Time for fundamental reform?

Sasha Walton reports from the King’s College London’s Maudsley Debate at Institute of Psychiatry, Psychology and Neuroscience (IoPPN).

The prestigious Maudsley Debates provide an opportunity for open discussions between academics, clinicians and policymakers on current issues within mental health. From practice to policy, these events are open to all, and offer a platform for voices at the grassroots to be heard.

The most recent debate was particularly poignant, in light of the Prime Minister’s announcement earlier this year for a review of the 1983 Mental Health Act, in a pledge to 'tackle the long-standing injustices of discrimination in our mental health system once and for all.' With over 60,000 people involuntarily sectioned in 2015-16, a disproportionate number of whom are Black, Asian and minority ethnic (BAME) individuals, it is time for a fundamental change of the way in which mental health is managed. But would a reform of the Act make the difference? Or perhaps it is an unnecessary distraction from other solutions?

Chaired by Professor Anthony David, Professor of Neuropsychiatry and Vice Dean at the IoPPN, the house proposed that fundamental reform of the Act is required to reduce discrimination and unnecessary detention. As a temperature check of the room, initial votes were cast by audience members – the majority agreed fundamental reform was necessary (124 votes), whilst a minority opposed (41 votes) and 63 voters abstained. It was time to hear what the speakers had to say. 

The proposing team kicked off the debate, with Professor George Szmukler, Professor of Psychiatry and Society in the IoPPN, raising his concerns the use of the current legislation. Current criteria, he argued, are open to interpretation and further perpetuate common discriminatory stereotypes of psychiatric patients. Individuals are often denied the right to make their own treatment decisions, and may face periods of detention against their will. These actions drive perceptions of those with mental illness as intrinsically dangerous, and incapable of making their own decisions. 'The decision that somebody lacks capacity is, in the view of many people, overridden by the fact that they have a mental disorder,' Professor Szmukler argued, 'and so they can be treated involuntarily despite fully having capacity.' Dismayed by the different standards of care to which mental health and non-mental health patients are held, Professor Szmukler called for capacity-based decision-making legislation, applicable to all.

Opposing speaker Professor Scott Weich, Professor of Mental Health at the University of Sheffield, raised concern over the viability of a capacity-based model in the real world. 'Judgements about capacity are situation specific, time limited, multi-dimensional and notoriously complicated in the real world', he argued. 'Overestimating somebody’s capacity to make life-changing or life-ending decisions runs a tremendous risk and that’s one as clinicians that we would find extremely difficult.' Perhaps our focus should instead be on resourcing rather than legislation, argued Professor Weich. Greater resourcing would allow us to invest in preventing crisis situations before they lead to detention. Between 2010 and 2015, he cited, NHS mental health budgets fell by eight per cent and local authorities social care budgets by 13 per cent, depriving many of the crucial preventative care they require. 'Unless services are properly funded, changing the law isn’t going to make things better for patients and it could make them worse.' 

Legislative reform, not resourcing issues are at the heart of this debate, interjected proposition speaker Rt Hon Norman Lamb MP, Liberal Democrat MP for North Norfolk, and there is a danger of conflating these separate issues. Reform of the Act is essential, he continued, in order to reduce discrimination in vulnerable groups. In reference to a green paper he published in 2015, he expressed concern about discrimination against those with learning disabilities and autism. 'Too often they end up in long-term detention,' he argued, '[which is] in my view a denial of their human rights.' In agreement with Professor Szmukler’s capacity-based model he highlighted current legislation in Northern Ireland which has equal protocol for assessing mental health and non-mental health patients. 'The Bamford review, which led to the reform in Northern Ireland said having one law for decisions about physical illness, and another for mental illness is anomalous, confusing and unjust.' Addressing the social determinants of ill mental health, including poverty, poor housing and discrimination could also help to reduce bias within the system.

Opposing speaker Professor Annie Bartlett, Forensic Psychiatrist and Advisor for the Department of Health, provided final remarks. Although not an advocate of the Act in its current form, Professor Bartlett argues we must look at alternatives for improving patient experience. 'Changing the law is not the same as changing the patient experience. We need to put our existing house in order, not just attempt to build a new one.' In particular she emphasised how exceptionally difficult it is to change the law. Describing the previous amendments to the Act in 2007, she highlighted the amount of time and money that were required, and that this did little to improve patient experiences. Future reform may be less fruitful, and has the potential to cause later issues. To close, she noted, 'we should consider our capacity, not our patient’s capacity, to make things worse than they are already.' 

Before the closing vote from audience members, there was time for some additional points from Professor Sir Simon Wessley, Chair of the current independent review of the Mental Health Act. He noted that fundamental reform alone would not reduce stigma or discrimination. With a Government currently pressed by issues surrounding Brexit, there is limited bandwidth for the legislative time required to consider reform of the Act. 'It’s an awful time to be contemplating major reform because there isn’t the space. So we want to take a longer term view for perhaps when we have a slightly more stable situation in which we could affect change.' 

To end the debate, a recount on audience votes revealed that perhaps there are more serious factors to consider before we move ahead with reform. In a landslide shift in opinion, the majority now opposed the motion of fundamental reform of the Act (115 votes), whilst a minority still believe this was the best option (96 votes) and 22 abstained. 

Sasha Walton is a freelance medical writer with a BSc in Psychology and MSc in Neuroscience.

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