This is the 2020/21 edition of Monitoring the Mental Health Act
Monitoring the Mental Health Act is our annual report on the use of the Mental Health Act (MHA). It looks at how providers are caring for patients, and whether patients' rights are being protected.
The Mental Health Act 1983 (MHA) is the legal framework that provides authority for hospitals to detain and treat people who have a mental illness and need protection for their own health or safety, or the safety of other people. The MHA also provides more limited community-based powers, community treatment orders and guardianship.
This report sets out CQC’s activity and findings from our engagement with people subject to the MHA and review of services registered to assess, treat and care for people detained using the MHA during 2020/21.
How we work
CQC has a duty under the MHA to monitor how services exercise their powers and discharge their duties when patients are detained in hospital or are subject to community treatment orders or guardianship. We visit and interview people currently detained in hospital under the MHA, and we require actions from providers when we become aware of areas of concern or areas that could improve. We also have specific duties under the MHA, such as to provide a Second Opinion Appointed Doctor (SOAD) service, review MHA complaints, and make proposals for changes to the Code of Practice.
In addition to our MHA duties, we also work to highlight and seek action when we find practices that could lead to a breach of human rights standards during our MHA visits. This is part of our work as one of the 21 statutory bodies that form the UK’s National Preventive Mechanism (NPM). The NPM carry out regular visits to places of detention to prevent against torture, inhuman or degrading treatment. Find out more information about this important role and our activities in the UK NPM annual reports.
As described in our last report, during the COVID-19 pandemic we suspended our routine on-site visits to carry out MHA monitoring reviews, to avoid spreading the infection between services. Throughout 2020/21, we replaced site visits with remote monitoring, where we aimed to provide support to services through video calls to patients, carers, advocates and many staff. On-site visits started again in July 2021.
Evidence used in this report
This report is largely based on feedback letters on the 620 remote monitoring letters following reviews of 682 wards carried out during 2020/21. These involved private conversations with 1,895 patients and 1,111 carers. We also spoke with advocates and ward staff. We have quoted from these letters in the report and, in the main, have not identified the services concerned, with some exceptions when we are describing good practice.
In addition, we have engaged at a policy level with a range of stakeholders in the use of the MHA, handled 2,280 complaints and contacts from patients and others, and took part in 77 Independent Care Education and Treatment Reviews (IC(E)TRs) of patients with a learning disability and autistic people who were being held in long-term segregation.
It is with thanks to all these people, especially people detained under the Act and their families, who have shared their experiences with us. This enables us to do or job to look at how services across England are applying the MHA and to make sure people’s rights are protected.
Evidence in this report also draws on quantitative analysis of statutory notifications submitted by registered providers, activity carried out by our SOAD service and complaints and/or concerns submitted to us about the way providers use their powers or carry out their duties under the Act.
The evidence in this report has also been corroborated, and in some cases supplemented, with expert input from our subject matter experts and specialist MHA reviewers to ensure that the report represents what we are seeing in our regulatory activity. Where we have used other data, we reference this in the report.
Throughout our report, in line with the Mental Health Services Dataset (MHSDS) we use the term ‘Black or Black British people’, recognising that this is a broad ethnic group that includes people from Caribbean or African ethnic backgrounds.
Through our MHA monitoring activity in 2020/21 we found:
1 - The workforce is under extreme pressure
The pandemic has placed additional stresses on staff, patients and carers. Many patients and carers have told us that they appreciate the extra efforts made by staff to mitigate the effects of lockdown restrictions and there has been some good practice. But staff are now exhausted, with high levels of anxiety, stress and burnout, and the workforce is experiencing high levels of vacancies. The negative impact of working under this sustained pressure poses a challenge to the safe, effective and caring management of inpatient services and to the delivery of care in a way that maintains people’s human rights.
2 - Community services are key to reducing levels of detention in hospital
Not getting the right help at the right time can lead to symptoms worsening and people needing inpatient care. During the pandemic this has been a particular concern for children and young people. We have seen an increase in the numbers of children and young people being cared for in inappropriate settings while they wait for an inpatient bed. The Independent Care (Education) and Treatment reviews have also shown the impact of a lack of community care, with people being admitted to hospitals for prolonged periods of time.
3 - Urgent action is needed to address longstanding inequalities in mental health care
We remain concerned that Black or Black British people are more likely to be detained under the MHA, spend longer in hospital and have more subsequent readmissions than White people. Reliable local and national data is key to identifying inequalities in care and measuring progress towards closing these gaps. This needs to be a focus across integrated care systems. We are keen to see the rollout of the patient and carers race equalities framework, a tool to help mental health trusts work with Black and minority ethnic communities to achieve practical change. We recognise that some factors in inequality are broader than health care provision.