CQC Report on the Mental Health Act

The number of people subject to the Mental Health Act rose once again last year: it was 5% higher than the year before. Almost all of this is due to the use of community treatment orders (CTOs), the number of which grew by 30% last year.

CTOs were introduced in 2008 and are fast becoming a preferred way of ensuring that people adhere to treatment – often medication based – although, as the CQC points out, people on CTOs do have the right to refuse medication while in the community, and such refusal is not in itself sufficient cause to recall the person to hospital.

At the same time, there is a danger that CTOs could become a means of avoiding the expense of keeping people in hospital or other accommodation, while still compelling them to be compliant to the treatment prescribed.

The CQC Report is based on 1,565 visits to in-patient units and meetings with more than 4,700 people receiving services, where talking with them was a central part of the process.

It looks at four main areas of concern:

Patients’ involvement and protection of their rights
CQC recommends: “Providers should make sure that the principle of patient participation in care planning is fully embedded in staff training programmes. Clinical leaders should be helped to create ward cultures in which patient participation is the norm.”

Consent to treatment
CQC states: “Although the Act allows some medical treatment for mental disorder to be given without consent, the patient’s consent should nevertheless be sought before treatment is given wherever practicable.”

Patients’ experience of care and treatment –
Minimising restrictions on detained patients and avoiding blanket restrictions.
The CQC were concerned at the continuing problems of overcrowding in in-patient units, and stated:
“To address the pressures on admission, we welcome the continued development of recovery houses (also called crisis houses) – these can provide care in a less restrictive setting, are generally popular with service users, and studies have shown that they are as effective as inpatient units in clinical terms.”

They still met with patients who raised issues about feeling bored or wanting more to do while they are in hospital – often with a sense that meaningful activities come some way down the list of considerations in their treatment or care plan. They recommend, “All staff with responsibilities for the provision of therapeutic activities should monitor participation in such programmes. Programmes should be reviewed as necessary to make sure they are relevant to patients’ needs and interests, and that there is a positive approach to engaging patients in them.”

Promoting patient safety
On this extremely important issue, CQC state, “We take the view that the wider patient involvement in care planning can be, the better the service will be. If there is an ethic of genuinely helping the patients to have a say in their treatment, including creating real opportunities for patients to record their own views and experiences following, for example, restraint incidents (through the help of independent advocacy if appropriate), then there is a smaller likelihood that abuse can occur.”

They make a similar point about the use of seclusion.

Deaths of detained patients
CQC were notified of 294 deaths of detained patients in 2009, and 283 in 2010. Three-quarters of them were due to natural causes. About a third of the patients who died of natural causes while detained in 2009 and 2010 did so before their 61st birthday. This supports findings of reduced life expectancy among people with long-term serious mental disorder.

Of the 115 deaths in 2009 and 2010 that were due to unnatural causes, most were due to suicide or self-harm. Overall, 44% of these unnatural deaths resulted from hanging or self-strangulation. However, the number of such deaths is declining owing to the removal of many non-collapsible curtain or bathroom rails.

As if to emphasise the recovery message, the summary report ends:

“One common failure in risk assessment has been a lack of support for patients who receive bad news, whether to do with their personal life outside hospital or their progress through the hospital system. It is vital that in these circumstances patients receive support from staff and a fresh assessment of risk is undertaken.”