MENTAL WELFARE COMMISSION

  1. The Commission welcomes the opportunity to attend the above meeting. In preparation for the meeting, we submit the following written evidence on the questions the Committee wishes some discussion.

How the Mental Welfare Commission, which was established to monitor the Act, has monitored the implementation of the principles of equality and non-discrimination and how it intends to do so in the future?

  1. The principles of equality and non-discrimination apply to the Commission itself as much as they do to the way we monitor the use of the Act by services. Actions we have taken to achieve this include:
  • Production of a toolkit to help people work with interpreters in interacting with people with mental illness or learning disability
  • “Touchtype” facilities for deaf people to access our advice and information service
  • Accessible web-based and paper information, with easy-read versions of all our major reports and leaflets
  • A DVD on the role of the Commission for people with learning disability
  1. The Commission monitors quantitative and qualitative data on the use of the Act. We include several examples of how we do this and what we have found.

Quantitative information

  1. We collect quantitative information on age, gender and Health Board area for all people subject to compulsory treatment. We look for significant gender differences, trends in the use of the Act for people of different ages and consider possible reasons for the wide geographic variations that we see. We look at the use of the Act for people with a learning disability. We have no quantitative data on other disability (e.g. sensory impairment or other physical disability), religion or sexual orientation as these are not reported to us on forms used to authorise or record actions taken under the Act.
  1. We try to monitor ethnicity of people subject to the Act. This has been difficult. Our data is incomplete and we only get, at best, ethnicity information on 70% of people. This is because the data is captured at the point where the person is first detained. The person is likely to be mentally unwell and is being admitted against his/her will. It is less easy to gain cooperation to get the person to describe his/her ethnicity. Also, the Government’s legal advice was that this information could be collected for reporting purposes but not stored against an individual’s case record.

Our main findings

  1. Gender:
  • Men are more likely to be admitted under long term civil orders and under criminal procedures orders. This is because severe and enduring mental illness presenting with significant risk and/or offending behaviour is more common in men.
  • Women are more likely to be detained under emergency orders and under the nurse’s power to detain. For emergency orders, the gap between women and men is growing. This is of some concern because there are fewer safeguards in the legislation for emergency detentions. There are gender differences in the way men and women present in mental health crises or the way that services respond. We have suggested that the excess in emergency detention of women might be a response to deliberate self harm (commoner in women) or because men might present with threatening behaviour towards others, may end up in police custody and be more likely to enter mental health care via the courts.
  • For young people (see our response to 4(b)), girls are more likely to be admitted to specialist adolescent mental health care than boys.
  1. Age:
  • Most people admitted are in young to middle-age and the overall spread appears to be in line with the population age profile.
  1. In recent years, we have seen rises in the numbers of older people detained. When we looked into this, we did not find inappropriate uses of the Act. Our concern was that some older people, especially with dementia, may have been “de facto” detained in hospital without the rights and protections conferred by the Act. This could represent age discrimination.
  1. Ethnicity:
  • In 2008-9, we had reliable data on 70% of people subject to the Act
  • Of these, 4% were “non-white” compared with 2% of the Scottish population. Black African/Caribbean was the highest single minority group. This data must be interpreted with caution due to the lack of completeness of ethnicity information.
  • We are working with the University of Edinburgh on a research project to link mental health act data with census data to improve information on ethnicity. This has ethical approval and is well under way. As a result, we should have ethnic information on at least 94% of people subject to the Act.
  1. Learning disability
  • Around 4% of people detained under mental health legislation have a learning disability (twice the prevalence on learning disability in the general population). This reflects the higher incidence of mental illness and “challenging behaviour” diagnosed in this group.
  • We conduct a census every two years of people with learning disability treated under the Act. This shows that people with learning disability are detained for longer, especially males.

Qualitative monitoring (including visits and investigations)

  1. We visit people subject to the 2003 Act and the Adults with Incapacity Act. We allow them to raise concerns with us and satisfy ourselves that they are receiving care and treatment that reflects the principles of the Act. Note that our duty to visit includes people not subject to compulsory treatment. We think the principles of the Act are good principles for everyone receiving care and treatment. If we think that there is deficiency in care and treatment, we bring this to the attention of care staff and may investigate further. We complete a form asking about ethnicity for everyone we visit.
  1. On our visits to people, we look at issues of equality. We ask to see anyone whose first language is not English, including deaf people who use sign language. We look at the person’s cultural and spiritual needs as well as their need for care and treatment. It is beyond the scope of this paper to give exhaustive lists of the issues we have raised but some relevant ones are:
  • Some years ago, we reported the case of “Mr J” who received poor attention to his cultural needs. We are delighted that we have not had to repeat this. Our recent visits show very good use of interpretation and cultural sensitivity to people for many different backgrounds
  • We frequently raise issues of lack of service for different age groups. We have found, for example, a lack of appropriate environments and psychological therapies available for older people. Our reports “Older and Wiser” and “Remember I’m Still Me” on hospitals and care homes have provided valuable lessons on care for older people. We are about to publish a report on older people in acute mental health care and will be visiting general hospitals to see people with dementia. We also find some “reverse ageism” in that some people with young onset dementia do not get as good a level of service as older people with dementia.
  • In restrictive care settings, we sometimes find that people are not given enough opportunity to pursue religious observance. When we find this, we raise it with care staff and help them to seek solutions, e.g. bringing people in to assist with faith observance.
  • We have raised issues about discrimination on the basis of sexual orientation. We found cases where a person in a same-sex relationship appeared to be treated less favourably than someone in a heterosexual relationship.
  • We have visited specific mental health projects for deaf people and are examining a case where the lack of a cohesive service may have resulted in poor care. Also, we meet people with physical disabilities and took a case of poor care, where a person was left in prison, to the Chief Executive of the NHS for action. We are pleased to say that this was a very rare case and it resulted in prompt action.
  • Our investigation reports often highlight inequalities for people from certain care groups or with certain diagnoses. For instance, we have reported on inadequate care for a young person (Ms Y), a person with autistic spectrum disorder (Mr Q) and, most importantly, a person with learning disability whose disability appeared to exclude her from the criminal justice system when she was sexually assaulted (Ms A).

How the recent ‘limited review’ of the 2003 Act took account of equalities issues?

  1. Other than restate the principles, the review was not specifically asked to examine equalities issues. We have, as part of the process, made recommendations to the Government that would improve our ability to collect and report on ethnic data. We think it would be difficult to collect data that covers all the strands of equality but would be interested to explore this in the round table discussion.

How any changes that will be made following the review relate to equalities issues?

  1. As above

What impact the Act has had for the care and treatment of the different equalities groups, in particular:

How advocacy services have developed specifically for 'equalities' groups following the provision of rights to advocacy under the 2003 Act?

  1. Everybody with a mental disorder has the right of access to independent advocacy and there is a duty place on Health Boards and local authorities to provide advocacy services. In our experience, there are some gaps in provision of advocacy services to certain groups in certain parts of the country. These include:
  2. People with dementia or acquired brain injury
  3. People from black and minority ethnic communities
  4. Young people
  1. While there may be advocacy available, it may lack the knowledge and expertise to properly advocate for these specific groups.

Whether children and young people are receiving services appropriate for their needs as required by the 2003 Act?

  1. We have been monitoring this for some years and remain concerned that, despite the Commitment in “Delivering for Mental Health”, there are still young people admitted to adult mental health care and where there is little or no age-appropriate input to their care. Our findings in 2008-9 were:
  • We received 149 reports of young people admitted to adult mental health care – a rise of 7 from the previous year and well short of the Government’s target for reduction.
  • While there was a fall in girls admitted to adult wards, this was more than matched by a rise in admission of boys to adult wards. This was especially evident for 16 and 17 year-olds.
  • Over 20% had no access to specialist adolescent mental health professionals.
  • Access to age-appropriate advocacy, activity and, in particular, education were limited. Loss of access to education was a major issue for our “Ms Y” investigation from the previous year
  • There are particular gaps in provision of secure care and provision for young people with learning disability.
  1. We have never argued that all young people must be admitted to specialist facilities but they should have access to age appropriate care. Indeed, there are some situations where a short admission to a local hospital is preferable to admission to a specialist adolescent unit many miles away. We do not consider it acceptable that so many young people are admitted to non-specialist units and did not get access to age-appropriate care while they are there.

How local authorities are taking account of equalities issues in their implementation of “Section 26”?

  1. We are not specifically monitoring the implementation of local authority duties under this section of the Act.

What the constraints are to fully realising the equalities principles of the legislation?

  1. This would be a good topic to focus on in round table discussions. Our views would be in the areas of:
  • Training and support for staff
  • Availability of information that is accessible to all groups
  • Legal requirements re data protection versus the duty to monitor equality issues.
  • How to gather data on equality strands from acutely unwell people when care staff are trying to establish a relationship
  • The size of the equality agenda and a need to set clear priorities based on information and intelligence from stakeholders.
  1. I hope this information is helpful and look forward to further discussion on March 9th. Further information on all the above can be found on our website:

Donald Lyons

Director

Mental Welfare Commission for Scotland

February 2010