Consider this fictional but likely scenario. A person is arrested by police at 7pm on a Friday night and taken to police custody. It becomes apparent the person is mentally disordered; they are de-arrested, a s.136 is imposed and they are transferred to a health-based place of safety (HBPoS) for a MHA assessment. The police may transport people in some areas but here, an ambulance was required and there was a long wait. No-one has notified the local Approved Mental Health Professional (AMHP) Service, they learn about the s.136 when the person arrives at the HBPoS. Some HBPoSs have doctors available, but in this case the AMHP located the on-call doctor who was unable to attend for several hours while they completed work elsewhere. By now it is 4am; the team decides to let the exhausted person rest and the assessment is handed to the daytime service. A new AMHP begins the doctor search again at 9am. By the time the assessment takes place, the person’s emotional distress has resolved somewhat and they are no longer considered mentally disordered. The s.136 ends, and the person is released, far from home with no transportation or money; after long negotiations between the AMHP, ward staff and senior manager, a budget code is found to fund a taxi to take the person home.
While my scenario involves police, local authorities, ambulance services, doctors, and place of safety and hospital staff, it would be recognised by the current method of producing MHA data as one use of s.136 and one use of a police station as a place of safety.
NHS Digital publishes The Mental Health Services Dataset (MHSDS), and monthly reports can be found here. MHA information for September 2021 includes the following figures for England:
- 3959 Detentions in the reporting period
- 2227 Short Term Orders in the reporting period
- 1551 Uses of Section 136 in the reporting period
- 439 Community Treatment Orders in the reporting period
Data is classified as experimental and subject to change; furthermore, NHS Digital relies on ‘hospital managers’ (NHS Trusts, NHS Foundation Trusts and independent hospitals) to provide accurate information regularly. It is not clear whether MHA activity in general acute or community hospitals is being captured at all. Since data is produced by hospitals accepting detained people, it does not include:
- Referral volume for assessments which conclude in a decision not to admit the person
- Ambulance response times to conveyance requests
- Ambulance providers (NHS or private) used
- The AMHP and section 12 doctor populations and the proportion undertaking MHA work
- Hospital bed availability (time and physical location) when an AMHP wants to undertake MHA work
Consequently, system activity and the capacity of the system to deal with demand is only understood locally.
The Children’s Commissioner’s report Who are they, where are they? published in November 2020 focuses on the invisible children detained in secure hospitals, prisons and children’s homes, but does not mention children subjected to the MHA in general hospitals, an issue which involved much Court activity in 2021 (for example, this case). These children are so invisible they do not feature in a report designed to make them visible.
Wider criticisms of national MHA data
Sir Simon Wessely’s Independent Review of the Mental Health Act 1983 called for improvements to the way MHA data is collected. In System Wide Enablers (p209), Sir Wessely states there has been no revolution in the way data is collected and we find ourselves in the unacceptable position that nobody can accurately articulate how the use of the MHA has changed and continues to change. These concerns were echoed in the Care Quality Commission’s (CQC) Briefing: Mental Health Act – Approved Mental Health Professional services. The briefing highlights inconsistencies in the collection and use of data, and the lack of information about AMHP activity and the role AMHPs play in the prevention of detentions.
This is significant because insufficient resources can have devastating consequences, and reliable data is crucial to identifying the greatest needs. For example, the CQC’s Monitoring the Mental Health Act report 2016-17 communicates AMHPs’ concerns that the reduction in beds had impacted their ability to complete assessments in a timely manner, particularly for patients needing a specialist bed. A year later, their 2017-18 report describes how coroners had made the CQC aware of at least seven deaths of people who were assessed as requiring admission to hospital, including under the MHA, but for whom no mental health bed was available.
With no robust, reliable data about system activity, and the frequency and outcomes of delays, how do commissioners make sure resources are allocated to the greatest needs?
The S12 Solutions team is working on ways to help. The platform demonstrates the number of AMHPs and doctors, MHA assessment work undertaken, and fluctuations in activity across days and times. We are starting to capture outcomes, and working with various local systems to understand how data about other elements, such as conveyancing, can be measured using platform processes. Even so, this work remains mainly developmental; the platform was not designed to be a data gathering tool. What is needed is the ‘data and transparency revolution’ called for in 2016 by NHS England’s Five Year Forward View for Mental Health. This revolution is yet to happen, but we are happy to play a part when it does.
Nick’s social work career began with a local authority mental health team before he became an Approved Social Worker. From there, Nick moved to AMHP management and spent three years as a Mental Health Act Commissioner with the CQC. Subsequent roles involved oversight of the MHA, Mental Capacity Act and MHA administration team within a Trust. In 2019, Nick consulted on the development of S12 Solutions’ Electronic Statutory MHA Form feature as part of its national working group, before he joined the team permanently as a Delivery & Account Manager in 2021.