It should have come as no surprise that the start of Mental Health Awareness Week heralded a major related policy announcement. Echoing and expanding upon her maiden speech as prime minister, Theresa May told us that a re-elected Conservative government would replace ‘in its entirety the flawed Mental Health Act’. Given that’s no small undertaking, why make the pledge?
Mental health advocacy organisations have long had their concerns with the Mental Health Act. The Mental Health Alliance, a coalition of 75 organisations from across the mental health spectrum, has set out its concerns with the existing Act. They ask that new legislation aims to reduce the need for compulsory detention, while ensuring that patients receive both an independent assessment of their needs, and to have those needs met with appropriate and high quality services. In publishing their election manifesto for mental health, MIND call for a review of the Mental Health Act, challenging government to identify the reasons behind the year on year rise in detentions.
I can’t be alone among my medical colleagues in vividly recalling the first ‘section’ I attended as a GP; a young man found wandering at the side of a busy Sussex A road. Visibly distressed, he paced the police cell he was held in, shouting at invisible daemons, pausing only to drop to his knees as though in prayer. Suffering from an acute psychotic episode, he didn’t need to be in a cell, but he did need to be in a place of safety. That perhaps is the crux of this matter; while patient pathways for acute medical illness are well defined, there is no equivalent ‘emergency department’ for people with acute psychiatric illness.
The proposed changes
In making her policy pledge, Theresa May highlighted two particular areas of concern; the detention of mentally unwell people in police cells, and ‘the discrimination and unnecessary detention that takes place too often’. This is likely to refer to both a rise in detentions under the Mental Health Act, and the fact that BME people are disproportionately more likely to be detained.
Lets take the first of those. It’s worth pointing out that the experience I described as a doctor on my first Section is actually relatively rare, and that the majority of Mental Health Act assessments happen in a planned manner. While the news that mentally unwell people are ever detained in police cells will surprise many, Section 136, the part of the Act on which those powers are based was initially included in an attempt to safeguard wellbeing of acutely mentally unwell people.
In lay terms, Section 136 gives a police officer the power to detain a person found in a public place who appears to be suffering from a mental disorder and who appears to be a threat to the safety of themselves or others. In my experience it’s been used in the sort of situation where a person is found walking down a motorway, or high on a railway bridge. It allows police to take them to a ‘place of safety’ where they can be assessed by medical and mental health professionals to ascertain whether further treatment or detention is necessary. A dashboard by NHS England shows a recent reduction in the number of Section 136 detentions in which a police cell was used as a place of safety, but many would argue that number should already be zero.
Achieving that would require consensus hitherto difficult to achieve. Though we can probably all agree that taking people to a place of safety seems reasonable, agreement within health services and the medical community on where those places should be remains elusive. Emergency Department colleagues rightly argue that a noisy, hectic emergency room isn’t the right place to assess someone with acute mental illness, and General Practices by and large don’t have the physical or workforce capacity to host urgent Mental Health Act assessments. I’m not sure how many of our psychiatric units have emergency assessment areas, but I’d hazard a guess it isn’t many.
Crucially, legislative reform will do little to solve this issue unless supported by the capital, workforce and operational capacity required to ensure that acute psychiatric emergencies gain parity with acute medical emergencies. That means having a safe and appropriate designated place of treatment. We can and must do better than a police cell.
Finally, what of the concerns about inequality and rising numbers of detentions under the Mental Health Act? Whilst reform of the mental health act may be one way to tackle this, I’d argue that without a preventative, social determinants-based approach any intervention will be limited in scope. Major risk factors for mental ill health include poverty, unemployment, social isolation and poor education. They should not be overlooked.
Though there are few who would wholeheartedly defend the Mental Health Act, reforming it will be a hollow gesture without attention not only to prevention, but to a funding package able to adequately support the infrastructure and workforce required to turn parity of esteem into parity of care.
Becks Fisher is a Clinical Fellow at the Health Foundation, www.twitter.com/BecksFisher