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Mental Health Act: The rise in the use of the MHA to detain people in England

Between 2005/06 and 2015/16, the reported number of uses of the Mental Health Act (MHA) increased by 40%. It is well established that people from Black and minority ethnic groups are much more likely to be detained than those in White British groups.1 In October 2017, in response to these and other concerns, the government announced an independent review of the MHA. This review will make recommendations for improvements to legislation and practice in late 2018.

In 2016, CQC committed to working with local services to gather views on the reasons for the national increase in the use of the MHA. During 2017, we visited eight NHS trusts, two independent mental health service providers and 23 local authorities to explore the factors that might account for the increasing use of the MHA. The sites included parts of the country where rates have fallen or remained the same over the previous three years, as well as areas where there has been an increase. On these visits, we met with more than 60 detained patients, 30 carers and more than 250 staff.

Although we cannot be certain about their relative impact, we identified a number of factors that might influence the rates of detention and grouped them into four broad themes:

1. Changes in mental health service provision and bed management More frequent readmissions – either as part of a plan of care or because of premature or poorly planned discharge. Loss of specialist community teams offering alternatives to admission. Presure on beds preventing early, informal admissions or leading to discharge without adequate support to stay well once out of hospital being in place.

2. Demographic and social change Increase in population size and in sections of the population 'at risk' of detention (especially older people with dementia). Rising inequality and social exclusion (for example rising homelessness). Impact of alcohol and substance misuse.

3. Legal and policy developments that have influenced practice 2007 reform of MHA widening definition of mental disorder and of treatment.
Increasing awareness of the factors of de facto detention as a result of the Bournewood judgement, and Mental Capacity Act led to more use of MHA for those lacking capacity. Greater police awareness of mental disorder leading to more diversions from the criminal justice system.

4. Data reporting and data quality Improved completeness of local returns that inform national data sets. Duplicate entries – including double-counting when a detained patient is moved from one ward or provider to another.

Our hypotheses for the rising rate of detention

We did not expect this qualitative work to identify all of the detailed factors that might cause the rising rate of detention. We also knew that it would not allow us to make confident statements about the extent to which each of the factors have contributed to the rise. However, based on the four themes, we developed eight hypotheses that we think are likely to cover all factors that might have made some contribution to the rise in use of the MHA:

1. The apparent rise in rate of detention since 2010 is in part due to the national data return being more complete or to an increase in duplicate returns.
2. More people are being detained on more than one occasion during a calendar year than was previously the case.
3. As bed numbers have fallen, more people with severe mental health problems are living outside of a hospital setting and so are at greater risk of being detained.
4. Some people are being detained under the MHA who would previously not have been detained. This is because clinicians are applying the criteria for detention differently to people with certain types of disorder (such as dementia or personality disorder). It could also be because more people with mental health problems are coming to the attention of mental health care workers (for example, through schemes that divert people from the criminal justice system).
5. People who need admission and who would previously have agreed to informal admission are now refusing and are being admitted as detained patients.
6. Admissions (some of which would be formal) that could in the past have been prevented are now not being prevented because less restrictive alternatives in the community are not available.
7. There has been an increase in the total size of the population of England and an increase in the size of those sections of the population that are more at risk of detention.
8. There has been an increase in the prevalence of risk factors for detention, such as social exclusion and problematic, untreated drug and alcohol misuse.