Mental Health Act review team: ‘We are committed to an opt-out advocacy system’

Psychiatrist Simon Wessely says the Mental Health Act review team he chairs is “committed” to championing reforms that would require mental health professionals to connect individuals to advocates, unless patients proactively opt out of a new system.

"The process of identifying and sourcing an advocate can play out as a Google scramble undertaken by the distressed patient themselves."

It is exactly twelve months since Prime Minister Theresa May appointed Professor Wessely to oversee a review of the law governing when people can be sectioned for their mental health against their will.

A report published by the Care Quality Commission earlier this year laid bare the lack of patient involvement in mental health hospital care plans.

32 percent of care plans reviewed showed no evidence of patient involvement. 17 percent showed no evidence of consideration of the least restrictive options for care. 24 percent showed no evidence of discharge planning.

The Prime Minister has asked for recommendations by December on areas including how to reduce detention rates and how to improve hospital experiences.

“There’s no question at all that we are committed to moving towards an opt-out system for advocates,” Professor Wessley told Mental Health Today.

What are advocates are why are they important?

Independent advocates are individuals who have undergone approved training to help patients understand their rights under the Mental Health Act.

While local authorities are technically obliged to ‘make advocates available’, the process of identifying and sourcing one can play out as a Google scramble, undertaken by the distressed patient themselves.

Mental Health Today’s ongoing ‘In Our Right Mind’ campaign calls for individuals and relatives to be connected to a directory of advocates at the first opportunity − as a new requirement placed on hospitals − under a revised Mental Health Act.

“That’s not a level of detail we’re yet at,” Professor Wessely said. “It may not be for us to say how it would work actually, but we are definitely committed to increasing advocates, particularly in areas of cultural sensitivity. There’s no question that we regard that as important.”

“We’re costing a system at the moment. Clearly local authorities need to know what the cost will be, so we’re moving along on that. Should we be saying exactly how it should work? I’m not sure. That might be going too far. I don’t think the law would ever say − the Mental Health Act would never say − you must do it this way, that way, or the other. It would say ‘you need to achieve this goal of ensuring that people have access to advocates where they’re necessary, needed or desired’.”

Will sectioning look and feel different in the future?

Professor Wessely was also asked by Mental Health Today whether the public can expect any changes to which professionals they see when they enter hospital and the order in which they see them.

Currently, a psychiatric assessment is undertaken as a first step. If two doctors diagnose that you have a mental health disorder (e.g. depression, bipolar disorder) and deem that you need to be treated for it to protect you or the public from your possible future actions, a recommendation may be made for treatment under hospital detention.

The application to detain someone against their will is then made by an ‘approved mental health professional’ (AMHP). They are usually social workers, but since 2007 they can also be psychiatric nurses, occupational therapists or psychologists.

Some have argued that it might be more therapeutic for the AMHP to be involved earlier, for the patient to be ‘heard’ before they are assessed and potentially diagnosed.

Others say patients should be given a legal right to challenge diagnosis (e.g. a right to a third opinion) as a safeguard against racial bias influencing assessment. A lawful detention for treatment hinges on whether a person receives a disorder diagnosis or not.

“I’ve seen that on the agenda [of proposals to consider],” said Professor Wessely. “We’re not planning on changing the bedrock of the current system, which is the idea to have medical recommendations, but the actual application to be made by a social worker.”

“We’re absolutely not touching the role of the [AMHP] at all. If anything we’d be expanding the range, so that bit isn’t changing but we’re going to ask [AMHPs] to do a lot more.”

“So for example there will be a requirement, in order to complete the [detention application] form, to have to look at things like advance directives. On the first [crisis] episode there may not be a requirement but there may be on others. ‘Have you found it? What does it say?’ Etc etc."

“Similarly, assessments of capacity will be built into the act, and so on and so forth. So there’s going to be more for people to do.”

The last comment, almost a throw-away line, will be of interest to those who have called for the new law to follow Northern Ireland’s efforts to ‘fuse’ the Mental Capacity Act and Mental Health Act. This has been ruled out by Professor Wessely in the short term. But it appears disorder and capacity may, nonetheless, become less conflated in the forthcoming recommendations.

• See also: Simon Wessely - 'ECT is in my own advance directive'

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