Psychiatric Bulletin (2007) 31: 374-377. doi: 10.1192/pb.bp.107.015446
© 2007 The Royal College of Psychiatrists
Before and after: introduction of the Mental Health (Care and Treatment) (Scotland) Act 2003
Helen Smith
Specialist Registrar in Forensic Psychiatry, Murray Royal Hospital,
Muirhall Road, Perth PH2 7BH, email:
helensmith6{at}nhs.net
Tom White
Consultant Forensic Psychiatrist, Murray Royal Hospital, Perth
Declaration of interest
T.W. is a medical member of the Mental Health Tribunal for Scotland.
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Abstract
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AIMS AND METHOD
The aim of the study was to assess the impact of the introduction of new
mental health legislation in October 2005 on general adult psychiatry
admissions. Patients were included in the study if they were admitted to
Murray Royal Hospital, Perth from December 2004 to July 2005 and December 2005
to July 2006.
RESULTS
Fewer patients were detained but they were more likely to progress to
longer-term detentions. Overall detained patients remained in hospital for
shorter periods.
CLINICAL IMPLICATIONS
The change in de novo detention procedures reduced the number of
de novo detentions. The new power to enforce medication in the
community may have contributed to the reduced length of detention in
hospital.
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Introduction
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The Mental Health (Care and Treatment) (Scotland) Act 2003 was implemented
in October 2005. It introduced some changes to the process and principles of
detaining patients in Scotland. The Act underlined ten principles which must
guide everybody involved in the Act, including non-discrimination, equality,
respect for diversity and reciprocity. Informal care should be used whenever
possible and the patient’s and carers’ past, present and future
wishes should be considered. There must be respect for carers and child
welfare. The least restrictive options should be used and the benefit to the
service user must be demonstrable.
Prior to October 2005 the gateway section to hospital treatment was section
24 or 25 of the Mental Health (Scotland) Act 1984. This section could be
completed by any registered medical practitioner and allowed for detention for
up to 72 h without leave to appeal. It was hoped with the introduction of the
new Act that the gateway section would be a 28-day section (section 44). This
section requires the doctor applying for the section to be approved under
section 22 of the Act as having special experience in the diagnosis and
treatment of mental disorder. With leave to appeal to a tribunal, much as in
the English and Welsh systems, this section requires the consent of a mental
health officer; family members can no longer consent. A new treatment option
was introduced to allow compulsory treatment in the community.
In this study we audited the admissions to the general adult psychiatry
wards in the Perth and Kinross area of Tayside prior to and after the
introduction of the new Act to assess the impact of the change in mental
health legislation.
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Method
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The study took place from December 2004 to July 2005 (sample 1) and then
December 2005 to July 2006 (sample 2). The new Act came into force on 5
October 2005, which gave 2 months to allow some of the immediate problems to
be resolved. The same months were chosen to reduce seasonal variations. The
patients were admitted to the two single-gender wards in Murray Royal
Hospital, Perth; the wards have 24 beds each and are open wards. The total
population of the catchment area was 135 000. All admissions to the unit were
included in the audit retrospectively.
A case-note review was undertaken. Simple demographic details were
collected via a specially designed pro forma (available from authors on
request). The admission and discharge diagnoses were recorded. The legal
status on admission and discharge was collected and the patient’s length
of stay in hospital calculated. The number of days the patient remained under
the Act was calculated for each admission.
The data were analysed using t-tests for continuous data and
2-tests for discrete variables.
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Results
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Sample 1 comprised 195 patients, but notes were missing for 15 patients
leaving 180 for study analysis. Sample 2 comprised 176 patients, with 25
missing notes leaving 151 for analysis. In total data were missing for
10.8%.
Analysis of the combined sample
In the combined sample, 58.9% of patients were male and 41.9% were female.
The mean age for the total population was 39.6 years (s.d.=11.4 years).
Most of the patients were admitted informally (71.9%). In the combined
sample significantly more male patients were detained than female patients
(P=0.01), but there was no significant difference in the mean age or
previous number of admissions. Patients who were detained had symptoms at a
significantly earlier age (24.97 years) compared with informal patients (30.27
years) (P=0.001).
Detained patients stayed in hospital much longer on average. The mean
length of stay for informal patients was 15.9 days v. 63 days for
detained patients (P<0.001). More patients with a diagnosis of
schizophrenia or schizoaffective disorder were detained (P=0.001)
than those with depression or primary substance misuse.
Detentions before and after the change in Act
There were no differences in the populations admitted before and after the
change of legislation in terms of gender, age, age at first symptoms or mean
length of stay. Patients admitted before the Act changed did have
significantly more previous admissions (P=0.001). The admission diagnoses are
shown in Fig. 1. The diagnoses
of those patients detained before and after the change did not differ.
The legal status at admission of the two samples is shown in
Table 1. Very few patients were
detained under emergency (72 h) sections after the Act was introduced. The
main gateway section was section 44 which requires an opinion by a section 22
approved doctor. Before the Act changed 36% of patients admitted were
detained, afterwards this reduced to 25.7%. The progression of the various
sections is shown in Fig. 2.
Only 41% of patients admitted under the new gateway section progressed to
further detention compared with 61% previously. Significantly more people were
detained before the change in the Act (P=0.05), but there was no
significant change in the number of people progressing to longer-term
sections.
The average length of stay of detained patients before and after the
introduction of the new Act is shown in
Table 2. Although the mean
length of detention for patients seems to be decreasing, it has increased for
patients under the short-term section.
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Discussion
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The results of this study indicate that fewer patients are being detained
de novo than previously. This could be due to a threshold effect, as
section 22 approved doctors (specialist registrars and consultants) as opposed
to general medical practitioners are involved in making the decision regarding
detainability. There were no differences in the diagnoses of patients detained
before or after the implementation of the new Act. Patients were more likely
to have their detentions extended but spent a shorter time in hospital,
possibly because of the use of community-based compulsory treatment
orders.
Under the old Act the Tayside area had one of the highest rates of use of
emergency and short-term detentions (Mental
Welfare Commission for Scotland, 2005). Tayside had between 100
and 120 detentions per 100 000 population compared with 60 per 100 000 in the
Borders area. When the rates of application for 6-month sections under the old
Act are examined, Perth and Kinross was third in the table, above the urban
centres of Glasgow and Edinburgh (Mental
Welfare Commission for Scotland, 2005). This has been a
long-standing finding and no satisfactory explanation has ever been produced.
However, after October 2005 Tayside no longer appeared to use the mental
health legislation more than other areas.
The rate of progression to a longer-term detention under the new Act in
Tayside was overall 46.7%. This compares favourably with the results produced
by the Mental Health Tribunal for Scotland
(2006a,
b). During the period
of January to June 2006 the rate of progression in various health boards
varied between 41.5 and 52.3%.
The introduction of the Mental Health (Care and Treatment) (Scotland) Act
2003 appears to have achieved in a relatively short period the aspirations of
the Millan report (Scottish Executive,
2001). There has been increased scrutiny by more experienced
practitioners before patients are deprived of their liberty in hospital. This
has led to an increase in the amount of consultant time devoted to
form-filling and attending tribunals which is placing added demands on
services. There has been reduced variability in the geographical application
of mental health legislation. The length of time that patients spend in
hospital under detention has also been reduced, and this is in keeping with
the principles of the Act to use the least restrictive option for treatment.
The availability of community-based compulsory treatment orders may have
contributed to this. It remains to be seen what long-term effects the
introduction of the Mental Health (Care and Treatment) (Scotland) Act 2003
will have on patient care.
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References
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MENTAL HEALTH TRIBUNAL FOR SCOTLAND (2006a) Quarterly
Statistics, January to March 2006.
http://www.mhtscot.orgMENTAL HEALTH TRIBUNAL FOR SCOTLAND (2006b) Quarterly
Statistics, April to June 2006.
http://www.mhtscot.org
MENTAL WELFARE COMMISSION FOR SCOTLAND (2005) Our Annual Report
2004–2005.
http://www.mwcscot.org.uk/web/site/GoodPractice/Publications/Annual_Reports.asp
SCOTTISH EXECUTIVE (2001) New Directions.
Report on the Review of the Mental Health (Scotland) Act 1984 (the Millan
Report). Scottish Executive.
Top
Abstract
Introduction
, before change; 
, after change.