Staying safe in an age of austerity

People with mental health problems are some of the most vulnerable members of society – but ensuring services are built round them has always been a challenge for the NHS, and never more so than when financial pressures make developing new services difficult.

Some enterprising mental health trusts are pushing forward with improvements and innovative services, often working closely with partners in other public services and the voluntary sector. This includes new ways of working, improving the level of care available in a crisis, and using online and social media to reach children and adolescents.

Partnership solutions

This is being driven by a number of factors. While the NHS has had savings targets to meet, the same has been true of many potential partners. This has meant these organisations have had to look very closely at how they use resources and this has had a knock-on impact on the NHS, which has had to adjust how it works to accommodate this. Working through problems together has helped to find solutions which are better for both parties.

People with mental health problems can sometimes pose a danger to themselves, and more rarely others. The law allows people to be held in a place of safety while they are assessed – a so-called section 136 detention under the Mental Health Act. Last year there were just over 14,000 “place of safety” detentions in hospitals and more than 7,700 in police custody suites in England.

‘Last year there were just over 14,000 “place of safety” detentions in hospitals and more than 7,700 in police custody suites in England’

Very often this involves someone who has tried to self harm, or who is badly intoxicated or has taken drugs, being taken to accident and emergency – for treatment of any physical injuries or just to sober up – and the police being involved. Until recently, they could not then be moved to another location once their physical condition had been addressed: only one place of safety could be used for each case, although individuals could be held for up to 72 hours.

This meant that many people with mental health problems – including young people and children – spent an inappropriately long time in an A&E department waiting for an assessment of their mental health. In some cases, the first place of safety used could be a police station – often even more inappropriate.

However, a change in the law means that they can now be moved to a different place of safety, offering the chance for more appropriate surroundings while an assessment is carried out. Some mental health providers are responding to this by moving people into suitable units as early as possible in the process. This often involves skilled staff as they may be suicidal.

Increased pressure

This also relieves pressure on the police – who otherwise have to put considerable resources into staying with service users in an A&E department and ensuring they don’t leave. Sharon Thomas, a lawyer with Hill Dickinson who works with a number of mental health trusts, welcomes this change.

“Before 2011 people were taken to A&E for an assessment of their physical state but could then be stuck there while being assessed,” she says.

She points out the police have found it increasingly difficult to remain with people in A&E until health staff are satisfied they can leave. “There is increased pressure on resources and staying has to be agreed at a higher level. It then falls to the hospital staff to try to make sure that the person does not leave.”

‘Staying has to be agreed at a higher level. It then falls to hospital staff to make sure that the person does not leave’

Such issues become particularly difficult when children and teenagers are involved. As well as the issues affecting any mental health patient around consent, confidentiality and competence to take part in decisions around their own treatment, there are issues related to their age.

Child protection can be an issue and a child who would normally be considered old enough to make decisions for his or herself may not be because of their mental state.

Dr Peter Hindley, chair of the Royal College of Psychiatrists’ faculty of child and adolescent psychiatry, points out the complexities of this legal landscape for those dealing with children and adolescents, sometimes at a point when they are in crisis.

Working with the family

A child may be judged to be “Gillick competent” below 16 and thus able to consent to their own treatment, and the Mental Capacity Act will apply if they are 16 to 18. But many psychiatric staff will try to involve parents or carers in cases involving young people as a matter of best practice. “From a child and adolescent mental health services (CAMHS) point of view we would always want to work as far as possible with the young person and their parents and families,” he says. However, some circumstances may make this difficult and it may only be possible to contact the family by telephone.

Complicating factors can include the physical state of the young person and potentially development conditions, such as autism. Mental health services will also often be working alongside other agencies, such as social services, which may have slightly different agendas and approaches.

But section 136 orders are only used in a crisis: stopping that crisis developing is the aim of mental health services. Early intervention services aim to reach young people with mental health problems at the earliest possible point. “If you can get it right then it usually prevents it going on to the later stage,” says Ms Thomas.

‘Complicating factors can include the physical state of the young person and potentially development conditions, such as autism’

Internet-based services

This can include internet-based services to address some of the many questions people will have about mental health and wellbeing. These can be particularly effective with teenagers, who are used to turning to the internet for information and, increasingly, advice. And as well as offering a different and more convenient way of getting information, it can relieve pressure on services.

Providing services to young people runs up against a raft of issues such as parental involvement and information sharing, capacity and consent, and child protection. There can be tension between CAMHS services and social services which may have different approaches to some of these issues. Effective partnership working means these issues have to be worked through.

Although many of these issues are not explicitly legal ones, trusts do sometimes turn to lawyers for advice to ensure they are on the right side of the law. “We go to quite a lot of best interest meetings because sometimes they are discussing where to go with young people to get the treatment they need and which is the best framework to look at,” says Ms Thomas.

Communication between the parties is vital, she says, and understanding of each other’s positions and issues can drive improvement.