Foreword

In our last report, Monitoring the Mental Health Act in 2019/20, we highlighted how mental health services had adapted to the COVID-19 pandemic, and the effect that this has had on patients, carers and staff. This year’s report reflects on the full year under the cloud of the pandemic.

This has been, of course, a time of unprecedented stress on services, staff, and on patients managing under restrictions introduced in response to the pandemic, as well as their detention in hospital under the Mental Health Act (MHA). There has been much tragic loss of life in mental health services, as everywhere else.

But both this year’s and last year’s reports also describe a story of resilience. In our discussions with patients, carers, advocates and staff during the year, people were appreciative of each other’s efforts. Some arrangements introduced in response to the pandemic have led to small improvements in patient care, for example better access to communications technology for contacting friends and relatives, or avoiding silo working between inpatient and community services.

In this report, we continue to emphasise the importance of person-centred care. This means, for example, maximising patient involvement in care-planning and decision-making. Despite strains on services, we still are able to report a number of good practice examples in this report.

NHS digital statistics on the use of the MHA, published in October 2021, while incomplete, suggest that during 2020/21 the overall use of the MHA increased by about 4.5%. This rise may in part reflect reduced access to community mental health services during the pandemic. It may also be that the reduction of inpatient bed capacity at the start of the pandemic led to an increase in the use of the MHA for the remaining bed capacity. This is not new; the impact of reduced bed capacity on use of the MHA was noted over a decade ago.

As discussed in this report, Black or Black British people are disproportionately likely to be detained under the MHA or be subject to community treatment orders; have longer periods of detention and more repeated admissions. They are also more likely to be subject to police holding powers under the MHA. It is commendable that the key motivation behind the current reform of the MHA is the injustice of this, as well as a wish to reverse the trend of rising detentions more generally. That reform process must, of course, look wider than mere changes to the wording of the statute. For example, MHA statistics for 2020/21 suggest that the rates of detention in the most economically deprived areas are more than three and a half times higher than the rate of detention in the least deprived areas.

Detention under the MHA is an intervention of last resort, but it can become necessary for want of any practical alternative or other resource that might otherwise have been available. At different points across mental health care people experience difficulty in getting access to the care they need, when they need it. The impact of this can be devastating.

In 2020, our report Out of sight – who cares? highlighted how not getting the right support early on could lead to people with a learning disability and autistic people being admitted to hospital. Even though these environments are often not therapeutic for people with a learning disability and autistic people, a lack of community alternatives has led to people being unable to leave, sometimes for years. In many cases, this has increased the risk of people being restrained, secluded or segregated.

As part of our ongoing work in this area, in December 2021 we published a progress report to highlight what has been achieved so far and which areas need more focus. To complement this, in this report we take an in-depth look at the findings from the Independent Care (Education) and Treatment Reviews for people with a learning disability and autistic people in long-term segregation, and the impact this has had on people and their families. A full progress report will be published in Spring 2022.

The data in this report on admissions of children and young people to adult facilities reflects the fact that, at times during the year, there were no available beds in suitable child and adolescent inpatient services to meet the needs of patients. The continued difficulty in discharging people with learning disability or autistic people from unsuitable services is, in part, due to the lack of alternative community placements or support.

Across the system, high bed occupancy levels slows inter-hospital transfers, and delays moving to lesser security when patients are ready for this. Addressing these areas of difficulty is not just a matter of increasing inpatient bed capacity, although that may be necessary in some cases. It is also about introducing system-wide solutions, including roles that track and review individuals and their care, and a focus on alternatives to admission and facilities for discharge to community services. We welcome government’s acknowledgement of the need for development in mental health services, and the Health and Social Care Committee’s establishment of an expert panel to evaluate progress on commitments.

We also welcome the government’s proposal to strengthen the role of CQC in monitoring the use of the MHA by extending the scope of our monitoring to those who commission services under the MHA. We feel this will strengthen our ability to take a system-wide view in monitoring the operation of the MHA. We are confident that this will be an addition to, and not a substitute for, our core statutory and National Preventive Mechanism function of visiting detained patients in hospital. We look forward to further discussion with DHSC in relation to the MHA reforms.

Jemima Burnage
Deputy Chief Inspector Hospitals and Lead for Mental Health

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