Mental Health Legislation In England Research Articles

Advance Statements for Black African and Caribbean people (AdStAC): protocol for an implementation study

BackgroundThe UK government committed to legislating for Advance Choice Documents/Advance Statements (ACD/AS) following their recommendation by the Independent Review of the MHA (2018). ACDs/AS are yet to be implemented in routine practice despite evidence and high demand; they are associated with improved therapeutic relationships and a reduction (25%, RR 0.75, CI 0.61–0.93) in compulsory psychiatric admission. Barriers to their implementation are well documented, ranging from low knowledge levels to logistical challenges in accessing the content during episodes of acute care. In the UK this is an issue for Black people, who experience detention rates disproportionately (over three times) higher than those of White British people and have poorer care experiences and outcomes. ACDs/AS allow for Black people to have their concerns heard by mental health professionals in a care system where they often feel their views are ignored. AdStAC aims to improve Black service users’ experiences in mental health services in South London by co-producing and testing an ACD/AS implementation resource with Black service users, mental health professionals and carers/supporters of Black service users.Methods/designThe study will take place in South London, England over three phases: 1) formative work through stakeholder workshops; 2) co-production of resources through a consensus development exercise and working groups; and 3) testing of the resources using quality improvement (QI) methods. A lived experience advisory group, staff advisory group and project steering committee will support the study throughout. The implementation resources will comprise: advance choice document/advance statement (ACD/AS) documentation, stakeholder trainings, a manual for mental health professionals to facilitate the processes of creating and revising advance statements, and informatics development.DiscussionThe implementation resources will help increase the likelihood of the new mental health legislation in England being implemented effectively; through aligning evidence-based medicine, policy and law to effectively provide positive clinical, social and financial outcomes for Black people, the National Health Service (NHS) and wider society. This study will likely benefit a wider group of people with severe mental illness, as when marginalised groups who are least engaged, can be supported with these strategies, then the strategies are likely to work for others.

Implications for mental health workforce strategy, professional training and supervision of more widespread adoption of the multi-professional Responsible Clinician role: Results of a qualitative inquiry

Within mental health legislation in England and Wales the Responsible Clinician for specific patients should be the Approved Clinician with the most appropriate expertise to meet their primary assessment and treatment needs. The study aimed to explore nurse and psychologist perspectives on becoming a Responsible Clinician in the context of their limited uptake of the role and calls for an increase in advanced practice roles within mental health. It comprised a qualitative inquiry in the form of a thematic analysis of 12 semi-structured interviews. Four sub-themes emerged under the theme of ‘becoming a Responsible Clinician’. They were: (i) the Responsible Clinician amongst other roles; (ii) developing in the role; (iii) working with psychiatrist colleagues; and (iv) organisational context. Responsible Clinicians were juggling the role with other senior clinical responsibilities, often without a coherent programme of ongoing educational development or organisational support structures. If mental health service provider organisations adopt this extended role more widely then role-specific support and supervision arrangements should be in place as part of a coherent workforce strategy. This is particularly important given the legal and ethical responsibilities of the Responsible Clinician.

Narratives of reform: the Mental Health Act (MHA) in England and Wales from the 1983 MHA to the Wessley Review (2018)

Purpose This paper aims to examine reform of mental health legislation in England and Wales. It covers the period from the introduction of the 1983 MHA to the proposed reforms outlined in the Wessley Review that was published in December 2018. Design/methodology/approach This is a literature-based project. Findings Reform of the mental health legislation reflects two potentially conflicting strands. One is the state’s power to incarcerate the “mad”, and the other is the move to protect the civil rights of those who are subject to such legislation. The failures to development adequately funded community-based mental health services and a series of inquiries in the 1990s led to the introduction of Community Treatment Orders in the 2007 reform of the MHA. Research limitations/implications The development of mental health policy has seen a shift towards more coercive approaches in mental health. Practical implications The successful reform of the MHA can only be accomplished alongside investment in community mental health services. Originality/value The paper highlights the tensions between the factors that contribute to mental health legislation reform.

Epistemic struggles: The role of advocacy in promoting epistemic justice and rights in mental health

Advocacy for people using health and social care services is widely promoted but its theoretical foundation is under-developed and its impact poorly conceptualised. This paper explores the liberatory potential of independent advocacy, using Fricker's concept of ‘epistemic injustice’ as a framework. People experiencing mental distress are particularly vulnerable to epistemic injustices as a consequence of deeply embedded social stigma resulting in a priori assumptions of irrationality and unreliability such that their knowledge is often discounted or downgraded. The mental health service user/survivor movement is at the forefront of validating personal experience and narrative to secure a different ontological and epistemological basis for mental distress. A foundational strand of this is advocacy to enable people to give voice to their experience.The case of independent mental health advocacy (IMHA) services under mental health legislation in England, provides an opportunity to critically examine whether advocacy can promote epistemic justice as a result of the legally sanctioned encounter between clinical assessment and subjective experience, pivoting on judgements about risk. This paper draws on empirical data from a national evaluation of IMHA services, which included 90 individual interviews with people subject to detention and three focus groups with mental health service users. Fricker's concept of epistemic injustice is used as a lens to investigate how this type of advocacy might mitigate forms of epistemic injustice, and thereby promote greater social justice in mental health.The concept of epistemic injustice provides a valuable theoretical basis for understanding the worth of advocacy in addressing testimonial injustice as well as its relative weakness in overcoming hermeneutical injustice. The challenge of independent advocacy to the dominant discourse within mental health is considered and questions raised about the place of advocacy in modern democratic mental health systems.

Response to the Commentaries

<p>We are immensely grateful to the commentators for their careful reading of the Model ‘Fusion’ Law (ML). The level of support for our proposal from most of the commentators is encouraging as is the news that Northern Ireland intends to introduce legislation along similar lines. The aim of the ML is to eliminate the unwarranted discrimination against people with mental disorder that is inherent in current mental health legislation in England and Wales and in many other jurisdictions. We remain convinced that the principles underlying the enterprise are right and that they can be translated into a practical form. At the same time, excellent points have been raised by the commentators that have stimulated us to think further and to propose a number of revisions.</p><p>The editors have invited us to respond briefly to the commentaries. We should have liked to engage with each of the commentators on a number of specific issues, but in our response we must focus on the major themes that have emerged.</p>

Timeliness of second opinion appointed doctors' assessments of treatment plans for patients detained in medium security hospitals in London, UK

Mental health legislation in England & Wales requires assessment by a second opinion appointed doctor (SOAD) to safeguard the rights of patients detained in a hospital under this law if they are either refusing certain treatments or are deemed incapable of consenting to them. Our aim was to evaluate timeliness of SOAD assessments. Data were collected from the Mental Health Act administrator on all SOAD requests in 1 year for all in-patients in two English medium security hospital units. One hundred and six patients required a SOAD assessment during the 1-year period examined, of a combined resident total of 295, as did a further 14 patients who had been discharged from hospital and were subject to a community treatment order. About half of the inpatients were seen by a SOAD within 30 days and a further quarter within 60 days, but the remaining quarter waited up to 150 days or more. These results suggest that in these trusts, unlikely to be atypical, neither patients nor clinicians are being adequately protected by legal safeguards on decisions to treat with medication (or electroconvulsive therapy) in the event of impaired competence for decisions about mental health treatments. There should be clear standards for the appropriate length of time from referral to assessment by an independent doctor (SOAD). Compliance with standards should be transparent, so anonymised data on the matter should be routinely collected and stored by health trust Mental Health Act offices. Data should be monitored at agreed intervals by an independent body.

Mental health legislation and human rights in England, Wales and the Republic of Ireland

In 2005, the World Health Organization (WHO) published its Resource Book on Mental Health, Human Rights and Legislation (Geneva: WHO) presenting a detailed statement of human rights issues which need to be addressed in national legislation relating to mental health. The purpose of this paper is to determine the extent to which revised mental health legislation in England, Wales (2007) and Ireland (2001) accords with these standards (excluding standards relating solely to children or mentally-ill offenders). Legislation in England and Wales meets 90 (54.2%) of the 166 WHO standards examined, while legislation in Ireland meets 80 standards (48.2%). Areas of high compliance include definitions of mental disorder, relatively robust procedures for involuntary admission and treatment (although provision of information remains suboptimal) and clarity regarding offences and penalties Areas of medium compliance relate to competence, capacity and consent (with a particular deficit in capacity legislation in Ireland), oversight and review (which exclude long-term voluntary patients and require more robust complaints procedures), and rules governing special treatments, seclusion and restraint. Areas of low compliance relate to promoting rights (impacting on other areas within legislation, such as information management), voluntary patients (especially non-protesting, incapacitated patients), protection of vulnerable groups and emergency treatment. The greatest single deficit in both jurisdictions relates to economic and social rights. There are four key areas in need of rectification and clarification in relation to mental health legislation in England, Wales and Ireland; these relate to (1) measures to protect and promote the rights of voluntary patients; (2) issues relating to competence, capacity and consent (especially in Ireland); (3) the role of “common law” in relation to mental health law (especially in England and Wales); and (4) the extent to which each jurisdiction wishes to protect the economic and social rights of the mentally ill through mental health legislation rather than general legislation. It is hoped that this preliminary analysis of mental health legislation will prompt deeper national audits of mental health and general law as it relates to the mentally ill, performed by multi-disciplinary committees, as recommended by the WHO.

Mental Health and Mental Capacity Law: Some Mutual Concerns for Social Work Practice

The roots of mental incapacity and mental health legislation in England and Wales are deeply intertwined. Changes in healthcare policy, human rights principles, demographics and social attitudes have highlighted deficiencies in the law to protect the interests and rights of people considered to lack decision-making capacity. This led to calls for legal reform from social workers amongst other groups. The Mental Capacity Act 2005 took shape alongside the more controversial Mental Health Act 2007. Whilst mental capacity and mental health legislation are separate once again, both are concerned with the care and treatment of adults who are perceived as lacking capacity to make specific decisions. The Deprivation of Liberty Safeguards enacted as part of the Mental Health Act 2007 to amend the Mental Capacity Act 2005 will change practice for many social workers as they will give rise to new assessments and roles. Social workers will need to be aware of the potential interaction of the two Acts to ensure compliance with the laws and to promote positive practice. This article explores the interface between the Mental Capacity Act 2005 and Mental Health Act 2007 in England and Wales and examines and speculates on some of the possible implications for social work practitioners.

Service-user and carer perspectives on compliance and compulsory treatment in community mental health services

This paper reports on a qualitative study analyzing service-user (SU) and carer perspectives on medication compliance and their experience of compulsory treatment. Eleven SUs and eight carers were interviewed. The research is set against the background of changes to mental health legislation in England, in the form of Supervised Community Treatment. This signals a change in community mental health practice and urges a reconsideration of concepts such as compliance, concordance and coercion. These concepts are discussed in the context of legislative changes and in relation to the perspectives of service-SUs and carers. Five themes emerged from qualitative interview data, analysed using an adapted form of grounded theory: loss of credible identity, playing the game, medicalization, therapeutic competence and incompetence and increased control. The findings suggest that SUs are initially reluctant to comply with mental health treatment, but do eventually accept the need for treatment; they also stress the significance of respectful relationships with professionals and the importance of communicative competence.

Mental Capacity and Decisional Autonomy: An Interdisciplinary Challenge

With the waves of reform occurring in mental health legislation in England and other jurisdictions, mental capacity is set to become a key medico‐legal concept. The concept is central to the law of informed consent and is closely aligned to the philosophical concept of autonomy. It is also closely related to mental disorder. This paper explores the interdisciplinary terrain where mental capacity is located. Our aim is to identify core dilemmas and to suggest pathways for future interdisciplinary research. The terrain can be separated into three types of discussion: philosophical, legal and psychiatric. Each discussion approaches mental capacity and judgmental autonomy from a different perspective yet each discussion struggles over two key dilemmas: whether mental capacity and autonomy is/should be a moral or a psychological notion and whether rationality is the key constitutive factor. We suggest that further theoretical work will have to be interdisciplinary and that this work offers an opportunity for the law to enrich its interpretation of mental capacity, for psychiatry to clarify the normative elements latent in its concepts and for philosophy to advance understanding of autonomy through the study of decisional dysfunction. The new pressures on medical and legal practice to be more explicit about mental capacity make this work a priority.

Powers to Detain under Mental Health Legislation in England and the Role of the Approved Social Worker: An Analysis of Patterns and Trends under the 1983 Mental Health Act in Six Local Authorities

The study reported makes use of an existing database in order to examine a group of individuals assessed by approved social workers (ASWs) under the Mental Health Act, with a view to detention in psychiatric hospital. The study aims to develop a profile of these individuals, their pathways to assessment and the outcome of the assessments, and to examine the social implications of the findings. The study also seeks to identify changes over a nine-year period. The role of the ASW is reviewed in the light of the analysis of the nine-year information. Key features in the social situations of individuals are identified that may be associated with mental health need. Specific aspects of gender and life-stage vulnerability are suggested, as are poor material resources, isolation and lifestyle issues such as drug and alcohol misuse. The close association of psychiatric severity and social disadvantage is evident, presenting assessing ASWs with challenging and complex assessments. Mental health social workers are uniquely equipped to identify issues in the social context that may contribute to mental health crisis. Interventions underpinned by social approaches, including social inclusion and the recovery model, have the potential to help provide services in the longer term that provide social support and minimize the need for crisis admission.

Ethical analysis of the new proposed mental health legislation in England and Wales

This paper ethically analyses arising out the proposed changes to the Mental Health Act for England and Wales. It looks in particular at thea shift in philosophy that the author claims has occurred with the proposals away from rights-focused principles to more utilitarian or outcome-focused principles. It gives examples of these changes and explores itstheir consequences.

England's new Mental Health Act represents law catching up with science: a commentary on Peter Lepping's ethical analysis of the new mental health legislation in England and Wales

Commentary Those of us working in mental health tend to forget that much of medical ethics consists of coming to terms with scientific discoveries. Whilst society is still digesting the news that we can choose a child's sex, genome researchers tell us we will soon be able to know its medical future as well. In this world of breakthroughs and bombshells, psychiatry is the hick town where nothing happens; its dilemmas are the timeless ones. Ethicists have always worried about balancing the rights of the individual against those of the general public, and the antiquarian overtones of terms such as non-maleficience remind us that Hippocrates (460–370 BC) got there first. So Lepping's paper has an elegiac tone; he laments the passing of respect for individual rights, swept away by the tide of utilitarianism.

Biochemistry and violence: The molecular basis of aggression

Violence is increasingly being recognized as a major international public health problem, resulting in significant mortality and physical, sexual, reproductive and psychiatric morbidity. Proposed new mentalhealth legislation in England and Wales places greater emphasis on public protection, and this, together with the Government's programme for those deemed dangerous as a result of severe personality disorders, has created a new sense of urgency in understanding the mechanisms underlying aggression and violence.

In relative danger

AIMS AND METHOD Among the proposed changes in the current review of mental health legislation in England and Wales is the abolition of the right of the nearest relative to discharge patients from assessment and treatment orders (Sections 2 and 3 of the Mental Health Act 1983). We aimed to determine the clinical outcome of patients whose nearest relative applies for discharge. A retrospective case—control cohort study in a south London NHS Trust of 51 patients successfully discharged by their nearest relative and 33 patients whose nearest-relative applications were blocked by the treating psychiatrist on the grounds of ‘dangerousness’. RESULTS Patients discharged from section by their nearest relative did not differ significantly from controls in all the measures of clinical outcome examined. CLINICAL IMPLICATIONS This study suggests that discharges by the nearest relative against psychiatric advice are not associated with a poor clinical outcome.

In relative danger? The outcome of patients discharged by their nearest relative from sections 2 and 3 of the Mental Health Act

Aims and Method Among the proposed changes in the current review of mental health legislation in England and Wales is the abolition of the right of the nearest relative to discharge patients from assessment and treatment orders (Sections 2 and 3 of the Mental Health Act 1983). We aimed to determine the clinical outcome of patients whose nearest relative applies for discharge. A retrospective case–control cohort study in a south London NHS Trust of 51 patients successfully discharged by their nearest relative and 33 patients whose nearest-relative applications were blocked by the treating psychiatrist on the grounds of ‘dangerousness'. Results Patients discharged from section by their nearest relative did not differ significantly from controls in all the measures of clinical outcome examined. Clinical Implications This study suggests that discharges by the nearest relative against psychiatric advice are not associated with a poor clinical outcome.

In relative danger? The outcome of patients discharged by their nearest relative from sections 2 and 3 of the Mental Health Act

Aims and MethodAmong the proposed changes in the current review of mental health legislation in England and Wales is the abolition of the right of the nearest relative to discharge patients from assessment and treatment orders (Sections 2 and 3 of the Mental Health Act 1983). We aimed to determine the clinical outcome of patients whose nearest relative applies for discharge. A retrospective case–control cohort study in a south London NHS Trust of 51 patients successfully discharged by their nearest relative and 33 patients whose nearest-relative applications were blocked by the treating psychiatrist on the grounds of ‘dangerousness'.ResultsPatients discharged from section by their nearest relative did not differ significantly from controls in all the measures of clinical outcome examined.Clinical ImplicationsThis study suggests that discharges by the nearest relative against psychiatric advice are not associated with a poor clinical outcome.

Murmurs of discontent: treatment and treatability of personality disorder

“They murmured, as they took their fees ‘There is no cure for this disease’.”Hilaire BellocTreatability is a confused and confusing concept in psychiatry. In its legal sense, it is a measure that limits the involuntary admission of patients with some particular types of mental disorder. The legal term itself has generated considerable discussion and dissent (e.g. Mawson, 1983; Grounds, 1987), and the Government's White Paper on reforming mental health legislation in England and Wales proposes to abolish it (Department of Health, 2000).

Fear, risk and mental health: Observations on policy and practice

Mental health legislation in England and Wales is poised for its biggest change since the Mental Health Act 1983 (MHA). A White Paper ‘Reforming the Mental Health Act’ (Department of Health, 2000) looks likely to become law. This paper attempts to locate these changes in a time of risk avoidance by discussing both legislators' and practitioners' pre-occupation with safety, and linking these to the increase in compulsory measures under the present MHA, and the proposed extension of such powers in a new MHA. It is argued that the rights of those with a psychiatric diagnosis are being eroded due to risk avoidance in both policy and practice.

Compulsory treatment in community plans unveiled

Mental health nurses face the prospect of treating patients compulsorily in tire community, following the publication of the government’s plans to reform mental health legislation in England and Wales.