Memorandum from the College of Occupational
Therapists (DMH 292)
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
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.
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 (Ch
1 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
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
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.
4.2.1 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
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 AMHPs 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
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
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.
10.2 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
10.3 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
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.
10.4 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.
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.
Genkeer L, Gough P and Finalyson B (2003) London's
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Northern Centre for Mental Health (2004) Leading
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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.
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