Mental Health Matters: Reforms spark fears over impact on workforce

Once-in-a-generation reforms to the Mental Health Act are one step closer to becoming reality after MPs and Lords had their say on the government’s proposals.

The joint committee on the Draft Mental Health Bill gave their verdict on plans to modernise what is widely considered one of the most coercive pieces of legislation in the UK: changes to which could have a major impact on healthcare professionals, patients, and carers. 

Headline recommendations include the creation of a statutory mental health commissioner. This role would track implementation of reforms, rolling out from 2024, and act as a national patient advocate.

Many aspects of the bill represents a move towards a more rights-based system which should give patients more control.

However, the overarching theme of the committee’s report is that the practical consequences of the proposed changes have not always been thought through. For instance, the draft bill proposes allowing patients to appeal their detention more than once, and the Royal College of Psychiatrists is concerned that the resulting increased workload for mental health tribunals would require at least 494 extra psychiatrists.

The proposed new law would make care and treatment plans, which set out a patient’s current and future needs and need to be regularly reviewed, a statutory requirement. There is also a new duty on clinicians to consider a patient’s wishes and feelings when deciding on detention. Patient will be able to request a second opinion from a doctor from the first day of their admission. Compulsory treatment must be pre-approved and regularly reviewed over a three-month period.

If that were not enough, the committee has recommended patients have a statutory right to request an advance choice document providing key information to health professionals on contacts, treatment, and their health needs.

Committee member, former health minister and NHS psychiatrist Dan Poulter told MHM they had recommended a full workforce impact assessment be carried out before additional duties on health professionals are introduced. They have also asked for a detailed implementation plan.

He said that oral evidence given to the committee by ministers and NHS England representatives “was disappointing and full of assertions”.

When asked in evidence how many full-time equivalent hours the extra tribunal workload may place on the consultant psychiatrist workforce and how many second opinion appointed doctors may be needed, neither ministers nor NHSE chiefs were able to give firm answers.

Dr Poulter added: “I hope that in light of our committee’s report, the government and NHSE will reflect more carefully about the impact of the proposed changes to ensure they are fit for purpose and do not have unintended consequences which impact quality and availability of mental healthcare.”

Harder to admit

The draft bill makes significant changes to detention criteria to ensure people are only detained when there is clear justification, requiring an assessment that serious harm may be caused to the health/safety of the patient or others unless they are detained.

Existing criteria only requires broad assessment that detention is necessary, or appropriate given the nature and degree of mental illness. There are concerns this could have unintended consequences, among them that tightened criteria might make it harder to admit people needing care.

Chloe Beale, liaison psychiatrist and suicide lead at East London Foundation Trust, warned people “will have to deteriorate quite a long way before meeting detention criteria, particularly people who might be overlooked already because of certain stigmas… people who are already not wanted in hospitals.”

The committee said the proposed changes need to be supported with adequate and accessible community-based alternatives to detention. Members were “disturbed” by evidence they received that the concept of “capacity” had been misused to deny treatment to very ill and potentially suicidal patients when they had voluntarily sought it.

There is also concern that removal of learning disability and autism as grounds for detention under part three of the MHA may lead to more detentions under different legal powers, with fewer safeguards, or diversion into the criminal justice system instead.

Families are concerned that, although changes aim to ensure people cannot be detained purely on the basis of their autism or learning disability, they may still be sectioned inappropriately based on a mental health diagnosis under part 3 of the MHA. 

The committee has also called for the abolition of most community treatment orders (where patients are discharged into the community under treatment conditions imposed on them by their clinician). These are 11 times as likely to be applied to black people. Evidence to MPs suggested CTOs were ineffective for most patients, yet were used more than was intended by the current legislation.

The existing bill makes amendments to provision and oversight of CTOs based on recommendations from Sir Simon Wessely’s 2018 review but does not commit to a timeline for their potential abolition. 

The proposal has been met with caution by Royal College of Psychiatrists’ president Adrian James, who said the college would need to consider implications of this change. 

NHS Confederation mental health lead Sean Duggan said CTOs should be reformed, but not scrapped. He said CTOs do work for those needing a more restrictive detention in hospital.

Other major recommendations from the committee include a duty on the health secretary to report disproportionate detention of ethnic minorities.

NHSE and the Department of Health and Social Care are currently considering the committee’s report. The DHSC said they will respond in due course, adding they are taking action to address unequal treatment of black, asian, and minority ethnic communities.