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CHAPTER 4: TIME AND COSTS

RESPONSE RATES

4.1 Response rates varied considerably across the type of orders (see Table 4.1). Seven MHOs and eight medical practitioners (psychiatrists and GPs) returned emergency order questionnaires (giving a response rate of 11.7) while 12 MHOs and 16 psychiatrists returned short-term questionnaires (giving a response rate of 21.9%). A total of 41 CTO questionnaires were returned, 22 from psychiatrists and 19 from MHOs (a response rate of 32.0%). Four psychiatrists and two MHOs returned the CORO questionnaires, while a further four psychiatrists returned the TTD questionnaire, (a response rate of 31.3%). Nine medical records staff questionnaires were returned, giving a response rate of 37.5%. In total, of 440 questionnaires sent out 103 were returned, giving an overall response rate of 23.4%.

4.2 It should be noted that these rates are for questionnaires returned completed. There were a number returned which were not filled in (a total of 28, fifteen of which were for emergency orders alone). The reasons for their return were that the person was not known at a given address (for all 15 returned emergency order questionnaires), had moved to a different job, were unable to complete the questionnaire because of time constraints or they had already filled one in on a different order. There were also a number of telephone and email messages from people apologising for not having the time to complete the questionnaire (n=8).

Table 4.1: Questionnaire response rates

4.3 Because the return rate (particularly for emergency orders) was so small, this limited the quantitative analysis, and caution should be expressed when making inferences about some of the results. Low response rates meant that any geographical analysis (in terms of comparing time commitments and costs) was not possible.

4.4 A full set of tables relating to the time (including the average time and ranges) and costs of each stage of the orders can be found in Appendix A (Tables A4.1-A4.29). The tables will be referenced throughout the chapter.

EMERGENCY DETENTION CERTIFICATES

Time commitment

4.5 It is estimated (see Table A4.1) that medical practitioners (psychiatrists/ GPs) spent an average of 225 minutes undertaking duties relating to emergency detentions. Much of this time was spent examining the patient, consulting with MHOs and preparing certificates. This was almost double the time spent under the 1984 Act. It was also estimated that MHOs activities take double the time. Duties under the 1984 took on average 72 minutes, which had increased an extra 73 minutes (to 145 minutes in total) under the MHCT Act (see figure 4.1 below).

4.6 Emergency certificates where no MHO consent had been obtained took on average 94 minutes to complete, 20 minutes more than under the 1984 Act (see Table A4.2). Most of this increase in time commitment was attributed to MHOs consulting with other parties.

4.7 At the time research was carried out there had been limited exposure to the later stages of emergency orders such as revoking and suspending emergency certificates (see Tables A4.3/A4.4). One psychiatrist indicated that they had spent 90 minutes revoking an order, compared with 60 minutes under the 1984 Act, and had spent 210 minutes on tasks to suspend an emergency certificate, 120 minutes more than previously.

4.8 Medical records staff spent on average 46 minutes undertaking duties in relation to emergency detentions, 23 minutes more than under the 1984 Act (see Table A4.29).

Costs

4.9 The estimated average cost for a medical practitioner undertaking duties in relation to an emergency detention was £255 (see Table A4.5). This was an additional cost of £131 compared to their commitment under the 1984 Act, although this difference is not significant. MHOs time commitment to an emergency certificate was estimated to cost £70, £35 more than under the 1984 Act, again a difference which is not significant. The costs of other stages of an emergency order are presented (see Table A4.5) but are not discussed, as they are the result of a lack of exposure to these stages by respondents at the time (see paragraph 4.7 above).

4.10 A summation of these costs for the first stage of an emergency detention order, 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 (46 minutes at £18 per hour), 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.

Figure 4.1: Increased time/cost of an emergency detention certificate under the MHCT Act
(additional to time/cost under the Mental Health (Scotland) Act 1984)

See paragraphs 4.7 and 4.9 above for an explanation of why time/costs for revoking or suspending an emergency order have not been presented. The limited information gathered on these stages can be seen in Table A4.3 (revoking) A4.4 (suspending) and A4.5 (costs).

SHORT-TERM DETENTION

Time commitments

4.11 For short-term detention certificates (see Table A4.6) the average time commitment for a psychiatrist under the MHCT Act was a total of 260 minutes (range: 115, 620). The review of short-term certificates accounted for a large amount of this time (on average 64 minutes), as did arrangements to transfer patients (although this in part is driven by one medical practitioner who stated it took them 3 hours to transfer a patient to another part of the United Kingdom). The average time commitment for an MHO under the MHCT Act was 508 minutes (range: 150, 840). The majority of this time was taken up by compiling and completing the social circumstances reports ( SCR), an average of 330 minutes.

4.12 Comparisons between the MHCT and 1984 Acts suggest that psychiatrists practitioners are spending on average 92 more minutes on a short term order, a difference which is highly statistically significant (95% CI: 38.30, 145.36). MHOs spent an even greater amount of additional time (179 minutes), a difference which is also statistically significant (95% CI: 59.46, 299.64) (See Figure 4.2 below). Activities contributing to these differences include the time taken to review a short-term order and the time taken to inform or consult with a named person, both of which take significantly longer under the MHCT Act.

4.13 When revoking a certificate (see Table A4.7), medical practitioners spent an average of 131 minutes undertaking each of the tasks involved, a large proportion of which (100 minutes) was spent preparing written or oral evidence. This was estimated to be 33 more minutes more than under the 1984 Act. Of those MHOs with experience of the process of revoking a short-term certificate, it was estimated it took a total of 328 minutes, compared with 41 minutes under the 1984 Act.

4.14 Approximately half of all respondents had experience of extending a short-term certificate. Few MHOs had experience of revoking an extension and/or suspending a short-term certificate. The average time commitment for a psychiatrist involved in extending a short-term certificate was 221 minutes, while an MHO spent on average 353 minutes (see Table A4.8). Both health professions were found to spend significantly more time under the MHCT Act than under the 1984 Act. Psychiatrists spend 83 minutes (95% CI: 28.22, 137.64) and MHOs 188 minutes (95% CI: 3.09, 371.91) more on this.

4.15 In terms of revoking an extension of a short term certificate (see Table A4.9), psychiatrists were estimated to spend on average 103 minutes undertaking the activities involved, which was estimated to be 48 minutes more than under the 1984 Act (a difference which is significant at the 5% level).

4.16 Suspending a short-term certificate was estimated to take 35 minutes and 148 minutes for psychiatrists and MHOs respectively. For psychiatrists this is 43 minutes more than under the 1984 Act, and this difference is significant).

Figure 4.2: Increased time/cost of a short-term detention certificate under the MHCT Act
(additional to time/cost under the Mental Health (Scotland) Act 1984

4.17 Medical records staff spent 46 minutes undertaking tasks relating to short-term detention certificates, on average 23 minutes more than previously (see Table A4.26). Tasks undertaken included receiving, checking and completing forms, recording and registering patient information, typing letters and photocopying, ascertaining named persons and contacting and advising appropriate others.

Costs

4.18 The opportunity cost (valued in monetary terms rather than as opportunities foregone e.g. not carrying out an outpatient clinic, see chapter 2, paragraph 2.24) of a psychiatrist involved in a short-term detention was £509, while for an MHO the opportunity cost was £246 (see Table A4.11). This first stage would appear to be the most costly (although exposure to the latter stages was limited). 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).

4.19 A summation of these costs (assuming that each order involves just one medical practitioner and MHO) would suggest that the average short-term order (in the first stage only, i.e. not including revoking or suspending) costs £755. If the cost of medical records staff time was added to this, although their cost estimates are likely to relate to all stages, then the cost approximates £769. Under the 1984 Act the average short-term certificate was estimated to cost £494 (or £501 including medical records staff time).

COMPULSORY TREATMENT ORDERS

Time commitments

4.20 Psychiatrists estimated that they spent an average of 448 minutes completing the initial stage of a CTO, 261 minutes more than under the 1984 Act (for a long-term detention). It was estimated that on average MHOs spent some 1214 minutes on CTOs under the MHCT Act, that is more than 20 hours for the initial stage. This is significantly more than their time commitment under the 1984 Act, an additional 734 minutes (12 hours) more. (See Figure 4.3 below). Increased time commitment for medical practitioners can be attributed to the time it took to attend hearings and prepare evidence, specifically when there is more than one hearing. For MHOs the increased time commitment was due to a number of factors, which include the activities of gathering information, preparing the care plan, completing the MHO report and attending tribunal hearings.

4.21 The operation of an ICTO/ CTO was also time consuming for both MHOs and psychiatrists (see Table A4.13). Psychiatrists spent on average 115 minutes undertaking these tasks, which was significantly more than under the 1984 Act. Much of this time commitment was found to be attributable to preparing and implementing care plans and informing patients of finalised care plans. MHOs indicated that they spent on average 493 minutes undertaking tasks in relation to this stage of a CTO which again was also significantly more than the average amount of time they spent under the 1984 Act (321 minutes).

4.22 Experience of detentions pending review and/or applications for variation were generally limited to MHOs at the time this research was carried out. On average they spent 131 minutes in related tasks, compared with 80 minutes under the 1984 Act (see Table A4.14). The pairwise mean difference (42 minutes) is not statistically significant. Similarly the increased time that psychiatrists spend is also not significant; the wide confidence intervals are due in part to the small sample size.

4.23 Psychiatrists spent some 149 minutes undertaking tasks in relation to the mandatory review process, compared with 55 minutes under the 1984 Act (see Table A4.15), while MHOs took on average 221 minutes doing tasks related to this review, compared with 88 minutes under the 1984 Act. These differences are both found to be statistically significant, although no single task or activity appears to contribute to the significant differences.

4.24 Revoking an ICTO/ CTO (see Table A4.16) was estimated to take similar amounts of time for both psychiatrists (91 minutes) and MHOs (87 minutes). For psychiatrists this was more than under the 1984 Act (an additional 43 minutes). Medical practitioners are also estimated to spend significantly more time under the MHCT Act undertaking tasks with respect to suspending compulsory measures specified in an ICTO/ CTO (Table 5.19). It was estimated that the average difference in time commitment was 51 minutes (95% CI: 30.40, 72.48).

4.25 Time commitments in relation to activity as a result of non-compliance with a community-based order were greater under the MHCT Act than the 1984 Act for both MHOs and psychiatrists (see Table A4.18). However, these differences are not statistically significant. The lack of significance is probably a result of the sample size, reflecting limited experience amongst respondents of non-compliance with a community based CTO/ ICTO.

Costs

4.26 The first stage of a CTO had an estimated opportunity cost of £918 for psychiatrists and £586 for MHOs (see Table A4.19). These average costs were significantly greater than under the 1984 Act, which were £536 for medical practitioners (95% CI: 295.82, 775.55) and £355 for MHOs (95% CI: 243.39, 465.86). The opportunity cost for operating an ICTO/ CTO was also significantly more for both medical practitioners and MHOs under the MHCT Act compared to the 1984 Act. The cost of mandatory review is also more for both professions, while the cost for psychiatrists of revoking an ICTO/ CTO and suspending compulsory measures are also greater under the MHCT Act.

Figure 4.3: Increased time/cost of a CTO under the MHCT Act
(additional to time/cost of a longterm order under the Mental Health (Scotland) Act 1984

4.27 Aggregating these costs suggested that the first stage of a CTO costs on average £1,505 (including the cost of medical records staff time which 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).

COMPULSION AND RESTRICTION ORDERS

Time commitment

4.28 The first stage of a compulsion/restriction order was estimated to take 149 minutes for psychiatrists and 1985 minutes for MHOs (see Table A4.20). A large proportion of MHOs time commitment was taken up by writing Section 57c reports and preparing care plans. Notably the time commitment for preparing care plans was similar under both the 1984 and MHCT Acts, so it is the new requirement of the Section 57c report that contributed to the additional overall time commitment for MHOs.

4.29 Mandatory review of orders (see Table A4.21) showed that there was considerable time commitment required by both psychiatrists and MHOs. Medical practitioners estimated that on average they spent 167 minutes (range 80 - 275), while MHOs claimed that their average contribution was 950 minutes. Note however the wide range (100 - 1800) so inferences should be made with caution.

4.30 With respect to extending or varying an order (see Table A4.22), revoking a compulsion order (see Table A4.23) and reviewing a compulsion order and restriction order (see Table A4.24), there had been little exposure at the time the research was carried out and, respondents' experiences were limited. This results in very wide ranges and confidence intervals where comparisons are possible.

Costs

4.31 The average cost of undertaking compulsion orders and restriction orders can be seen in Table A4.25. The lack of involvement of MHOs in this area prior to the MHCT Act means that mean differences have not been estimated. The opportunity cost of a CORO under the MHCT Act was on average £305 for psychiatrists and £959 for MHOs. This suggested that actioning a CORO costs, in total, £1,264, or £1,279 if the cost of medical records staff time was included (50 minutes at £18 per hour).

TRANSFER FOR TREATMENT DIRECTIONS

4.32 Of returned questionnaires only one respondent had had experience of a transfer for treatment direction. This respondent estimated that their time commitment between the 1984 and MHCT Acts was identical. Some 450 minutes were spending undertaking tasks for transfer of treatment directions, a large proportion of which was spent doing the multi-disciplinary assessment and preparing the care plan. They also indicated that they had spent on average 290 minutes reviewing a transfer for treatment order.

4.33 Because of the low response rate, no further analysis, including cost estimation in relation to this order was undertaken.

COSTS OF COMPULSORY POWERS

4.34 The average total cost of staff time commitment for each initial stage of an emergency certificate, short-term certificate and CTO can be seen in Table A4.26. Combining these average costs with information on the number of detentions allowed some estimation of the additional costs of some aspects of the MHCT Act. Data from the Mental Welfare Commission on the number of emergency, short-term and compulsory treatment orders made over two five month periods are reproduced in Table A4.27. It is evident that the number of emergency detentions has fallen dramatically, whilst the number of short-term orders remained similar.

4.35 With respect for emergency detentions, although costs for individual ED's is higher, the overall number of ED's is less than half that in the previous period resulting in some cost savings. The 2410 emergency orders in the five months leading up to the introduction of the MHCT Act cost approximately £453,661, compared with £311,058 for the 920 orders after October 2005 (see Table A4.26).

4.36 From the 1 April to 4 October 2005 there were 1511 short-term detentions, compared with 1666 from 5 October 2005 to 31 March 2006. Multiplying each of these by the average cost of a short-term certificate in the corresponding period, short-term detentions in the five months leading up to the MHCT Act would have cost an estimated £757,493 of staff time. After the introduction of the MHCT Act, the 1666 orders made have cost an estimated £1,280,330. This is an additional financial burden of approximately £522,845 (see Table A4.26).

4.37 In the five months preceding the introduction of the MHCT Act there were 773 long- term detentions. If each of these cost on average £791 of staff time, then that is a total cost of £472,063. The number of orders in the five months following the introduction of the MHCT Act was lower, at 469, but the large increase in required time commitments and the subsequent average costs, estimates that these detentions have cost £712,476.

4.38 Note that no significant figures are available for CORO or TTD as so few respondents had had experience with these orders. Also, none of these figures include the cost of the Tribunal service which were not available.

SENSITIVITY ANALYSIS

4.39 The results of sensitivity analysis that employs alternative unit cost values given in Table 2.2 (see chapter 2) can be seen in Table A4.28. These values include the qualification costs (or investment costs) of medical practitioners. The higher unit cost for MHOs reflects the fact that (a) this post may attract individuals with more qualifications, and (b) that a number of local authorities provide incentives to attract MHOs, and additional payments for out-of-hours provision (Noyes, 2005). The costs were higher than their baseline equivalents (see Tables A4.5, A4.11, A4.19 and A4.25).

4.40 The second stage of the sensitivity analysis estimated the range of total costs. The minimum and maximum cost estimates related to each professional's time commitments (using baseline unit costs) were aggregated and multiplied by the number of activities. The additional financial burden was then estimated for this range of total costs. The five monthly total cost estimates can be seen in the third and fourth columns of Table A4.26, while the financial burden is given in the final column.

4.41 If much of this estimated time commitment is assumed to be due to a period of adjustment, a time when health professionals are adapting to new regulations and procedures and thereby taking longer, then one might argue that the minimum values are a better reflection of the true cost. For example, for short-term detentions this implies that the additional financial burden is reduced and is now estimated to be £219,945. Similar reductions are seen for other orders.

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