The new Mental Health Act can catch up with social awareness of how best to support people in distress, following public workshops in London and Newcastle staged this week that will be communicated back to Downing Street.
“We can never ‘get it right’, because new evidence will always continue to emerge, but we can make sure the new Mental Health Act ‘catches up’ with where it should be.” These words were uttered this week by the man tasked with reshaping what can and can’t legally occur when you go to hospital for your mental health in England and Wales. Understated? Perhaps. Encouraging? It felt that way.
Professor Simon Wessely is a psychiatrist. He was speaking at a venue two doors down from the British Medical Association HQ. The event was arranged by a handful of the government department of health’s senior civil servants. But despite the trappings, what followed did feel like a transition away from legislation that interprets mental health as something that can be restored purely through transferring control of an individual’s biology over to an institution.
"Even as a medical student I knew that psychiatry was for me – it was about biology, but it was also about psychology, and sociology, ethics, politics and much else." Professor Simon Wessely, Chair of the Mental Health Act review, writing in 2013.
A transition away from the prevailing model feels like it has been a long time in coming. Legislation shapes best-practice for patients but really legislation should follow rather than form it. Hence the will for the law to “catch up” and this desire was shared earnestly by everyone at Mary Ward House in Euston, central London this week for a landmark gathering.
It was an amalgam of people: individuals who know what’s it like to be sectioned – some who’ve been scarred by it and many who continue to depend on ‘it’ – along with carers (this writer), psychologists, doctors, disability activists, lawyers, advocates, NHS staff and others with lived experience of the current law and practice.
Rounded support while in clinical care
There will always be a role for medication while there is demand, but this event was a workshop about everything else that there is demand for. Two key questions were considered: 1) ‘How can we reduce the need for detention?’ 2) How can we improve the experiences of people who are detained?’ Over 100 people signed up to have their say in London on Monday (February 26). The following day there was a similar event in Newcastle. Ideas articulated at these events and through other channels will be fed back to the government and the public around Easter.
Many of the ideas were not new, but this week represented the first public sessions initiated by Downing Street to collate and learn from them, to change how society responds to people when they have escalating mental health needs. Having asked for these ideas, the Prime Minister and parliament will be expected to support their legislation.
So what can we expect to see in the new Mental Health Act?
A bigger role for the relative you feel best understands you and an earlier role for advocates
The Mental Health Today community has campaigned for advocates to be involved in crisis care from an earlier stage and for individuals to be able to choose which relatives can support them. This is so that it doesn’t necessarily need to be your next of kin, who you may have fundamental differences with. This sentiment was expressed regularly during the workshop and from a range of speakers.
In the week that the CQC shared that one in three patients detained for their mental health are having no say in their own treatment, the issue of improving communication and partnership in treatment is paramount. This will be reflected in the new Mental Health Act.
Consent to be required, sought and established in more instances
In Northern Ireland, there is a greater presumption of capacity than in England and Wales and we can expect this to be emulated. Workshop participants made it clear that being able to write in advance what treatment you’d like to receive if you fall into distress could and would work in most scenarios.
Scotland has a register of advance notices and England will likely follow suit. Participants shared that this could extend to a variety of preferences, including what should happen to your children or pets when you’re hospitalised. One participant shared that a relative carried a home-made card detailing how she likes people to respond if and when she experiences hypo-mania.
Learning disability is not something to be hospitalised for
This is something that technically remains on the NHS’s ‘transforming care’ agenda but it has lost momentum and profile. There remain as many people with LD living in hospital settings (2,500 - 3,000) as around the time of the Winterbourne View abuse exposed by Panorama’s documentary. Parents and activists present at the London workshop made it plain that, as indeed the NHS's most senior nurse wrote in MHT recently, hospitals are places for people with treatable needs only.
Disappointment for ethnic minorities
Mental Health Today hopes to be proved wrong, but we are concerned that the important question of how to reduce the disproportionate rates of BAME individuals effectively living in hospital will not be tackled.
The department of health failed to engage minorities to attend the London meeting, with less than five percent non-white attendance. One attendee said: “How can we understand and address this properly when I am white and there are no different races here?”
MHT is sharing lived experience pieces authored by BAME writers with the government. We are also conducting polling to ascertain demand for BAME representation on risk-assessment panels and for cultural awareness modules to become mandatory on all qualifying degrees for mental health professions.
One workshop participant called for more extensive research to be initiated into the causes of disproportionate rates, although plenty has already been undertaken. The department of health told MHT they were planning further bespoke workshops to follow up on BAME meetings already convened.
Detention experiences likely to improve, but detention rates unlikely to fall without supporting alternatives to detention
Detention rates have increased nine percent over the last two years and it was this rise that prompted the Prime Minister to call for the law to be looked at. However, Simon Wessely made clear to MHT very soon after starting the review work that he ‘couldn’t promise’ detention rates will actually fall as a result of the change to the law. Speaking this week he again reflected that greater investment in services would do more than any change to the law. When you consider that just seven percent of the mental health budget is currently spent on children, then it’s clear that ‘distress prevention’ is undervalued.
It’s important to reflect that the topic of resources shouldn’t end conversations. Let's keep working to get it higher up the agenda of course, but we all have a responsibility to look laterally and constructively in the meantime. Any one of us could come to rely on good mental health care long before significant investments return to mental health services in the UK.
As one participant said this week: ‘It costs thousands of pounds a week to provide an NHS bed, couldn’t that money be better spent on stopping that person needing a bed in the first place?’
BAME campaigners remain dubious about efficacy, profiling and cultural empathy in hospital treatment for distress. The Division of Clinical Psychology would like to see a greater emphasis placed on trauma-informed counselling and less focus on disorder diagnosis. A voice-hearer at the London workshop was plain that she didn’t want or need treatment hospital – she was comfortable with her hallucinations and don’t put anyone at risk of harm. Samaritans Cymru reiterated this month that economic security is the foundation for good mental health. Drama, art therapy, story-telling, new approaches to work and social prescribing are each methods that have been the making of many. All these perspectives need to be recognised and credited before we arrive at a society that does not feel it needs to detain people to reduce their distress - and equally, where individuals do not need to rely on hospitals for their mental health as poignantly as thousands currently do.