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EXECUTIVE SUMMARY

CHAPTER 1: INTRODUCTION

• The Mental Health (Care and Treatment)(Scotland) Act ( MHCT Act) came into effect in October 2005 to broad general acclaim. Of concern was the impact of the new procedures on the workload of staff, particularly psychiatrists and mental health officers ( MHOs).
• The civil compulsory powers under the MHCT Act are emergency detention certificates, short-term detention certificates, compulsory treatment orders/ CTOs (including intermediate orders, suspension and revocation of orders), compulsion orders ( COs), compulsion orders with restriction orders ( COROs), transfer for treatment directions ( TTDs). All patients were given leave to appeal against conditions of excessive security.
• New features of the MHCT Act which were thought to have an impact on the duties and tasks surrounding the administration of compulsory treatment are: changes to the criteria for compulsory treatment; the introduction of the Mental Health Tribunal for Scotland; the introduction of the named person; the introduction of advance statements.
• Although Health Boards and Local Authorities had had two and a half years to prepare for the implementation of the MHCT Act and Joint Local Implementation Planning procedures were set up it was not clear that all Boards and Authorities were fully prepared.
• The main aim of the research was to develop an overview of the administration required by new compulsory powers and to assess the impact of this work on the workload, roles and responsibilities of relevant professional groups.

CHAPTER 2: METHODS

• A number of approaches were employed in the study to address the research aims. These consisted of: background interviews, questionnaires and telephone interviews.
• Background discussions were carried out with a range of groups/individuals to establish themes and understanding of background and individual responsibilities to aid the design of questionnaires and interview schedules.
• A mapping exercise was carried out to identify the key tasks to be undertaken in invoking the compulsory orders under consideration in this study. This involved reviewing the MHCT Act and the accompanying Code of Practice.
• Questionnaires were developed to cover 5 orders, for professional groups (psychiatrists, GPs, MHOs) involved in those orders. It was not possible to cover appeals against excessive security, (see paragraph 2.10 for an explanation). A further questionnaire was developed for medical records staff.
• Telephone interviews were designed to expand on the questionnaire data collected and asked more specific questions about the impact of the MHCT Act on individual workloads.
• The total time commitment for each stage of an order was calculated by summing the time commitment of medical professionals, MHOs and medical records staff. The costs discussed are conservative costs, as they do not include the cost of the Tribunal service or the opportunity cost of the time commitments of other professionals who attend hearings. This information was not available at the time the research was carried out. The cost of each stage of an order was estimated by multiplying each respondent's given time commitment by the appropriate unit cost. Comparisons between the MHCT Act and the 1984 Act were undertaken using a paired samples t-test.

CHAPTER 3: ADMINISTRATIVE TASKS AND RESPONSIBILITIES

• Specific tasks are required to be carried out in relation to compulsory orders as specified in the MHCT Act (and within the Code of Practice as related to best practice). These tasks are highlighted in this chapter.

CHAPTER 4: TIME AND COSTS

• The costs discussed are conservative costs as they do not include the cost of the Tribunal service or the opportunity cost of the time commitments of some professionals ( e.g. nurses) who attend hearings. This information was not available at the time the research was carried out. Therefore it was not possible to estimate the total cost of each order at this time. Costs here are based on the time commitment for psychiatrists, MHOs and medical records staff. The Scottish Executive will address the costs of the Tribunal through a study of the Tribunal as well as through their annual reporting process. This should give a clear picture of the costs of the new Tribunal service.
• Response rates varied considerably across the type of orders, and also within stages of the orders with an overall response rate of 23.4%. This limited the quantitative analysis, and caution should be exercised when making inferences about some of the results.

Emergency detention certificates

• A summation of costs for the first stage of an emergency detention certificate suggested that the involvement of a medical practitioner and MHO would bear an opportunity cost of £324. Adding the time costs of medical records staff, gave an estimated cost for the average emergency detention of £338. The cost of an average emergency detention under the 1984 Act (including the time of medical practitioners, MHOs and medical records staff) was estimated to be £188.

Short-term detention certificates

• Comparisons between the MHCT and 1984 Acts suggest that psychiatrists are spending on average 92 more minutes on a short-term order. MHOs spend an even greater amount of additional time (179 minutes). Medical records staff spent 46 minutes undertaking tasks relating to short-term detention certificates, 23 minutes more than previously.
• The opportunity cost of a psychiatrist involved in a short-term detention was £509, while for an MHO the opportunity cost was £246. For psychiatrists the additional time commitment required under the MHCT Act was estimated to cost an additional £175. The additional time commitment of MHOs was estimated to cost £87. There were significant differences in the opportunity cost for psychiatrists in terms of extending a short-term certificate (an additional cost of £170), revoking an extension (an additional cost of £99) and suspending a short-term certificate (an additional cost of £88).
• A summation of these costs, assuming that each order involves just one psychiatrist and MHO, suggested that the average short-term order (in the first stage only) costs £755 (with medical records staff time included: £769). Under the 1984 Act the average short-term certificate was estimated to cost £494 (£501 including medical records staff).

Compulsory treatment orders

• It was estimated that psychiatrists spent an average of 448 minutes completing the initial stage of a CTO, 261 more minutes than under the 1984 Act (for a long-term detention). It was estimated that MHOs on average spent 1214 minutes on CTOs under the MHCT Act, more than 20 hours. This is significantly more than their time commitment under the 1984 Act, an additional 734 minutes (12 hours) more.
• The operation of an ICTO/ CTO was also time consuming. Psychiatrists spent on average 115 minutes undertaking these tasks, significantly more than under the 1984 Act. MHOs spent on average 493 minutes undertaking tasks in relation to this stage of a CTO; significantly more than the average amount of time they spent under the 1984 Act (321 minutes).
• Experience of detentions pending review and/or applications for variation were generally limited to MHOs. On average they spent 131 minutes in related tasks, compared with 80 minutes under the 1984 Act (Table A4.14).
• Psychiatrists spent an average of 149 minutes undertaking tasks in relation to the mandatory review process, compared with 55 minutes under the 1984 Act, while MHOs took on average 221 minutes doing tasks related to the review, compared with 88 minutes under the 1984 Act.
• Revoking an ICTO/ CTO was estimated to take similar amounts of time for both psychiatrists (91 minutes) and MHOs (87 minutes). For psychiatrists this was significantly more than under the 1984 Act (an additional 43 minutes). Psychiatrists spent significantly more time under the MHCT Act undertaking tasks with respect to suspending compulsory measures. It was estimated that the mean difference in time commitment was 51 minutes.
• Time commitments in relation non-compliance with a community based order were greater under the MHCT Act for both MHOs and psychiatrists, but were not statistically significant. The lack of significance is probably a result of the limited sample size, reflecting limited experience amongst respondents of non-compliance with a community based CTO/ ICTO.
• The first stage of a CTO had an estimated opportunity cost of £918 for psychiatrists and £586 for MHOs. These average costs were significantly greater than under the 1984 Act, which were £536 for psychiatrists and £355 for MHOs. The opportunity cost for operating an ICTO/ CTO was also significantly more for both psychiatrists and MHOs under the MHCT Act. The cost of mandatory review is also significantly more for both professions; while the cost to psychiatrists of revoking an ICTO/ CTO and suspending compulsory measures are also greater under the MHCT Act
• Aggregating costs suggested that the first stage of a CTO costs on average £1,505 (including the cost of medical records staff time gave a higher estimated cost of £1,519). This was more than double the cost of staff time under the 1984 Act which was £611 (or £602 without the medical records staff time commitment).

CHAPTER 5: BARRIERS AND FACILITATORS

Planning and training for the MHCT Act

• In general it was acknowledged that prior to implementation discussions amongst staff both within and across disciplines had created anxiety and concern about what the impact of implementation would mean for those working in this field.
• Relevant professional groups were all required to undertake statutory training on the MHCT Act before its implementation. A number of staff interviewed had been involved in developing and contributing to local training. Where joint training had been successfully undertaken this was seen to be valuable in recognizing the impact of the Act across the multi-disciplinary group.
• Training provided nationally was seen having been relevant and of good quality by MHO respondents. Responses from psychiatrists interviewed, however, indicated a mixed experience with regard to training.
• The majority of respondents felt that despite training being provided prior to implementation it was only when work with the MHCT Act began that the real impact on workloads became clear.
• The majority of MHOs and psychiatrists interviewed felt that the impact of the additional workload associated with the MHCT Act had not been well enough considered and that further resources should have been deployed to meet this need.

Forms

• Forms for applying for CTOs were highlighted as being significantly longer than previously was the case. These forms were seen as being more complex in terms of the process of completion and often repetitive.
• Clinicians were very concerned about the time taken to complete suspension forms as well as the number that had to be completed. The requirement of doing this meant that in many instances forms had to be filled out each day for some patients.
• Difficulties were being experienced downloading forms or filling them in on-line. This was adding additional time to the application process.
• MHOs commented on the additional time required to access administrative support to complete forms as administration staff were already overstretched.

Tribunal Hearings

• Time spent at a tribunal hearing varied considerably but was generally significantly longer than would have been the case at the Sheriff Court.
• The unknown time commitment required by a tribunal contributed to difficulties in planning other tasks. The length of some tribunals (occasionally 4+ hours) was of concern both for the impact on patients as well as taking staff out of their work environment, depending on travel time, for a whole day.
• A number of psychiatrists had not expected to have to attend every hearing, which meant that the time spent at hearings had not been calculated for regarding workload.
• It was acknowledged that as a radical change in the way detention is organized coupled with the introduction of the MHTS system and the processes associated with it, it was to be expected that the first 12 months of operation would be extremely challenging.
• Travel to and from tribunal hearings was a problem particularly where local venues for hearings were not widely used and in rural areas.
• The necessity of beginning paperwork for a full CTO only 14 days into a STDC concerned all professionals interviewed. Psychiatrists argued that this timeframe meant they were being asked whether or not grounds for the CTO were being met too early in the process.
• The short turn around for notification of dates for tribunal hearings have had a number of impacts on time management. Other colleagues were having to pick up work or appointments with patients cancelled in order to attend a hearing.
• There was concern that despite the MHTS being informed when individuals were on leave, hearings, which could only result in interim orders, were still being scheduled. This was felt to be a considerable waste of time and unnecessarily distressing for the patient. It must be noted, however, that to protect the rights of the patient and to fulfill their legal obligations the Tribunal must convene a hearing within five days of the application being made.
• The number of interim orders being made meant attendance at more than one hearing per order was commonplace. Some respondents indicated that they had to attend up to three hearings before a full CTO was granted. In addition presenting evidence to different tribunal members at each hearing was seen as problematic as it meant repeating information. This again required staff to spend significantly more time on an application than previously and was seen as distressing for patients. The overall impact on workload will clearly depend on the number of patients that each psychiatrist or MHO has attending tribunal hearings.
• The issue of the appointment of a curator ad litem to protect the rights of those patients who lack capacity to instruct a solicitor was also cited as an area which caused time delays and which required clarification.
• The named person
• It is a responsibility under the MHCT Act for the MHO to ascertain the name and address of the patient's named person. The use of the right to nominate a named person was not thought to be widespread at this early stage in implementation.
• While MHOs ensured that a patient knew their rights in relation to the named person some patients seemed reluctant to nominate (thus the nearest relative was nominated by default). This was seen to be a potential problem for some patients who did not want their nearest relative informed. It was also unclear to some (and is not made clear in the MHCT Act) whether a patient who was deemed competent could forego having a named person at all if they chose.
• There was no consistent method of recording the details of the named person, nor was access to the named person's details standardized.

Advance statements

• The use of advance statements were seen in general as a positive development for patients, but they were not well used to date. There was a lack of clarity over who is responsible for raising the issue of making an advance statement with the patient and therefore practice varied.

Principles

• It was reported that the principles underlying the MHCT Act were at the forefront of everyone's mind, particularly the least restrictive alternative. Most respondents stated that the system set-up to evoke compulsory powers made them think through the principles at all points in the process.
• Respondents reported feeling compromised, in some instances, to go for outcomes which they felt the tribunal would agree to, rather than what was clinically best for the patient.

CHAPTER 6: IMPACT ON OTHER SERVICES

• The majority of respondents were able to identify impacts on their time and other services because of MHCT Act work.
• A shared concern of both psychiatrists and MHOs was the danger of a two-tier system developing for those with mental health problems. For those requiring the support and protection of compulsory powers there would be an immediate response. For those requiring more informal support, longer waiting times appeared to be becoming commonplace.
• As psychiatrists have had to focus more on the work surrounding applications other work was being cancelled, disrupted or rescheduled. Patient contact had also been reduced for some. For others more clinical and administrative work was being displaced into personal time/unpaid overtime Other areas affected included multi-disciplinary meetings e.g.CPA, ward rounds, reviews and contact with the broader mental health population.
• MHOs raised concerns about the long-term effect of working almost entirely on statutory work and the impact this may have on their ability to work closely with clients. This was compounded by the complexity of dealing with the demands of the MHCT Act as well as the Adults with Incapacity (Scotland) Act 2000.
• For MHOs outwith dedicated posts broader social work tasks were not being undertaken and were given a much lower priority. Often they were unable to provide the general social work function to individuals either because of lack of time or specific service re-design in response to the implementation of the MHCT Act.
• Medical records/administrative staff reported that there had been a major impact on their workload and other activities.

CHAPTER 7: DISCUSSION

• There are several limitations which should be borne in mind when considering the findings of this study and relate to issues around the timing of the study, the unavailability of some information and the impact of a low response rate on the results.
• Increased workload in this study has been calculated in terms of financial costs. The small numbers make drawing too many inferences from this unsafe. It is only an actual additional cost to the service if more people are employed, which in most areas does not seem to have been the case. Rather, there has been an impact on patient services in other ways, either through cancellation/postponement of services or duties being carried out by other staff.
• Considerable concern was expressed about the impact of the very high number of interim orders on workload. This had not been anticipated prior to the introduction of the MHCT Act and thus was not factored into workload estimates for either professional staff groups nor for the Tribunal itself.
• Concern was raised that evidence is required to be presented in full on a number of occasions where more than one hearing takes place and when different Tribunal members are present.
• While there is agreement that repeated hearings are in no-one's interest, least of all the patient's, an interim order means that a patient could be detained for 61 days, calculated by reference to, 28 days as authorised by the RMO in terms of the STDC plus five days during which the first hearing will take place and one interim order of 28 days (28+5+28). There may also be two interim orders granted in which case the patient could be detained for a maximum of 89 days without a full hearing (See chapter 7, paragraph 7.26 for further clarification).
• The appointment of a Curator ad litem was seen as contributing to the number of interim orders issued. If it is not known (or decided) that a person needs a curator appointed until the tribunal hearing then there will necessarily be a second hearing and possibly a third.
• It was thought that the presence of solicitors at tribunal hearings was making them adversarial and overly legalistic. The variation in experience of different staff groups at tribunal hearings led some to seek guidance from in-house legal staff or to seek their own legal representative at the hearing. This may have important implications for the nature of tribunal hearings in the future.
• It has been suggested that all patients, rather than being asked whether they want to see a solicitor, have arrangements made for them to see one irrespective of incapacity status. Discussion of this issue is outwith this study but requires further consideration.
• A number of issues were raised in relation to the time taken, repetitive nature and necessity for some of the detention forms. The Mental Health Law team has consulted on this and changes are being made. Work is currently being undertaken by the Mental Welfare Commission to carry out the agreed changes and new versions of the forms will be issued in due course.
• The Mental Health Tribunal have the capacity and processes in place to allow for the admission of detention forms electronically. Electronic submission of CTO1 forms have been piloted by the Tribunal in a small number of local authorities (to date) and will continue to pilot the scheme in the other authority areas.
• There remain issues relating to the effective use of an electronic application system. Local authorities need to ensure that appropriate systems are in place to allow for electronic applications to occur on a regular basis.

CHAPTER 8: CONCLUSIONS

• 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.
• 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 will remain to be seen as individuals become more accustomed to workings with the MHCT Act and some of the more time-consuming and potentially expensive elements are re-assessed.
• Professionals were acutely aware of their roles in relation to the new legislation and that this work was being given a high priority. There is a need to look systematically at whether other services are being compromised because of the prioritization of MHCT Act work.
• The introduction of the Mental Health Tribunal for Scotland was on the whole seen as a welcome addition in relation to patients' rights. Experiences of attending tribunal hearings varied and there are still issues that needed to be 'ironed out'.
• A major concern centering on the Tribunal 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, a solution to the problem would seem to be urgent.
• Despite these problems there remains considerable good will in relation to the underlying principles of the MHCT Act. The concern was that these should remain the priority, and not lost sight of because of the demands of fulfilling the detailed requirements of the MHCT Act.
• A set of recommendations can be found at the end of chapter 8 of this report.

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