PAUCITY OF ESTEEM SYMPTOMS OF A CRISIS

Tom Burns will always remember the three or four times he ‘got it wrong’.

One of those occasions –among hundreds of ‘painful and distressing’ detentions he has made under the MHA (Mental Health Act) – was a 22-year-old hypomanic art student. ‘I was going to take her in,’ Professor Burns, a retired psychiatrist, recalls. ‘Her dad was desperate for her to stay out, she was desperate to stay out.

‘I let her stay out.

‘She killed herself that night.’

Professor Burns, emeritus professor at the University of Oxford, could hardly give a more powerful example of the seriousness of an assessment under the MHA – of the effect a decision whether to detain or not can have, and the extreme pressure on psychiatrists and other healthcare workers making these choices.

The decisions – ultimately depriving someone of their liberty because they are so unwell and pose a risk to themselves or others – are always a ‘last resort’. Some doctors describe these moments as a ‘privilege’, others as ‘daunting’ and ‘emotionally demanding’. Each is a whirlwind of complexity –with a demanding cocktail of patient history and judgement required from clinicians.

This is the context for an investigation by The Doctor which shows there were thousands more detentions under the MHA in 2021/22 than in 2016/17, with analysis of NHS data highlighting a 16 per cent rise from 45,864 to 53,337, with year-on-year increases.

Through a number of interviews with leading psychiatrists and other healthcare professionals, academics, charities and policy experts, The Doctor has built a picture of the reasons for the rise in seriously ill patients being detained – including the dismantling of the structures that for decades built in continuity of care for mental health patients.

Services overloaded Doctors reveal the effects of evolving drug misuse, austerity policies crippling deprived communities, and cuts to early intervention services as massive contributing factors.

Psychiatrists also paint a frightening picture of typical inner-city mental health hospitals, with huge rates of severe mental illness among those ‘contained’ on chaotic wards and the rate of acute illness now so high only those with the most worrying conditions are admitted.

On top of this, mental health professionals are under pressure to find beds for those in the most severe crises, leading to many patients being discharged early, piling pressure on stretched community services with police forces now questioning their roles as they face staggering numbers of emergency mental health calls.

It is a perfect storm which we assess in detail across two features – the second of which focuses on societal factors and will appear in the next issue of the magazine.

Prof Burns says a typical ward of 20 patients today might have 18 patients sectioned under the MHA. Twenty years ago, he says that would be closer to five. It is, he says, ‘much more overwhelming’ for clinicians.

Sir Robin Murray, professor of psychiatric research at the Institute of Psychiatry at King’s College London, says: ‘In order to get into one of these beds, you have to be very ill.’

He describes crumbling wards ‘full of almost everybody being acutely psychotic’, as a ‘very unpleasant’ environment in which patients ‘can interact and make each other worse’.

Swaran Singh, a professor of social psychiatry in Warwickshire, agrees and describes wards as ‘places of containment’ because of the lack of resourcing where ‘we provide no care, no compassion’.

The extreme threshold to be admitted to acute wards means there is no space for some patients in severe states of crisis, those who would have been admitted for treatment in years gone by, or they are sent out of area. Psychiatrists also spend more time dealing with court hearings and have less time for hands-on care.

BMA analysis of NHS data shows the number of NHS mental health beds in England dropped by 24 per cent from 23,607 in the fourth quarter of 2010/11 to 18,029 in the same period of 2022/23.

Low bed stock

At the same time occupancy rates have flatlined between 87 and 90 per cent, above the 85 per cent ‘risk threshold’, the level generally considered to be the point beyond which safety and efficiency are at risk. Meanwhile, mental health referrals have soared from three million in 2016, when comparable records began, to a staggering record 4.6 million in 2022.

Veena Raleigh, an epidemiologist at the King’s Fund, says NHS bed stock has consistently been lower than other comparable countries for years. In 2021, according to the Organisation for Economic Cooperation and Development, rates stood at 0.34 psychiatric beds per 1,000 people compared with 1.31 in Germany, 2.58 in Japan, and 0.61 in Poland.

‘Services are overstretched,’ she says. ‘And if people don’t have timely access to care, they can get more acutely ill and then come in crisis to the service.’

Dr Raleigh says the ‘supply side issue’ means ‘there are long lead times to access mental health services’.

The system, it seems, is storing up unwell people until they are in absolute crisis.

AMHPs (approved mental health professionals) are responsible for coordinating MHA assessments and detentions with the consultation of doctors.

Greater Manchester-based social worker Christina Cheney, chair of the National AMHP

NHS beds down while referrals soar

NHS mental health beds dropped by 24 per cent from 23,607 in the fourth quarter of 2010/11 to 18,029 in the fourth quarter of 2022/23

Mental health referrals have soared from 3 million in 2016 to 4.6 million in 2022

The growing number of detentions under the Mental Health Act

Leads Network, reports ‘a pattern of people cycling in and out of hospital’.

She says the lack of beds means ‘people come in too late and are discharged too soon, to make space’ which results in more requests to assess people for detention shortly after they have been discharged from hospital as they ‘very quickly become unwell again’.

As a result, working in acute services becomes ‘ever more pressured’ so recruiting and retaining staff becomes increasingly difficult, and ‘capacity decreases again’ which ‘repeats the impact’.

For patients and staff these horrendous cycles are deeply damaging.

More patients than ever are being treated by a smaller workforce. Vacancy rates of medical professionals working in mental health services have been above 11 per cent since 2017, and now stand at 14 per cent.

Admission threshold

Lade Smith, president of the Royal College of Psychiatrists, says often the ‘threshold for coming in is so high that you only get in if you’re detained’.

One statistic perhaps exposes the state of things more powerfully than any other. Detentions on admission to hospital have risen by 25 per cent since 2017/18 and now make up nearly two thirds of detentions, while detentions following admission have fallen by 22 per cent.

It is a stark situation where people are so unwell when they get to hospital that there is no time to see if their condition escalates, or if they can be managed without detention, Dr Smith says.

And Sir Robin, who cares for patients within the National Psychosis Unit at South London and Maudsley NHS Trust, says conditions are so ‘unpleasant’ that people immediately want to leave and are detained when they try.

As a result of pressures in acute wards, problems are pushed back into community services, where staff deal with patients with increasingly severe conditions and, as a consequence, cannot offer therapeutic or preventive services to as many people with milder symptoms. Without early intervention, those patients’ conditions worsen and become severe while others are simply not seen.

Look Ahead, a charity working in East London and Kent, works with patients who have been discharged from hospital. It reports a rising level of acuity among patients amid a wider NHS ‘strategy’ to keep people out of hospital.

Angelina Morgan, the charity’s director of complex specialist services, says hospital bed pressures also mean a growing number of patients being discharged ‘who are not well’ and would previously have stayed in hospital for longer.

This results in some psychotic patients living in the same supported housing as people ‘at other points in their recovery’, increasing pressure on staff.

A lack of hospital beds

CHENEY: Work becoming ever more pressured hasn’t happened by accident. Successive governments have driven reductions. Alongside this trend, CTOs (community treatment orders) were introduced in 2008 in an apparent bid to reduce the number of so-called ‘revolvingdoor’ patients and free up those inpatient beds.

They can be applied to people detained under the MHA who are unlikely to pose a risk to others. Use of CTOs peaked in 2020/21, when 6,070 were issued – and 10 per cent (621) of patients were recalled to hospital – but dropped to 5,552 in 2021/22.

However, Prof Burns, who wrote a paper on their use with BMA consultants committee mental health lead Andrew Molodynski, says there is ‘no evidence that they work’.

‘If someone needs to be detained, get them to hospital and treat them,’ he says. ‘To deprive someone of their liberty when they’re well enough to be out of hospital poses an ethical challenge.’

Ms Cheney also wants a rethink on the use of CTOs. She says they have ‘no impact’ on numbers of detentions and suggests they are a back-door mechanism by which ‘compulsory powers are being extended long after an admission is ended’.

Among the most critical factors driving the rise in detentions, psychiatrists say, is the ‘steady decline’ of continuity of care over the last two decades.

‘If a psychiatrist knows you, he or she is much better placed to judge whether you really do need to be in hospital or whether you would manage at home,’ Sir Robin says.

‘Someone seeing you for bma.org.uk/thedoctor

‘Increasing pressures mean more staff burn out and conditions only get worse. It’s a vicious cycle and an unsustainable model’ the first time starts entirely afresh and may be more alarmed than necessary.’

Continuity of care lost

Dr Smith says the landscape has changed from a model whereby patients would be looked after long-term by the same team, under the overall responsibility of the same consultant – whether they were in hospital or the community.

That meant teams would ‘get to know the patient really well’ and ‘step up support’ when necessary – either seeing them more often or prescribing appropriate medication.

‘It helped keep people out of hospital,’ says Dr Smith, who practises in South London. ‘And if they did need to come in, you would bring them in earlier, informally. Then when people were in hospital, you could bring them out quicker, knowing you’d be there to watch them.’

Dr Molodynski says: ‘This investigation shows how nearly every mental health patient in hospital is detained now, in what are often not therapeutic, but noisy, busy, austere, and coercive environments.

‘The deinstitutionalisation of the UK over many decades has been a remarkable achievement, but recent reductions in NHS mental health beds have gone too far.

‘People are often discharged much earlier into their recovery because of the lack of beds. Riskier patients are being treated in the community, which is now separated from inpatient care, hindering vital continuity.

‘Increasing pressures mean more staff burn out and conditions only get worse. It’s a vicious cycle and an unsustainable model, as we are increasingly seeing.’

For Prof Burns that model of continuity of care, which he says is ‘vastly more important’ to mental health than physical health, is crucial.

He wants clinicians to have more autonomy to create multidisciplinary teams that can get to know, and keep in touch with, patients. Those relationships between clinicians and patients are of the utmost importance, he says.

Neither Prof Burns’ expertise nor motivation are in much doubt. Improving the system is about preventing illness and saving lives.

The potentially unnecessary suffering of every extra patient who becomes so unwell that they need an MHA assessment is a tragedy which also increases the burden on services and staff and, ultimately, the risk of mistakes.

Even in retirement he has never forgotten that 22-yearold art student and the three or four times he ‘got it wrong’.

Additional work by Claire Chivers and Olivia Clark