I’m not surprised by RCPsych’s concerns. The White Paper proposed that detailed Care and Treatment Plans (CTPs) - for children, young people, autistic and learning disabled people these will be called Care, Education and Treatment Plans (CETPs) - will be put on a statutory footing and must be in place by day 7 of detention and signed off by the clinical/medical director by day 14 and become living documents to be amended and reviewed. The pivotal person to do this work would be the Responsible Clinician (RC), who will usually be a consultant psychiatrist. In its response to the White paper consultation, the government said it would seek to ensure that these new statutory Plans take into account existing requirements round care planning, that they encourage joint working and that there is flexibility regarding the contents of the Plans so that they are truly patient led. The Care Programme Approach is being replaced by personalised care and support planning (see eg. previous post) and I'm not sure if it's clear what impact this is having, and statutory plans need to reflect these changes. The government also said it would work with stakeholders to review the proposed timelines and governance structure to ensure that any statutory requirements placed on staff are aimed at facilitating a culture of high quality, co-produced care and treatment planning for all patients detained under the Act. Even taking the apparent mollification of these statutory Plan requirements following the consultation, the likelihood is that psychiatrists' workload will have to increase to meet the demand.
Actually, the analysis by The Strategy Unit estimated that the primary driver for an increase in psychiatrists will be the additional time required to prepare and attend Tribunal hearings. I'm sure the statutory Plans will be helpful for that preparation. What surprised me was that none of the scenarios The Strategy Unit used anticipated a reduction in detentions (and presumably therefore Tribunal hearings), including what the report called DHSC assumed growth. The impact assessment (see previous post) produced with the White paper assumed that investment in the Long Term Plan in crisis teams and community mental health teams would slow historical increases in detentions, independent of MHA changes. It did not present monetised benefits for the proposed changes in the Act, instead using a breakeven analysis to illustrate the amount of benefits per patient required to offset the costs of the policy. For example, a reduction of 2 days in the average length of detention was said to be sufficient.
The sensitivity analyses by The Strategy Unit and the government are complex and I'm not sure I understand them completely. I'm not against increasing the number of psychiatrists, particularly for inpatient work. What I would like to know is what the government thinks the impact on detentions will be of a new Bill, but I guess we won't get this information completely until the Bill is produced next year. Is it really assuming that detentions will continue to increase despite the changes in legislation, as The Strategy Unit seems to suggest?
In fact, I have been arguing in several previous posts (see eg. Doctors have too much power in the current Mental Health Act) that the proposals do not go far enough to reduce compulsion. For example, repealing Community Treatment Orders (CTOs) (see eg. another previous post) would both reduce coercion and probably costs. The government does not want to re-open this issue as it caused so much controversy when CTOs were introduced by the 2007 amendments to the Mental Health Act (see my webpage, now largely defunct). But the evidence is that they have not been effective (see another previous post).
Fundamentally, the new Act should help reverse the re-institutionalisation of mental health services that has taken place over recent years (see previous post), particularly by reducing the number of secure beds both in the NHS and private sector. There doesn't seem to be much point in reforming the Act if this process does not lead to a reduction in detentions and enforced treatment. I think detentions can be further reduced, maybe even further than the government seems to think they can be, by repealing CTOs, expanding Mental Health Tribunal powers (see eg. previous post) and improving advocacy (see eg. another previous post). I wish RCPsych would engage more with these issues than apparently seeking to block reforms of the Act, which, after all, are designed to reduce unnecessary coercion.
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