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CHAPTER 8: CONCLUSIONS AND RECOMMENDATIONS
8.1 This research was carried out within the first year and a half of the introduction of the new Mental Health (Care and Treatment) (Scotland) Act 2003. The picture the research paints is complex. Although there was general support for the principles of the MHCT Act and admission that the legislation was undoubtedly better for patients, some of the procedures and tasks that came with the new legislation were causing concern to staff groups involved in the detention process.
8.2 It is important to recognise that the time/cost aspects of the research is merely a cost analysis and says nothing about the outcome of the MHCT Act relative to the 1984 Act. Future research should seek to establish whether these procedures and policies are value for money, whether the added time and cost equates to improved outcomes for patients subject to the new legislation and mental health service users in general. As such it will be essential to assess how the MHCT Act is impacting on patients to ascertain whether the new aspects of the legislation are being effective. In relation to this the Scottish Executive has commissioned a cohort study to explore service user, carer and service professional experience of living and working under the new Act (which will report in 2008).
8.3 The data presented on the extra time and cost of each order seems to indicate that in some cases the cost has more than doubled. Whether this will continue at this rate will remain to be seen, as individuals become more accustomed to the workings of the Act and some of the more time-consuming and potentially expensive elements are re-assessed.
8.4 The research found that professionals were acutely aware of their roles in relation to the new legislation and that this work was being given a high priority. The question then arises as to what this means for other services. There is a real need to look at whether other services are being compromised because of the prioritization of MHCT Act work. There is a great deal of concern that a two-tier system of care may develop where the non-detained population of mental health service users will lose out because of the workload demands of the new legislation.
8.5 The impact of the extra time being spent on MHCT Act work was crucial to professionals' concerns. Where MHCT Act work had been prioritized, according to respondents this had a negative impact on other work and services (particularly for non-detained patients), most notably for psychiatrists in the delay or cancellation of clinics, on how much CPA work was being carried out, the inability to attend meetings or offer adequate teaching slots. The extra duties carried out by MHOs (particularly those with other social work duties) meant that there was less time for other aspects of their job such as CPA, direct contact with clients and with work relating to the AWI Act. It would seem there is a risk that for this group the responsibilities under the AWI Act and the MHCT Act might eventually outstrip capacity.
8.6 Some areas have taken a strategic approach and redesigned services ( e.g. introduction of designated MHOs). Elsewhere there seems to be a more individual and reactive approach, for example, people canceling individual clinics, ward rounds and similar. There does not seem as yet to be any planned approach to how additional workloads of perhaps a few hours per week will be managed.
8.7 It is clear that the impact of the extra activities involved in carrying out MHCT Act work needs to be monitored in a systematic way to ensure that other services are not being detrimentally affected in the long-term.
8.8 The introduction of the Mental Health Tribunal for Scotland was on the whole seen as a welcome addition to the law in relation to patients' rights. Experiences of attending tribunal hearings did vary and it was clear that there were still a number of issues that needed to be 'ironed out'. In particular the matter of when the necessary paperwork for a CTO application should go to the Tribunal (within the 28 day limit) was contested. As has been stated discussion on this issue, as well as the use of a curator ad litem, are now taking place.
8.9 Another concern centering on the tribunal service was the unanticipated number of interim orders being granted leading to multiple tribunal hearings. Given that all agreed that this was in no-one's best interests, least of all the patient's, a solution to the problem would seem to be urgent.
8.10 It is clear that the new legislation is, at this time, a work in progress. While the first months following implementation were about learning the processes and procedures, there is a sense now that some procedures viewed as being problematic are now in the process of being developed and improved. All of this is invariably part of a learning curve which, it can be argued, is part and parcel of adjustment to major changes in a new law.
8.11 Despite these problems there remains considerable good will in relation to the underlying principles of the Act. The concern is these should remain the priority and not lost sight of because of the demands of fulfilling the detailed requirements of the MHCT Act.
RECOMMENDATIONS
Monitoring recommendations
1. The impact on the workloads of professional groups under the MHCT Act should continue to be monitored to ensure that good practice is followed and the principles of the Act are being upheld in the spirit in which they were intended.
2. The impact of the escalation of MHCT Act work on non-detained work as well as on the AWI Act work is problematic and needs to be monitored more comprehensively on a national as opposed to local level. What specific activities are being affected or lost because of this should be addressed.
Administration/Process
3. A considerable amount of time is being spent on administration in relation to the MHCT Act. This needs to be addressed in relation to how much of it is essential to the effective working of the Act.
4. The timescale for submitting a CTO application needs to be reviewed as present restrictions are causing considerable concern for MHOs, psychiatrists and medical records staff.
5. There is a lack of clarity about who is responsible for raising the issue of making advance statements with patients. This requires clarification if such an innovative mechanism is to be adopted by a broader range of patients than is currently the case.
Tribunal
6. The number of interim orders being issued at tribunal hearings needs to be addressed to minimise the time taken to attend multiple hearings by professionals as well as the potential distress to patients.
7. Consideration should be given to using more local venues for tribunal hearings where practicable to reduce the time pressure on staff and patients. Consideration should also be given to allowing witnesses to give evidence either by telephone or via video conferencing.
8. The development of systems to allow for detention applications to be sent electronically should be further encouraged. There remains a need for local authorities and the NHS to supply the equipment and software necessary to allow for this potentially time saving procedure to become common practice.
Information recording and storage
9. There is a need for a more consistent method of recording and storing information relating to the named person. This information needs to be stored in a way that allows it to be centralised as well as being accessible both out of hours and across disciplines.
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