The Mental Health (Care and Treatment) (Scotland) Act 2003 came into force in Scotland in October 2005, replacing the previous Mental Health (Scotland) Act of 1984. It was hoped that this new piece of legislation would enhance the care of vulnerable patients who required compulsory treatment of their mental illness and further protect their human rights. In early 2006 we conducted a survey of Scottish psychiatrists’ views and experiences of the new Act (Reference Carswell, Donaldson and BrownCarswell et al, 2007). There was a feeling that patient care had not improved, and the survey identified numerous concerns about the Act and its implementation. We presented the results of this survey at various meetings and were consistently asked to perform a follow-up study. It was felt that, although the initial study provided valuable results, doctors might view the Act differently when given more time to become accustomed to the new ways of working. We decided to repeat the survey 1 year after the initial study to assess whether psychiatrists’ views had changed over this period.
Method
The Royal College of Psychiatrists kindly provided the names and addresses of consultants and specialist registrars in psychiatry working in Scotland who agreed to be contacted for survey purposes. We excluded those on the list who were known to have retired, those who had left post and those known to be psychotherapists, because of their limited use of the Mental Health Act. From a total of 399 doctors, 43 names were excluded, leaving 356 eligible contacts.
An anonymous one-page questionnaire was devised. The questions asked were similar to those in our original study to allow for comparison, and assessed respondents’ views of how the Act has affected patient care, the tribunal process, satisfaction with the Act, workload changes, out-of-hours practice and payment for Mental Health Act work. There was space at the end of the questionnaire for free text comments. The questionnaires were posted to the selected psychiatrists in March 2007. A self-addressed envelope was enclosed and replies were collected over the next 2 months.
The local ethics committee did not feel this survey required ethical approval.
Results
Of 356 surveys posted, 237 were returned, giving a response rate of 66.6%. Replies were received from all health boards in Scotland except the Western Isles and Orkney. The results are shown in Table 1. The results from our 2006 survey are included for comparison where applicable.
Table 1. Survey results
| 2007 survey % (n) | 2006 survey % (n) | Comparison | |
|---|---|---|---|
| Regarding the Mental Health (Care and Treatment) (Scotland) Act 2003 | |||
| Do you feel patient care has improved when compared with the care received under the 1984 Act? | |||
| Yes | 27 (64) | 12 (31) | P<0.00011 |
| No | 69 (163) | 81 (208) | |
| Unanswered | 4 (10) | 7 (18) | |
| Do you feel the tribunal process is better than the court system for longer-term detentions? | |||
| Yes | 53 (126) | 34 (87) | P=0.00031 |
| No | 41 (98) | 52 (135) | |
| Unanswered | 6 (13) | 14 (35) | |
| Do you think the care of voluntary patients has been adversely affected (due to time spent on detained patients)? | |||
| Yes | 64 (152) | 65 (167) | P=0.47881 |
| No | 30 (72) | 26 (68) | |
| Unanswered | 6 (13) | 9 (22) | |
| Overall how satisfied are you with your use of the Act so far? | |||
| Very | 1 (3) | 1 (3) | P<0.00012 |
| Reasonably | 53 (125) | 36 (92) | |
| Unsatisfied | 34 (81) | 44 (112) | |
| Very unsatisfied | 9 (20) | 18 (47) | |
| Unanswered | 3 (8) | 1 (3) | |
| If you could choose which Act to use, which would it be? | |||
| 1984 | 43 (103) | ||
| 2003 | 51 (120) | ||
| Unanswered | 6 (14) | ||
| Regarding your workload | |||
| Has your daytime workload changed as a result of the new Act? | |||
| Increased | 89 (211) | ||
| Decreased | <1 (1) | ||
| No change | 9 (22) | ||
| Unanswered | 1 (3) | ||
| Has your out-of-hours workload changed as a result of the new Act? | |||
| Increased | 40 (96) | ||
| Decreased | <1 (1) | ||
| No change | 56 (133) | ||
| Unanswered | 3 (7) | ||
| Regarding your own practice out of hours | |||
| At weekends do you review patients who are subject to emergency detention certificates? | |||
| Yes | 63 (149) | 70 (181) | P=0.02071 |
| No | 30 (72) | 21 (53) | |
| Unanswered | 7 (16) | 9 (23) | |
| Regarding payment for Mental Health Act work | |||
| Are you receiving sessional payments for increased workload associated with the Act? | |||
| Yes | 17 (39) | ||
| No | 81 (193) | ||
| Unanswered | 2 (5) |
Eighty-six respondents (36%) made free text comments in the space provided at the end of the questionnaire. Four respondents made generally positive comments: improved working with mental health officers was noted, along with benefits from early review of emergency detentions, and some felt that overall patient care had improved. Eighty-two respondents made generally negative comments. The criticism fell into a number of themes: 28 people criticised the paperwork for the new Act, commenting that it was overly bureaucratic and time-consuming, whereas 27 people raised concerns about tribunals with particular worries about their organisation and inflexibility with regard to dates and time scales. There were also concerns over the number of interim orders granted, which therefore necessitated further full tribunal hearings with new panel members who did not know the case. The remaining comments covered a wide range of problems, including concerns about the cost of implementing the Act, possible financial gain for legal teams and difficulties applying the Act to elderly patients.
Discussion
In this study we obtained a 66% response rate, which appears to be a significantly better return than in similar studies conducted by the College and the Scottish Government (Reference Atkinson, Lorgelly and ReillyAtkinson et al, 2007). The reasons for our relatively high response rate are unclear but our results show that psychiatrists continue to express a high degree of interest in the workings of the Mental Health (Care and Treatment) (Scotland) Act 2003.
There was a statistically significant improvement in satisfaction with the new Act over the year between the two surveys, with 54% satisfied or very satisfied compared with 37% in 2006. An increase in satisfaction with the Act over time would be expected as psychiatrists become more familiar with the procedures and paperwork. Although there may continue to be further improvement in the future, there is clearly still a considerable degree of dissatisfaction with the Act at present, with 43% of respondents unsatisfied or very unsatisfied. In the second survey there was a statistically significant increase in respondents who felt that patient care had improved, but 69% of psychiatrists continued to express the view that patient care had not improved with the new Act.
The tribunal process for determining whether longer-term detentions should be granted has had a great deal of criticism. There was a statistically significant increase in the number of respondents who felt that the tribunal process is better than the previous court system (53% in 2007 compared with 34% in 2006); however, there continues to be a considerable minority who have concerns about the system. The comments received from respondents give some insight into the perceived problems.
This survey indicates that psychiatrists’ workload has increased since the introduction of the new Mental Health Act. Daytime workload appears to be most affected, with 89% of respondents indicating an increase in Mental Health Act duties during normal working hours. This finding is not surprising when the results of a recent report from the Scottish Government are taken into account. It estimates that the average time commitment for a psychiatrist dealing with a Short Term Detention Certificate (28-day detention) is 260 min, and for the initial stages of a Compulsory Treatment Order application (6-month detention) it is 448 min (Reference Atkinson, Lorgelly and ReillyAtkinson et al, 2007). This increase in Mental Health Act workload appears to be having an adverse impact on the care of voluntary patients, with 64% of respondents indicating concern during this study and 65% in the 2006 study. The concerns raised regarding this issue in the earlier study do not appear to have been resolved.
Although additional funds were made available from the Scottish Executive for implementing the new Mental Health Act, these extra monies do not appear to have been made available to many existing psychiatrists. Only 17% of respondents received additional payments for Mental Health Act work despite the vast majority feeling that their daytime workload had increased and 40% feeling that their out-of-hours workload had increased. A Scottish Government report found the majority of respondents had always used their own time to complete their day-to-day workload but that they had been needing to use more unpaid time since the Act was introduced (Reference Atkinson, Lorgelly and ReillyAtkinson et al, 2007). This increased workload without additional financial compensation may have a detrimental effect on morale and recruitment. It should be noted that this survey also included a number of specialist registrars who would not have been paid on a sessional basis.
The comments noted at the end of the survey were generally negative, which is not surprising given the probability that people are more likely to comment if they are dissatisfied with the Act. It is worth noting, however, that the majority of the negative comments are about the implementation and processes of the Act rather than the Act itself and its principles. These identified problems are therefore more amenable to change.
Overall, psychiatrists appeared to view the 2003 Mental Health Act a little more positively than they did in the preceding year. However, there are still significant areas of concern which need to be addressed. We hope this repeat survey helps identify some of these concerns and ultimately leads to improvements in the workings of the Act.
Declaration of interest
None.
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