Exclusive interview: ‘This is a once in a generation opportunity to make mental health care civilised, not coercive’

Sir Simon Wessely is Professor of Psychological Medicine at King’s College. He is also Consultant Psychiatrist at King’s College Hospital and the Maudsley Hospital.

On an average day, 180 members of the public are ‘sectioned’ under the powers of the 1983 Mental Health Act, detained for compulsory treatment for days, months or in some cases years. The numbers are rising. Today is not an average day however, it is one of the most significant in the history of mental health care in England and Wales.

•  The basics: The Mental Health Act 1983

A call for evidence from service users and carers is today made by the man commissioned by the prime minister, Theresa May, to review the law. The brief is to establish how the process of detaining people can become exceptional rather than routine.

“A mental health act is the sign of a civilised society. I have been to countries without one and I wouldn’t want to be treated for my mental health there. Equally, I am against scenarios where the majority of mental health care takes place in prison, as is the case in America.”

The invitation to chair the review was one that Professor Sir Simon Wessely could not turn down. “I’m at a time in my life where I want to make a difference,” the esteemed psychiatrist, 60, tells Mental Health Today. “I want mental health [interventions] to be less coercive,” he says, when pushed to describe the change he wants to see. “I think we’ve become more mature in our attitude towards risk and safety over the years and more appreciative and sensitive of the fact that the purpose of the mental health act is to improve mental health.”

It's time

It is over a decade since the Mental Health Act was last looked at. The climate then was one in which a majority of the public felt threatened by people with mental health needs, rather than sympathetic. Things are different now and Professor Wessely is enthused by the prospect of facilitating legislation that can make mental health care about rights, choice and collaboration rather than, as it sometimes can be, enforced and prescriptive.

“For the last review, the main thing at the forefront of politicians’ minds was Michael Stone, [a man diagnosed with antisocial personality disorder who was convicted of murder shortly after telling mental health care professionals he was having homicidal thoughts]. That case influenced the review greatly. I think we’ve moved on. That review was led by the home office but this review is being led by [the department of] health and is chaired by a clinician not a lawyer.”

The shadow cast by the Michael Stone’s case resurfaced in the media this week however. His lawyers fronted a press conference in which they claimed new evidence implicated the killer of teenager Milly Dowler, rather than their client. It serves as a reminder of how complex, emotive and charged Wessely’s work will be. It is one thing to brief for solutions to the, rightly characterised, “burning injustices” of escalating detentions, it is another to reconcile the fact that the spectrum of mental health conditions do include some individuals who are a risk to the public. Equally, there are many individuals who receive care for suicidal thoughts.

Wessely is well versed in the challenge he is confronted with. An expert in PTSD and a specialist in many other areas, he has written over 800 papers. The first paper he wrote, as part of his PhD at the London School of Hygiene and Tropical Medicine, tested the hypothesis that people with schizophrenia were more likely to be convicted of a crime than those with other mental health conditions. The same paper acknowledged [some] police bias towards ethnic minorities.  It found no evidence of diagnostic bias towards ethnic minorities, something that has been contested by some campaigners and artists. 

May's "burning injustices"

In many ways, the analysis Professor Wessely takes on from today will mirror the research challenge of that first study, the work that laid the foundations for his future career. The over-representation of BAME (Black, Asian, Minority-Ethnic) individuals in mental health services is one the Prime Minister has said she is most keen to see explained and confronted.

“We can’t end discrimination through legislation,” Wessely argues. “I can’t even promise that the work we do will result in detentions reducing.” Wessely’s pragmatism teeters on pessimism when Mental Health Today asks him when the new legislation will actually come into force. “Any time in the next century,” he suggests… He’s joking though. He stresses his “determination”.

“Last time, from the point we are at now, to new legislation, I think it took eight years. The Dutch took 26 years. It’s a review to give advice. Even if we weren’t doing some other rather large piece of unnecessary legislation at the moment, which we are [Brexit], it would still take a long time to draft legislation and go through all the parliamentary process. There is some parliamentary time but then there’s also a rather unstable parliamentary position at the moment; we pretty much have a hung parliament.”

Some changes could be achieved more quickly. “Our review will take a year, at the end of which we hope to make some short term suggestions that can hopefully be implemented pretty quickly. As for the rest of it: it will give a direction of travel that we should be going in over the next ten years.”

12 month window of opportunity

Wessely's team will share their initial report around Easter 2018. Service users and all other interested parties will then have another six months to feedback again, before finalised recommendations are shared with the government by the end of 2018.

It is precious work, perhaps the most nuanced domestic social issue of our times. “A mental health act is the sign of a civilised society. I have been to countries without one and I certainly wouldn’t want to be treated for my mental health there. “Equally, I am against scenarios where the majority of mental health care takes place in prison, as is the case in America.”

What does ‘treatment’ mean to Professor Wessley? “I believe in a medical model and that’s one that is biological, psychological and social. I will never get tired of explaining that definition." Does there remain a role for compulsory detentions in the context of recoveries? “I don’t know.” 

These is plenty that is up for debate and readers are encouraged to play their part. As well as inappropriate detentions and inappropriate responses to BAME individuals, the review will also look at the mental capacity act, questions over Compulsory Treatment Orders, questions over the balance over risks, protection and rights, and the “position” of relatives and carers. Anyone can submit evidence through writing to MHActReview@dh.gsi.gov.uk. Other means of contributing can be found online at this dedicated website.