CHAPTER SEVEN CONCLUSIONS & RECOMENDATIONS
The overall aim of the research was to explore the detailed operation of the MHTS, with a specific focus on processes that are perceived to have increased the number of interim compulsory treatment orders. In order to address this overarching aim, five specific objectives were outlined by the commissioning team. The starting point for this chapter will be to re-visit these objectives, to draw together the evidence from all three strands of the research, and to put forward conclusions. The chapter will then present recommendations for the future development of the MHTS process, which can inform the review of the MHSA.
The operation and impact of the MHTS, in practice, from the perspectives of all relevant stakeholder groups.
There was consensus that the new system had improved patients' experiences, and reflected the guiding principles, by being:
- Fairer for patients than the Sheriff Court system
- More 'patient focused' - it was deemed friendly, open and accountable
- More participatory, allowing patients to feel that they were listened to (even if they do not agree with the final decision) and to have a voice.
However, there were concerns that:
- It can be very upsetting for patients and families to hear the evidence presented and have their mental ill health discussed in front of strangers.
- The new system may have a damaging impact on the therapeutic relationship between a patient and their psychiatrist/ MHO, especially if they are giving evidence to support a CTO that the patient does not want.
- Some venues were criticised as being inappropriate for hearings - for example, insufficient or non-existent, private space for families and for patients to talk to their solicitor.
The data collected for administrative purposes by MHTS and local authorities and health boards may not be wholly adequate for a wider monitoring and audit function. In particular, the format of data processing with uncoded free text entered in PDF format, inhibited certain analyses which may be useful - for example, by diagnostic category.
The input and impact of the range of participants who may be involved in each MHTS hearing
The participation of the range of people other than panel members who may be required or may wish to attend a hearing (including the MHO, the RMO, solicitors, Advocates, Named Persons, social workers, CPNs and patients themselves) is affected by the sometimes short notice of hearings.
The processes involved in making a civil order under MHSA which may be contributing towards the high level of interim orders and multiple hearings.
In general, respondents tended to support the view that the number of iCTOs was high, but it was apparent that this was seen, to some extent, as an inevitable consequence of the new patient-centred system. Despite this, a number of suggestions were made to explain why so many iCTOs were granted. The most common reasons cited were:
- The need to appoint a Curator Ad Litem (which has since been resolved)
- Requests for an Independent Medical Report ( IMR) which it may not be possible to conduct in time.
While there was general agreement that it is every patient's right to request a second opinion via an IMR, there were concerns that its use can sometimes be for 'dubious reasons', including suggestions that some solicitors may use the IMR as a stalling tactics for their own financial gain. However, it was also clear that there were several "legitimate" reasons that were outwith solicitors' control why - within the context of the requirement to hold a hearing within a short time period, - an IMR cannot be conducted in time and may result in an iCTO. These include late notice of a hearing where there is no time to organise an IMR in advance, and a shortage of psychiatrists (which seem to be more of a problem in Highland than the central belt) to conduct an IMR.
There were also concerns that the electronic submission of applications was hampered on the one hand by a lack of knowledge that this facility was available and, on the other hand, by technical difficulties associated with electronic submission.
The administrative processes may also be hampered by the often late arrival of CTO applications within the 28 day STDO period, leaving little time to fulfil the MHSA stipulation for hearings to be convened with five days of a STDO expiring.
External factors which may be affecting the efficacy or efficiency of MHTS processes.
The main external factors identified by respondents was the need to work within the constraints of the Act. In particular, the timing of hearings within a narrow window and the sometimes compounding influence of late submissions.
The costs of the MHTS system, in total and on an individual case and hearing basis.
- The total audited costs for MHTS-related activity in 2006-07 are estimated at £12,784,909. This includes all MHTS administration costs, SLAB costs and known costs associated for the time of RMOs, MHOs and medical records staff. MHTS Administration costs accounted for £8,301,000, with Panel Members' fees accounting for more than 50% of the total. Total SLAB costs were £1,997,000 which includes the cost of solicitors' time and expenses, independent medical reports and curators. Many of the costs incurred by local authorities and health boards relating to mental health tribunals are subsumed within existing budgets and, therefore, it was not possible to provide any accurate figures for how much they spend on tribunal related activities. However, local authorities currently receive an annual grant of £13 million to improve mental health services and help implement the MHSA 2003. As the precise allocation of these funds is not known and cannot be attributed to defined areas of work (be they capital or recurrent), they are not reflected in the figures presented here.
The average cost per hearing is estimated at £3,774. This includes the costs for MHTS Administration, Man of Skill, SLAB, independent medical reports, time spent by RMOs, MHOs and medical records staff but no further costs covered by local authorities or health boards. However, if the grants to local authorities and health boards are included, then the actual cost per hearing is almost certainly considerably greater.
Recommendations
The research informants made a number of suggestions about how the MHTS might be improved. We believe there is a greater utility in working with key groups to consider whether and how perceived deficiencies might be addressed and changes to practice might be incorporated and are, therefore, wary of presenting these as recommendations per se.
Throughout the rest of this chapter we will highlight the possible changes and revisions to practice which flow from the findings, drawing on the observations and insights of the informants both within interviews and group discussions, but also from the System Mapping Event. The System Mapping Event deliberations are also presented in a stand-alone document which was sent to participants ( see appendix H).
Improving systems for monitoring and audit
- Ensure that the data are processed in a format that allows statistical analysis of key variables in relation to information that is not currently accessible in a format for statistical analysis, such as diagnosis
- If a more informed picture of health board and local authority costs are required, there is a need to develop systems for recording time and costs associated with Tribunals
Improving systems for the submission and processing of CTO applications
- Revision of the application form to make it more user-friendly and to avoid repetition
- Improve mechanisms for submission, particularly so that applications can be submitted by email, ensuring that all relevant parties are aware that they can submit electronically
- Pre-tribunal preparation and screening by MHTS to facilitate earlier identification of errors or omissions, or the need for a Curator Ad Litem, legal representation and an independent medical report
- Consider whether variations to CTO need to be heard at a hearing or whether that can they be dealt with more efficiently by paper
- Where an appeal is lodged against a CTO, the papers from the original application should be made available to the appeal Tribunal. The report for that hearing should then describe the case history since the last hearing/ decision.
Specific roles
- Involve Advocacy workers earlier on in discussions around the need for a CTO as they might encourage the patient to take treatment voluntarily and negate the need for a CTO
- The appointment of the Curator Ad Litem before the first hearing could reduce the number of interim orders and reduce costs, time and effort, but requires a decision about who has the financial responsibility for the appointment.
Dealing with the consequences of the legal / evidential nature of the tribunals
Consider ways in which the possible negative impact on the therapeutic relationship of legal requirements to cross examine might be minimised, including:
- Avoidance of repeated oral hearings in which the reasons for a patient's detention are reiterated.
- Replace RMOs' full reports with a brief statement indicating that each of the 5 criteria have been met. (The RMO is present for the hearing and so could elaborate if necessary).
- Consider whether all patients coming to Tribunal should routinely have an independent medical opinion. The increase in efficiency and reduction in interim treatment orders would more than compensate for the increased report-writing.
Training
Some of the actors in the MHTS process may contribute to delays or confusion because they do not fully understand the law or complete the forms as intended. There is a need, in the first instance to:
- Review the training that is available and its take-up, both for those coming new to the process and as a 'refresher'
- Consider ways in which understanding the roles and perspectives of other participants might be facilitated
- Improve understanding of the role of the Named Person
- Increase number of MHOs, particularly in geographically widespread areas; and political commitment to organise and pay for out-of-hours MHO cover
- Address the real deficit, particularly in rural areas, in the number of lawyers skilled and enthusiastic to represent clients at Tribunals and psychiatrists to conduct IMRs
- There is a need to encourage a greater number of lawyers to undertake mental health work and to provide training as part of that process
- Increase efforts to recruit and train more members of the public, service users and carers to be panel members
The Act and MHTS
Finally in relation to the terms of the Act itself and its administration:
- There were suggestions that the number of applications for CTOs could be significantly reduced if the duration of the STDO was increased to 42 days to allow improvements to patients' response to treatment to become manifest, or
- Consider extending the five day period of grace to give the administration more time to process the application and organise a hearing, and therefore, address the problems associated with the current short notice for hearings.
- Merge the MHTS with all Scottish tribunals into one body. This could enhance staff opportunities, venues could be shared and therefore be closer to where people live, and better use would be made of clerk and clerk assistant time.