The SARS-Cov-2 pandemic has produced challenges for mental health services, but it also provides opportunities to reassess and improve our mental health care system. When National Health Service England (NHSE) asked service providers to free up inpatient capacity1, many, particularly in London, discharged large numbers with informal reports of up to a fifth of people who were previously detained being discharged. In Lombardy and Madrid mental health beds were closed and wards converted for Covid-19 patients, but clinical colleagues tell us that this was not achieved by discharging people who had been legally detained. If we understand how this discharge rate was achieved, and why it was different to other services in Europe then we might be able to improve services in the future.
There have been no changes to the detention criteria that could justify why people who pre-covid warranted formal detention, now no longer warranting that detention now the pandemic is upon us. These discharge rates raise questions about whether the threshold for detention was adequately stewarded pre-covid-19. Perhaps we have been depriving people with mental health difficulties of their liberty unjustly?
More than 50,000 new detentions occurred in 2018-192 and since 2006-7 there has been a 40% increase. Disturbingly there is also a disparity in the rates of detention among ethnic minority groups, with individuals from black ethnic groups being four times more likely to be detained than those from white groups.2 The Mental Health Act (MHA, 1983) defines the legal framework, the individual’s right to assessment and treatment in hospital, and the pathways back into the community. Detention under the Act requires that someone is considered to pose a risk to themselves or to others.
One driver for these discharges was the NHSE and Chancellor of the Exchequer saying, “Whatever extra resources our NHS needs to cope with coronavirus – it will get”. The purpose of “maximis(ing) capacity where needed across mental health and learning disability and autism services” is to “free up inpatient capacity” and “as providers seek to safely discharge as many patients as possible, those with beds on acute trust campuses should also consider how those will be configured in the context of increasing pressures on critical care”(p4-6).1
Did these individuals, in fact, pose continuous risks to themselves or others? As these are the grounds for continued detention. If they fared reasonably well on discharge, then how did our clinical judgment become so skewed that we started to detain people unjustly? We also need to understand if these rapid discharge decisions differentially affected people from ethnic minority communities?
Discharge decisions were made at top speed—how was this possible? The levers included a stringent senior management review and, importantly, lifting economic barriers to discharge allowing suitable accommodation to be found. But financial pressures are not a reason for continuing to detain someone in hospital against their will.
Investigating discharge effects will not be easy as staff shortages, caused by the pandemic, mean that community follow up has been limited and atypical. Some poor outcomes might be attributed to this limited community support, rather than the appropriateness of the person’s continued formal detention. Quarantine is also associated with stress3 and “lockdown” affects people with pre-existing mental health difficulties disproportionately.4 These effects may lead to spikes in readmission rates which could look like continued detention would have been justified.
Psychiatric teams may have focused too much on optimising symptom control but many people experience symptoms and yet function well enough if there is adequate provision for their psychosocial needs (housing, employment, health etc). If we are to move mental health services “back to better” then we will need a review of how decisions are made and their consequences.
An individual’s view of the therapeutic value of inpatient wards also affects the chance of their accepting admission.5 We know that introducing psychological or other evidence-based treatments to inpatient wards improves therapeutic value views of those and is also another part of “back to better”.6
Mental health services have an opportunity to review health and social care in a holistic and population-based way in a post-covid world. Partnerships across health and social care are no longer an option but an imperative. Investment in these services is critical if we are not to return to old practices. Collaboration with third sector providers, voluntary and faith groups, informal networks, and families and carers needs to take place on a wholly different scale with a shift in the balance of power towards enabling people to make decisions in their own best interest. This is the reason the Mental Health Act was reviewed (The MHA Review, 2018)7 and we look forward to the government acting on it.
Alison Beck, Head of Psychology and Psychotherapy at South London and Maudsley NHS Foundation Trust.
Til Wykes, Professor of Clinical Psychology and Rehabilitation, Institute of Psychiatry, Psychology & Neuroscience, King’s College London
Competing interests: None declared
1 Managing capacity and demand within inpatient and community mental health, learning disabilities and autism services for all ages. 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/Managing-demand-and-capacity-across-MH-LDA-services_25-March-final-1.pdf(accessed 27th April 2020).
2 Mental Health Act Statistics, Annual Figures 2018-19. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-act-statistics-annual-figures/2018-19-annual-figures (accessed 27th April 2020).
3 Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, Rubin GJ. The psychological impact of quarantine and how to reduce it: rapid review of the evidence.Lancet2020; 395: 912-920.
4 Jeong H, Yim HW, Song YJ, Ki M, Min JA, Cho J, Chae JH. Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiology and health2016; 38.
5 Csipke E, Williams P, Rose D, Koeser L, McCrone P, Wykes T, Craig T. Following the Francis report: investigating patient experience of mental health in-patient care. The British Journal of Psychiatry2016; 209(1): 35-9.
6 Wykes T, Csipke E, Williams P, Koeser L, Nash S, Rose D, Craig T, McCrone P. Improving patient experiences of mental health inpatient care: a randomised controlled trial. Psychological medicine2018; 48(3): 488-97.
7 Modernising the Mental Health Act Increasing choice, reducing compulsion. 2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/778897/Modernising_the_Mental_Health_Act_-_increasing_choice__reducing_compulsion.pdf (accessed 27th April 2020).