Fighting to improve services

SANE continues to fight to improve mental health services despite a growing awareness and public perception in recent years.

All efforts to raise awareness and combat stigma have not been matched by increased provision at the front line. Despite some progress and advances in treatments, the lives of those affected by mental illness are not improving.

Services remain ill-equipped to provide consistent care and the daily reality experienced by those who contact SANE often remains bleak.

People affected by serious mental illness are not informed or advised about local services, struggle to access crisis support and do not feel involved in decisions affecting their everyday life.

We believe that people with schizophrenia continue to be failed by a system that has never prioritised their care.

Despite it being the single most challenging illness which, when untreated, can lead to fatal consequences such as suicide, homicide and neglect, schizophrenia does not receive the funds or resources needed to help those affected.

Care crisis

SANE’s campaigning highlights the acknowledged crisis in psychiatric care, calling for the restoration of beds in hospitals and units; a substantial increase in the workforce to make good the current acute shortage of consultants, psychiatric nurses, therapists and other skilled mental health staff; more resources for community-based teams; and action to prevent patients and their families having to travel hundreds of miles to receive in-patient treatment.

Other issues we highlight include the need for new research; medications, treatments and therapies; the impact of the internet on mental health; the rising levels of depression and anxiety, especially among girls and young women; and the alarming increase in self-harm and suicide, particularly among adolescents.

Schizophrenia and Employment

SANE knows that work is generally good for people’s mental health, and that a significant percentage of people with severe mental illness can and would like to be in employment. However, employment rates for people with severe and enduring mental illness remain low.

SANE carried out a survey of 79 people with schizophrenia, which included questions about the impact of their condition as well as their experiences of the health service, levels of employment support received and the attitudes of employers. 

The key areas where barriers to employment were identified were:

• Access to healthcare and employment support programmes.

• Levels of encouragement from healthcare professionals.

• Stigma and discrimination from employers.

Following this work we developed three key policy levers which were identified as important opportunities to better incentivise and support the commissioning of employment support services for people with severe mental illness locally.

Reforming the Mental Health Act

Current Areas of Concern

With regard to the existing Mental Health Act, SANE has long argued for a more humane legislative framework, that matches compassion with coercion. We regarded the 2007 reform of the Act as a missed opportunity to embed a positive right to treatment in the Act, as well as enshrining the right of families and carers to information and support.

SANE believes that a reformed Act should contribute to ensuring safe, compassionate care in hospital settings using the least restrictive methods possible. Patients need to be treated with respect, have their dignity preserved, and have their needs and wishes taken into account.

Families and carers should also be involved at all points in considerations about care, including care plans, and there should be effective information sharing between these parties and rigorous record-keeping.

Other specific areas of concern regarding the current system include:

• Crisis Care

SANE’s experience, drawn from the many people that contact us, as well as conversations with clinicians and experts, is that far too many people in crisis are being turned away because no local beds are available, or deprived of their liberty under section as the only way to receive treatment. They may find themselves locked in police cells, shunted around the country or placed under the care of overstretched crisis resolution teams, where they are now three times more likely than in-patients to take their own lives. The increase in recent years in the use of the Act to detain people is in part a consequence of overstretched community-based mental health teams, especially early intervention, that are unable to cope with demand and sustain people safely in the community, and who may be expected to see this demand increase further as a result of the Covid pandemic.

• Inpatient Services

We have lost almost half the psychiatric beds in England since 2000 and have seen occasions in recent years when there are no psychiatric inpatients beds available anywhere in England. Our view that there are now too few beds available is supported by the Royal College of Psychiatrists, which has argued we need 1,000 new beds to meet demand. SANE believes that we need to restore sufficient local beds for those in crisis or with severe and relapsing mental illness, otherwise people will continue to be discharged early, admitted to a psychiatric unit out of their area, or refused admission altogether, and avoidable tragedies and loss of life will continue.

• Patient Discharge

Mental health patients are at heightened risk of death in the first few weeks following their discharge from hospital. Recent published research from Denmark – the most comprehensive study on this subject – found not only that discharged patients were 32 times more likely to die by suicide than the general population, but that fatal drug overdose, irrespective of intent, was more than 90 times more likely amongst this group. Yet all too often SANE hears of people discharged with little or no care plan, and inadequate contact with community services that can support the patient at this critical time. We are also concerned at the increases in delays to patient discharge, which are unhelpful at best for the patient and which add further to the pressure on inpatient beds.

Response to Recommendations

We are encouraged to see that the new proposals, building on Sir Simon Wessely’s recommendations, address many of the issues SANE has campaigned over. Our specific responses to the proposals are below:

• Detention criteria

We welcome the decision to strengthen detention criteria, governed by the two principles of ‘therapeutic benefit’ and ‘least restriction’ to the patient. However, SANE has long been concerned about the increasing numbers of patients in crisis who find themselves unable to access inpatient care and a place of safety, all too often due to a lack of available beds. We would however not wish to see the principle of applying the least restriction to patients enshrined in legislation, if the interpretation of what constitutes “substantial risk of significant harm being caused to themselves of others” is drawn so tightly that people continue to be turned away from support and treatment when they are at their most vulnerable.

• Nominated Persons

SANE has long been aware of how families and carers can be sidelined from involvement in the treatment of patients by mental health services, despite the insight and information they can contribute, which can help mental health services make better and more appropriate interventions, either in hospital settings or in the community. We are pleased to see a proposed new right for patients to choose a nominated person to ensure their interests are considered if they find themselves detained under the Act, and agree with extending the powers that the nominated person may have to contribute to decisions regarding issues such as care plans, hospital transfers and the use of community treatment orders. We would however like to see it made mandatory that concerns raised by families and carers are recorded to help ensure an effective response, especially when a patient’s mental state is deteriorating.

• Places of safety and the role of the police

As much as one third of police time is spent on mental health-related callouts, often conducted in response to people in mental health crisis. Moreover, despite government pledges, police custody suites are still far too often used as ‘places of safety’ for people who are suicidal or self-harming, and who need experienced psychiatric staff providing evidence -based care in a therapeutic inpatient setting. Patients can feel doubly punished, by their illness and by being locked in a police cell, which risks undermining their prospects for recovery and their trust in the system to provide the help that they need. As first-responders to many mental health crises the police, along with mental health and other statutory services, need much greater information-sharing and co-operation. A number of street triage schemes have proved successful in improving responses to patients in crisis, and while individual schemes should have the freedom to organise resources to meet the specific needs of their community, we would like to see national standards for co-operation and information sharing that could help to improve the experiences of people with severe mental health problems across the country.

• Out of area placements

Beyond the increased role of the nominated person that would allow them to be consulted regarding hospital transfers, there appears to be little reference to the current practice of patients being placed in hospitals or inpatient units out of their area and away from their family, community, and healthcare professionals that know them. In the months leading up to the end of 2020, the time patients were spending in inappropriate out-of-area placements began to climb, despite government pledges to end this practice by 2020/21. SANE would like to see a requirement in the legislation that patients should be treated in their area, in an inpatient unit that is part of their local network of services. Without this requirement the principle of ‘therapeutic benefit’ that is supposed to underpin the reformed Mental Health Act is undermined.

• Care Plans

SANE welcomes the proposal to put care and treatment plans on a statutory footing for the very first time. We are also pleased to see that such plans will involve consultation with the patient and will give them the freedom to choose alternative evidence-based treatments, which we hope will improve trust between them and their clinicians. We also hope that the steps announced will provide a firmer foundation to expedite safe patient discharge from hospital and help to ensure the critical first few weeks back in the community can be navigated more successfully, and more safely, by patients.

• Community Treatments Orders (CTOs)

SANE welcomed the introduction of CTOs in the Mental Health Act (2007), arguing that with rigorous safeguards they could provide release for some patients trapped in the revolving door between hospital and community. We were concerned at the time however that there was no right to assessment, care or treatment, or enhanced rights to information and support for carers and families. As such we are pleased to see that these concerns have been addressed in this White Paper, and hope this may encourage more of the most vulnerable and disturbed patients and their families to build trust with mental health services and improve outcomes.

Our Conclusion

While the number of patients detained under the Act has risen by 40 per cent between 2006 and 2016, it remains SANE’s experience that far too many people in crisis are turned away from help when they are at their most vulnerable, and told they must make do with returning home to await a phone call from a crisis resolution / home treatment team.

The use of the Act to detain patients has risen in part as a consequence of the increasing difficulty patients (and clinical staff) experience when they try to voluntarily admit themselves to hospital treatment. More than half of psychiatric inpatients are now in hospital having been detained under the Act because they have become so unwell.  

The threshold for admission has now become so high that clinicians tell us if anything the Act is not used enough and too many patients are let down when in crisis, despite the steep increase in the use of the Act in recent years. Staff retention is also compromised when lead practitioners (key workers etc.) in the community are carrying too much unjustifiable risk amongst the patient cohort they are responsible for.

The fundamental purpose of these changes in legislation must be to improve the experience of patients with severe mental health problems and ensure that more people are able to recover and lead more productive and fulfilling lives.

To this end legislation is only one part of the jigsaw. What is urgently needed is far greater investment to encourage more healthcare staff to specialise in mental health and retain them, and more local inpatient beds to meet the needs of those who find themselves in crisis.