Should the English Mental Health Act be reformed in light of the CQC review?
A “A series of errors and misjudgments” at Valdo Calocane’s mental health service led to him being discharged – even though he repeatedly missed his medication and showed signs of aggression – months before he killed three people in Nottingham, a Care Quality Commission (CQC) investigation has found.
The Guardian spoke to experts about how mental health services in England can be improved to better prevent future tragedies.
Ensure proper enforcement of the current powers of the Mental Health Act
According to Professor Sir Simon Wessely, chair of the independent review of the Mental Health Act, while reform of the current legislation is necessary, it is clear that the powers already provided in the Act have not been properly implemented in the case of the failings that led to the deaths of three people in Calocane.
“The need to reform the Mental Health Act is not one of those issues, because it is quite clear that the necessary powers that could have prevented the killings already exist,” Wessely said. “The question that needs to be answered is not what needs to change, but why the existing powers to compel Calocane to undergo treatment against his will were not used. Of course, we cannot know what would have happened differently if they had been used, but I think most people would agree that the likelihood of the tragedy would have been significantly reduced.
“The tragedy in Nottingham does not necessarily require an overhaul of the MHA – instead we should look to the inquiry to ask why existing powers that could have prevented the horror were not deployed.”
Despite this, Wessely insisted that reform of the Mental Health Act was vital. “The reasons that drove the review have not gone away and are just as important, if not more important, than ever before,” he said.
Greater understanding of conditions such as psychosis
Prof Anthony David, Director of the UCL Institute of Mental Health, explained that serious conditions such as psychosis often affect a person’s insight.
He argued that mental health professionals need to gain a better understanding of conditions such as psychosis and should not be afraid to assess the extent to which patients are able to recognise and accept that they have a mental illness.
“Some mental health professionals avoid attributing a lack of insight to patients because they think it is just labeling or discrimination, but insight strongly predicts the need for treatment, decision-making capacity, and has both a neurological and social basis. This requires more understanding,” David said.
Cultural change in the way mental health is treated
Dr Vishal Bhavsar, a psychiatrist who works in forensic and parental mental health in south-east London, said a culture change was needed in NHS mental health services around violence and around the way professionals worked with families. “This isn’t just about training – we need training that is supported by organisational leadership and the right support and supervision for all staff.”
Andy Bell, the director of the Centre for Mental Health, also called for a change in culture. “It is clear that the experiences of many people with mental health support is that there is a culture of delayed intervention, waiting until someone reaches a crisis point before they get support, and not listening to people and families when they ask for help,” he said.
Increase in mental health resources
Minesh Patel, deputy director of policy and campaigns at Mind, said the mental health system in England was at “breaking point”.
“There is an urgent need to deliver not just the quality care but also the safety that people with mental health problems and the public need,” Patel said. “A clear commitment to prioritise and address the mental health crisis, which has been growing for years, is essential. The human cost of deprioritising mental health is clear, not only in the devastating Nottingham case, but also through abuse and neglect scandals such as Edenfield, Huntercombe and Cheadle Royal Hospital.”
A lack of resources was also acknowledged by Bell, who said: “We can’t ignore the fact that mental health has been relatively underfunded compared to other areas of health for decades. That’s important because it’s one of the reasons why we see people having to wait for long periods of time, and people being turned away and being told they’re not sick enough, and people being discharged when they clearly still have an ongoing need.
“If we had adequate funding, those things would certainly be less likely. So we need to look at why we continue to disadvantage mental health care compared to other areas of health care.”
Reform of the Mental Health Act
Brian Dow, deputy chief executive of Rethink Mental Illness, argued that reform of the Mental Health Act is long overdue. “Too often we hear about how people with serious mental illness spend their lives in the revolving door of hospital admissions and community care,” he said. “Reform offers the opportunity to give people more choice in their treatment and more confidence in the system, factors that play a huge role in supporting people’s recovery.”
Dr Lade Smith, president of the Royal College of Psychiatrists, said that given the tragic circumstances surrounding the Nottingham bombings, “there has been increased focus on reform of the Mental Health Act in England and Wales. The safety of patients and the public is one of the most important functions of the Act and that must continue to be the case.”
Smith added: “The government should focus its efforts on ensuring that people with mental illness receive timely, evidence-based treatment.”
More attention to prevention in mental health care
Mark Rowland, chief executive of the Mental Health Foundation, said prevention had to be the focus of reform. “Anyone who has had any experience of mental health in England will tell you that despite incredible progress, the system is still in a precarious state,” he said. “Our current approach invests almost nothing in prevention and cases like Valdo Calocane’s are the tragic consequences.”