April 14, 2024

  1. Narut Pakunwanich, academic foundation doctor, interventional neuropsychiatry;, NIHR associate principal investigator (clinical trainee) for neuropsychoimmunology, PPiP212,
  2. Jeremy Bjørndal, freelance journalist3,
  3. David Seedhouse, professor of deliberative practice4
  1. 1University of Cambridge, UK
  2. 2University of Oxford, UK
  3. 3Netherlands
  4. 4School of Pharmacy, Aston University, UK
  1. Correspondence to: N Pakunwanich np606atcam.ac.uk

Access to comprehensive psychiatric aftercare is necessary for patients who have been sectioned, but this is overlooked and undervalued by current mental health law, write Narut Pakunwanich, Jeremy Bjørndal, and David Seedhouse

Few professionals outside psychiatric services are aware that eligibility for aftercare depends on which section of the Mental Health Act 1983 a patient has been categorised under.1 This act underpins psychiatric care in England and Wales and allows for detainment and the treatment of severe mental illness, even if a patient with capacity refuses.

Section 2 of the act allows inpatient hospital detention for 28 days, while section 3 permits detention for six months but only after section 2 has been used. The concept of the “sick role” is entrenched in this legal model,2 with psychiatric “sickness” defined solely by compliance and section 3 reserved for “sicker” non-compliant patients. Thus, section 3 is used by clinicians for severe mental illness.

A difference in funding is that aftercare support under section 117 of the act is available only to people previously categorised under section 3. Importantly, section 117 provides non-means tested, fully funded aftercare. These aftercare services are defined by section 75 of the Care Act 2014 to include any service that assists people with mental illness in avoiding common obstacles and setbacks during their recovery.3 The current legal framework falsely presumes that the severity of mental health issues and long term aftercare needs correlate directly with a patient’s non-compliance in acute settings. Furthermore, decisions on sectioning are based on arbitrary, compliance based section 3 criteria, not a patient’s aftercare needs. This exclusionary and binary system, which uses patient compliance as a proxy for disease severity to determine aftercare funding, should be replaced by a universally accessible, needs based framework.

The current exclusionary framework stems from a misunderstanding about the fundamental aim of healthcare, which is to create autonomy in the person being cared for, equally and without discrimination.4 This framework fails to acknowledge that autonomy—the generalised ability to act in life—can be created through medical treatment by liberating patients from pain or disease. Autonomy is not merely “compliance” or something “to be respected,” as reflected in this reductionist, dehumanising legal framework. The ethical justification of sectioning should be that, in people lacking autonomy because of mental ill health, creating autonomy through treatment should be prioritised over respecting it, until the patient’s autonomy is sufficiently restored.

Therefore, while hospitals provide care to create autonomy during sectioning, social services need to provide aftercare to support that autonomy after discharge. Systemic exclusion from aftercare that can prevent relapses may contribute to future hospital admissions and deterioration of mental health.

Deciding who is “sick enough”

Patients with severe mental illness have highly variable presentations. In certain presentations, such as negative symptom schizophrenia or severe depression, they might not resist treatment or attempt to leave care facilities. Because they are “complying” with treatment they are not placed under section 3 and are therefore systematically denied access to long term support. But patients who resist treatment because of a different, more florid, non-compliant presentation of psychosis, and are placed under section 3, would be eligible. It is unfair to deprive more “compliant” patients of the necessary support afforded only to those who are less compliant with treatment.

These laws, designed for acute non-compliance, also fail to account for chronic mental illness. Section 2 detention lasts 28 days, and if recovery occurs in this period the patient cannot be placed under section 3. This means that chronically ill patients who have acute, yet short term, episodes of illness are excluded from section 3. Meanwhile, patients who have a prolonged presentation without chronic issues are eligible for aftercare funding if they are under section 3.

Significant ambiguity exists even for patients who approach the 28 day limit of section 2. Certain clinicians may argue that converting patients’ status to an informal, voluntary one increases their autonomy, in accordance with the “least restrictive” principle. But the absence of section 117 aftercare can be detrimental to the patient’s autonomy in the long term. In clinical practice, section application is heavily influenced by the incentive of section 117 aftercare, as clinicians wish to help patients navigate an underfunded social care system.

A patient centred, needs based approach should be created to reflect the diversity of mental health illnesses and associated needs. Currently, psychiatrists are forced to determine which patients receive social care funding through the implications of their clinical decisions in ambiguous situations, between the bureaucratic nuances of sections 2 and 3.

As a substitute, we should create a system where any patient under section 2 or 3 would be entitled to vital, relapse preventing aftercare support under section 117. All patients with severe mental illness can then be assessed and supported as individuals. This also frees clinicians from aftercare considerations, allowing them to pursue a least restrictive approach in section application.

Acknowledgments

We thank Alana Durrant and Albert Michael at Norfolk and Suffolk NHS Foundation Trust for their helpful and insightful comments. Thanks also to Southgate Ward at Wedgwood House for allowing NP to attend section 117 meetings. We further thank Steve Bracewell and Nicholas Mullin, at Lancashire and South Cumbria NHS Foundation Trust, for inspiring this piece through reflective, case based discussions.

Footnotes

  • Competing interests: NP is an academic foundation doctor at Norfolk and Suffolk NHS Foundation Trust on a psychiatric inpatient ward, working closely with mental health patients. He conducts research into integrating physical and mental healthcare at the Interventional Neuropsychiatry Group, University of Cambridge. He also investigates exclusionary practices in health systems at the National Institute for Health Research’s School for Public Health Research via Fuse (the Centre for Translational Research in Public Health), alongside collaborations with the University of East Anglia and Teesside University.

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

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