Comment

Reform of the Mental Health Act — everything to play for

By David Branford

The Secretary of State for Health and the Home Secretary recently presented to Parliament the White Paper on the reform of the Mental Health Act 1983. It is in two parts: the first considers the new legal framework for mental health services and the second the needs of high-risk patients. The publication of the two parts together is fascinating.

For years mental health services have tried to distance themselves from any involvement with dangerous people with personality disorders, maintaining that they are untreatable and should be dealt with by the prison system. The second part of the White Paper looks specifically at developing a more satisfactory service for such people involving both mental health and prison services.

I am going to concentrate largely on the first part of the White Paper — the legal framework. The UK Psychiatric Pharmacy Group (UKPPG) has actively participated in each stage of the consultation process for the replacement of the Act. This involved providing evidence to an expert panel, commenting on the expert panel's report and then responding to the Department of Health consultation document on the reform of the Act.

One of the wonders of modern technology is the ability to scan for particular words. A quick scan of the White Paper fails to reveal the vital “pharmacy” word anywhere! It would be tempting to bemoan two years of wasted effort and to view this document as yet another missed opportunity for pharmacy. In this case I think one would be hasty to come to such a conclusion. The original UKPPG submission made a range of recommendations about the use of medicines in mental health and the need for safeguards. It also made suggestions about how mental health pharmacists could help. Although many of the recommendations about the use of medicines in mental health appear in some form or other, unfortunately none about pharmacists playing a key role appears. However, neither does the White Paper specify many other professional groups.

The big headlines are: “Community treatment orders”, “Legal control of the sectioning process”, “A new role for the Mental Health Act Commission (to be called the Commission for Mental Health)”, and “Oversight of the care of people with dementia and learning disabilities”.

“Community treatment orders” is by far the most controversial of the recommendations and is fundamentally opposed by most patient (user) groups. The new proposal is for care and treatment under compulsory powers to take place in a number of settings, not just in hospital. Such treatment orders may require the patient to allow access to mental health practitioners, attend particular places or comply with medication. Community treatment orders will specify what action the clinical supervisor may take if the patient does not comply. Understandably patient groups regard this as an infringement of personal liberty.

Before 1959, compulsory admission to mental hospitals was controlled by the legal profession. The 1959 Mental Health Act changed that responsibility to the medical profession and this is regarded by some to have encouraged the development of community care.

There is a view that the processes of treating patients are incompatible with those of detaining patients and that separation of the functions will improve the therapeutic relationship between doctor and patient. Many practitioners remain unconvinced by this argument.

Other really interesting changes are:

l plans to widen the scope of Mental Health Act legislation to include the treatment of a further 44,000 people with dementia and learning disabilities. (The UKPPG was one of a number of groups to raise concerns about people who suffer long-term incapacity but have none of the safeguards of the Mental Health Act. The care and treatment plan must be in the patient's best interest and these patients will come within the remit for the Commission for Mental Health.)

• plans for the development of a range of facilities for people with dangerous behaviour
• use of the term “mental disorder” and including within it people whose primary diagnosis may be personality disorder
• plans for the third person in the detaining process not necessarily to be a social worker but perhaps be a suitably trained other professional
• plans for the clinical supervisor to be either a consultant psychiatrist or a consultant psychologist
• plans for all patients to have access to independent specialist advocacy services
• plans for the code of practice to be produced by the Department of Health rather than the Mental Health Act Commission and for it to be a statutory document
• plans to change the role of the “second opinion doctor” so that he or she will consider whether the treatment is consistent with acceptable practice in the treatment of mental illness as well as it being consistent with the illness itself. (The UKPPG had argued that agreeing to a drug treatment solely on the grounds that a person suffered an illness was of little value. The prescriber had to demonstrate that the treatment was of benefit.)

But what about treatment? Upon first reading it all sounds familiar with similar rules for psychosurgery, electroconvulsive therapt and psychotropic medicines. There will be guidelines in the code of practice on polypharmacy, high doses and physical medicines required as a result of behaviours arising from mental disorders. Compliance with treatment and contact with services will be enforced under the new legislation. This is intended to prevent patient relapse and unplanned admission to acute hospital wards. Also patients need not be kept in hospital simply to ensure compliance with medicines.

Much of the detail will be in a code of practice that will be published by the Department of Health before the Act and it will provide the next opportunity for consultation. At this stage more appropriate responses would be “work in progress”, “very interesting” and “everything to play for”.