As major reforms to mental health legislation have been unveiled, Breastfeeding time spoke with leading nurses to get their perspective on the proposals and the implications they have for the profession.
The government issued a new white paper in January outlining suggested changes to the Mental Health Act 1983 (MHA) that aim to give patients more control over their care and treatment.
The white paper paves the way for the introduction of a new mental health bill next year.
Under the plans, a higher threshold would be introduced to be able to detain someone under the law, in the hope that more people will be able to get the help they need outside of the hospital.
The new approach is based on four principles (see box below) widely welcomed by nurse leaders, as well as on commitments to reduce inequalities encountered under the current MHA for people from black, Asian and ethnic communities. minority (BAME) and those with learning disabilities or autism. .
But concerns have been expressed that the reforms may increase bureaucracy for mental health nurses and add additional pressure on community nursing teams, as well as funding being needed to support them.
Four principles of the Mental Health Act reforms
- Choice and autonomy – ensure respect for the opinions and choices of service users
- Less restriction – ensure that the powers of the law are used in the least restrictive way
- Therapeutic benefit – ensure that patients are supported to get better, so that they can be relieved of the act
- The person as an individual – ensure that patients are considered and treated as individuals
Alison Blofield, a nurse consultant working in inpatient mental health care at the Midlands Partnership NHS Foundation Trust, is one of the few nurses in England to be approved by the Secretary of Health as a ‘registered clinician’ for the purposes of MHA.
This status allows her to be designated as the “responsible clinician” of those detained under the law, which means that she is solely responsible for their care and treatment.
As the Royal College of Nursing’s expert representative on MHA, Ms Blofield contributed to the review by Sir Simon Wessely on which the white paper is based.
On the proposals, Ms Blofield said she welcomed the “additional safeguards” for patients they would create – citing the stricter detention criteria as one of them.
Currently, a person can be admitted for mental health treatment without consent if their symptoms pose a risk to themselves or to others.
However, as part of the reforms, it will have to be proven that the risk is “substantial” and the potential harm “significant”.
A new requirement to demonstrate that the detention of this person would have “therapeutic benefit” should also be added.
One of Ms Blofield’s concerns was the additional workload that would be created for staff through additional courts by giving patients more opportunities to appeal decisions.
She said the pressure would be felt not only by approved clinicians like her, but also by mental health nurses who had to provide evidence.
It would also be the role of the clinician responsible for completing and maintaining the care and treatment plans, which would become statutory for each patient detained.
In addition, Advance Choice Documents (ACDs) could be introduced to allow people to express their care and treatment preferences before they need to go to hospital.
As part of the reforms, legally, DCOs should be factored into the care and treatment plan if a patient lacks capacity.
Ms Blofield hailed the move because of the “choice and autonomy” it would give to patients, but noted that it could cause “strain” and “hardship” for nurses, if patients’ wishes went against what they thought was best, based on clinical evidence and experience. .
One proposal that she said would be most welcomed by nurses was to allow patients to choose a “designated person” to represent them.
Currently, the next of kin is automatically selected – and could be someone whose patient is far away or who has caused them additional distress.
Ms Blofield also “absolutely” supported proposals to reduce inappropriate admissions for people with learning disabilities and autism.
“We have had examples where I think the nurses provided the best care possible, but the patient did not receive the best care because it was not proper care, and often they stay in the hospital way too long. a long time, ”she said.
Meanwhile, she noted that the higher detention threshold could cause community nurses to deal with people who were “sicker than those with current cases.”
She did not disagree with the stricter criteria, saying “there is a lot more we could do in the community”, but said more resources would be needed to do so.
Her comments were mirrored by Sean Duggan, chief executive of the NHS Confederation Mental Health Network, and a former mental health nurse.
“There may be new challenges – community nurses may work with patients at a higher level of risk, for example – but by expanding and improving community services, nurses will be better able to care for people before. that they do not reach the crisis ”, he declared.
Another commitment in the white paper concerns the creation of a “clearer line” between the MHA and the Mental Capacity Act 2005 (MCA) and, in particular, the Deprivation of Liberty Protections (DoLS).
He noted how the confusion between laws, as well as the administrative burdens associated with DoLS, meant that in some cases MHA could be used when MCA was best.
By April 2022, DoLS is expected to be replaced with a new “simpler” process called Liberty Protection Safeguards, which the government hoped would fix problems.
However, it does not exclude going further and seeks feedback on the subject, within the framework of a public consultation on white paper.
Gemma Robinson, MCA Officer and Appointed Adult Protection Nurse at the Rotherham NHS Foundation Trust, helps nurses use both acts.
For her, the decision to detain someone under the MHA or submit them to DoLS should always be made “on an individual person basis”.
However, she admitted that there was some confusion and that the distinction between the legislation “probably needs to be a bit more black and white”.
“I don’t think you can put people in a box, but you need a clearer path for people to understand and [one they] are more likely to use correctly, ”she said.
She added that if the LPS and the new reformed MHA were deployed at the same time, it would be a good opportunity to educate staff about them at the same time.
Meanwhile, Steve Morgan, MHA leader and associate director of nursing at Mersey Care NHS Foundation Trust, said the commitment to make a clearer distinction between MHA and MCA was “probably the most important thing. important “for him since the redesign.
Noting that he didn’t think the MCA was widely understood, he added, “I absolutely applaud the idea that they’re trying to tell the difference between the two acts much more clearly. If we could do that, we would have solved a real problem.
He echoed the concerns Ms Blofield raised about DCOs and how it would work in practice.
Coupled with the new legal care plans, Mr Morgan said: “It could get more bureaucratic, which is always a concern for nurses who are in the field.”
He said the four principles of the reform could not be questioned, but noted that the test for therapeutic benefit could be “quite difficult to prove, especially for certain groups of patients such as those with the disorder. of personality ”.
Clarification was also needed on funding, he said, as the white paper stated that the submission of proposals was “subject to future funding decisions”.
Dave Munday, senior professional mental health manager at Unite, which hosts the Mental Health Nurses Association, said it was critical that the commitments made in the white paper to address issues under the MHA for members BAME communities are respected.
Currently, blacks are four times more likely than whites to be detained under the law and experience poorer outcomes.
“The staff I have spoken to since the launch of the review absolutely support the idealized attempt to address these issues,” he said.
“But they fear that these are just warm words with no action behind them.”
Closer work for nurses and paramedics
The new white paper reaffirms the NHS ‘commitment to bringing mental health nurses into ambulance control rooms.
The move “would improve triage and response to mental health calls, and increase the mental health skills of ambulance personnel through an education and training program,” he said.
The London Ambulance Service NHS Trust has had mental health nurses in its control room clinical center since 2015.
Due to the success of this initiative, in 2018 it launched an emergency car service so mental health nurses can accompany paramedics on calls where psychological care might be needed.
Carly Lynch (pictured below), nurse consultant in mental health to the trust, said: “Mental health nurses play a crucial role in the clinical center of the control room, providing an enhanced telephone assessment for patients in mental health crisis, clinical monitoring thereof. awaiting response and guidance to on-site teams to ensure they and our patients receive the support they need. “