of mental disorder and is bound to jeopardise the improved
mental health care to which the Government aspires.
References
Genkeer L, Gough P. and Finalyson B. (2003) London's
Mental Health Workforce: A review of recent developments.
The King's Fund
mentality (2003) Working Well Report London.
mentality
Northern Centre for Mental Health (2004) Leading
Roles in Mental Health: Opportunities and competencies for community
mental health occupational therapists. Northern Centre for
Mental Health
Onyett S., Hepplestone T. and Bushnell D. (1994)
Organisation and operation of CMHT's in England: A National
Survey. Sainsbury Centre for Mental Health.
Sainsbury Centre for Mental Health (2002) Finding
and Keeping: review of recruitment and retention in the mental
health workforce. London. Sainsbury Centre for Mental Health.
Woodbridge K. Fulford K.W. M (2004) Whose values?
A workbook for values-based practice in mental health care.
London. Sainsbury Centre for Mental Health
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