SOCIETY OF CLINICAL PSYCHIATRISTS RESPONSE

TO THE BODY REVIEWING THE MENTAL HEALTH ACT 1983.

Dr. M. T. Haslam 

The Society of Clinical Psychiatrists is a body of senior psychiatrists who, over the years since its foundation, have concerned itself with matters of importance and have acted as a ginger group in this respect in psychiatry.  Our response to the proposed redrafting of the Act has considered a number of issues which have been suggested.

We are concerned about proposals for care plans.  Care plans have already caused considerable disquiet amongst jobbing psychiatrists, since getting all the requisite people together to implement a care plan procedure, whilst a worthy aim, is time consuming and often impractical.  For it to be done properly requires more manpower because of the time factor and to expand it would therefore be an even bigger problem.  Is the Government really aware of the great shortage of staff both in medical and nursing terms when it glibly suggests producing a thousand more doctors or three thousand more nurses?  Where are they to come from?  Training of such individuals will take many years and we have, over recent years, seen medical schools in London facing closure and a continuing heavy reliance on overseas doctors.  Thought must be given therefore to the manpower of such changes if the report is ever to be implemented in many of our life times!

We are unhappy with ideas concerning the redrafting of the areas which the Mental Health Act might cover and particularly the redefining of areas covered by the current term learning disability and personality disorder.  We would say that the definition of psychiatry can be that it specialises in the management and treatment of conditions which affect thinking, emotion and memory and arising out of this behaviour.  Thus it might include such conditions such as epilepsy, concussion and the consequences of excessive alcohol or drug usage and the psychiatric consequences of learning disability or mental handicap to use an old term.

Nor are we entirely happy with the removal of reference to psychopathic disorder.  This is a well-defined term and a well-defined problem, which does frequently require compulsory admission and does need, in our view, different specialist management from general mental illness.  The term personality disorder is far too broad a concept to have any real meaning in this regard.  We feel that the manner of dealing with psychopathic disorder under the 1959 Act was extremely helpful and the changes created in the 1983 Act have not been progress but have, in fact, caused the management of such people to deteriorate.

We are concerned also as to who should be in a position to assess the mental state of an individual (Paragraph 10 0f the paper).  If any member of the public is to have a right to an assessment of their mental state, presumably by someone properly qualified, and to be examined, then again the manpower implications of this are immense.  Currently there would not be enough psychiatrists to provide anything like this level of service.  Where are all the approved professionals going to come from who will be able to do these "time limited assessments"?  We assume also that some fee would be payable for some additional work and would draw attention to the costing implications of this.

We do have some concerns as to the proper constitution of a body competent to judge the necessity of further detention of the mentally ill.  Such an individual would, we feel, need to be skilled and experienced in the diagnosis, treatment and behavioural consequences of all the conditions which might present in psychiatry and would need to have a good knowledge of the Mental Health Act legislation and would need to have a good knowledge of the patient and his or her needs and of the local facilities.  They would also need to have good background training both in general medicine and psychology in order properly to make a diagnostic assessment.  We would suggest that this, by and large, describes a Consultant Psychiatrist and that they are the only people with that breadth of training.  If there (as contained in Paragraph 15 of the discussion paper) everyone to take on this role would need to be trained to this level, then we are certainly excluding lawyers, social workers and general practitioners and clinical psychologists.  We are back therefore to the old problem of practicability and time.  We suggest that the old system, as in the 1959 Act, was not such a bad one but perhaps much of the time the only person fully qualified by their training should be allowed to get on with it and be allowed to make the occasional executive decision for once!

We are unclear as to the meaning of the term clinical supervisor as contained in Paragraph 17 of the discussion paper.  Is this the responsible medical officer as defined in the Act or someone more lowly?  If some more lowly then are they responsible to the responsible medical officer, if not then the responsible medical officer must perforce cease to be responsible and must not therefore be held to account for the decision made.  Who is to make the decision about capacity?

We have further concerns about the "right to independent legal advice" as contained in Paragraph 26.  Whilst it is desirable in theory we should only put into place things which it is practical to carry out.  We fear that this will be abused and that little time is going to be left in all this for seeing and treating patients who are ill.

We have, over the years, had considerable problems of confidentiality when sharing information, for example, with social services and indeed they perhaps with us.  There is a different ethos and a different way of looking at things and a different set of statutory obligations and, thus, often a reluctance to share.  Some joint training both to social work students and trainee nurses should be built back into the training of such people.  Lectures by psychiatrists have largely been dropped from the training of nurses and social workers and there is, thus, very little shared understanding at this level.  These professions have tended, for this reason to drift apart.

Finally under this section we would be unhappy if the control which the next of kin or nearest relative can currently exercise (if only to restrain the occasionally dogmatic social worker) should be lost in the understandable desire not to place such a relative in the invidious position of "having to put their loved one away".  We feel, in practice, the 1983 Act already has such safeguards built into its structure that any change here would be unnecessary.

Questions have been posed as to the method of defining mental illness which should be used (Paragraph 37). The professional opinion of many in the service is certainly not in favour by defining mental disorder by reference solely to the International Classification of Diseases or to DSM 4.  Such classifications are useful for those doing research and probably favoured therefore by those in Ivory Towers but considerably less well thought of by the grass roots working at the coalface.  Sir Martin Roth has, in his time, had comments to make about the DSM 4.  We therefore agree with regard to the Code of Practice as contained in the discussion document.

As to exclusions (page 19) this is a minefield in terms of human rights.  Certainly private sexual practice and gender issues should have nothing to do with either the law or medical practice in any sense of compulsion.  This is another reason why many of us are unhappy with ICD X and DSM 4 since they contain within it conditions which are really not the provinces of medical practice at all.  One recalls Shakespeare and Shylock pointing out that people still bleed if you prick them and can be ill like the rest of us, but the conditions described in the classifications of themselves in the view of many of us are not disease as such but rather aspects of an individual's personality variants.

The discussion on whether learning disability should or should not be included still within the mental health framework (Paragraph 46) also concerns us.  Whilst the Mental Health Act may not be a good framework for learning disability per se, we must remember that much research by reputable workers such as Ken Day at Morpeth have shown firstly that there is a much higher incidence of psychiatric illness associated with learning disability than in general population and, furthermore, that specialised units specifically designed  for these peoples' particular needs are much more effective than placing people in a general hospital ward.  They are not well accepted in an ordinary inpatient unit anymore than are psychopathic patients, alcoholics or drug addicts.  We suggest that some special regulations out with the routine ones for ordinary psychiatric admission still need to be addressed since the individual with learning disability often has related psychiatric problems (and indeed medical problems) where, indeed, diagnostic acumen and expertise necessitates the specialty of a consultant in learning disability still developing these skills.

There are serious problems in the compulsory assessment of a patient in the community (Paragraph 65).  What nurse in this day and age is going to be happy with the concept of "assaulting" an individual in the community by forcibly plunging a syringe full of a sedative or major tranquilizer into their bodies against that individual's wish?  We would need to get the nursing unions views on this but would suspect that most would be much happier if such activities were placed within the hospital and the cover in terms of avoiding being sued that this might hopefully provide.

We are concerned that the release of a no longer detainable patient is often currently delayed by the length of time it takes to get a tribunal or case conference together involving, as it does, people with other jobs in the community (page 70 to 73).  How quickly can one see this process being able to work in practice?  Would it not be just as realistic to rely on the opinion of the consultant in such matters, since he or she is the one with the final responsibility?  We cannot see the average lawyer bothering to get medical or social work opinion before deciding on how to proceed on matters in which he, in fact, is an expert and there seems no more reason why a doctor should have to get an opinion for the same kind of situation.  These things can be very wasteful of a specialist's time.

We agree strongly that the length of time of the short detention section should remain 36 hours or three days.  Surely the main reason for this is because of the problems in finding the necessary people between Friday night and Monday morning.  We see considerable problems with a 24 hour section.

We remain seriously worried by the current trend for lawyers to create an adversarial as opposed to an inquisitorial hearing in patients who appeal to the tribunal.  We feel that some redefining of roles is sensible here.  We feel it would be better for the patient to be returned to hospital rather than be in the community when such an occasion might arise (Paragraph 112).  We are concerned (Paragraph 123) that, if a patient were detainable, that the proper criteria for detention are met.  Would it be legal to detain someone while waiting for a care package to be determined?  On call social workers, for example, might live thirty miles away from the scene, psychiatrists not be immediately available being involved in other commitments elsewhere at the time etc.

We agree that the power of the manager to discharge should be scrapped.

We take issue with the use of the phrase medical model (Paragraph 135) in what seems to be a restrictive and thus somewhat purjoritive sense. What makes anyone think that current therapy and care in psychiatry is not embraced by medical practice?  Psychiatrists indeed invented most of it.  It is best therefore not to use this term.

We are concerned about the current position viz a viz the "third professional" in SSAD visits as mentioned earlier in our paper.  This is often a farce.  Half the time there is nobody there of that type, often they don't exist at all and often the patient is too ill to avail themselves of their services.  Someone therefore is scrambled up whose opinion, by their own admission, is valueless.  It is a farce and should be scrapped.  The chairman of our group said as much at an MHAC meeting a couple of years ago and was not long after dropped from the SOAD list, no doubt for heresy!

Finally we feel that the conditions be determined before ECT is given should be thought through very carefully before being finalised.  How can one decide before the patient becomes depressed that they are prepared to have ECT?  Equally, how can opinion be genuinely formed once one has depression bad enough to need ECT?  It is surely better to rely on the consultant's judgement in such a situation, since he certainly ought, by his training and experience, to know best in such matters.  Is the Society old fashioned in this brave new world?  We know which we'd prefer to steer a ship through troubled waters between a specialist and a committee.  We feel that an advocate would need to have some knowledge of mental illness to be effective and useful.  How would they obtain this experience for it to be seriously worth listening to?

We feel that the discussion document makes very valuable points and that some of the areas are certainly in need of a review.  We are not, however, entirely happy with the points as raised above and feel that considerable more work needs to be done in this area before it is sensible to start changing the law yet again on this subject.