stressLegislation intended to safeguard people with mental ill health, including Community Treatment Orders (CTOs) and the Deprivation of Liberty Safeguards (DoLS), are not working effectively and need to be reviewed, a Parliamentary committee has concluded.

The Parliamentary Health Select Committee’s review of the working of the 2007 Mental Health Act also found that patients’ basic human rights are being violated and, in some cases, people are being sectioned unnecessarily just to access a hospital bed.

Committee chair Stephen Dorrell MP said that DoLS – introduced to protect patients who lack mental capacity, typically patients who suffer from dementia or severe learning difficulties – are not working well. “We found that it is commonplace for DoLS to be ignored leaving many people at heightened risk of abuse,” he said. “DoLS are seen as complicated and difficult to implement, but this is no excuse for the extreme variation in their application across the country. The current approach to these vital safeguards is profoundly depressing and complacent and the Government must immediately instigate a review which details an action plan for improvement.”

Community Treatment Orders

The 2007 Act also introduced CTOs, which allow for patients to be treated in the community while still being subject to recall to hospital if their condition deteriorates. However, the Committee found that while the principle of supervised community treatment is welcome, they have not worked as the legislation intended. “A convincing body of evidence was presented to us questioning whether CTOs prevent readmission to hospital; there is wide variation in the use of CTOs across the country and the availability of this new form of community treatment has not reduced the number of patients detained in hospital” Dorrell said.

“It is time for Ministers to properly review the effectiveness of CTOs and undertake a detailed analysis to understand when they are clinically appropriate and how they can be improved.”

The Committee was also concerned that pressure on hospital beds may be driving increased use of CTOs. “Financial pressures should never distort clinical judgements, but the absence of clear guidelines for clinicians makes this all the more likely,” Dorrell added. “The Royal College of Psychiatrists must lead on developing a consistent approach to CTOs.”

Over capacity

Indeed, the Health Committee found that there is huge pressure on beds in many psychiatric wards but was “shocked” to find evidence that patients who need hospital treatment are being sectioned unnecessarily in order to access a bed. “This represents a serious violation of patients’ basic rights and it is never acceptable for patients to be subjected to compulsory detention unless it is clinically necessary,” said Dorrell.

“A clinician who is complicit in this approach has compromised their professional obligations; both the professional regulators and the Government should urgently investigate the prevalence of this practice within the mental health system.”

Accessing advocacy

The MPs also looked into the use of Independent Mental Health Advocates, which aim to help patients take advantage of their rights while in hospital. However, they found that those who need advocacy the most are least likely to be able to access an appropriate service.

“Local authorities are responsible for commissioning a suitable service and Health and Wellbeing Boards should seek firm evidence from them that a high quality advocacy is available for all patients,” Dorrell said.

“Worryingly, we were told that the presence of independent advocates has resulted in some clinical staff retreating from their obligations to help patients understand their rights. The Committee is in no doubt that a patient’s primary advocate should be their clinician and independent advocates, ultimately, provide an important, but supplementary, service.”

Welcome review

The Mental Health Alliance welcomed the Health Select Committee's report. Alliance chair Alison Cobb said: "When a person is detained under the Mental Health Act, they are at their most unwell and every possible care must be taken to ensure that it is done in the right way.

"We particularly back the committee's call for a review of CTOs. The Alliance expressed serious concerns about the criteria for CTOs when they were first proposed and has since raised serious concerns that they are being used far more frequently that originally intended, meaning more and more people are being treated coercively in the community. They should not be used routinely as a way of discharging people from hospital. The Department of Health needs to understand why CTOs are being used so often and to investigate whether in fact they are having a beneficial effect on people's lives and recovery.

"We welcome the Committee's recognition of the need to improve the use of DoLS. The links between mental health and mental capacity legislation are still poorly understood in many places. Improved understanding of how to use the Mental Capacity Act is vital to ensure people's human rights are being upheld at all times.

"We also welcome the Committee's call for improvements in the availability of independent advocacy. We agree with the Committee that the way the Mental Health Act is administered is fundamental to achieving 'parity of esteem' between physical and mental health. Without investment in the best possible mental health care at a time of crisis, parity will remain a distant aspiration."