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Modernising the Mental Health Act Increasing choice, reducing compulsion Final report of the Independent Review of the Mental Health Act 1983 December 2018 © Crown copyright 2018 Published to GOV.UK in pdf format only. www.gov.uk/dhsc This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open- government-licence/version/3 Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. 1 Contents FOREWORD - REVIEW CHAIR .......................................................................................... 4 INTRODUCTION AND EXECUTIVE SUMMARY - REVIEW CHAIR AND VICE CHAIRS. 16 LETTER FROM THE REVIEW'S SERVICE USER AND CARER GROUP ....................... 35 HOW THE REVIEW CARRIED OUT ITS WORK .............................................................. 39 THE CASE FOR CHANGE ................................................................................................ 45 UNDERSTANDING RISING RATES OF DETENTION .................................................. 49 SERVICE USER EXPERIENCE ..................................................................................... 53 STEPS TO TACKLE THE DISPROPORTIONATE NUMBER OF PEOPLE FROM ETHNIC MINORITY COMMUNITIES DETAINED UNDER THE ACT ............................ 58 HOW WE ARE MEETING OUR HUMAN RIGHTS OBLIGATIONS ................................ 60 MENTAL CAPACITY AND DECISION MAKING IN THE MHA....................................... 63 A NOTE ABOUT LANGUAGE ........................................................................................ 64 NEW MENTAL HEALTH ACT PURPOSE AND PRINCIPLES .......................................... 65 PRINCIPLE 1 - CHOICE AND AUTONOMY ...................................................................... 69 MAKING DECISIONS ABOUT CARE AND TREATMENT ............................................. 69 FAMILY AND CARER INVOLVEMENT .......................................................................... 85 ADVOCACY ................................................................................................................... 90 COMPLAINTS ................................................................................................................ 95 DEATHS IN DETENTION ............................................................................................... 98 PRINCIPLE 2 - LEAST RESTRICTION ........................................................................... 103 TACKLING THE RISING RATES OF DETENTION ...................................................... 103 CRITERIA FOR DETENTION ....................................................................................... 109 A STATUTORY CARE AND TREATMENT PLAN ........................................................ 114 LENGTH OF DETENTION ........................................................................................... 117 CHALLENGING DETENTION ...................................................................................... 122 DEPRIVATION OF LIBERTY: MCA OR MHA? ............................................................ 126 COMMUNITY TREATMENT ORDERS (CTOs) ............................................................ 132 COERCION AND RESTRICTIVE PRACTICES WITHIN INPATIENT SETTINGS ....... 140 PRINCIPLE 3 - THERAPEUTIC BENEFIT ...................................................................... 142 CARE PLANNING AND AFTER-CARE ........................................................................ 142 HOSPITAL VISITORS .................................................................................................. 149 INPATIENT SOCIAL ENVIRONMENTS ....................................................................... 152 2 INPATIENT PHYSICAL ENVIRONMENTS .................................................................. 154 PRINCIPLE 4 - THE PERSON AS AN INDIVIDUAL ........................................................ 158 PERSON CENTRED CARE ......................................................................................... 158 RECOGNITION OF PATIENT INDIVIDUALITY AT THE TRIBUNAL ........................... 161 THE EXPERIENCES OF PEOPLE FROM ETHNIC MINORITYCOMMUNITIES ........ 163 CHILDREN AND YOUNG PEOPLE ............................................................................. 173 PEOPLE WITH LEARNING DISABILTIES, AUTISM OR BOTH .................................. 183 POLICING AND THE MHA ........................................................................................... 191 PATIENTS IN THE CRIMINAL JUSTICE SYSTEM ...................................................... 197 IMMIGRATION DETENTION ........................................................................................ 205 VICTIMS ....................................................................................................................... 207 SYSTEM-WIDE ENABLERS ........................................................................................... 209 DATA ............................................................................................................................ 209 DIGITAL ENABLERS ................................................................................................... 212 QUALITY IMPROVEMENT AND MONITORING .......................................................... 214 STAFFING .................................................................................................................... 215 THE APPLICATION OF THIS REVIEW IN WALES ......................................................... 220 THE FUTURE DIRECTION OF TRAVEL – FUSION OF THE MHA AND MCA ............... 222 CONCLUSION ................................................................................................................. 228 AFTERWORD - REVIEW CHAIR .................................................................................... 229 ANNEXES ........................................................................................................................ 232 Annex A: Treatment choices......................................................................................... 232 Annex B: Treatment of involuntary placement/treatment and mental capacity by international and regional human rights bodies ............................................................ 241 Annex C: Summaries of commissioned evidence ......................................................... 248 A qualitative exploration of perspectives on the Mental Health Act and people of African and Caribbean descent: summary ................................................................................................................................. 290 Annex D: Qualitative analysis of the Service User and Carer Mental Health Act survey ..................................................................................................................................... 296 Our Recommendations ................................................................................................. 297 The Review Team ........................................................................................................ 315 Glossary ....................................................................................................................... 316 Acronyms ..................................................................................................................... 320 3 FOREWORD - REVIEW CHAIR It has been an honour to Chair this Independent Review of the Mental Health Act. But it has been more than that - a great responsibility and a profoundly moving experience. I have learnt much as the Review progressed, as well as having the opportunity to meet a remarkable range of people. The result is an extraordinary piece of collaboration, across a range of disciplines, putting into the practice the principles of co-production with patients and service users, which some outside observers have described as a model for future independent reports requested by government. But what follows is a single voice - my personal view on the background to the Review and some of the issues that shaped my thinking as the year progressed. Should you wish to hear from me again, I will also sum up what this means and pay tribute to all of those who have made this possible in a brief afterword. For those of you who have opened this document to find out what we have recommended, my first recommendation is to skip this introduction and move straight to the next section. Why do we have Mental Health Acts? On the one hand, the Mental Health Act takes away your liberty and imposes treatment that you don’t want. It can be traumatic, frightening and confusing. But on the other it can help restore health, and even be life-saving. It is an imposition on personal freedom, but it can also help people to become freer from the pain and distress that accompanies the most severe of mental illnesses. This paradox or tension is nothing new. Society and State have been debating for two centuries or more how to balance an individual's right to autonomy with the desire of a civilised society to protect its most vulnerable. Our cultural and ethical traditions support the concept of autonomy. Allowing everyone to make the decisions that affect their life and accept the consequences of those decisions is a key aspect of respecting the unique value and character of each human person. And in recent years it has become clearer that there
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