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Mental Health Act reform plans 'do not show nurses they are valued'

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A major review commissioned by the government into mental health legislation has failed to recognise the important role played by nurses, a nursing chief has warned.

Catherine Gamble, professional lead for mental health at the Royal College of Nursing, said the recommendations made as a result of the inquiry were “less than radical”.

“The experience of people detained under mental health legislation would improve by extending the role of nurses”

Catherine Gamble

Prime minister Theresa May announced in October 2017 that the Mental Health Act would be reformed due to concerns about rises in the number of people being sectioned and the disproportionate detention of those from black, Asian and minority ethnic (BAME) backgrounds.

An independent review was carried out and the findings were published today (see PDF attached below).

One of the key themes in the report is around the need for seriously mentally ill patients to have a greater say in their care and be given more chances to challenge treatment decision.

The report also calls for improvements to community mental health services to reduce the need for people to be held in hospital to keep themselves or others safe.

While the RCN was consulted as part of the review, Ms Gamble expressed concern that the views of members were not properly heard.

She said: “Nurses had hoped this report would empower clinicians and allied health professionals to act more autonomously, reduce barriers to patients receiving a seamless service and prove to nurses they’re a valued aspect of the system that cares for our most vulnerable and severely mentally ill. It’s difficult to see how this report will enable that.”

Royal College of Nursing

‘Disappointing’ lack of progress in community mental health

Catherine Gamble

Ms Gamble said nurses were the largest and most diverse professional group in the mental health workforce and they should be “tapped into” to support, represent and advocate for BAME patients, whom the report noted were more likely to be admitted for treatment against their will.

She also said there was a need to address variation in teaching of the Mental Health Act for nurses in this field.

“The experience of people detained under mental health legislation would improve by extending the role of nurses, providing clear direction on the extent of nurses’ holding powers and addressing the varying quality of education mental health nurses receive on mental health legislation,” she added.

Ms Gamble added that it was “disappointing” that the report did not tackle safe staffing “head on”, noting that 14.3% of mental health nursing posts were vacant.

However, the report did highlight workforce shortages as a possible barrier to the reforms.

It said: “Many of the recommendations in this report depend heavily on the staff who work within our services. Their dedication, compassion and expertise play an essential part in the patient’s treatment and we know their working conditions are often very difficult.

”Services that are underfunded and overcrowded, with high turnover and vacancies adding to the challenges,” the report added.

The government has committed to delivering on two recommendations from the report as part of its new Mental Health Bill to modernise services.

The first is to enable those who are detained under the act to nominate a person of their choice to be involved in decisions about their care. Under the current system, patients have no say in the matter and their nearest relative is contacted.

”I am determined to make sure those suffering from mental health issues are treated with dignity and respect”

Theresa May

The second is to introduce law-binding “advance choice” documents in which patients can express their preferences for care and treatment that must be followed should they lose capacity.

A spokesman for the Department of Health and Social Care declined to comment on the criticism from the RCN but said the government would issue a formal response to the review’s recommendations in the new year before preparing the new legislation.

Ms May said: “The disparity in our mental health services is one of the burning injustices this country faces that we must put right.

“For decades it has somehow been accepted that if you have a mental illness, you will not receive the same access to treatment as if you have a physical ailment. Well, that is not acceptable.

“I commissioned this review because I am determined to make sure those suffering from mental health issues are treated with dignity and respect, with their liberty and autonomy respected,” Ms May said. 

She added: “By bringing forward this historic legislation – the new Mental Health Bill – we can ensure people are in control of their care, and are receiving the right treatment and support they need.”

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Readers' comments (1)

  • I agree with many of the recommendations, as a mental health nurse, but the underlying problem with a move to less coercive mental health care is lack of funding and resources for community mental health care as an alternative to admission, and a lack of experienced staff.

    What does not appear to have been mentioned in the document, which does report a shortfall of 14% in mental health nurse vacancies, is that many posts have simply been cut, so that 14% shortage figure appears to be a gross underestimate. I would suggest that in community mental health teams the reduction in MH nursing posts is as high as 50%, that's based on the last 2 CMHTs I have worked for: one working age, one older adult. The staff that remain in those teams are often inexperienced, and staff turnover is high possibly as a result. There isn't a varied enough skill mix to ensure support for the less experienced staff. Even if the government were to shake its 'money tree', experienced staff are not prepared to work in these teams as they currently are: unmanageable caseload sizes, increasing documentation (since many trusts have switched to digital documentation the forms have increased massively and often are unwieldy, and the managers audit them more often so clinicians have to keep on top of them), and increasingly risky patients. I know the authors of the report suggest that mental health staff are too risk averse, but that is not my experience. We are currently carrying a lot of risk, and we are professionally liable. Standing in the dock of the Coroner's court is not pleasant, and we did not enter the profession to watch people die.

    Training budgets for mental health staff have also been cut to the bone. Even if training is available, many trusts have introduced fairly stringent conditions to recoup the costs if you dare to leave the Trust, even if you stay within the NHS. As a result of potentially incurring a £4k liability I recently refused training to become an AMHP, they are in very short supply.

    The use of personal budgets to support people in the community is also a mixed bag: it is very time consuming to arrange a personal budget, and then to audit them, and they are not always used effectively. Often we have not been able to find suitable support in the private sector for people with personal budgets: put simply no one tenders for the business.

    In addition, I have tried to interest many patients in having an Advance Statement under the current MHA. I have only had one patient agree to write one, even with support.

    Finally, suggesting the use of the incredibly slow and already overloaded Court of Protection for ECT under the MHA is potentially deadly. ECT is usually used as the last resort, especially in older adults who are not eating or drinking. How many people would die waiting? I am no fan of ECT but there is a reason it is still used: sometimes it is the only thing that will work.

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