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Monitoring the Mental Health Act in 2015/16

Presented to Parliament pursuant to Section 120D(3) of the Mental Health Act 1983

The Mental Health Act 1983 (MHA) is the legal framework that provides authority for hospitals to detain and treat people who have a serious mental disorder and who are putting at risk their health or safety, or the safety of other people. The MHA also provides more limited community-based powers, called community treatment orders and guardianship.

The MHA includes safeguards for people’s rights when they are being detained or treated by professionals. It does this by providing rules and requirements for professionals to follow. It also provides statutory guidance to mental health professionals and services in the MHA Code of Practice. Managers and staff in provider services should have a detailed knowledge of the Code and follow its guidance, or document the justification for not doing so in any individual case.

Our job is to check that patients’ human rights are being protected, and look at how services in England are applying the MHA safeguards. We carry out visits to see how mental health services are supporting patients, make sure providers have effective systems and processes to meet the MHA, and check that staff are being supported to understand and meet the standards set out in the Code.

There are 57 NHS trusts and 161 independent hospitals that provide mental health care for people under the MHA in England. During 2015/16, we carried out 1,349 monitoring visits, and met with 4,282 patients.

Detention rates have continued to rise in recent years, and 2014/15 saw the highest ever yearon-year rise (10%) to 58,400 detentions. It is a challenging time for all health services, including mental health care: resources are tight and as outlined in our State of Care 2015/16 report – our annual overview of the quality of health and adult social care in England – the sector is under significant financial pressure. But over the last few years, reports such as the Winterbourne View – Time for Change have highlighted inequalities and failings of care for some people who are detained under the MHA, and changes are needed in response.

Throughout our monitoring visits and inspections, we saw many examples of good practice, and met hundreds of dedicated staff who provide the best support and treatment for their patients. We hope that examples of good practice shared in this report will support and encourage other providers to improve quality of care. Further examples can be found in State of Care 2015/16.

However, good practice is not consistent across the country. Our concerns are supported by our findings in State of Care 2015/16, which found that inpatient mental health services performed less well in general than community-based services. Some services are not meeting the expectations of the Code of Practice, leading to variation in the quality of care for people detained under the MHA. These are not technical issues of legal process, but failings that may disempower patients, prevent people from exercising legal rights, and ultimately impede recovery or even amount to unlawful and unethical practice.

In 2015/16, we have found little or no improvement in some areas that directly affect patients, their families and carers and that we have raised as concerns in previous years. This includes:

• For 12% (515 out of 4,344) of patients interviewed on our visits in 2015/16, there was no evidence that they were informed of their right to an Independent Mental Health Advocate (IMHA). Advocates are an important safeguard, offering support to patients and enabling them to be involved in decisions about their care. Many services have adopted the Code of Practice’s recommendation that IMHAs should automatically be asked to visit patients who may lack the capacity to ask for help. We expect all services to do this. We have seen some examples of innovative practice enhancing the support provided by IMHA services at key points of treatment and care, such as during care planning or when interventions such as seclusion are used.

• There was no evidence of patient involvement in care planning in 29% (1,214 out of 4,226) of records that we examined. Similarly, 10% (452 out of 4,407) of care plans showed that patients’ needs had not been considered. Research suggests that co-production of care plans and developing advance statements with patients can be an effective way for services to address the rising number of detentions.1 Some services have shown good practice in involving patients from the moment they are admitted, including staff taking time to explain everything as often as the patients needed to help them feel informed and reassured about their care and treatment.

We expect all services to consistently make it possible for patients to be fully involved in their care and treatment, understand their rights and exercise their autonomy. Only through such an approach can services ensure that those powers are used proportionately and fairly, and that they help the recovery process.

Overall, we required more than 6,800 actions from providers to improve practice as a result of our monitoring visits. Although we do not rate how well services apply the MHA, if we find poor practice we limit a provider’s rating for the question ’are services effective?’.

It is clear from our visits that, one year on from its introduction, that some providers are not doing enough to implement the revised Code of Practice or inform patients of their rights. The revised Code came into force in April 2015. We asked providers to update their policies and practices by October 2015, to make sure they supported delivery of the new standards. We also expected services to make sure that staff with statutory MHA roles are trained with the right skills and knowledge to meet the Code’s standards to support the delivery of high-quality care.

However, fewer than half of the wards we looked at from September 2015 to April 2016 had provided staff with any form of training on the revised Code, or updated their policies and procedures to reflect the new guidance. All staff in statutory MHA roles must be provided with training – staff need to be better supported in looking after people with mental health issues, and they need stronger leadership to make this happen.

Where we have found failures to comply with the recommendations of the Code due to lack of staff training or policies, we have made sure, and will continue to make sure, that our teams use our enforcement powers to improve the support for staff and patients.