Joint Committee on the Draft Mental Health Bill Written Evidence

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 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.


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 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 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 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.

  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 new role.

  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 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.

  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 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.

October 2004

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