Comment: Overreaction? ‘Mentally ill patients sectioned unnecessarily’

14 August 2013

The Independent lead today on a story entitled ‘Mentally ill patients sectioned unnecessarily just to gain access to a hospital bed’. To summarise, the House of Commons Select Committee on Health has uncovered ‘more than anecdotal’ evidence that the shortage of voluntary beds for mentally disordered patients has led to doctors sectioning patients under section 2 of the Mental Health Act 1983 (MHA 1983) in order to trigger (rapid) involuntary admission. Under section 2, a patient may be admitted to hospital for mental heath assessment for a period of up to 28 days on the recommendation of two doctors if:

(a)he is suffering from mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment (or for assessment followed by medical treatment) for at least a limited period; and
(b)he ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons.

The Indy quote evidence from Dr Julie Chalmers ‘that, in some areas, “being detained is the ticket to getting a bed”’. Simon Lawton-Smith, from the Mental Health foundation is also states on the record that: ‘is [sic] was possible a clinician might section a patient who in the past would not have been sectioned in order to access a psychiatric unit’ (Indy’s paraphrase).

What should we make of this? Obviously, it is very concerning that there are not enough beds available for mentally disordered individuals seeking treatment. Mental health services suffer from underprioritisation, and individuals with mental health issues are subject to much undeserved stigma. People deserve better.

However, I also want to focus on the comments of Stephen Dorrell MP, the chair of the Health Select Committee, who said:

“This represents a serious violation of patients’ basic right and it is never acceptable for patients to be subjected to compulsory detention unless it is clinically necessary.”

I want to try outline how Dorrell’s response is possibly an overreaction, using the following hypothetical example:

Let’s say I’m a GP, and I have a patient, Nigel, who has possible mental health issues, but is not at present a risk to himself or others. Nigel, says that he would consent (let’s stipulate that he is able validly to consent) to mental health assessment and treatment on a voluntary basis. I explain to Nigel that there is a long waiting list in our area, and it is unlikely that he will be seen for assessment for some considerable time. I offer him the option of sectioning under section 2 MHA 1983, and explain the risks to him. In particular, I stress that discharge in involuntary detention cases is reliant on doctors’ clinical assessments, whereas voluntary patients can withdraw consent, which in principle will result in discharge (although the patient who withdraws consent runs the risk of being sectioned). Nigel consents to sectioning, and a colleague and I do the relevant paperwork.

To the extent that Nigel is not at present a risk to himself or others, Dorrell is right that sectioning is not clinically necessary. However, on the example that I have given, a) arguably sectioning is necessary, since it is the only way to access services in a timely fashion and b) it is hard to see how Nigel’s rights have been violated. On my scenario, Nigel’s interest in accessing mental health services has been promoted; he has voluntarily consented to being ‘involuntarily’ detained in order to receive the assessment and possible treatment he needs. Of course, the situation is not ideal, given the risk of actual involuntary detention once the 28 day period is up. However, if Nigel is aware and willing to accept this risk,* why should we deprive him of this option?

Of course, I have no evidence to suggest that this is what patients and doctors actually do in order to access mental health services.** Nevertheless, cases like Nigel’s may provide a plausible explanation for the some of the increase in sectioning. And if cases like Nigel’s do exist, I argue that what patients and doctors do is not wrong: they merely collude to game a dysfunctional system. If so, Dorrell (and others) should avoid making simplistic statements about people’s’ rights being violated when in fact they are being vindicated in a non ideal fashion.

*The risk might be mitigated if the treating mental health professionals are made aware that Nigel should really be a voluntary patient.

**Although Nigel’s case is perhaps analogous to those in which doctors manipulate insurance systems in order to provide care to the uninsured, for which there is substantial evidence.