1

MentalHealthTribunals:Examiningcurrentpractice,risingcaseloads

andfuturereform

REPORT

ProfessorNicolaGlover–Thomas

UniversityofManchester

2

CONTENTS

Acknowledgements 3

ExecutiveSummary 4

1. INTRODUCTION 6

2. DETENTIONRATESUNDERTHEMENTALHEALTHACT1983 10

2.1. Introduction

2.2. Asystemunderstrain?

2.3. Risinguseofsection2

2.4. Decliningcommunitysupportanditsimpact

2.5. TheCheshireWesteffect(andothercases…)

2.6. Theriseinsection136use

2.7. Candetentionratesbereduced?

3. MENTALHEALTHTRIBUNALCASELOADS 30

3.1. Risingcaseloads

3.2. Thepatientvoice

3.3. Theroleofindependentmentalhealthadvocacy

3.4. Mentalhealthtribunaldelays

3.5. Otherchallenges

4. NEXTSTEPSFORMENTALHEALTHTRIBUNALS 38

3

ACKNOWLEDGEMENTS

This report arises out of a seminar held in December 2017, which examined

currentmentalhealthtribunalpractice.TheworkwasfundedbytheUniversityof

Manchester and an external partner, the UK Administrative Justice Institute

(UKAJI). The work was further supported by the Department of Health, the

MinistryofJusticeandHMCourtsandTribunalsService.Thanksmustalsogoto

allthosewhopresentedpapersandcontributedtothediscussionthroughoutthe

seminar.

Theauthoraloneisresponsibleforthisreport.

NicolaGlover-Thomas

UniversityofManchester

February2018

4

EXECUTIVESUMMARY

This report results fromaone-daypolicyseminar inDecember2017 - Mental

HealthTribunals:EvaluatingCurrentPracticeandMovingForward-fundedbythe

UniversityofManchesterandTheUKAdministrativeJusticeInstitute(UKAJI).The

seminar explored the following issues: (i) what are the drivers for increasing

detention rates under the Mental Health Act 1983? (ii) what challenges face

mental health tribunalswith rising caseloads? And, (iii)what is the future for

mentalhealthtribunals?

Theseminarwasattendedby30peoplefrom:centralgovernmentdepartments;

theUKAdministrativeJusticeInstitute;tribunals;clinicians;IndependentMental

Health Advocates (IMHAs); in addition to representatives and academics with

expertiseinmentalhealth.Theprojectwassponsoredbytwoexternalpartners:

UKAJIandHMCourtsandTribunalsService.1

The seminar discussion unveiled the complexity of the issues. The tension

betweenimprovingefficiencywithinthementalhealthtribunalsystemwhilealso

maintainingarobustsystemofchecksandbalancestoprotectthevulnerable.Itis

important to have an effective system that works well and produces just

outcomes. At the same time, there are practical limitations, such as limited

resourcesandinformationdeficits.Thisposesarangeofchallengesthatrequire

sometrade-offsandcompromise.

ThereportofferssomereflectionsastowhyuseoftheMentalHealthAct1983is

rising,particularlygiventhepolicyshifttowardsandreinforcementofcommunity

focussedcarefollowingtheMentalHealthAct2007.Thereportalsoconsidersthe

inextricable link between mental health legislation usage and the tribunals

system.Itdrawsuponthesharedlearningfoundwithintheseminardiscussionto

1Thisreportcontainstheauthor’sviewsaloneanddoesnotrepresentthoseofHMCourtsandTribunalsServiceorUKAJI.

5

identify key issues that may be encouraging this trend, while also identifying

aspectsofthesystemthatworkwell.

6

CHAPTER1

INTRODUCTION

Mental illness costs the UK economy £100 billion a year.2 In 2012, HM

Governmentspent£126billiononhealth,3andpledgedtospendafurther£400

milliononpsychologicaltherapiesandmentalhealthcareprovisionforchildren

andyoungpeople.4Mentalhealthneedsremainacuteandhavegarneredfurther

supportandpromiseforsupportintheyearstocome.Followingthe2017Autumn

budget£6.3billionofextraNHSfundingwasannounced,ofwhich£2.8billionwill

bepouredintoday-to-dayhealthservicesand£3.5billioninnewbuildingsand

equipment.5However,giventhedemandsontheNHSandacutesectorsoverall,

concernsremainthattherewillbelittleadditionalmoneyformentalhealthcare.

This funding picture provides an important backdrop for considering how the

mentalhealthlegislationisdeployedwhenrespondingtoseriousmentalhealth

supportneeds.TheMentalHealthAct(MHA)1983providesthelegalframework

which governs decisions made concerning the care and treatment of those

suffering frommental disorder where they may pose a risk to themselves or

others.6 The legislation sets out the circumstances when mental health

professionalscanmakedecisionsaboutdetentionand/ortreatmentwithoutthe

patient’sconsent.

The conflicting perspectives of the patient and the care provider are often the

sourceoftensionandchallengewithinmentalhealthlaw.Ontheonehand,theAct

2S. Johnson, ‘Thecostofmental illness,’TheGuardian,17thMay2016.Seealso,P.McCrone,S.Dhanasiri,A.Patel,M.Knapp,S.Lawton-Smith,PayingthePrice:TheCostofMentalHealthCareinEnglandto2016,London,TheKing’sFund,2008.3HMTreasury,Budget2011,London,TSO,March2011,HC836,chart14 HM Government, No Health Without Mental Health: A Cross-Government Mental HealthOutcomesStrategyforPeopleofAllAges,London:TSO,2011,p3.5 HM Treasury, Autumn Budget 2017 NHS spending. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/661432/NHS_spending.pdf.6 Implementationof theMentalHealthAct1983 issupportedby theMentalHealthActCodeofPractice, London, Department of Health, 2015. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/435512/MHA_Code_of_Practice.PDF

7

seekstoprovideaworkablesystemofchecksandbalancestoensurerobustand

justifiabledecisionsaremade.Ensuringtheinterestsofpatientsarewell-served

isanimportantandfundamentaldriver.Yet,situatedattheheartofthelegislation

isalsotheneedtoprotectothersfrompotentialharm.Gettingthebalanceright

remainsaprimarygoal.Navigatingthroughtheminefieldofconflictinginterests

isdifficult.

GettingthisrighthasbecomeevenmorecrucialsincetheHumanRightsAct1998

whichrequiresUKcompliancewiththeEuropeanConventioninHumanRights.

Articles 3, 5, 6, and 8 play a central rolewithin themental health law sphere.

Article 3 provides the right not to be subjected to torture or to inhuman and

degrading treatment or punishment. Article 5 provides a right to liberty and

securityexceptondefinedanddiscretegrounds.Article6providesarighttoafair

andpublichearingthatisbothtimelyandindependent.Article8providesaright

to respect for private and family life unless interference is justified as a

proportionateresponsetoalegitimatereason.

Detention isallowedunderArticle5ECHRwhenthere isevidenceof ‘unsound

mind’anditisthiswhichhassofarprovidedjustificationforthementalhealth

legislationcurrentlyinplace.AslongasapatientmeetstheWinterwerpcriteria,7

detentionwill be lawful. Thepatientmust reliablybe shown tobeof unsound

mind;thementaldisordermustbeofakindordegreewarrantingconfinement;

and the validity of the confinement depends on the persistence of themental

disorder.Thesecriteriamustbemetineverycase.

Winterwerpalsolaiddownguidanceconcerningthepatient’srighttochallengehis

currentdetention.Theremustbetransparencyandlegalcertainty.Thedetention

criteriamustbe ‘inaccordancewithaprocedureprescribedby law,’ setout in

legislationthatcanthenbescrutinisedincourt.ApatientdetainedundertheMHA

1983 is providedwith this and access to amental health tribunal offering the

7WinterwerpvTheNetherlands[1979]ECHR4.

8

apparatus to review and challenge detention.8 This right to review was first

establishedundertheMHA1959andhassincebeenamendedandrefinedwith

furtheramendmentsintroducedbytheMHA1983andtheMHA2007.

Thementalhealthtribunalhearingseekstoprovideaninformal,inquisitorial,and

supportiveatmosphere.Theyareusuallyheldinprivateatthehospitalwhichis

detaining the patient with an adjudicatory panel of three (presiding lawyer,

medicalandlaymember).Aseparatespaceshouldbeprovidedforapatientto

conferwithherlegalrepresentative.Areviewapplicationtriggersthewritingof

various reports from hospital managers, the Responsible Clinician (RC) the

ApprovedMentalHealthPractitioner(AMHP),relevantnurses,psychologistsetc,

whichareusuallyprovidedtothepatientandthepanel.Patientsareabletoobtain

anindependentmedicalreport.

Access to and timing of a tribunal hearing depends upon the nature of the

detention.9 The detention rates of these different categories will necessarily

impactuponoveralltribunalcaseloadandthelevelofpressureexerteduponthe

tribunalsystem.Patientswhosedetentionissubjecttorestrictionsfaceadifferent

reviewtimeframetothosepatientswhosedetention,whethercivilorcriminal,is

not subject to restrictions. Restrictions refer to s.41 patients; those detained

‘duringherMajesty’spleasure’; thoseacquittedonthegroundsof insanity,and

thosefoundunfittoplead.Onlyoneapplicationtothetribunalcanbemadeduring

‘the relevantperiod’which, for them, isbetween six and twelvemonthsof the

courtdisposalandonceayearthereafter.TheHomeSecretarymustreferacaseif

the patient is a detained patient whose case has not been considered in the

8Section66,MentalHealthAct1983outlineswhenthepatientsorhisnearestrelativemaymakeandapplicationtothementalhealthtribunal.9Apatientcanbesectionedunderseveraldifferentpartsofthelegislationforassessmentortoreceive treatment for a mental disorder. Part II of the Act deals with the civil commitmentprovisions.Thesearethesectionsthatdonotinvolvethecriminallawandincludesection2(forassessment),section3(detentionfortreatment),section4(emergencydetention),and,sections5(2)and5(4)(holdingpowers).PartIIIoftheActdealswiththeforensicsections.Theydealwithpatients who have been involved in criminal proceedings and include section 35 (remand tohospital forreport), section36(remandtohospital for treatment), section37(hospitalorder),section38(interimhospitalorder),section47(transferofsentencedprisonertohospital),section48(removaltohospitalofunsentencedprisoners),section47/49(transferfromprisontohospitalwithrestrictions),section48/49(removaltohospitalofotherprisonerswithrestrictions),section37/41(hospitalorderwithrestriction)andsection41(theconditionallydischargedpatient).

9

previousthreeyears;apatientwhowasunfittopleadanddidnotmakeareferral

in the first 6months; or, a conditionally discharged patientwho is recalled to

hospitalandthecasemustbereferredwithinonemonthofrecall.

Forunrestrictedpatients,onlyoneapplicationcanbemadeduring‘therelevant

period’ which differs depending upon the nature of the patient’s detention or

circumstance giving rise to the application. For section 2, admission for

assessment, the application must be made within 14 days of admission. For

section 3, admission for treatment the application must be made within six

monthsofadmission.Followingrenewalofdetention,applicationstothetribunal

can initially take place within the first six months, then every twelve months

thereafter. Review following transfer from guardianship to hospitalmust take

placewithinsixmonthsandforhospitalorders,reviewapplicationscanbemade

between six and twelve months of order and then every twelve months. The

tribunalsystemisplacedunderparticularstrainasaresultofthetightprocessing

timeforsection2patients.

This report argues that the increased caseloadofmentalhealth tribunals is an

inherentconsequenceofincreaseddetentionundertheMentalHealthAct1983.

Detentionratesunderthementalhealthlegislationhavebeenrisingandthishas

beenaconsistenttrendoverthelastdecade.Thishashadaknock-oneffectupon

tribunalapplications.Tounderstandhowtobestreducethecaseloadofmental

healthtribunals,itisnecessarytodeterminethefactorsthatinfluenceinitialentry

intothesystem.Thereasonsbehindacceleratingformaldetentionratesunderthe

MentalHealthAct1983arecomplex,andoftenmulti-factorial.Eachpatientand

theirneedsareuniqueandtheclinicalandsocialresponsereflectsthis.

Thisreportofferssomereflectionsontheoperationofmentalhealthtribunalsand

the drivers for its increasing caseload. It draws on the shared learning and

experiencesofsomeofthepeopleinvolvedinthecare,treatmentandsupportof

mentally illpeopleand those involveddirectly in the legalprocessdesigned to

supportandprotectthem.

10

CHAPTER2

DETENTIONRATESUNDERTHEMENTALHEALTHACT1983

2.1.Introduction

The number of people detained under the Mental Health Act 1983 is rising

exponentially–atrendthathasbeencontinuingforthelastdecade.Some63,600

peopleweredetainedunder theMHA1983 in2015/16comparedto43,400 in

2005/06-anincreaseof47%.The2015/16detentionfigureisthehighestithas

beensince2005/06when43,361detentionswererecorded.

Fig.1

Source:NHSDigital,InpatientsformallydetainedinhospitalsundertheMentalHealthAct1983andpatientssubjecttoSupervisedCommunityTreatment:2015/16,Annualfigures,November30,2016

Specifically,detentionsunderPartIIoftheMentalHealthAct1983,thatissection

2 admission for assessment and section 3 admission for treatment, have seen

particularrisesfromover28,500in2011/12tonearly39,000in2015/16(nearly

a27%increase).Forsection2detentionsalone,therehasbeenariseofnearly

32%between2011/12and2015/16.

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

2011/12 2012/13 2013/14 2014/15 2015/16

Alldetentions

11

Fig.2

Source:NHSDigital,InpatientsformallydetainedinhospitalsundertheMentalHealthAct1983andpatientssubjecttoSupervisedCommunityTreatment:2015/16,Annualfigures,November30,2016

2.2.Asystemunderstrain?

Theseincreaseshaveoccurredatatimewhenbothmentalhealthandsocialcare

provisioncontinuetoexperiencesignificant financialchallenges.Withausterity

continuingtobite,mentalhealthprovisionhasnotalwaysreceivedtheattention

itdeserveswithphysicalhealthneedsdominatingresourceallocation.However,

mentalhealthconditionsaccountfor23percentofthetotalburdenontheNHS,

butonly13percentofNHSspendingisdirectedtowardspsychiatricandrelated

services. Thisunder-investmentisnotnewanddespitefundsbeingchannelled

throughPrimaryCareTrustsataregionalleveltorecognisedareasofneedprior

totheHealthandSocialCareAct2012andnowthroughClinicalCommissioning

Groups(CCGs)followingthe2012Act,resourceshortfallscontinue.Mentalhealth,

commonlyreferredtoasthe ‘Cinderella’service,hasbeenstrugglingunderthe

weight of systemic neglect for a considerable time. Mental health care must

competewithallotherhealthandsocialcareneeds,ofwhichmostarefarmore

evidentandpositivepost-treatmentoutcomesmoreeasilyquantified.

- 10,00020,00030,00040,00050,000

2011/12 2012/13 2013/14 2014/15 2015/16

DetentionsunderPartIIoftheMentalHealthAct1983

DetentionsunderPartIIoftheMentalHealthAct

Section2

Section3

12

Theneedsassociatedwithmental ill-healthhavebeenexplicitlyrecognised for

some time. In 2011, a new mental health strategy was published,No Health

WithoutMentalHealth:aCross-GovernmentMentalHealthOutcomesStrategyfor

PeopleofAllAges,10followedbyanimplementationframeworkwhichsoughtto

reinforcementalhealthasakeypriority. Thestrategyaimedtoprovidebetter

mental health for all and to increase the likelihood of recovery, while the

implementation framework focused on the provision of strong outcomes

monitoring.IntheHealthandSocialCareAct2012,thesementalhealthobjectives

weremappedontotheNHSrestructuringprocess.The2012Actsoughttodothis

byexplicitlyrecognising thatmental ill-healthshouldbegivenparityalongside

otherphysicalhealthneeds.

Despite these efforts to reinforce theneed to supportmental healthprovision,

mental health continues to experience the effects of low funding and

underinvestment compared to itsphysicalhealth counterparts. Identifying and

understandingthesourceofthisunderinvestmenthasprovendifficult.CCGshave

underinvested in mental health services relative to physical health services.

However, the degree of the disparity has largely been obscured by the way

spendingonmentalhealthconditions isgroupedtogetherandreported,unlike

spend on physical health care, which is disaggregated by specific conditions.

SpendingpercapitaacrossCCGsvariesalmosttwo-foldinrelationtounderlying

need.Thesocialcaresystemisalsoundersustainedandgrowingpressure,with

significantreal-termscutsinspendingresultinginareductioninthenumberof

peopleaccessingpubliclyfundedcare.11

In 2016, the pressure placed upon theNHSwas recognised. The provision of

universal,highqualityhealthcareremainsasteadfastcommitment,butthewayin

which the NHS operates to meet this requires change to accommodate the

modern-daycontext.In2016,NHSEnglandpublishedareport,FiveYearForward

ViewforMentalHealth,whichidentifiedkeyrecommendationstoimproveboth

10HMGovernment,Nohealthwithoutmentalhealth:Across-governmentmentalhealthoutcomesstrategyforpeopleofallage,London,HMGovernment/DepartmentofHealth,February,2011.11TheKing’sFund,Briefing-Mentalhealthunderpressure,London,TheKing’sFund,November2015.

13

the experience of health care and overall outcomes. The report identifies key

changesthatnecessitatearadicalrethinkaroundhealthcareprovision.Notably,a

central aspect of the strategy is the recognition that stepsneed to be taken to

respondtoincreasinginflexibilitywithintheNHS.Thisimpedesthewayinwhich

health careprovision isundertakenand the creationof artificialbarriersoften

stymy effective policy and practical implementation. Successful joint working

betweendifferentfacetsoftheNHShasbeenhindered–ofinteresttothisreport

isthegapbetweenphysicalandmentalhealthhasbecomeossifiedovertime.

Modern day mental health care emphasises the view that more people when

carriedout inthe leastrestrictiveway.12Themoretraditional interpretationof

thisnotionfocusesaroundkeepingpeopleoutofhospitalandinthecommunity

asoftenaspossibleandprovidingthesupportneedsrequired.Inpractice,thishas

notalwaysbeeneasytoachieveintermsofprovidingthelevelsofcommunity-

based support needed. However, understanding that patients are much more

likely to have a better outcome if allowed to stay within a familiar home

environmentwhileaccessingsupportnetworksisuniversallyaccepted.Itisalso

acknowledgedthatwhenpatientsdohavetogotohospital,andrequireformal

detention, the experience is less traumatic andmore likely to have a positive

outcomewhenapatientisdetainedlocally.

Datasuggests thatachieving this is increasinglydifficult.Sendingpeopleoutof

area for acute inpatient care as a result of local bed pressures has become a

spirallingproblemandishavinganegativeimpactuponthewayinwhichmental

healthcareoperatesandhowpatientsexperiencetheircare.13Initsreport,The

Five Year Forward View for Mental Health, the Mental Health Task Force

12 Mental Health Act Code of Practice (p 22): one of the five overarching principles is leastrestrictiveoptionandmaximisingindependence.InessencethismeansthatwhereitispossibletotreatapatientsafelyandlawfullywithoutdetainingthemundertheAct,thepatientshouldnotbedetained. Seealsoat a global level,WorldHealthOrganisation,MentalHealth,HumanRights&Legislation: Denied Citizens, Including the Excluded. Available at:www.who.int/mental_health/policy/legislation/2_HRBasedMHLaws_Infosheet.pdf.Accessed18thApril2011.13See,NHSDigital,OutofAreaPlacementsinMentalHealthServicesDataQualityStatement2017,October2017.

14

recommended round the clock community-based mental health crisis care

available in all areasacrossEnglandandadequately resourced intensivehome

treatmenttoreinforcetheemphasisuponnon-inpatientcarewhenappropriate

andtoreduceincreasingrelianceonoutofareaplacements.14

There are complex underlying reasons behind the increase in detention. The

causesmaydifferfromoneareatoanother.Furthermore,thelegislativelandscape

surroundingtheprovisionofmentalhealthcare,supportforthevulnerableand

theprovisionofcarebothwithinhospitalandinthecommunity,canbefraught

withuncertainty.

2.3.Risinguseofsection2

Anareaforconcernistheincreaseduseofsection2.Thissectionauthorisesthe

compulsory admission of a patient for the purpose of assessing the patient’s

mental condition. Section 2 also allows for medical treatment to follow

assessment. Treatment under this section15 has the same scope as that found

undersection3.However,thepowertodetainistimelimitedforupto28days.

Consequently,section2maybeusedinpracticeasawayofprovidingshort-term

treatment.

Section2requiresadmissionforassessmentmaybemadeinrespectofapatient

onthegroundsthat—

(a)heissufferingfrommentaldisorderofanatureordegreewhichwarrantsthe

detentionofthepatientinahospitalforassessment(orforassessmentfollowed

bymedicaltreatment)foratleastalimitedperiod;and

(b)heoughttobesodetainedintheinterestsofhisownhealthorsafetyorwith

aviewtotheprotectionofotherpersons.

14TheMentalHealthTaskforce,TheFiveYearForwardViewforMentalHealthAreportfromtheindependentMentalHealthTaskforcetotheNHSinEngland,February2016.15 Section 145 MHA 1983 (as amended) states that ‘medical treatment’ includes nursing,[psychologicalinterventionandspecialistmentalhealthhabilitation,rehabilitationandcare).

15

InRv.Wilson,exparteWilliamson,16thecourtemphasisedtheimportanceofusing

theappropriatesectiontodetainapatient.Section2useshouldonlybeforashort

durationandforalimitedpurpose.Itshouldbeusedtoassessapatient’scondition

to determine whether treatment would be effective and whether a section 3

applicationwouldbeanappropriatenextstep;yet,thedatasuggeststhatsection

2isbeingusedwellbeyondthesenarrowremits.

There are several reasons for the increased use of section 2. The provision is

thoughttoassistwithaccesstomentalhealthservices.Theavailabilityofbedshas

decreased and bed shortages are resulting in delayed admission. With bed

occupancyratesininpatientfacilitiesbeingwellaboverecommendedlevels,use

of voluntary admission as a preferred method of entering the mental health

systemisbeinghamperedbyscarceresources.Whereapatientisdeemedinneed

of care in hospital, resort to civil commitment may be the quickest means of

openingupservices.Thebedoccupancydataforallmentalhealthovernightbeds

was largely stable throughout 2017, thoughdemonstrated a significant overall

decline.AcrossEnglandthereiswerejustover18,000bedsavailable.In2015/16

mentalhealthbedsforovernightusewereintheregionof22,500.Thisaccounted

for a 20% drop in available beds between 2015 and 2017. In 2001, 34,214

overnightbedswereavailableforuse.Thisrepresentsa47%reductionofmental

healthbedssince2001.

16[1996]COD42.

16

Fig.3

Source:NHSEngland,AverageDailyAvailableandOccupiedBedsTimeseries2010/11-2017/18,NHSEngland:Unify2datacollection-KH03,November232017.

Mental health inpatient bed occupancy is frequentlywell above recommended

levels.Communitycare facilitiesandservices,particularlycrisis resolutionand

hometreatmentteamsthatoftendealwithacutecareneeds,struggletoprovide

sufficientlevelsofsupporttocompensateforbedscarcity.Thisiscreatingintense

pressureonbothhospitalandcommunityservicesandishavinganegativeimpact

on safety andquality of care.17 Furthermore, the lackof available local beds is

leadingtohighernumbersofout-of-areaplacements for inpatients.Whenbeds

are unavailable locally patients are being transferred to facilities outside their

area.

The Care Quality Commission has highlighted the extent of the problem. In

2012/13over4%ofadultemergencyadmissionswereoutofarea.Insomeareas,

relianceuponoutofareabedsisparticularlywidespreadandhasmeantjourneys

ofmorethan300milesforsomepatients.Movingpatientsoutoftheirareaand

awayfromfamilyandsupportnetworkshasbeenfoundtohaveanegativeimpact

upon the patient’s experience. For patientswith a bed on an acuteward, the

17CareQualityCommission,MonitoringtheMentalHealthActin2015/16,London,CQC,2016.

-

5,000

10,000

15,000

20,000

25,0002010/11

2010/11

2011/12

2011/12

2012/13

2012/13

2013/14

2013/14

2014/15

2014/15

2015

/16

2015

/16

2016

/17

2016

/17

2017

/18

Bedavailability- MentalIllness

MentalIllness

17

environmentmaynot alwaysbe safe or therapeutic, or conducive to recovery.

While for those waiting for a bed because of bed shortages, any lack of early

interventionorcrisiscaresupportmayworsentheirhealthforcingadecisionto

movethemoutofareainordertosecureabed.

Anotherareaofconcernbelievedtobedirectlyimpactinguponformaldetention

ratesistheroleofinequalitiesandcognitivebiasindecisionmaking.Datafrom

2016/17 illustrates that peoplewithin a broad Black ethnic groupweremore

likelytobedetainedundertheMentalHealthAct1983,withthosefromtheBlack

Caribbeangrouphavingthehighestrateofdetentionofallethnicgroups.Workis

currently being undertaken to understand why these differential rates of

detentionaretakingplace.18

Fig.4

Sources:Ratesofdetention (per100,000)under theMentalHealthAct1983byspecificethnicgroup in England 2016/17, Mental Health Services Dataset at:http://content.digital.nhs.uk/mhsds

2.4.Decliningcommunitysupportanditsimpact

18TheMentalHealthAct:independentreviewiscurrentlyunderway,chairedbyProfessorSirSimonWessely,aformerPresidentoftheRoyalCollegeofPsychiatrists,andisduetobereportedonbyautumn2018.OneparticularareaofworkledbytheAfricanandCaribbeanworkinggroupwillexamine the experiences and perspectives of black people in relation to the mental healthlegislation.

18

A further factor thathas influenced the increasinguseof thecivil commitment

proceduresundertheMentalHealthAct1983isthedecline incontactpatients

experience when in the community.19 Evidence supports the view that a key

componentofasuccessfulcommunitycareexperienceisthepresenceofstrong

familyandsocialnetworksfortheindividualconcerned.20Lintern’sworksuggests

thatwithlesssupportinthecommunity,thesafetynettheseservicesprovideis

inadequate to meet needs.21 Keeping patients out of acute crisis becomes

increasinglydifficultandafactorintherisingnumbersofdetentions.Withreal

termcutsinfundingbytheNHSonmentalhealth,accesstocareoutsideofacute

provisionhasbecomemoredifficult.22Forexample,assertiveoutreachprovision

aspart of traditionalCommunityMentalHealthTeamshas suffered significant

fundingcuts.23

Withoutsufficientfundingtosupportcommunity-basedcare,accessingservices

forpatientshasrequiredgreaterrelianceonformalhospitaldetentionprovisions.

However,theinpatientdatasuggeststhatentryintothementalhealthsystemfor

manycontinuestobethroughsection2.Unlessthecriteriaforsection3admission

fortreatmentaremet,mostpatientswillbedischargedwithin28days.Formany

patients,thisbriefwindowoftimeisenoughtostabilisetheirconditionandallow

forcontinuedgoodhealthinthecommunity.

19CareQualityCommission,MonitoringtheMentalHealthActin2015/16,London,CQC,2016.20N. Glover, ‘Mental health andhousing:A crisis on the streets?’ Journal of SocialWelfare andFamilyLaw (1999)21(4),p327-337;P.Allmark,S.Baxter,E.Goyder,L.Guillaume,G.Crofton-Martin,‘Assessingthehealthbenefitsofadviceservices:usingresearchevidenceandlogicmodelmethodstoexplorecomplexpathways,’Health&SocialCareintheCommunity(2013)21;1,pages59-68.21S.Lintern,‘Mentalhealthcharityfundingfallsasdemandgrows,’HealthServiceJournal(2012)31May.22A.McNicoll,‘Mentalhealthtrustfundingdown8%from2010despitecoalition’sdriveforparityof esteem’,Community Care, (2015)March 20; S. Lintern ‘Analysis revealsmental health trustfundingcuts,’HealthServiceJournal(2014)14August.Seealso,CareQualityCommission,Righthererightnow:people’sexperiencesofhelp,careandsupportduringamentalhealthcrisis,London:CareQualityCommission,2015.23TheKing’sFund,Briefing-Mentalhealthunderpressure,London,TheKing’sFund,November2015.Seealso,M.Firn,K.Hindhaugh,D.Hubbeling,G.Davies,B.Jones,S.WhiteSJ‘Adismantlingstudyofassertiveoutreachservices:comparingactivityandoutcomesfollowingreplacementwiththeFACTmodel,’SocialPsychiatryandPsychiatricEpidemiology(2013)48,pp997–1003.

19

However, for others, as the Care Quality Commission suggest in its report -

Monitoring theMentalHealth Act in 2015/16,24 increasing detention ratesmay

have been affected by the rise of revolving door patient numbers. These are

patientswhooftenexperiencerepeatedinvoluntarilyhospitalisations.However,

trying todetermine theextent towhich inpatientdata includes revolvingdoor

patientsisdifficult.Thedataisnotsufficientlynuanced;itdoesnotdemarcatethe

natureoftheadmission,pastpsychiatrichistoryandcommunitycareexperience.

Constructinganaccurate representationofpatients entering thementalhealth

systemundertheMentalHealthAct1983isthereforeproblematic.

Revolvingdoorpatientshavebeenanongoingproblem.CommunityTreatment

Orders(CTOs),introducedundertheMentalHealthAct2007,wereanattemptto

respondtothechallengespresentedbythispatientpopulation.However,further

questions have been raised about the potential correlation between rising

detention rates and the introduction of CTOs. Whether Parliament should

introducearegimeofsupervisedcommunitytreatmentinEnglandandWaleswas

along-standingquestion,whichbeganwiththedecisioninRvHallstrom,expW.25

TheCTO(alsoknownas‘SupervisedCommunityTreatment’,orSCT)26authorises

community-basedsupervisionofcompulsorypatients following theirdischarge

fromhospital.27ApatientdischargedontoaCTOmustcomplywiththeconditions

oftheorderorfacerecalltohospital.28

ArgumentsagainstCTOshavelargelycentredoncivilliberties,publicprotection

andtheprofessionallegitimacyofcareandtreatmentproviders.29Itappearsthat

aslongas‘thepracticeisproperlyregulated,itscriteria,procedures,andpowers

are clearly specified by law, it makes proper use of medical expertise, and it

24CareQualityCommission,MonitoringtheMentalHealthActin2015/16,London,CQC,2016.25[1985]3AllER775.26Communitytreatmentprovisionunderthe2007Act isreferredtoas ‘supervisedcommunitytreatment’ but the 2007 Act refers to the legalmechanism giving effect to it as a ‘communitytreatmentorder’.27Section17A-17G,MentalHealthAct1983.28Section17B(3)(a),MentalHealthAct1983.29 See, e.g., S. Ridgeley, et al, International Experiences of Using Community Treatment Orders,InstituteofPsychiatry,2007;J.Dawson,CommunityTreatmentOrders:InternationalComparisons,Dunedin:OtagoUniversityPrint,2005.

20

applies inaproportionatemanner’30 supervisedcommunity treatmentwillnot

violateapatient’shumanrights.31Thestrongestargumentinfavourofsupervised

communitytreatmentholdsthatitservesasamechanismforacontinuoussystem

ofcareallowingeffectivetransitionbetweenhospitalandcommunitycare.32This

framework for long-term community carewas thought to reinforce rights and

responsibilities33forbothusersandprovidersofthisservice.34

Despite the anticipated benefits associated with CTOs, evidence suggests that

these have yet tomaterialise. The result of theOxfordCommunityTreatment

OrderEvaluationTrial(OCTET),35undertakenin2012suggeststhatCTOshave

not reduced the rate of readmission to hospital as compared with the use of

section17leave.36In2011/12,therewere4,220CTOsinoperation.By2015/16

thiswas4,361.37TheearlyexpectationwasthatCTOusewouldgraduallyincrease

over time assuming that these community-based provisions would enable a

formalshiftawayfromin-patientmentalhealthcare.Theimpactassessmentfor

theMentalHealthAct2007projectedNHSsavingsofapproximately£34million

peryearby2014-15assumingthat10%ofsection3admissionswouldinsteadbe

placed under supervised community treatment. The data tells us that the

30 J. Dawson, 'Supervised Community TreatmentOrders’, in J.McHale, et al, (eds)Principles ofMentalHealthLawandPolicy,Oxford,OUP,2010.31 L v Sweden (App No 1080/84), unreported; Johnson v UK (1997) 27 EHRR 296. See also, PBartlett,etal,MentalDisabilityandtheEuropeanConventiononHumanRights,MartinusNijhoff,2007andG.Richardson,‘CoercionandHumanRights:aEuropeanPerspective’(2008)17JournalofMentalHealth245.32See,KvCraig[1998]UKHL54,whichdiscussedthebenefitsthatcanflowfromacommunity-basedprogrammeofcare.Thiscaseconsideredtheseissues inrelationtotheearliersystemofsuperviseddischargewhichwasintroducedbytheMentalHealth(PatientsintheCommunity)Act1995.Thisregimehassincebeenrepealed.33See,e.g.,S.Romans,etal,‘HowMentalHealthCliniciansViewCommunityTreatmentOrders:aNationalNewZealandSurvey’(2004)38ANZJPsychiatry836.34J.Swanson,etal,‘InterpretingtheEffectivenessofOutpatientCommitment:aConceptualModel’(1997)25JournalofAmericanAcPsychiatryandLaw5.35T.Burns,J,Rugkasa,A.Molodynshi,‘TheOxfordCommunityTreatmentOrderEvaluationTrial(OCTET)’,RoyalCollegeofPsychiatrists(2008)32(10),p400.Seealso,J.Rugkåsa,A.Molodynski,K.Yeeles,M.VazquezMontes,C.Visser,‘Communitytreatmentorders:clinicalandsocialoutcomes,andasubgroupanalysis fromtheOCTETRCT’,ActaPsychiatricaScandinavica (2015)131(5)p321–329.36Section17,MentalHealthAct1983providesforleaveofabsencefromhospitalforpatientswhoarecurrentlyliabletobedetainedinahospital.37 Full datasets for community treatment order usage can be found at:https://www.digital.nhs.uk/search?q=community+treatment+order&s=s

21

expectation around patterns of decision making behaviour have not changed

radicallywithdetentionfigurescontinuingtorise.

2.5.TheCheshireWesteffect(andothercases…)

TheSupremeCourtinPvCheshireWestandChesterCouncil;P&QvSurreyCounty

Council [2014] UKSC 19 (‘Cheshire West’) clarified an ‘acid test’ for what

constitutes a ‘deprivationof liberty.’Theoutcomeof this casehas significantly

loweredthethresholdfortheengagementofArticle5ECHR.Theacidteststates

thatanindividualisdeprivedoftheirlibertyforthepurposesofArticle5ECHRif

they:lackthecapacitytoconsenttotheircare/treatmentarrangements;areunder

continuoussupervisionandcontrol;andarenotfreetoleave.Allthreeelements

mustbepresentfortheacidtesttobemet.38

This case raised several fundamentalquestionsaround the conceptofphysical

libertyandwhatisneededtobothprotectthisandensuredetentionislegitimate.

A vital question addressed by the cases was whether the concept of physical

libertyprotectedbyarticle5isthesameforeveryone,regardlessofwhetheror

nottheyarementallyorphysicallyimpaired.Linkedtothiswasasecondquestion,

around what the essence of deprivation of liberty was, and what could be

permissible and non-permissible deprivations of liberty under article 5. In

determiningwhethertheacidtestwasmet,thecourtheldthatitwasirrelevantif

thepersonconcernedcompliedorsimplydidnotobject.Furthermore,therelative

normalityoftheplacementwasirrelevantaswasthereasonorpurposebehinda

particularplacement.Keytothispolicydrivendecisionwastherecognitionthat

thepositionofextremelyvulnerablepeopleneedstobesubjecttoindependent

periodicchecks.

TherulinginCheshireWesthadsignificantpracticalimplications.Datapublished

by the Health and Social Care Information Centre (HSCIC) confirmed that,

following theSupremeCourt judgment, in the firstyear,DeprivationofLiberty

38TheCourtofProtectionhasheldthattheacidtestalsoappliesinacutenon-psychiatrichospitalsettings.See,HSTrust&OrsvFG[2014]EWCOP30.

22

orders(DoLS)applicationsroseapproximatelyten-fold.In2013/14therewere

approximately 13,700 applications. In 2014/15 there were 137,540. Of these,

62,645applicationswerecompletedbylocalauthoritiesduringtheyear,almost

fivetimesasmanyasin2013-14.39

Theimmediateincreaseinapplicationshadanumberofrepercussions.Theextra

activityforhealthandcareproviderswassignificant:increasesinthenumberof

DoLS authorisations prepared and submitted, higher Court of Protection

applicationsandlocalauthorityteamswererequiredtorespondtomorerequests

to assess authorisations and where appropriate, authorise any deprivation of

liberty.Thesignificantincreaseinrequestsforauthorisations,resultedinmany

localauthoritiesleftstrugglingtoprocessthesewithinthelegaltimelimit.

Formentalhealthpatients,therepercussionsofCheshireWesthavealsobeenfelt.

Thebroader impactof thedecisionhasreinforcedacautionaryapproachtobe

adoptedbyclinicians.Section131MHAallowstheinformaltreatmentofpatients

withtheirconsent.40Lookingatthedataaroundinformalpatientnumbers,astark

shift is evident following the Cheshire West decision. The number of informal

patients in psychiatric facilities reducedwhile formal detentions increased. In

2008/09,therewere75,843informalpatients,whiletherewere30,913formally

detained patients. By 2014/15, the balance between these two categories of

patienthadshiftedconsiderably,with51,196informalpatientsand54,225formal

patients.41Thissuggeststhatpost-CheshireWesthealthandsocialcareproviders

anddecision-makersmaybemuchmoresensitivenowtotheriskofunauthorised

deprivation of liberties and this has consequently had a knock-on effect upon

formaldetentionrates.

Theimpactof‘risk’asamorenebulousconstructhasalsobeenfeltinrecentyears

inthementalhealthcarefield.42Historically,riskhasalwaysfeaturedprominently

39Forthefullstatistics,see,https://digital.nhs.uk/catalogue/PUB17509.40BUTdoesnotallowdeprivationofliberty-HLvUK45508/99.41MentalHealthMinimumDataSet/MentalHealthandLearningDisabilitiesDatasetandHospitalEpisodeStatistics,NHSDigital;OfficeforNationalStatistics.42Forawiderdiscussiononhowriskisusedtodefineandregulateactivityinseveralareas,seeC.Hood,etal,TheGovernmentofRiskUnderstandingRiskRegulationRegimes,Oxford,OUP,2001.

23

inmentalhealthcare.43 FollowingtheMentalHealthAct2007,riskassessment

and management have become the explicit concerns of the civil commitment

process.Itreflectedpolicy-makersconcernsthat‘thesafetyofboththeindividual

patient and the public are of key importance in determining the question of

whethercompulsorypowersshouldbeimposed’andthatthiswasnotsufficiently

thefocusofthementalhealthlegislationpriortothe2007Actamendments.For

thatreason,‘concernsofrisk[begantotake]...precedence’.44

Mental health decision-makers must seek to achieve a balance between their

patients’personal freedomsandthepublic’ssafety.Riskprovidesamechanism

(albeitaproblematicone)withwhichdecision-makersmayachievethisbalance,

by deploying the compulsory powers under the Mental Health Act where a

patient’s level of risk becomes so great that he/she poses a threat to either

him/herselforothers.Thestandardswhichthecompulsorycriteriarequireare

ambiguous.Decision-makersenjoyawidediscretiontointerpretrelevantfactors

accordingtotheirprofessionaljudgment.Sections2(2)(b)and3(2)(b)presume

thatdecision-makerswillassessapatient’s levelof risk.Risk isanopen-ended

construct for decision-makers to assess and interpret according to their

professionaljudgmentandexperience.45

Rose argues that the language of risk seems ‘all-pervasive’ in contemporary

mental health practice.46 This is unsurprising: risk determines the nature,

durationandextentofapatient’sengagementwiththementalhealthservices.47

Similarly, apatient’s riskprofiledetermines thenature,durationandextentof

his/hersupervisioninthecommunity.48Yetmentalhealthdecision-makinghas

43Laing,J.M.‘RightsversusRisk?ReformoftheMentalHealthAct1983’MedicalLawReview(2000)8(2),p210–250.44HMGovernment,ReformingtheMentalHealthAct:PartI:TheNewLegalFramework,London:theStationeryOffice,December2000,Cm5016-I,para2.16.45N.Glover-Thomas, ‘TheAgeofRisk:RiskPerceptionandDeterminationfollowingtheMentalHealthAct2007’,MedicalLawReview(2011)19(4)p581-605.46 N. Rose, ‘Governing Risky Individuals: The Role of Psychiatry in New Regimes of Control’,Psychiatry,PsychologyandLaw(1998)5(2)177-195,p177.47See, e.g.,1983Act (asamendedby the2007Act), sections20(durationofauthority)and23(dischargeofpatients).48See1983Act,sections17A-17G(insertedbythe2007Act).

24

always entailed an element of risk assessment.49 Successive legislative

frameworkshavereflectedthispracticalreality,albeitinafairlyobliquemanner.

Consequently, a patient’s risk either to him/herself or others always plays a

significant part in the decision to engage the civil commitment procedures.50

Whilesoftlaw,suchastheCodeofPracticeandgenericNHSTrustClinicalRisk

AssessmentTools,51providesomeguidance,whatconstitutesarisktoapatient’s

healthorsafetyortoothersisamatterfordecision-makersalone.Howreliable,

valid andprofessionally rigorous risk assessments remainsopen toquestion.52

Bartlettcontendsthatsomedecision-makersmayfindthemselvesoperatingina

systemdrivenbypersonalexperiencewithafairlyadhocsystemofinterviewing

anddetermination.53

Therefore, concerns around risk in terms of understanding what it is, how to

assess it and manage it accurately and effectively remain a central feature of

mentalhealthcarepractice.Behaviouralresponsestothishavealsobeenshaped

byexternalinfluences,ofwhichtheCheshireWestcaseisone.Twofurthercases

involvingtheassessmentofsuicideriskhavealsohadanimpactuponriskandits

management regarding clinical decision-making. In Savage v. South Essex

Partnership NHS Foundation Trust54 failures to take reasonable precautions to

protect the lives of patientswith suicidal thoughtswas found to have violated

Article2ECHR.55InRabonev.PennineCareNHSFoundationTrust56theCourtheld

49Casteldefinesriskmanagementas‘theidentification,assessment,eliminationorreductionofthepossibilityofincurringmisfortuneorloss’.Inhisview,riskhas‘becomeanintegralpartoftheprofessional responsibility of all those involved with psychiatry’. See, R. Castel, ‘FromDangerousness to Risk’, in G. Burchell, et al, The Foucault Effect: Studies in Governmentality,HarvesterWheatsheaf,1991.50MentalHealthActCodeofPractice,paras4.6,4.7.51MerseyCareNHSTrust,OrganisationPortfolio:ClinicalRiskAssessmentTools,March2009.52MGrannetal,PsychiatricRiskAssessmentMethods:AreViolentActsPredictable?ASystematicReview(SummaryandConclusions)2005;SBUReportNo175.Thissuggeststhattheinaccuracyofpsychiatricassessmentmethodsisintherangeof25to30percent.53P.Bartlett,‘CivilConfinement’inJ.McHale,etal,(eds)PrinciplesofMentalHealthLaw,Oxford:OUP, 2010. See also, J. Langan and V. Lindow, Living with Risk: Mental Health Service-userInvolvementinRiskAssessmentandManagement,2004,p11.54SavagevSouthEssexPartnershipNHSFoundationTrust[2008]UKHL74.55Thestatehasaresponsibilitytoprotectanindividual'srighttolifeandthelawreflectssuchaposition.Article2oftheEuropeanConventiononHumanRights,statesthat,“everyone'srighttolifeshallbeprotectedbylaw”.56Rabonev.PennineCareNHSFoundationTrust[2012]UKSC2.

25

thattheoperationalduty57toprotectlifecouldbeowedtoinformalpsychiatric

patientsaswellasformallydetainedpatientsundertheMentalHealthAct198358

as long as therehasbeen ‘an assumptionof responsibilityby the State for the

individual's welfare and safety (including by the exercise of control)’.59 The

EuropeanCourtalsoagreedthatthedutycouldbeowedtoaninformalpatient.60

Thepractical impactof thesecases isnoteworthy.Healthservicesmustensure

highprofessionalstandardsaremetandeffectivesystemsofworkareinplace.61

Therecognitionoftheoperationaldutytoprotectthelifeofaspecificindividual

incasesofsuicideriskwhereitisknownorshouldhavebeenknownthatthere

wasa‘realandimmediateriskofsuicide’62hasreinforcedtheobligationplaced

uponhealth care professionals. Given the acknowledgeddifficulty surrounding

accurateriskassessment,63anissuethatwashighlightedinRabone,bothSavage

and Rabone present significant implications for public bodies who assume

responsibilityofvulnerablepeople.

TheeffectofCheshireWest,SavageandRabonehasledtogreatersensitivitytorisk

andthepotentialrepercussionsshouldsomethinggowrong.Whenthereisdoubt

oruncertainty,itisnowmorelikelythecivilcommitmentprovisionsintheMental

HealthAct1983willbeseenasthebestoptionanduseofinformalhospitalisation

willbelessattractive.

2.6.Theriseinsection136use

57SeeLCBvUnitedKingdom[1998]ECHR108;OsmanvUnitedKingdom(1998)29EHRR245.58N.Allen,‘Therighttolifeinasuicidalstate’,InternationalJournalofLawandPsychiatry(2013)36(5-6),p350-357.59Rabonev.PennineCareNHSFoundationTrust[2012]UKSC2,atp22.60Reynoldsv.UnitedKingdom(2012)55EHRR35.61PowellVUnitedKingdom(2000)30EHRRCD362.62KeenanvUnitedKingdom(2001)(Applicationno.27229/95).Itshouldbenotedthatariskofharm,evenseriousharmwouldbeinsufficient.Fortherisktoberealitmustbeobjectivelyverified,andforittobeimmediate,itmustbepresentandcontinuing(Re:OfficerL[2007]UKHL36).63 K. Heilbrun, ‘Prediction Versus Management Models Relevant to Risk Assessment: TheImportanceofLegalDecision-MakingContext’(1997)21(4)LawandHumanBehavior347-359.See also, Regulation and Quality Improvement Authority, Review of the implementation ofpromotingqualitycare(PQC)goodpracticeguidanceontheassessmentandmanagementofriskinmentalhealthandlearningdisabilityservices(May2010):overviewreport,Belfast,RegulationandQualityImprovementAuthority,2012.

26

PoliceinEnglandandWalesareprovidedundersection136oftheMentalHealth

Act1983withpowerstoremoveapersontoaplaceofsafetyortokeepaperson

inanexistingplaceofsafetywhereitisbelievedthepersonneedstobeexamined

by a doctor and interviewed by an AMHP. Police are required to make an

assessmentofindividualsfoundinapublicplacewhoappeartobesufferingfrom

symptoms ofmental illness. The purpose of any section 136 assessment is to

determinewhetherapersonoughttobedetainedinhospitalundertheMental

HealthAct.64

AlthoughthereisapresumptionthatresorttotheMentalHealthActshouldbea

lastresort,ashiftintheuseofsection136bythepoliceisapparent.

Fig.5

Source:NHSDigital,InpatientsformallydetainedinhospitalsundertheMentalHealthAct1983andpatientssubjecttoSupervisedCommunityTreatment:2015/16,Annualfigures,November30,2016.

64Following therecentchanges tosection136MHA1983by thePolicingandCrimeAct2017,policepowerswillextendbeyondthepublicplaceandcannowbeusedanywherethatisnotthatperson’sprivatehome.Therequirementofbeingfoundhasbeenremoved,sosomeonemaybekeptatapolicestationpotentiallywheretheyarenolongerliabletobedetainedunderthePoliceandCriminalEvidenceAct1984.Aregisteredmedicalpractitioner,registerednurseorapprovedmentalhealthprofessionalmustbeconsultedwith,ifpracticablebeforeremovingsomeonetoorkeepingthemataplaceofsafetyunderthissection.Thesechangesprovidefurtheropportunitiesforsection136tobeused.

0

5,000

10,000

15,000

20,000

25,000

2011/12 2012/13 2013/14 2014/15 2015/16

Allproviders

Section136rates

Section136

27

Morenotably,theshiftinsection136reliancehasimpactedonconversionrates.

With the presumption that section 136 should only ever be used if no other

avenueswereavailable,conversionratesfromsection136tosection2andsection

3werehigh.Sincetheearly2000s,conversionrateswereintheregionof85%

suggesting that thepolicewereprimarilyputtingpeopleona section136who

warrantedinformaladmissiontohospital.Thosetakenoutofapublicplacebythe

policewerehighly likely toneedmentalhealthsupport.However, theCheshire

Westdecisiondiscourageduseoftheinformalpatientstatusundersection131.

Theincreasinglyheavyuseofsection136islikelytohaveanimpactonsection2

and3 figures. Since2014, conversion rates fromsection136 toboth section2

(29%increasesince2014)andsection3(32%increasesince2014)haverisen.

However, drawing a firm conclusion that theCheshireWest decisionhashad a

marked and direct effect on conversion rates is difficult given the presence of

multi-factorialdrivers,thoughithascertainlyplayedasignificantrole.

Fig.6

Source:NHSDigital,InpatientsformallydetainedinhospitalsundertheMentalHealthAct1983andpatientssubjecttoSupervisedCommunityTreatment:2015/16,Annualfigures,November30,2016.

Thisdatasuggestsanumberofthings.First,theuseofsection136hasgoneupas

hastheconversionratefromsection136tosections2and3.Therefore,thereisa

directbearinguponoveralldetentionfiguresandconsequentlytribunalreceipts.

Second, evidence suggest that revolving door patients are being identified by

2,142 2,1352,587

2,882

3,660

440 291 295 303 439- 500

1,0001,5002,0002,5003,0003,5004,000

2011/12 2012/13 2013/14 2014/15 2015/16

Allproviders

Conversionratesfromsection136- tosections2and3

136to2 136to3

28

policeandsection136isbeingused.Third,theCareQualityCommission’sconcern

that community-based services are becoming increasingly fragmented65 with

more gaps forming in service provisionmay be requiring greater input by the

police. Finally,concernsaroundpatientseithernotbeingabletoaccessmental

health services when they need it or being discharged too quickly because of

overstretchedacutecareservices,maybeleadingtomorevulnerablepeopleon

the streets which the police are having to identify and support.66 This data

providesausefulinsightintothefragilenatureofthecontemporarymentalhealth

systemandimpactofthisonmentalhealthtribunalactivity.

2.7.Candetentionratesbereduced?

Severalthingsmightrelievesomeofthepressureonthesystem.Reducingreliance

onsection2wouldsignificantlyfreeupthementalhealthcaresystemandcreate

space in thecorrespondingreviewprocess.Asdiscussedabove, several factors

influencetheheavyuseofsection2.Someofthesefactors,suchastherisinguse

ofsection136,havearisenbecauseofbroaderpolicyandfundingchangestothe

mentalhealthsystemandsoarenoteasilyfixed.Ensuringthatsection2isused

onlyformentalhealthassessmentpurposeswouldreducetheavailabilityofthe

section foraconsiderablenumberofpatients.StrengtheningtheMentalHealth

Act Code of Practice might be an initial way forward. Likewise, the practical

demandsplacedonclinicianswishingtodetainapatientundersection3could

alsobemodified toenableaccess tocarevia section3possible.Currently, it is

necessarytoidentifyinpatientfacilitiesforpatientstobedetainedundersection

3.Giventightbudgetsandfluidresources,itisnotalwayspossibletodothis.

Cliniciansoftendetain individualsundersection2 toallowbreathingspace for

inpatientbedstothenbesourced.Theimpactofthisistwofold.Patientsarenot

placedon theappropriate carepathway that their conditiondemands, and the

deployment of section 2 instead of section 3 instigates two review processes

65CareQualityCommission,Righthererightnow:people’sexperiencesofhelp, careandsupportduringamentalhealthcrisis,London,CQC,June2015,p77.66RDBorschmann.SGillard,KTurner,MChambers,AO’Brien‘Section136oftheMentalHealthAct:anewliteraturereview’,MedSciLaw2010;50:34–39.

29

insteadofone.Thetribunalsystemistakenupbypatientsthatwouldhavebeen

betterservedbyappropriatesectioninginthefirstinstance.However,problems

aroundresourcesrequiremorethanonestepsystemfixes.

Whilegaps remainelsewhere in thementalhealthandsocial care system, it is

unlikelythatamoreliteral interpretationofsection2admissioncriteriawould

necessarilyhelp.Thosenotadmittedundersection2(astheydonotjustrequire

assessment)butforwhomservicesarenotavailableforthemundersection3,may

simplyfindthemselvespickedupelsewhereinthesystem,suchasundersection

136.Better communication, local joint protocols and jointworking in termsof

procurement anddeliverybetweendifferent agencies and stakeholderswould,

however,bebeneficial.67

The seminar revealed the complexity of the issues and the constraints facing

clinicaldecisionmakersindeterminingthebestcourseofactionfortheirpatients.

Atthesametime,italsouncoveredsomeofthesystemicdifficultiesintermsof

meetingthechallengeofmentalhealthwithlimitedresources.

67N.Glover-Thomas,W.Barr,‘Re-examiningtheBenefitsofCharitableInvolvementinHousingtheMentallyVulnerable’,NorthernIrelandLegalQuarterly(2008)59,2,p.177-200.

30

CHAPTER3

MENTALHEALTHTRIBUNALCASELOADS

3.1.Risingcaseloads

TheupsurgeininpatientdetentionundertheMentalHealthAct1983,hasclear

and direct implications for tribunal caseloads. Between 2007/8 and 2016/17,

tribunalreceiptsincreasedfromnearly22,000toover33,000receipts–ariseof

over33%.

Fig.7

Source:Datatakenfrom:MinistryofJustice,Tribunalsandgenderrecognitioncertificatestatisticsquarterly–JulytoSeptember2017,London,MinistryofJustice,2017.

Section2caseshaveincreasedbyaround32%,thoughthisalsoreflectstherising

volume of section 2 detentions (a rise of nearly 32% between 2011/12 and

2015/16).68LookingatdatapublishedbytheCareQualityCommission,section

2 related tribunal activity increased overall between 2014/15 and 2015/16.

Section2applications increased from9,729 in2014/15 to10,093 in2015/16,

68ForadetailedbreakdownofactivityintheFirst-tierTribunal(MentalHealth),see,CareQualityCommission,CareQualityCommission,MonitoringtheMentalHealthActin2015/16,London,CQC,2016,p51.

05,00010,00015,00020,00025,00030,00035,00040,000

2007/08 2009/10 2011/12 2013/14 2015/16 Year

TribunalReceiptsandDisposals

Receipts Disposals Section2detentions Section3detentions

31

while hearings increased by over 7%. Section 2 dischargesmade by tribunals

droppedbyapproximately1.5%overthesameperiod.69

Increased tribunalworkloadspresentsignificantpractical challenges.Section2

reviewapplications,inparticular,haveraisedspecificproblems.Hearingsmustbe

listedwithin7daysofapplication,andundertakenwithin14daysofthedateof

admission.Withthepressureontimeandmountingdemandstomakeeffective

and efficient decisions, the increasing number of section 2 applications have

meant thatmentalhealth tribunalshavehad tomanage thiswhilemaintaining

standards. Ensuring effective decision-making may be affected by the level of

information, data and supporting documentation available at the hearing. The

short timeframe to prepare a casemay result in the quality and depth of the

accompanying responsible authority reports being compromised.70 Theremay

have been insufficient time for the clinical team to be in a position where a

judgement can be made about the patient’s current mental state. Treatment

optionsmaynothavehadenoughtimetoprovideanindicativepictureofpotential

success.Formanycases,writingareportaboutapatient forwhomtheclinical

teamstillknowslittlewillbedifficult.Addedtothisistheoften-chronicdemands

for reports to be produced quickly and at short notice. With insufficient

information, projected treatment outcomes unknown and little time for the

patient to settle, both the clinical team and tribunal panel are faced with a

decision-making situation that is fraught with difficulty and necessarily

encouragesacautiousapproach.Forthetribunalsystem,increasedcaseloadsalso

meanmorejudicialsittingsandincreaseddemandonlimitedjudicialresources.

The increased use of detention powers by hospitals and increased tribunal

caseloadshasdownstreamcostimplicationsespeciallyfortheMinistryofJustice.

69SeeCareQualityCommission,MonitoringtheMentalHealthActin2015/16,London,CQC,2016,p51andcomparewithCareQualityCommission,MonitoringtheMentalHealthAct in2014/15,London,CQC,2015,p68.70See,PracticeDirectionFirst-TierTribunalHealthEducationandSocialCareChamberStatementsandReportsinMentalHealthCases,October2013.Thisprovidesdetailsabouttherequiredcontentof reports required for mental health cases. Available at:https://www.judiciary.gov.uk/publications/practice-direction-first-tier-tribunal-health-education-and-social-care-chamber-statements-and-reports-in-mental-health-cases/

32

Normally, onewould expect that an increased caseloadwould result in delays

beforetribunals.Thishasnotoccurredinthecontextofmentalhealthtribunals.

The timeliness of cases has remained relatively static and has shown

improvementduringtheperiodinwhichcaseloadshaveincreased.In2013,the

averagetimelinessofcaseswasasfollows:1weekforsection2cases;13weeks

for restricted patients; and 8weeks for non-restricted patients.71 In 2017, the

average timeliness was: 1 week for section 2 cases; 12 weeks for restricted

patients;and6weeksfornon-restrictedpatients.72

Whathaschangedhasbeenincreasedjudicialsittingstocopewiththecaseload.

Asfigure8belowshows,thenumberofjudicialsittingsinmentalhealthtribunals

increased from 41,500 sittings in 2010/11 to 50,953 sittings in 2015/16. The

increaseinjudicialsittingshasbeennecessarytoensurethatcasesareheardand

decidedinatimelyway.Oneconsequenceofincreasedjudicialsittingsisthatthe

Ministryof Justice,as theresponsiblegovernmentdepartment,willhaveborne

theadditional costsof such sittings.Accordingly, theMinistryof Justicehasan

interestinreducingdemandintothetribunalsystem.

Fig.8

Source:MinistryofJustice,TribunalStatisticsQuarterlyJune2017

71July2013TribunalStatisticsQuarterly.72July2017TribunalStatisticsQuarterly.

40,000

42,000

44,000

46,000

48,000

50,000

52,000

Total Total Total Total Total Total Totalr Total

2009/10r2010/11r2011/122012/132013/142014/152015/16 2016/17

Judicialsittings

Year

Judicialsittingsinmentalhealthtribunals

33

3.2.Thepatientvoice

Arelatedchallengeconcernstheneedtoensurethatpatientscanhavetheirvoice

heard.Oneofthekeyvaluesthatinformstheworkoftribunalsistheuseoffair

procedures by which affected people can participate in decision-making.

Achievingthisinpracticeinthementalhealthcontextposesvariousdifficulties.

Nonetheless,despitethepracticalconstraintsmentalhealthtribunalssometimes

face,a2011reportbytheCareQualityCommission,Patients'experiencesofthe

First-tierTribunal(MentalHealth),73suggeststhatthetribunalprocessprovides

patientswithanumberofhelpfulopportunities.Importantly,patientscanhave

theirvoiceheard.Suchanobservationcanbeinterpretedinanumberofways.

Thepositivesarethatthehearingprovidesanopportunityforthepatient’scase

tobereviewedandforthemtospeakabouttheirexperiences.Ontheotherhand,

thementalhealthcaresystemshouldbeabletoofferapatientavoicethroughout

the experience. Patient collaboration is recognised as offering the most

therapeuticapproachtocareinmostclinicalsettings;betterpatientengagement

isachievedthroughpartnershipandthisrequirespatientstobefullyinvolvedin

theprocess.74Formanypatients,dischargefromhospitalmaynotbethegoal,but

atribunalhearingprovidesaforumtoscrutinisethepatient’sprogress,consider

nextstepsandevaluatethepatient’scontinuingneeds.Importantly,thetribunal

hearingactsasaprotectivemechanismtosafeguardthepatient.

3.3.Theroleofindependentmentalhealthadvocacy

Following the introduction of Independent Mental Health Advocates (IMHAs)

under the Mental Health Act 2007, access to some form of independent legal

support and representation has been strong. The Care Quality Commission

observed that most detained patients knew that they were entitled to legal

support both in terms of providing legal advice and representing themduring

73CareQualityCommission,Patients'experiencesoftheFirst-tierTribunal(MentalHealth)Reportof a joint pilot project of the Administrative Justice and Tribunals Council and the Care QualityCommission,London,CQC,March2011.74A.Coulter,J.Ellins,‘Effectivenessofstrategiesforinforming,educating,andinvolvingpatients’,BMJ(2007)335(7609),p24–27.,

34

tribunal hearings.75 However, easily accessing support and high quality legal

provisionmaynotnecessarilybeauniversalexperiencebypatients,wheremany

relyonhospitalreferralsforlawyers.76Thereiscurrentlynoresearchonthisand

it is an areawhich should be examinedmore closely. IMHAs, however, offer a

valuablebridgebetweenthepatient,lawyersandtheclinicalenvironment.77The

lack of information regarding a patient’s detention status, their rights and the

tribunalprocesshaspreviouslybeenrecognisedasamajorconcern.78Theuseof

independent advocacy may offer an effective response to this by increasing

patient self-determination79 and providing a mechanism to support patients

present amoreholistic picture of their current state of health,80 though again,

mapping IMHA presence nationally would be a valuable step. The role of an

advocateistoactasaconduitforpatientstoenablethemtopromotetheirown

voices,81expresstheirwishesandtofacilitateparticipation.82However,despite

the valuable contributions made by IMHAs, practical limitations remain.83

Difficultieswithfundingcontinuityexperiencedbymanydifferentorganisations

providing independent advocacy services prevent individual advocates from

buildinguprapportwithpatientsoverthelongerterm.Thebenefitsofadvocacy

requiresufficienttimeandcertaintytoenabletrustandconfidencetoflourish.

75CareQualityCommission,Patients'experiencesoftheFirst-tierTribunal(MentalHealth)Reportof a joint pilot project of the Administrative Justice and Tribunals Council and the Care QualityCommission,London,CQC,March2011.76WHOAdvocacyforMentalHealthGeneva,WorldHealthOrganization,2003.77K.Newbigging,J.Ridley,M.McKeown,KMachinK.Poursanidou,‘Whenyouhaven'tgotmuchofavoice’:anevaluationofthequalityofIndependentMentalHealthAdvocate(IMHA)servicesinEngland’,HealthandSocialCareintheCommunity(2015)23(3),p313–324.78CareQualityCommission,Patients'experiencesoftheFirst-tierTribunal(MentalHealth)Reportof a joint pilot project of the Administrative Justice and Tribunals Council and the Care QualityCommission,London,CQC,March2011.79S.Eades‘ImpactevaluationofanIndependentMentalHealthAdvocacy(IMHA)serviceinahighsecure hospital: a co-produced survey measuring self-reported changes to patient self-determination,’MentalHealthandSocialInclusion(2018)22(1)p53-60,80 I. Freckleton, ‘MentalHealthReviewTribunalDecision-making:ATherapeutic JurisprudenceLens’,Psychiatry,PsychologyandLaw(2003)10(1),p44-62.81 J.Ridley,K.Newbigging,M.McKeown, J. Sadd,K.Machin,K.Cruse, S.DeLaHaye,L.Able,K.Poursanidou, IndependentMentalHealthAdvocacy -TheRight toBeHeard:Context, ValuesandGoodPractice,London,JessicaKingsleyPublishers,2015.82R.Henderson,M.Pochin,ARightResult?Advocacy,JusticeandEmpowermentBristol,ThePolicyPress,2001.83Forexample,gettingthefundingmodelrighthassofarproveddifficult.ThiswashighlightedinDepartmentofHealth,Post-legislativeassessmentoftheMentalHealthAct2007:MemorandumtotheHealthCommitteeoftheHouseofCommonsCm8408,London,TSO,July2012,p9.

35

3.4.Mentalhealthtribunaldelays

Despitethevaluableroleofthementalhealthtribunal,somesignificantsystem

problemsexistwhichnegativelyimpactonthepatientexperience.Notably,delays

areparticularlyproblematic.Wheresomedetainedpatientsmustbeseenquickly,

forexample,section2patients,othersareforcedtowait.Delays intheprocess

contribute tomanynegativepatient experiences, leading to additional distress

andanxiety.Thisisnotanewproblem,thoughithasbeenexacerbatedbytherise

indetentionratesacrossthevariouscommitmentprovisionsintheMentalHealth

Act1983.84In2002,itwasfoundinthecaseofRvMentalHealthReviewTribunal

andSecretaryofStateforHealth,exparteKBand6Others85thatdelaysinmental

healthtribunalhearingsbreachedpatientrightstotimelyreviewsunderArticle5

ECHR. In this case, the individuals concerned had all experienced repeated

adjournments.Thestrainonthementalhealthtribunalsystemaroundthistime

emerged following policy shifts around funding patterns andpractice changes.

Patientswerebeingplacedinsmallerunitsratherthanlargehospitalsandthis

had had a knock-on effect in terms of the number of tribunals that needed to

conveneandthefrequencyinwhichtheymet.Atthetimeofthiscase,shortages

inconsultantpsychiatristssittingon tribunalpanelswasnotedasa factor that

influencedtheopportunitiestoarrangetribunalhearings.Althoughthepractical

challengesfacingthetribunalsystematthetimewereacknowledged,delayswere

deemedunjustifiedanddetrimentaltothepatient.Delayswerefoundtobreach

article 5(4) of the ECHR. The delays reflected systemic inadequacies and

inefficienciesintheadministrationofthetribunalsystem.Furthermore,patients

werebeingdeniedtheirabsoluterighttoaspeedyhearingwhichthestatewas

obligedtoprovide.Inanefforttoreducedelaysandcountertheeffectofrising

caseloads, judicial sittings have risen to cope with the increased demand.

However,toensurecasesareheardquicklyandinatimelyfashion,tribunalcosts

aregoingup.

84S.Blumenthal,S.Wessely,‘ThepatternofdelaysinMentalHealthReviewTribunals,’PsychiatricBulletin(1994)18,p98-400.85KB&Ors,R(ontheapplicationsof)vMentalHealthReviewTribunal[2002]EWHC639(Admin).

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3.5.Otherchallenges

Otherchallengeswiththehearingprocessexistwhichcanimpactnegativelyupon

boththepatientexperienceandtheefficiencyofthetribunalsystem.Forexample,

the pre-hearing medical examination. Details of the pre-hearing medical

examination of the patient is laid down in rule 34 of the Tribunal Procedure

Rules.86 Themedicalmember of the tribunal panelwill conduct a pre-hearing

examinationof thepatient inallsection2cases,unless thepatientobjects.For

otherpatients,theexaminationwilltakeplaceifthetribunalisinformed14days

beforeandinwritingthatanexaminationiswantedorthetribunalhasdirected

thatthereshouldbeanexamination.Medicalexaminationsshouldnormallyoccur

whereapatientfailstoattendthehearing.87Forpatientsthathavehadapre-hearing

medicalexamination,theexperiencehasnotalwaysbeenhelpful.Raisedlevelsof

anxietyandfeararequitecommon.TheMentalHealthAct1983CodeofPractice

notes that ‘[h]ospitalmanagersmustensurethat themedicalexaminercansee

patients who are in hospital in private, where this is safe and practicable.’88

Examinations are sometimes rushed, inconsistently undertaken with different

approaches,andoftenwithdiverseemphases.Questionsareraisedregardingthe

value of the examination, given the recognised limits of the process, and the

influenceofitonthehearingoutcome.89

Otherissuescancreateproblemswithinthetribunalsystem.Hearingsareusually

heldatthehospitalwherethepatientiscurrentlydetained.Thishastheadvantage

86TheTribunalProcedure(First-tierTribunal)(Health,EducationandSocialCareChamber)Rules2008(2008No.2699(L.16)PART4CHAPTER1Rule34.87See,Amendments to theTribunalProcedure(First-tierTribunal) (Health,EducationandSocialCare Chamber) Rules 2008 at:http://www.mentalhealthlaw.co.uk/media/Practice_Direction_and_Guidance-_Medical_Examinations.pdf88MentalHealthActCodeofPracticeLondon,DepartmentofHealth,2015,para.12.23.89Agrowingsourceofresearchaboutthesocialoutcomesoflegalpractices,broadlyconceived,iscontainedinthe‘therapeuticjurisprudence’literature,whichfocusesontheimpactoflawonthehealthof the individual.Thismodel focusesuponthe idea thatwithin ‘court’processesgreateremphasisondevelopinghearingpracticesthathavehealingoutcomesisnecessary.See,D.Wexler,‘Justice,mentalhealth,andtherapeutic jurisprudence,’ClevelandStateLawReview(1992)40,p517–526;D.B.Wexler,B.J.Winick (Eds.).Law inaTherapeuticKeyDurham,CarolinaAcademicPress,1996;B.Winick‘Therapeuticjurisprudenceandthecivilcommitmenthearing’,JournalofContemporaryLegalIssues(1999)10p37–60;B.Winick,‘Coercionandmentalhealthtreatment,’DenverUniversityLawReview(1997)74,p1145–1168.

37

of making it easier for the appellant to appear in person before the tribunal.

Hearingsarenotthenlike‘courthearings.’Theyaretypicallyheldinprivateunless

thetribunalconsidersthattheintheinterestsofjusticethehearingshouldbein

public.Yet,mentalhealthtribunalpanelsarefacingincreasingpressurebecause

there is a lack of private space left available in hospitals for hearings. This is

problematicasthealternativeisforhearingstotakeplaceonthewardorinother

more public locations. This issue is intensifying with increases in tribunal

caseloads. The importance of the built environment upon legal proceedings is

signalled as a major issue around how legal processes and proceedings are

perceived.90Furthermore,difficultiesoverspacewithinhospitalsforhearingsalso

raisesthequestionabouttheperceivedindependenceoftheprocesswhencarried

outin-situ.Itispossiblethataperceptionmayarisethatthetribunalisnotacting

asanindependentjudicialmechanism.Yet,overcomingthismaybedifficultgiven

thepracticalchallengessurroundingtheneedsofmentalhealthpatients.

Theseminarexposedtensionsandconstraintsfacingmentalhealthtribunalsin

dailypractice.Thediscussionhintedatalevelof‘crisismanagement’neededto

dealwith the significant rise in caseload.Therewasalsoa real sense from the

discussion that all aspects of the ‘system’ from clinicians making detention

decisions,throughtotribunalpanelmembersweredoingtheverybesttheycould

given thepractical limitations they faced.Thevalueof the tribunalprocess for

patientswashighlighted,andispartiallydependentuponthewayinwhichthe

hearing is organised anddirectedby thepanelmembers. The inextricable link

betweentheentryofpatientsintothementalhealthsystemandtribunalcaseload

wasacknowledged.Reducingcaseloadisnotanyeasytaskandreliesuponamulti-

agencyapproachtoaccommodatethecomplexityoftheproblem.

90L.Mulcahy,LegalArchitecture,Oxford,Routledge,2011.

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CHAPTER4

NEXTSTEPSFORMENTALHEALTHTRIBUNALS

TheMinistryofJustice'sTransformingJusticepaper91setsoutafar-reachingplan

for court reformwith technology and innovation as its heart. Althoughmental

healthtribunalsarenotcurrentlythefocusofthisreformprogramme,thepaper

notes ‘potential to extend…[these proposals to]…other areas such as Mental

Health.’92Theexpectationisthatuseoftechnologywillimproveaccesstojustice,

providingtoolstohelppeopleunderstandwhattheirrightsareandhowtoprotect

them.Besidethis,robustcasemanagementsystemsaretobeputinplacewiththe

intentionofimprovingefficiency.Ambitiousplanssuchastheseholdthekeyto

significantgainsinsystemmanagement,however,itisrecognisedelsewherethat

challengesarealsopossible.93

Scopefortechnologyinthementalhealthtribunalsystemisevidentandmayhave

avaluableimpactinovercomingsomeofthepracticaldifficultiesexperiencedby

panels and patients on a regular basis. For patients, with the help of legal

representativesand/orIMHAs,onlinesupportcouldimprovepatientexperiences.

OneoftheconcernsnotedbytheCareQualityCommission94wasthatpatientsdid

notalwayshavetheinformationtheyneededbothintermsofhowthedetention

processworked,what theirrightswereandhowtheycould initiate thereview

process. The introduction of IMHAs has made considerable inroads into

respondingtothisconcern;accesstoonlinesupportwouldbevaluableandwould

91MinistryofJustice,TransformingOurJusticeSystembytheLordChancellor,theLordChiefJusticeand the Senior President of Tribunals, September 2016. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/553261/joint-vision-statement.pdf92Ministry of Justice, TransformingOur Justice System by the Lord Chancellor, the Lord ChiefJustice and the Senior President of Tribunals, September 2016. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/553261/joint-vision-tatement.pdf,atp15.93 R. Thomas, J. Tomlinson, Current issues in administrative justice: Examining administrativereview, better initial decisions, and tribunal reform, November 2016. Available at:https://ukaji.org/2016/11/21/new-esrc-report-launched-current-issues-in-administrative-justice-examining-administrative-review-better-initial-decisions-and-tribunal-reform/94CareQualityCommission,Patients'experiencesoftheFirst-tierTribunal(MentalHealth)Reportofa jointpilotprojectof theAdministrative JusticeandTribunalsCounciland theCareQualityCommission,London,CQC,March2011.

39

reinforce the position of the patientwithin the relationship. Use of technology

couldalsogreatlyassistintheevidencegatheringprocess,thehearingitselfand

follow-up.

Despitethebenefitsthatmaycomefromgreateruseoftechnology,thereisaneed

tobemindfuloftheparticularvulnerabilityofindividualsbeingformallydetained

andbeingseenbymentalhealthtribunals.Thereisacleartensionbetweenthe

focusonefficiencyandensuringlegalsafeguardsandprotectionsaremaintained.

Thisissueisparticularlyevidentwhenexaminingthequestionofwhethercases

shouldbedecidedafteranoralhearingorsolelyonthepapers.Studiesexamining

other tribunals systems have considered the debate.95Oral hearings offers the

benefitofthetribunalpanelmeetingthepatient.Inadditiontothemedicalreports

andotherpaper evidence supplied aspart of thehearingprocess, the tribunal

panelhaveanopportunitytoheardirectevidencegivenbythepatientthemselves.

Theinformalandinquisitorialnatureofthetribunalalsoenablesthepaneltoask

questions and assist the patient allowing evidence to be drawn out from the

patientthatmightbeimportant.Indeed,mentalhealthtribunalproceedingsare

oftenlikenedtoacasereview.96Hearingacaseonthepaperslosesmuchofthis

exchange.Atribunalwillonlybeabletobaseadecisiononthepaperevidence

submittedandtherewillbenoopportunitytointerrogatethisevidencefurther.

Withinmentalhealth,paperhearingswithoutthepatientpresentdotakeplace.

For example, in 2016/17, out of 4,645 applications against CTOs, 520of those

were undertaken on the papers only. Taking account of the withdrawn

applications,thisfigurerepresentsnearly14%ofthehearingsundertakenduring

thisperiod.97

Paperhearingsdoaidtimelinessandassistwiththegoalofdrivingupefficiency.

However, as Thomas observes, oral appeals are more commonly allowed

comparedtothoseheardonthepapers.‘Lookingatthesedata,itisapparentthat

95 R. Thomas, Oral and paper tribunal appeals, and the online future, January 2017. Available at:https://ukaji.org/2017/01/31/oral-and-paper-tribunal-appeals-and-the-online-future/96E.Perkins,Decision-makinginmentalhealthreviewtribunalsLondon,PolicyStudiesInstitute,2003.97TribunalSecretariat,OutcomesofapplicationsagainstCTOs to theFirst-TierTribunal (MentalHealth),2016/17.

40

appellantswhoopt fororalappealsexperiencehighersuccessrates thanthose

appellantswhoseappealsaredeterminedonthepapers.’98

In order to respond to the challenge of increasing mental health tribunal

caseloads, it is important to ensure reforms are informed by evidence. More

research, consultation anduse of pilots are essential. Building on the research

undertakenbytheCareQualityCommissiononpatientexperienceofthetribunal

systemwouldalsobevaluable.Detailedmappingandevaluationoftheroleand

impact of IMHAs to date and the potential expansion of the role as a bridge

betweenthecareandlegalsystemwouldalsooffersignificantinsight.

Improvingefficiencywithinthementalhealthtribunalsystemisnotaneasytask.

Thisislargelybecausethetribunalsystemcannotbeviewedseparately.Tribunal

caseloadsaredirectlylinkedtoinitialdecisionstodetainundertheMentalHealth

Act 1983.Mental health tribunals review all cases whereas in other tribunal

contexts, such as immigration and social security, the appellant must decide

whetherornottoappeal.Whiledetentionrates(underallrelevantprovisions)are

highandgettinghigher,theimpactwillbefeltbymentalhealthtribunals.Looking

forward,itisimportanttounderstandbetterwhygreaterrelianceisbeingplaced

upon theMentalHealthAct, andwhat, if anything canbedone to resolve this.

Undertakingempiricalresearchintothisisessential.

98R.Thomas,Oralandpapertribunalappeals,andtheonline future, January2017.Availableat:https://ukaji.org/2017/01/31/oral-and-paper-tribunal-appeals-and-the-online-future/