• Isabel Walton

We Must Reform the 1983 Mental Health Act



Following three nationwide lockdowns and almost two years of stress and anxiety surrounding covid-19, it must come as no surprise that the UK is currently described to be experiencing a growing mental health crisis [1]. With the system running thin, and a drastic increase in demand for mental health charities, this inevitably raises the question: ‘How does the NHS provide the nation with effective, yet concurrently autonomous, mental health treatment?’.


It may surprise you to hear that the current legislation which dictates the treatment of those mentally ill - the treatment of arguably society’s most vulnerable - is a piece of legislation created almost 40 years ago. The 1983 Mental Health Act essentially outlines the treatment and rights of those suffering from mental illness, and it is also the statue which provides healthcare professionals with the power to detain individuals against their will. With minimal changes since its implementation, yet substantial development of public acceptance to mental illness and change in public views, we must question why we allow our current mental health treatment to be controlled by laws created by people living in a society which heavily stigmatised and hid mental illness with shame. Do we not deserve a Mental Health Act which fits our society now?


With autonomy being one of four ethical healthcare principles, it is imperative the NHS upholds this concept, especially regarding the treatment of those against their own will. Impairment of the mind, which results in the inability to make rational decisions is what physicians call lack of mental capacity. In these instances where mental health patients fail to exhibit sufficient mental capacity to decide whether or not they want to refuse medical treatment, the 1983 Mental Health Act gives healthcare professionals the power to decide on their behalf. It can be frightening to know that the decisions about our own lives and bodies can be surrendered to someone else following the decline of our mental capacity, which is why we need a more modernised Mental Health Act. For this is the only guarantee of patient choice and user autonomy. I believe the way in which we can begin to do this is by increasing the involvement of mental health patients in their own treatment, as well as investing in alternatives to detention.


Patient autonomy is defined as ‘making informed decisions about the care, support, or treatment that he or she receives’ [2] and by involving patients in their own treatment as much as possible, we can ensure this concept is upheld. Recent evidence suggests that our means of mental health treatment, inpatient, and outpatient, are not as inclusive as they should be. For example, in 2020, a survey published by Care Quality Commission, which evaluated experiences of community mental health services, found that around 50% of patients receiving medicines felt that they were not ‘definitely’ involved as much as they wanted to be in deciding what medicines to use [3]. This alludes that our current Mental Health Act lacks legislation to ensure patients have the opportunity to decide what treatment they want and that patients are not being involved in their treatment as much as they should be, which a more modernised Mental Health Act should strive to improve.

Regarding treatment decisions for patients who lack mental capacity, a modernised Mental Health Act would require new legislation to increase patient autonomy before their mental capacity deteriorates. For instance, the Independent Review, published in December 2018, recommended the introduction of statutory Advance Choice Documents (ACDs) [4]. These ACDs would allow for patients to document their medical wishes prior to psychiatric decline and degeneration of mental capacity. Currently, the 1983 Mental Health Act only documents the concept of formal status advance decision making in very few instances [4] and in order to increase user choice, this needs to change. The idea of ACDs reduces possible coercion effects clinicians may have on the mentally vulnerable by allowing patients to make autonomous decisions before they lose the ability to do so [4]. It also means preference of treatment can be acknowledged even if it opposes a clinician’s advice. With this in mind, it is still important that patients have sufficient information about the available treatment, so they have the ability to make an educated choice beforehand.


Although rates of detention from 2005 to 2016 have increased by 40%, rates of severe mental illness have remained mostly constant, raising a particular concern that people are being detained at a higher rate due to our lack of community-based services [5]. An increase in autonomous community-based services would help prevent the degeneration of mental health to the state in which patients face detention and involuntary treatment where personal choice would be overridden by clinician choice instead. Therefore, an investment in autonomous alternatives to detention would essentially increase patient choice by reaching the patient and allowing them to express their wishes before their mental capacity begins to decline and clinicians are forced to take control of their treatment.


Regarding current alternatives to detention, the government implemented a controversial means of community-based treatment, whilst briefly updating the Mental Health Act in 2007 [6] – community treatment orders (CTOs). CTOs were introduced as an attempt to reduce the number of patients hospitalised [7], however, as regarded earlier, it has only been matched with increased rates of detention [5]. Although CTOs allow patients to live in the community rather than involuntarily in a hospital, they have been described as ‘stigmatising and disempowering’ [8] as CTOs essentially strip patients of their autonomy by threatening to penalise them with rehospitalisation if they don’t comply with treatment decisions [9]. This raises a concern as CTOs give power to the clinician by removing patient choice and replacing it with a clinician’s expertise (CTOs require clinicians to use prior knowledge and ‘expertise’ to decide if patients should be hospitalised and have treatment inflicted). This concept opposes the idea of increasing user autonomy that a modernised Mental Health Act should be embracing. With little evidence to support the effectiveness of CTOs [8], a modernised Mental Health Act should look to invest in alternatives to detention that actually increase patient choice rather than alternatives, like CTOs, that instead increase the impact of clinical expertise.


As just established, to modernise the Mental Health Act we need more autonomous options for alternatives to detention. One particular alternative already established in the USA is the concept of peer respite diversion therapy. This is a community-based programme focused on supporting individuals who are at risk of detention through less coercive methods in an attempt to prevent hospitalisation [10]. Led by staff who have themselves experienced psychiatric crisis in the past, the peer-run nature of these programmes makes this type of treatment very effective by building trust between patients and staff, as well as increasing patient choice by removing the coercive effects that come alongside clinician expertise. A study comparing a peer respite programme against inpatient psychiatric treatment found that the peer respite programme not only resulted in a greater improvement (based on self-reported psychopathology) but gave rise to much greater patient satisfaction [10]. The concept of peer respite therapy as a more autonomous alternative to detention is something we should embrace regarding a more modern Mental Health Act, along with other autonomous options as an attempt to reach patients before mental degeneration to allow for autonomous treatment and less clinical intervention.


So, how does the NHS provide the nation with effective yet autonomous healthcare treatment? Regarding mental health services, there is still much to be done in regard to increasing patient autonomy and user choice as just outlined in this article. Moving forward, in preparation for the inevitable fall out, regarding nationwide mental health, in response to the pandemic, as the NHS says in its constitution [11], we must ‘aspire to the highest standards of excellence’ and do this by modernising our Mental Health Act to fit our modernised society.




Bibliography


[1] Bibby, Jo (2021) Latest data highlights a growing mental health crisis in the UK. Available at: https://www.health.org.uk/news-and-comment/news/latest-data-highlights-a-growing-mental-health-crisis-in-the-uk

[2] HIQA (2016) Supporting people’s autonomy: a guidance document. Available at: https://www.hiqa.ie/sites/default/files/2017-01/Supporting-Peoples- Autonomy.pdf

[3] Care Quality Commission (2020) Community mental health survey 2020. Available at: https://www.cqc.org.uk/publications/surveys/community-mental-health- survey-2020

[4] Department of Health and Social Care (2018) Modernising the Mental Health Act – final report from the independent review. Available at: https://www.gov.uk/government/publications/modernising-the-mental- health-act-final-report-from-the-independent-review

[5] Equality and Human Rights Commission (2019) Our advice to parliament: reforming the Mental Health Act. Available at: https://www.equalityhumanrights.com/sites/default/files/parliamentary- briefing-mental-health-act-review-july-2019.pdf

[6] BMJ (2010) China’s psychiatric hospitals collude with officials to stifle dissent, say civil rights’ groups. Available at: https://www.bmj.com/content/340/bmj.c3371/article-info

[7] The King's Fund (2008) Briefing - Mental Health Act 2007. Available at: https://www.kingsfund.org.uk/sites/default/files/briefing-mental-health-act- 2007-simon-lawton-smith-kings-fund-december-2008.pdf

[8] Macpherson, R. et al. (2010) Supervised community treatment: guidance for clinicians. Advances in psychiatric treatment, Volume 16, pp. 253-259.

[9] Mfoafo-M'Carthy, M. & Williams, C., 2010. Coercion and Community Treatment Orders (CTOs): One Step Forward, Two Steps Back? Canadian journal of community mental health, 29(1).

[10] Gooding, P. & McSherry, B., 2018. Alternatives to Compulsory Detention and Treatment and Coercive Practices in Mental Health Settings. Journal of Law and Medicine, 26(2), pp. 300- 305.

[11] NHS (2021) The NHS Constitution for England. Available at: https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england