On 20 March 2003 the Mental Health (Care and Treatment) (Scotland) Act 2003 was passed by the Scottish Parliament. It was hailed as a major piece of enlightened legislation that would provide enhanced safeguards for those patients obliged to accept treatment against their will. It sought, among other things, to ensure that the human rights of patients were protected, that any restrictions imposed were the minimum necessary and that the views of patients and carers were given due weight. It also introduced the Mental Health Tribunal of Scotland, which aims to provide a responsive, accessible and independent service for making decisions about compulsory treatment.
It was clear that the implementation of the Act would place considerable demands on mental health services. It seemed likely that much of this increased workload would fall on consultant psychiatrists who, as approved medical practitioners, were given a new range of responsibilities.
The implementation of the Act was delayed to give local services the opportunity to undertake redesign, recruitment and staff training. The Act came into force on 5 October 2005.
Informal discussions with colleagues suggested some discontent about how well the Act and the tribunal were working in practice. We therefore decided to assess how widespread these perceptions were and undertook a survey of Scottish consultants and specialist registrars.
Method
We obtained contact details of specialist registrars and consultant psychiatrists who had permitted their work address to be released by the College (n=357). This list did not include child and adolescent psychiatrists. We further excluded those who we knew to be retired, working in private practice or not participating in out-of-hours rotas. We presumed these groups would have limited experience of the Act. This left a total of 340 psychiatrists who were each sent a postal survey.
We designed a 1-page questionnaire, which was anonymous but asked for basic demographic information of grade, specialty and health board. Respondents were then asked seven questions concerning out-of-hours practice regarding detention, local psychiatric emergency plan, training for the new Act, patient care and the tribunal process. In addition we asked whether there had been a change in the out-of-hours workload and how satisfied respondents were with their use of the Act so far. A space was available at the end of the questionnaire for general comments.
The survey was posted at the beginning of February 2006 and data collected from those who responded in the following 4 weeks. Data were analysed using Microsoft Excel spreadsheets. As this was a survey, the local ethics committee did not consider ethical approval to be necessary.
Results
Of the 340 psychiatrists sent questionnaires, 257 responded (a response rate of 76%). Out of these respondents, 210 identified their grade: 176 were consultants and 34 specialist registrars. Replies were received from all health board areas in Scotland and the State Hospital (the high-security hospital for Scotland and Northern Ireland); 210 respondents identified their health board area.
The results from the questionnaire regarding psychiatrists’ experience of the Act are shown in Table 1. When asked ‘Overall how satisfied are you’, only 3 respondents (1%) were very satisfied, 92 (36%) were reasonably satisfied, 112 (44%) were unsatisfied and 47 (18%) were very unsatisfied.
Table 1. Psychiatrists’ experience of the Mental Health (Care and Treatment) (Scotland) Act 2003
| Regarding the Mental Health Act 2003 | Yes n (%) | No n (%) | No change n (%) | Blank n (%) |
|---|---|---|---|---|
| Do you feel patient care has improved? | 31 (12) | 133 (52) | 75 (29) | 18 (7) |
| Were you adequately trained? | 121 (47) | 128 (50) | NA | 8 (3) |
| Is the tribunal process better than the court system? | 87 (34) | 135 (52) | NA | 35 (14) |
| Has the care of informal patients been adversely | 167 (65) | 68 (26) | NA | 22 (9) |
| affected (owing to the time spent on detained patients)? |
There were 151 respondents (59%) who reported that their out-of-hours workload had increased and 94 (36%) whose workload had remained unchanged, since implementation of the Act. Of those who reported an increase in out-of-hours workload, 20 (13%) said this was mostly at night, 55 (36%) said this was mostly at weekends and 60 (40%) that it was both at weekends and night (16 respondents left this question blank). There were 79 respondents who commented upon their experiences of the Act and its implementation; 76 of these comments were generally critical and 3 were generally positive. The 3 people who made positive comments noted good support from the tribunal organisation and the Mental Welfare Commission. Of note, 42 people criticised the paperwork involved under the new Act, generally commenting that it was time-consuming and overly bureaucratic. There were 19 people who criticised the tribunal process and 6 of them noted they did not feel they had been given enough notice for forthcoming tribunals. There were 15 people who commented on the increased time they were spending on implementing the Act.
Further results regarding local psychiatric emergency plans and respondents’ own practice out of hours are shown in Table 2.
Table 2. Psychiatrists’ views and experience of local psychiatric emergency plans and out-of-hours practice
| Yes n (%) | No n (%) | Blank n (%) | |
|---|---|---|---|
| Regarding your local psychiatric emergency plan | |||
| Do you have a clear understanding of your local plan? | 127 (49) | 113 (44) | 17 (7) |
| Do you agree with the guidelines in the plan regarding out-of-hours detention certificates? | 153 (60) | 66 (26) | 38 (14) |
| Regarding your own practice out of hours: at weekends do you review patients who are subject to emergency detention certificates? | 181 (70) | 53 (21) | 23 (9) |
Discussion
As far as we are aware this is the first survey of psychiatrists’ views of the Act since its implementation. The results raise a number of important points. The high response rate suggests that psychiatrists are interested in the issues raised by the survey. Although our respondents are a subsample of a group who allowed their contact details to be released by the College, we have no reason to believe that this is an atypical group. With a sample of this size we assume this is representative of Scottish specialist registrars and consultant psychiatrists as a whole.
It is worrying that 65% of the group feel that the care of informal patients has been adversely affected by the Act. The Scottish Association for Mental Health (a patient group) raised the concern that the Act could have ‘ an adverse effect on those receiving care and treatment on a voluntary basis if resources are concentrated on those subject to the Act's powers’. This worry was also highlighted by psychiatrists, suggesting that ‘consultants may only have time to see detained patients, at the expense of informal patients’ (Reference GrantGrant, 2003).
Prior to this new Act, section 18 (equivalent of a compulsory treatment order) hearings were held in the local sheriff court. The stigmatisation and perceived criminalisation of mental health problems through this process has long been criticised and it was hoped the new tribunal process might improve this situation. However, 52% of respondents in our survey did not consider the tribunal system better than the court system. The reasoning behind this is outside the scope of this survey. It should be remembered, however, that the aim of the Act was to benefit patients, not psychiatrists. It would be interesting to assess how other parties, for example patients and mental health officers, view the tribunal process in comparison with their experience of the sheriff court.
Our results indicate that the Act has increased the workload for many psychiatrists. Out-of-hours workload was felt to have increased by 59% of the respondents. This is perhaps not surprising given that the preferred route to detention is by a short-term order (which necessitates assessment by a section 22-approved doctor) and that at weekends 70% of respondents are reviewing patients subject to emergency detention. We did not specifically ask whether daytime workload had increased, however respondents frequently described this in the comments section of the survey. In 2002 the Scottish Division of the Royal College of Psychiatrists assessed the additional work arising from the new act as requiring approximately 30 whole-time equivalent extra consultants. At the time of writing we are unaware of any actual increase in staffing. The long-term implications of this increased workload remain to be seen. Potentially this could influence recruitment and retention of Scottish psychiatrists.
Of the 79 free-text comments, 76 were negative. We suggest, however, that those people who were dissatisfied with the Act were more likely to use the opportunity to comment than those who were satisfied. In general, the comments may well prove useful as they highlight areas, for example paperwork, which perhaps could be addressed in the future.
Conclusion
This survey has limitations: it is not based on a random sample of all Scottish psychiatrists and it includes only the views of psychiatrists and is not counterbalanced by the views of the other parties affected by the Act. None the less it gives an early indication of psychiatrists’ views regarding the Act and its implementation. We hope that these results will be useful in the ongoing review of the Act.
Declaration of interest
None.
Acknowledgements
We thank Margaret Orr and Lesley Holdsworth for their help with this survey.
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