Review of Mental Health Act must address excessive detention rates

My Post (4)Theresa May’s speech at the Conservative Party Conference on Wednesday 4 October was one mired by illness, a prankster and a backdrop that fell apart, presenting journalists with countless opportunities for cheap metaphors. But while the gaffs of her mea culpa overshadowed the announcement of new policies, for those that could see past the cringe-induced spectacle there were a number of interesting points.

One of these announcements was how the Government would be carrying out an independent review of the Mental Health Act. Building on her Brexit speech in January, where she vowed to correct the ‘burning injustices’ in modern society, May explained how a particular priority for her was ‘tackling the injustice and stigma associated with mental health’ (May, 2017).

She emphasised her desire for parity between mental and physical health through reiterating the Government’s pledge of increased investment in mental health. Recent announcements of an additional £1.3 billion to transform mental health services by 2021 (Health Education England, (HEE), 2017) were met with mixed reactions from key health bodies. It was said the funding will go towards the creation of 21 000 new posts, including 4600 nurses working in crisis care settings and 1200 nurses and midwives in child and adolescent mental health services (Department of Health, 2017). However, organisations such as the Royal College of Nursing said the Government’s proposals ‘appear not to add up’ (Royal College of Nursing, 2017). Other policies include giving an extra 1 million patients access to mental health services at an earlier stage, round-the-clock services and the integration of mental and physical health services for the first time.

The Mental Health Act
The Mental Health Act was passed in 1983 and is the main piece of legislation that sets out when and how a person can be detained and treated in relation to their mental illness. People detained under the Mental Health Act need urgent treatment for a mental health disorder and are deemed to be at risk of harm to themselves or others. In May’s speech she argued that the three decades old legislation is leading to ‘shortfalls in services and is open to misuse’ (May 2017). While the Mental Health Act was amended in 2007, it is felt by many that a more substantial revision is needed. This amendment was originally a proposed bill, but many felt it was ‘too draconian’ (BBC news, 2007).

The Five Year Forward View for Mental Health called for the Mental Health Act to be revised ‘to ensure stronger protection of people’s autonomy, and greater scrutiny and protection where the views of individuals with mental capacity to make healthcare decisions may be overridden to enforce treatment against their will’ (Mental Health Taskforce, 2016).

Reducing detention rates
Current detention rates under the Mental Health Act are too high. The latest published figures show the number of detentions under the Act are rising annually, increasing by 9% to 63 622 in 2015–2016, compared to 58 399 detentions in 2014–2015 (NHS Digital, 2016). Over the last 10 years they have increased by almost 50%. Of those detentions, a disproportionate number are of people from black and minority ethnic populations — four times as many black people as white people are detained. It is unclear why there are disproportionate detention rates between different communities, but this must be identified to ensure equal access to earlier intervention and crisis care services.

While reviewing the Act will use changes in legislation to help reduce the rates of detention, the difficulty will come in figuring out how the delivery of care must be changed so that detention can be avoided in the first place (Wessely, 2017). Additional focus is needed on the provision of earlier support. By identifying vulnerable people and addressing their mental health needs early, they can receive the support and care they need before detention becomes an unavoidable necessity.

For those that are detained, there needs to be a review of the areas constituting a ‘place of safety’. Police custody is not an appropriate area of safety. Around half the deaths that take place in or following police custody involve detainees with some form of mental health problem (Independent Police Complaints Commission (IPCC), 2017). Although police custody is only used as a last resort, it can exacerbate a person’s mental state, and has the effect of criminalising people who are in need of medical attention (IPCC, 2017).

Undertaking the review
The review will be carried out by Sir Simon Wessely, professor of psychological medicine at the Institute of Psychiatry, King’s College London. He is the former President of the Royal College of Psychiatrists and current President of the Royal Society of Medicine. Wessely will produce an interim report in early 2018 and develop a final report containing detailed recommendations, by autumn 2018.

References

BBC News. Ministers lose Mental Health vote. [Online]. 2007. [Cited on 25 Oct 2017]. Available from: http://news.bbc.co.uk/1/hi/uk_politics/6374547.stm

Department of Health. Thousands of new roles to be created in mental health workforce plan. London: The Stationery Office; 2017 Aug 30 [cited 2017 Oct 18]. Available from https://publichealthmatters.blog.gov.uk/2017/08/30/moving-forward-with-theprevention-of-mental-health-problems/

Health Education England. Stepping forward to 2020/21: The mental health workforce plan for England. Leeds: Health Education England; 2017 [cited 2017 Oct 18]. Available from https://www.hee.nhs.uk/sites/default/files/documents/CCS0717505185-1_FYFV%20Mental%20health%20workforce%20plan%20for%20England_v5%283%29.pdf

Independent Police Complaints Commission. Mental health and police custody [Internet]. Sale: IPCC; 2017 [cited 2017 Oct 19]. Available from https://www.ipcc.gov.uk/page/mental-health-police-custody

May T. Theresa May’s Conservative conference speech, full text [Internet]. London: The Spectator; 2017 Oct 4 [cited 2017 Oct 18]. Available from https://blogs.spectator.co.uk/2017/10/theresa-mays-conservativeconference-speech-full-text/

Mental Health Taskforce. The Five Year Forward View for Mental Health. Leeds: NHS England; 2016

NHS Digital. Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment. Uses of the Mental Health Act: Annual Statistics, 2015/16. London: Health and Social Care Information Centre; 2016

Royal College of Nursing. RCN responds to Mental Health Workforce Plan. London: RCN; 2017 [cited 2017 Oct 18]. Available from https://tinyurl.com/yavm3ulq

Wessely S. The Prime Minister Has Asked Me To Lead A Review Of The Mental Health Inequality In Britain – Here’s Why. London: The Huffington Post; 2017 Oct 6 [cited 2017 Oct 19]. Available from http://www.huffingtonpost.co.uk/professor-sir-simonwessely/mental-health-act_b_18192476.html

Taken from British Journal of Healthcare Management, published November 2017.

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London Trauma Conference addresses key questions in emergency medicine

The ninth London Trauma Conference took place at the Royal Geographical Society, Kensington Gore, between 8 December and 11 December 2015. A main programme of presentations, where speakers addressed a number of topical questions in trauma and emergency medicine, was supplemented by breakaway sessions held parallel to the main conference. The concurrent London Cardiac Arrest Symposium also returned for another year. The Journal of Paramedic Practice once again attended the Air Ambulance and Pre-hospital Care Day held on 10 December, which focused on trauma issues directly relevant to professionals working in the pre-hospital setting.

Proceedings began with Prof Pierre Carli discussing pre-hospital extracorporeal membrane oxygenation (ECMO). Carli gave an overview of how the treatment works in Paris, providing results and considering its role in the future. Interestingly, it was found in France that transferring into hospital for ECMO with ongoing cardiopulmonary resuscitation (CPR) had very poor results, and so the need for earlier intervention and pre-hospital ECMO became apparent.

Dr Thomas Lindner then spoke on CPR in helicopter emergency medical services (HEMS) and the new European Resuscitation Council Guidelines. He explained how the key message in cardiac arrest remains minimal interruption of high-quality chest compressions. He also emphasised how an automated external defibrillator takes 20 seconds to shock, and so clinicians should use that time to decide if a patient needs shocking so they can continue compressions.

Dr Marius Rehn then gave a talk on rapid response cars (RRCs) and whether they are more dangerous than aircraft. Rehn highlighted how London’s Air Ambulance attends around five jobs a day, 32% by aircraft and 68% by RRC. He pointed out that while aviation is heavily regulated, RRCs are not. He noted that one of the easiest ways to improve safety in RRCs is to strap the equipment and ensure passengers are restrained and seated.

Assoc Prof Andrew Pearce followed with a talk on making the best of long distance critical care. Pearce explained how the remoteness of much of Australia makes the provision of pre-hospital care challenging. However, he emphasised that as pre-hospital practitioners you are ‘never alone’, as there is always someone you can call for help and advice. He went on to say that the need for a retrieval service is not just about transport, but about being able to bring critical and definitive care to patients.

After coffee, Mr Andy Thurgood gave an engaging talk on the agitated trauma patient, considering causes, rules and practicalities. He explained how agitation is a feeling of aggravation or restlessness brought on by provocation or a medical condition. Thurgood suggested it is important as a health professional to consider what may cause the provocation of a patient. For example, an agitated patient could be ‘a dying patient that is trying really hard to stay alive.’ One of the most interesting take home points from Thurgood’s talk was that there is not always a medical cause for agitation in the trauma patient. He suggested that trapped agitated patients may have nothing wrong with them and simply want to be talked to and reassured.

Dr Leif Rognas discussed setting up a national retrieval service in Denmark, where the brief was to set up a state-of-the-art pre-hospital care service, with rapid access to highly specialised hospital treatment, to the entire Danish population. This was followed by Dr Rhys Thomas, who discussed setting up a retrieval service in Wales. Thomas explained that starting a national retrieval service takes a good story, organisation collaboration, hard work and persistence. The clinical model of the Welsh national retrieval service consists of pre-hospital critical care, adult and paediatric time-critical stabilisation and transfer, neonatal and maternal support to free-standing midwifery-led units and home births, and major incident and mass-casualty support. An interesting comparison: governmental funding for the retrieval service in Denmark means the service is more dependent on government, but acquiring funding is easier and it offers a higher degree of political awareness.

Dr Per Kristian Hyldmo gave the final pre-lunch talk on a reconsideration of spinal immobilisation, including when it may be appropriate. The discussion surrounding immobilisation remains ambivalent; however, Hyldmo closed with the amusing question: ‘When there is little evidence what are your options: Cochrane? Or GOBSATT (good old boys sitting around the table talking)?’

Mr Tom Judge gave the first talk after lunch on US air ambulances. Judge explained how in the US, if ambulance services transport the patient you get paid, whereas if you do not, you get no money. As a result, this has led to unhealthy competition, where contemporary HEMS in the US is driven by demand. But, with a market-driven system medical necessity often goes down and costs go up. This sparks the question as to whether this is an aviation business or a medical service? However, Judge presented evidence to suggest there is reasonable cost benefit in having air ambulances. He also argued that helicopters should be seen as instruments of time: time to team, time to tertiary centre, and total time.

The keynote talk for the day was delivered by Prof Sir Simon Wessely on the myth of panic. Wessely’s entertaining talk highlighted how approximately 10% of the population think their health is at risk no matter what is going on at the time. Considering associations of distress, Wessely emphasised how people who cannot reach friends or family following major incidents find themselves more affected than those who can. Debriefing has been used whenever something bad happens; however, it does not always work. Not everyone wants or needs to talk re-traumatisation, it interferes with the recovery process, and it impedes people talking to who they want, when they want. Wessely also argued that debriefing increases post-traumatic stress disorder. He said that only 1% of Londoners thought they needed professional help after the 7/7 bombings. The immediate mental health measures that are needed after mass-casualty incidents, such as bombings, are accurate and timely, practical information; communication; security, food, warmth, shelter and transport; and practical assistance with the legal system, employers, authorities etc. And if people want to talk it should be when they want to, and to who they want to. Wessely noted that less than 10% of soldiers want to talk to medical professionals or welfare services about traumatic incidents. Most want to talk to friends and family.

Prof Kai Zacharowski then spoke on pre-hospital sepsis, considering how to make a diagnosis, what interventions count, and whether biomarkers are the future. Zacharowski emphasised that sepsis should be a serious consideration among ambulance services, as care can begin pre-hospital. By raising suspicions of possible sepsis to hospital staff, the patient can be prioritised correctly.

Prof Zacharowski followed with a quick fire session on point-of-care testing in pre-hospital haemorrhage.

Dr Julian Thompson then questioned if pre-hospital crew resource management (CRM) and standard operating procedures (SOPs) can be implemented in the hospital. Defective judgement and poor teamwork affects ability to provide successful airway management, so can pre-hospital CRM and SOPs be implemented in hospital? Thompson concluded that it is probably not possible across an institution, it is highly applicable to high-risk situations, and that clinicians should select a small well-governed team and aspire to excellence at the point of greatest need.

Dr Samy Sadek then looked at pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) a year on, considering whether or not it works. Sadek presented results of REBOA by London’s Air Ambulance since being introduced 2 years ago. He reported seven cases of successful placement and four deaths (none due to exsanguination). The lack of REBOA cases illustrates how it is only considered in the sickest patients. A year on from last year’s talk that Sadek gave, a number of questions can be answered. In terms of potential complications, London’s Air Ambulance have reported one dissection, no ruptures, a thrombus, and no cases of displacement. Tolerance remains unknown—the maximum length of time undertaken by London’s Air Ambulance was 2 hours and 47 minutes. Diagnostic certainty is still unclear as there have been a few cases that were missed. While the definite benefit of REBOA is still unclear, Sadek offered a very sincere reflection of his own REBOA experience, where he feels he has definitely saved the lives of people who would otherwise have died.

Dr Matt Thomas then spoke on pharmacologically assisted laryngeal mask insertion (PALM), considering whether it was an elegant rescue technique or a dangerous compromise. Thomas concluded that it is a rescue technique rather than a primary technique, and should be considered as a plan B. However, if you are considering PALM then the patient probably needs a rapid sequence induction.

Mr Tom Judge closed the day with a talk on videolaryngoscopy, asking whether it is the standard of pre-hospital airway care. Judge highlighted that use of videolaryngoscopes increased first tube and overall intubation success rate. However, it remains expensive and in-hospital clinicians are already good at endotracheal intubation, with a 95% success rate.

The Air Ambulance and Pre-hospital Care Day represented a fraction of the packed programme of presentations on offer at this year’s London Trauma Conference. The invited speakers had a truly international breadth, offering an unparalleled excellence in the level of learning on offer. It is therefore with great anticipation that we look forward to the London Trauma Conference 2016.

Taken from Journal of Paramedic Practice, published 8 January 2016.