Key insights from CQC’s Monitoring the Mental Health Act in 2023 to 2024

Last week the Care Quality Commission published their annual report on the use of the Mental Health Act 1983. 

It runs to 77 pages and will be an essential read for all those involved in the provision of services under the MHA.

It is based on findings from 823 monitoring visits which involved speaking to 4,624 patients and 1,435 carers.

For those interested in statistics these are covered in the summary of CQC’s regulatory activity at pages 63- 70.

Foreword

The Foreword is written by Jenny Wilkes, Interim Director of Mental Health. She highlights that:

• The report this year highlights the ongoing challenges in mental health care that are compounding the pressures on mental health inpatient services.
• The findings reinforce concerns raised both in last year’s report and in the 2022/23 State of Care report
• CQC have raised concerns in successive reports that community mental health services are struggling to support all the people who need it

She observes that some of the provisions of the revised MHA may takes years to implement.

Wilkes states that CQC remain concerned about abuse and closed cultures.

Chapters

There are six key areas covered:

CQC and the Mental Health Bill (see pages 10 – 12)

CQC will be monitoring several areas closely to ensure they translate into positive changes:

Overrepresentation of Black people detained under the MHA and placed on CTOs.

• • Ongoing problems with care pathways and lack of community provision for autistic people and people with a learning disability.
  • Persisting abusive and closed cultures in too many mental health services.
  • Impact on CQC’s SOAD service.
  • Protecting patient’s rights. 

Systems (see pages 13-21)

• • The number of people in contact with secondary mental health services increased by 43% between March 2019 and March 2024 which cannot be accounted for by population growth alone. In 2022/23 52,458 new detentions under the MHA were recorded.
  • As at March 2024 there were 16.706 patients recorded as being detained in hospital under MHA powers.
  • This chapter covers both inpatient admission as well as discharge planning and support

Workforce (see pages 22 – 30)

• • This covers recruitment, retention and skill mix, challenges in addressing staffing issues, training and the Second Opinion Appointed Doctor (SOAD) service.
  • CQC note that they continue to see different interpretations of the interface between the MHA and the Mental Capacity Act. They remind us how in recent State of Care reports they have raised concerns that providers’ understanding of deprivation of liberty safeguards (DoLS) remains varied which affects how the safeguards are applied and means people may not have a DoLS authorisation in place when they need one.
  • Whilst they have suggested that the Government update the respective Codes of Practice to reflect evolving case law needs, they note that this has not happened.
  • CQC remain concerned that clinicians may not always be considering where the MHA can be used when the DoLS framework is not appropriate and where the patient is objecting to their placement. This concern is heightened by widespread delays in DoLS assessments. CQC are concerned that when urgent applications expire delays mean that patients and clinicians are left in “legal limbo”, without any effective safeguard or procedure.
  • They specifically flag how patients in independent health providers are excluded from the reach of state obligations under the Human Rights Act when in “legal limbo”. However, CQC note this has been raised in Parliament during the passage of the Mental Health Bill.
  • Reforms to the MHA mean there will be additional expectations of the SOAD service for which additional funding is needed but that alone will not be enough to address the issues facing the service. In 2023/24 CQC received 15,689 requests for a second opinion. For most patients (77%) treatment plans were not changed following a review by a SOAD. The Mental Health Bill will introduce both urgent SOAD certification and remote technology.

Inequalities (see pages 31 – 39)

• • This covers discrimination, communication and people’s rights, meeting patient’s needs and care for autistic people with a learning disability. 
  • CQC express concern that without suitable community-based alternatives there is still a risk that people may be detained in sub optimal hospital placements under alternative legal powers such as DoLS. This leads them to state that it will therefore be essential to ensure that improved community support is in place throughout the country before the reforms are implemented.

Children and Young People (see pages 40 – 52) 

• • This covers staffing and quality of care, quality of environments, restrictive practices, and challenges in transitions in care.
  • In 2023/24 CQC were notified of 120 instances where children and young people under 18 years old were admitted to adult wards. The most notifications were in the Central and North regions

Environment (see pages 53 -62)

• • This covers ward environments, security and privacy, outdoor and kitchen access, restrictive practices and single sex accommodation.

Throughout the report there are references to both CQC’s special review of Nottinghamshire Healthcare NHS Foundation Trust as well as to external reports from Mind, HSSIB, The Centre for Mental Health, Laing Buisson and the King’s Fund.

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