Community treatment orders are not helping people with mental illness | Sarah Wollaston

Community treatment orders are not helping people with mental illness | Sarah Wollaston The use of compulsory detention in hospital has not dropped as expected, and the Department of Health needs to find out why.

The health select committee reports today on the implementation and operation of the 2007 Mental Health Act. Campaigns such as Time to Change have made a real difference in tackling the stigma around mental illness but there continue to be long-term implications for those who have been detained under the Mental Health Act.

It had been hoped that the introduction of community treatment orders (CTOs) would help to reduce the use of compulsory detention in hospital. It was predicted that 10% of people admitted under the act could instead be discharged and treated in the community under compulsory supervision and that it would reduce the risk of readmission. In 2008-09 when the provisions came into force there were 42,208 detentions for assessment or treatment but this had risen to 44,894 in 2011-12.

Although the causes of this increase are poorly understood, there is a link between a lack of bed capacity in psychiatric units and an increase in compulsory detention. The Care Quality Commission has found that in more than half of wards there was 90% occupancy and in 15% of wards 100% occupancy. In such circumstances clinicians have little flexibility to provide the best care. It may be that some patients are more unwell by the time they are eligible for a bed and then need to be sectioned, but there was also a disturbing suggestion that some patients were being detained because this was the only way to access a bed.

Both are unacceptable, but the second would be a serious violation of civil rights as well as an abuse of professional obligations. It can never be acceptable to use sectioning powers if that is not justified by a person's clinical condition. There also needs to be greater debate about whether it is right for voluntary patients to be held under de facto detention by threatening to detain them if they attempt to leave. In such a situation they are in effect detained without access to a tribunal or the right to advocacy.

The Department of Health must investigate this as a matter of urgency and address the shortage of inpatient beds. A commitment to parity of esteem for mental illness under the Health and Social Care Act and NHS Mandate will have a hollow ring unless that translates into better care, especially for the most vulnerable people with severe mental illness.

The Oxford Community Treatment Order Evaluation Trial has demonstrated that CTOs do not reduce readmissions and there has been great variation in their use, with some areas discharging 45% of patients with a CTO and others none at all. Psychiatrists are divided on their use with some believing them to be unethical. Many patients find them to be stigmatising and the clinical variation in their use is a matter for urgent professional and service user review.

Access to independent mental health advocates (IMHAs) for detained patients in the 2007 act was a key improvement in the legislation but there is evidence that many people are not being informed of their rights to advocacy. Responsibility for providing IMHAs passed to local authorities from April this year but the service should also now switch to become opt-out rather than opt-in to address the variation in access to this important safeguard. In view of the concern about the number of patients under de facto detention having been admitted voluntarily, it is also time to extend advocacy to all in patients undergoing treatment on psychiatric wards.

Section 136 of the Mental Health Act allows police officers to remove a person from a public place to a place of safety if they believe he or she is suffering from a mental disorder. That detention may last for up to 72 hours and should most appropriately take place in a mental health unit. There has been a 25% fall in the use of police stations for these assessments since 2005-06 but it is still a concern that only two-thirds of patients are assessed in a hospital-based environment. A police station should only be used in exceptional circumstances. Fewer than one in five people detained under section 136 are subsequently detained in hospital, which is surprisingly low. Too often it is the lack of access to community services that leads to police involvement with a distressed individual in a public place. In particular, the use of section 136 for at least 300 children last year needs urgent review to look at the causes and consequences.

One of the most shaming findings of the committee report was the continued and disproportionately high rates of detention among certain minority ethnic groups. Mixed, black and black British people are up to 13 times more likely to be detained than expected. All over the world migrant communities have higher rates of mental illness but this is especially marked in London. This may be because of social isolation but also the fear of detention and mistrust of services, which prevents people seeking help at an early stage. Culturally sensitive services and effective advocacy services could help to address this injustice. The Guardian