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Workload implications of the proposed new Mental Health Act — an audit

West London Mental Health NHS Trust, Gloucester House, 194 Hammersmith Road, London W6 8BS

Clive Meux, Consultant Forensic Psychiatrist

The Oxford Clinic, Littlemore Mental Health Centre, Oxford OX4 4XN

Declaration of interest

None.

	Abstract

Top Abstract Introduction The study Findings Comment References

 
AIMS AND METHOD

To estimate specific time and resource implications for professionals, if proposed changes to the Mental Health Act 1983 (England & Wales) in the Government's white paper were to be implemented unchanged. An audit of time spent on current procedures was extrapolated.

RESULTS

The amount of time required to comply with the Act will rise substantially (by 27% overall). Social workers and independent doctors will spend 30% and 207% more time respectively, complying with the Act, but psychiatrists providing clinical care to forensic patients should be largely unaffected.

CLINICAL IMPLICATIONS

If the Government presses ahead with its plans for mental health law reform as currently proposed, extra resources will be required to provide additional social work and independent medical time — or other services for patients will suffer.

	Introduction

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Over the past few years, there has been a ‘root-and-branch review’ (Scoping Study Committee, 1999) of mental health legislation in England and Wales. In spite of the involvement of a large number of interested parties, many with strongly contrasting points of view, the process has resulted in a white paper (i.e. proposal for legislation) which embodies clear and consistent principles — albeit ones which, taken together, are substantially different from those of the present Mental Health Act and which do not seem to please everyone. A thorough critique of the proposals is beyond the scope of this paper, and can be found elsewhere (e.g. Royal College of Psychiatrists, 2001; Szmukler, 2001; Zigmond, 2001; Mind, 2001). However, in broad terms, the white paper represents a shift away from the Percy Commission's model of compulsory treatment being given only in the best interests of the individual patient and only as a last resort (Percy Commission, 1957) towards a model where protecting the public from the perceived dangerousness of patients assumes equal importance with providing care in the patient's best interests. The white paper, while carefully worded in an attempt to avoid conflict with the Human Rights Act 1998, would seem to permit a massive increase in the use of compulsory powers, by widening the criteria for detention, by effectively establishing community treatment orders, and by delegating the power to detain, not to psychiatrists (with their emphasis on the best interests of the individual patient) but to new quasi-judicial mental health tribunals (which may well develop a broader view of their responsibilities).

This paper makes the assumption that part 1 of the white paper will be enacted without any substantial alteration and that the use of compulsory powers will, at the very least, not be reduced. We have not considered the resource implications of part 2 of the white paper, relating to high risk patients and ‘dangerous severe personality disorder’. The Mental Health Act 1983 included more bureaucratic checks and balances than its 1959 predecessor, and required a significant increase in resources. Because there are similar fears about the white paper (Royal College of Psychiatrists, 2001), we have tried to evaluate these concerns in a formal way, despite the lack of clarity for some of the details in the proposals. We are unaware of the publication of any other structured attempt to do this.

	The study

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This audit set out to calculate the amount of time professionals had spent complying with the requirements of the current Mental Health Act (England & Wales) in a given setting and during a given period. It was then estimated how much time would have been required, had a new Act based on the white paper been in force. For practical reasons, and because a forensic psychiatric unit concentrates on detained patients, the Oxford Clinic was chosen for the study. This is a 30-bed, purpose-built, medium-secure forensic psychiatric unit with a catchment area (Oxfordshire and Berkshire) of approximately 1.5 million people. All patients in the unit are detained under the Mental Health Act, and the usual length of stay is 18-24 months. This is typical for medium-secure units, as compared with an average length of stay of nearly 8 years for the three English high-security hospitals. All 54 patients admitted to the unit in the 18 months prior to May 2001 were identified, around two-thirds of whom were still in-patients. The full medical notes for all these patients were obtained and scrutinised by Sean Whyte, anonymously recording every ‘statutory process’. This was administrative work, carried out by a professional, which related directly to detention under the Act, over and above work which would have been done as a matter of course during the clinical care of the patient. Detention (‘section’) papers, photocopies, letters and clear descriptions in notes were all accepted as evidence of statutory processes.

Separately, the average times required for each of the statutory processes were estimated after consultation with a selected group of colleagues from the two main professional disciplines relevant to the Act (psychiatrists and social workers). Between them, the chosen colleagues had experience of the different sections and parts of the Act, and of the different roles which could be played (e.g. responsible medical officer (RMO), second opinion approved doctor (SOAD) etc.). The cost of each process was estimated using the hourly rates at the mid-point of the salary scales for each of the professionals concerned or the relevant fees, where paid.

Finally, both authors jointly considered the most probable way that each of the patients in the audit would have been dealt with, had a new Act based on the white paper been in force; the figures were then recalculated on this basis. Box 1 illustrates how these calculations were made in the case of one individual patient.

	Findings

Top Abstract Introduction The study Findings Comment References

 
The main results of the audit are summarised in Table 1. The key finding is that the audit predicts a substantial rise (27% overall) in the amount of time professionals will have to spend to comply with the requirements of a new Act, but that this rise will only be significant for social workers and for independent doctors, working on behalf of the mental health tribunal (MHT).

We predict that social workers or, in some cases, their equivalent under a new Act, involved in the area included in the study will spend an extra 129 hours a year (a 30% increase in time required) complying with the requirements of a new Act. This is principally because they will need to contribute to the full care plans and reports demanded by more frequent MHTs, although this will be offset somewhat by the abolition of managers' meetings.

Even more significant is the prediction that the time required by independent doctors (similar to SOADs) who will be employed by the new MHTs will be tripled. They will have to spend a considerable time assessing patients and writing reports in advance of each MHT meeting. This is an entirely new function, distinct from the ‘medical member’ of the current mental health review tribunals, who does not write a formal report and is to be separately replaced by a third MHT member, and distinct also from the right of the patient to employ their own independent psychiatrist.

	Comment

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There are many limitations to this study, not least the biased nature of the in-patient forensic psychiatric sample and the necessarily subjective nature of our estimates of the times required to comply with a new Act. Our estimates make a number of assumptions which may well turn out to be incorrect. These include assuming that the white paper will be enacted unchanged, that working practices will not alter other than as required by the Act and that the frequency of use of compulsory powers of detention will not change.

Notwithstanding these limitations, however, our central findings are likely to hold true, that social workers and independent doctors will be required to spend substantially more time complying with a new Act, whereas psychiatrists responsible for the clinical care of patients will not be significantly affected. This is particularly true for professionals working with patients from medium-secure units. We believe that these findings are also likely to apply to the many patients in other forensic psychiatric settings.

Our findings do not apply directly to general adult psychiatric services, where compulsory powers are used less frequently and different parts of the Act are employed. However, in a similar way, where care and treatment orders are used, social workers and independent doctors are still likely to need a lot more time than they do at present.

The implication of these findings for policymakers, if they are even partly true, is that the implementation of a new Act on the lines described in the white paper will require extra resources, both financial (to pay for the additional social work and independent medical time) and human. Even without these additional pressures, there are already worrying shortages of SOADs and independent doctors available to the mental health review tribunal. Unless this resource issue is tackled before the new legislation is enacted, patient clinical care is likely to be adversely affected.

	Acknowledgments

 
We thank Lyn Taylor, Kathy Smith and the staff of the Littlemore Medical Records Department who assisted with locating notes, and our psychiatric and social work colleagues who helped us estimate times.

	References

Top Abstract Introduction The study Findings Comment References

 
MIND POLICY AND PARLIAMENTARY UNIT (2001) Mind and the Mental Health Act: 1-5. London: MIND.

PERCY COMMISSION (1957) Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency (Cmnd 169). London: HMSO.

ROYAL COLLEGE OF PSYCHIATRISTS (2001) White Paper on the Reform of the Mental Health Act 1983. Response from the College's Mental Health Law Sub-Committee. London: Royal College of Psychiatrists.

SCOPING STUDY COMMITTEE (1999) Review of Mental Health Act 1983. Draft outline proposals by Scoping Study Committee (Richardson Committee). London: Scoping Study Committee.

SZMUKLER, G. (2001) A new mental health (and public protection) act. BMJ, 322, 2-3.[Free Full Text]

ZIGMOND, A. S. (2001) Reform of the Mental Health Act 1983: the Green Paper. Psychiatric Bulletin, 25, 126-128.[Free Full Text]

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