Sectioned

Social Services and the 1983 Mental Health Act

Franz Brentano

• Publisher: Routledge
• Year: 2002
• ISBN:
  9781134983186
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

PUBLICITY TITLE Only major research into 1983 Act Ric Bowl was one of the authors of Social Work in Context, 1983, Tavistock (life sales 2018)

Chapter 1
COLLABORATION IN THE STUDY OF NEW LEGISLATION

The research project from which this book derives has been an unusual one both in its subject matter and in the way in which it was undertaken. Its origins were in the concerns of social services managers that the Mental Health Act, 1983 was yet another piece of legislation placing new demands on already overstretched resources. The early 1980s had seen a number of significant new pieces of welfare legislation that demanded time to be devoted to understanding their requirements, training for staff involved in implementation, and the establishment of new procedures, if not new resources: the 1980 Child Care Act, the 1980 Foster Children Act, the 1980 Residential Homes Act, the 1982 Juvenile Justice Act, the 1983 Health and Social Services and Social Security Adjudications Act, the 1984 Registered Homes Act, and the 1984 Data Protection Act

The Mental Health Act, 1983 required attention to be focused on an aspect of the personal social services that rarely achieved any priority. It appeared to imply an expansion of mental health resources to make it possible to prevent hospital admission and to provide aftercare following discharge, it generated an immediate need for substantial new training programmes and procedures to approve formally a new type of designated social worker, and it appeared to open up the activities of social services workers undertaking duties under the legislation to much greater public scrutiny than before. We discuss in some detail the expectations that accompanied the passage of the Act in Chapter 3.

Concern about both the direct resource implications of the Act and about the potential indirect effect it would have on other services by diverting attention away from what were normallyregarded as priority areas led to decisions to set up internal systems within some social services departments to monitor the impact of the new Act. Thus one important characteristic of the genesis of this project was a somewhat defensive, but understandable, concern about the time and resource costs of its implementation. More generally a concern was developing both within the social services research community, and amongst those responsible for putting into practice new policy decisions, that new policy directions were being determined centrally, often embodied in legislation, with no attempt being made to monitor what effect this was having either on those responsible for implementing decisions or on recipients of services who should be the ultimate beneficiaries of policy development.

In 1983 representatives of the Social Services Research Group (SSRG) and of the Association of Directors of Social Services (ADSS) met to discuss research priorities and it was agreed that the impact of new legislation was one area that should be given priority. As well as identifying priority topic areas, these discussions also highlighted the repetitive and unco-ordinated nature of much of the research undertaken within social services departments and suggested that priority areas would benefit from a common approach. Thus when it became obvious that a number of departments were starting to set up individual systems to monitor the implementation of the Mental Health Act, 1983, a group of SSRG members got together to propose a common system in which all interested departments could be involved.

Thus the first unusual feature of the project was that it was designed and undertaken by a group of researchers, the majority of whom were employed as full-time researchers within social services departments. As such it represents an example of the benefits of large-scale collaboration across social services departments and between those departments and the university departments that were also represented in the group (see Barnes, 1987). It did not depend on a large research grant that had to be negotiated before the project could start. Rather, it was launched by all those departments that wanted to become involved ‘buying in’ by contributing a small fee to meet non-personnel costs of the project and committing staff time to varying degrees for the purposes of administration, data collection, and analysis.

This model of research has considerable advantages in terms of achieving immediate and specific relevance for those operational agencies that became involved, and providing a comparative overview of the picture across the country. However, from another perspective, the fact that monitoring the implementation of new legislation was left to local initiative and was dependent on individual researchers and individual directors of social services being willing to accord priority and time to the project, can be seen as an example of the State’s somewhat ambivalent attitude towards social policy. New social welfare legislation is passed with few consistent attempts to determine what impact it has on the lives of those it is designed to affect, in spite of Seebohm’s caution that the new personal social services departments would be ‘experiments’ in meeting social need and as such should be evaluated to ensure that the experiments were achieving what was intended (Seebohm, 1968). Once the project was underway, additional financial support was provided by both the Department of Health and Social Security (DHSS) and the Joseph Rowntree Memorial Trust and this enabled the project to be further developed. Considerable interest in the findings has been expressed by the DHSS, but it is far from certain that such a project would have been initiated from within the government department responsible for the oversight of social welfare legislation.

All social services departments in England and Wales were invited to join the project (the main provisions of the 1983 Act did not extend to Scotland or to Northern Ireland). The response was larger than expected: of a total of 117 social services departments in England and Wales, 42 departments joined the project and collected the data that forms the basis of the following discussion. These 42 departments (36 per cent of the total) were from all parts of the country and included 13 English shire counties, 15 metropolitan districts, and 13 London boroughs. Some 16 million (34%) of the 47 million people in England and Wales in 1985 were covered. The distribution according to type of SSD is shown as follows (excluding the Isle of Wight and Channel Island Authorities). Whilst they were self-selected, the size and distribution of the sample authorities is sufficient to have confidence that the picture they present is not likely to be an unusual one. The size of the response necessitated establishing a structure to deal with administration and liaison. Members of the central steering group took on responsibility for liaising with groups of departments on a regional basis and each individual department was asked to nominate a local liaison officer to act as contact point.

Table 1.1

Thus, distribution of data-collection forms, instructions, notification of meetings and feedback devolved from the centre to regional liaison officers and thence to individual departments. The regional liaison officer was the first point of contact if there were queries about the project in general or any specific queries about particular aspects of data collection. Inevitably, reaching common agreement across such a large number of participants was not always easy. Therefore, regional groups of participating departments met on occasion to discuss the progress of the project and any problems or issues that had arisen. If queries arose amongst regional groups that needed central discussion or agreement, these were brought to the steering group, which continued to meet regularly throughout the course of the project. Despite this intricate procedure the possibility remained of there being rather more inconsistencies in procedure and interpretation than in a project of a smaller scale, managed more tightly by a small number of external researchers. This we considered was outweighed by the uniquely collaborative nature of the project.

COVERAGE OF THE PROJECT

The project was designed to monitor all work arising from the Mental Health Act, 1983, which was referred to the 42 departments during the 12 months from April 1985 to March 1986. There are a number of significant implications of this for the conclusions we have been able to draw. Perhaps the most important of these concerns the nature of the target population. We have been able to collect information about all those who were considered for possible detention under the Act whether or not they were subsequently admitted to hospital. Thus we are able to reach conclusions about who is being considered for detention and the different rates at which different groups within that population are admitted or receive some other form of care. We are also able to comment on the impact that assessment by an approved social worker (ASW) has on admission rates, as we are able to compare the nature of requests made with the outcomes achieved. The majority of research concerned with people detained under mental health legislation has focused on people who have already been admitted to hospital—those who are often referred to by health and social services professionals as having been sectioned, i.e. detained under a section of the Mental Health Act. Retrospective comparisons have been made of those who have been admitted formally compared with those who have become voluntary patients (e.g. Szmuckler, et al. 1981), but those assessed and not admitted have not been visible. If one of the underlying aims of the 1983 Act was to clarify and strengthen the role of the approved social worker as an actor in the decision as to whether or not to admit to hospital people with a mental disorder, it is important to know who they do not apply to have admitted as well as those for whom an application is made. We refer to an outcome that does not result in hospital admission following assessment as a diversion. It is also important to know what happens to those who are not admitted, but whose mental state has obviously been of sufficient concern to lead to someone making a request for an assessment under the Act. We are able to provide information on alternative sources of care given to people who were not admitted to hospital.

Because we collected information on all referrals to social workers under the Act, we are able to reflect both on the number of times social workers were required to take action and on the number of people involved in those actions. It is well known that information on hospital admissions overcounts the number of people actually admitted. Our method of data collection enables us to distinguish between the number of referrals and the number of people referred. This is important not only to avoid distortinganalysis of who is being considered for action under the mental health legislation, but also in commenting on the extent to which actions follow on from decisions made previously. Many of the people referred to social workers during this period were referred more than once. We term each action taken as an incident. The more normally used term referral could include more than one incident, for example, a referral for an assessment and a request for a social-circumstances report. These would be separated out in our study in order not to obscure the range and number of actions requested.

The study also included actions other than assessments that could lead to compulsory detention. On the data collection form we specified the major sections of the Act that could lead to a request to a social worker. These included requests for reports to Mental Health Review Tribunals, requests to consider aftercare needs as set out in section 117, and requests for consultations under the provisions for second opinions about consent to treatment (sections 57 and 58). Social worker involvement potentially goes beyond sections such as those that prompted considerable discussion when the Act was passed and we asked social workers to record information about any incident of work arising from the Act. In the majority of cases it was clear that the action requested did relate specifically to the Mental Health Act, 1983. Where there was some doubt about whether an action should be included, this was checked out via liaison officers and, if necessary, guidance and clarification notes were issued to all participants. We include in Appendix 1 a more detailed definition of the criteria for inclusion of work in the study.

Since the criteria for inclusion referred to the nature of the work, our coverage of workers included a number of different work locations. Social workers based in generic fleldwork teams, in specialist mental health or crisis-intervention teams, in hospitals and in emergency duty teams were all involved in work arising from the Act and contributed data to the study. Thus as well as different geographical areas with different population structures, we also cover different types of organizational responses to the provision of mental health services and to the statutory duties of social services departments under the Mental Health Act.

DATA COLLECTION AND ANALYSIS

This was not a methodologically complex research project. Rather it was a large scale monitoring exercise that would enable us to obtain an overview of the size, nature, and outcome of work arising from the Act, and to comment on the reality of legislation in action. Thus, having defined the scope of the project, the task was to design a monitoring form capable of being used consistently in a large number of settings, by an even larger number of workers, with limited supervision at the time of completion. A copy of the monitoring form, with its accompanying guidance notes, is included as Appendix 2.

As well as recording information about the person referred, the circumstances in which the referral was made, the action requested, and outcome achieved, the forms were coded to enable us to link different incidents relating to the same person. Details of these codes were retained within the departments concerned so that information about named clients did not leave the departments and confidentiality was retained. Coding also enabled us to establish the number of incidents responded to by each worker, as well as by the different teams and departments represented in the study.

Monitoring forms were duplicated so that one copy could be held in the department in which it was generated, whilst the other copy was sent off for central analysis at Birmingham University. Analysis took place after forms were returned relating to the first 3 months of the period, again after 6 months, and then when data for the full 12-month period had been received. Funds made available by the DHSS enabled the employment of a research assistant to undertake extra checks on the consistency of returns from different authorities and many authorities were asked to complete further checking and amendment of their returns. The frequency and speed of feedback was another unique feature of the way in which the project was undertaken. Large-scale research of this type often gives rise to complaints that, by the time all the data has been fully analysed and written up, the world has moved on, the situation has changed, and the insights derived from the research are no longer relevant. This is a particular complaint of managers and policy makers who have decisions to make on short time scales determined by operational and political imperatives. Ifresearch is to have an impact in this environment, it cannot afford to ignore those imperatives and researchers working in operational rather than academic environments are more immediately aware of this. From the start the decision was made to provide regular feedback of results as they emerged in order to respond to the concerns that gave rise to the study and to ensure continuing interest and commitment to it. This was important for the quality and consistency of data input, which depended on individual social workers being willing to fill in monitoring forms throughout the entire period.

We know that this regular feedback resulted in some changes in practice. One department, for example, was amazed at how much work under the legislation was being dealt with by hospital social workers. This led to the movement of mental health specialists into area teams and a corresponding reduction from between 30–40 per cent of work being done by hospital social workers to 5 per cent.

Feedback also proved useful to departments when discussing services with Mental Health Act commissioners and social services inspectors. This may have produced less direct changes during the course of the project. Whilst the decision to provide regular feedback will have contributed to the fact that our final results do not describe what was a static situation during the year in which data was collected, we are not concerned about this. Our aim was not simply to describe and analyse, but to inform policy and practice development in order to ensure that those referred under the mental health legislation receive a fair and helpful response. The fact that our findings have been and continue to be used to review and develop the way in which mental health services are being provided in participating departments, is more important in our eyes than the ‘contamination’ of our subject of study by the application of interim findings. We also feel that specific organizational changes like the one referred to above would have been easier to achieve than more fundamental changes in the patterns of outcomes of assessment. This core element of our analysis of the way in which the Act has been implemented and the implication of that is unlikely to have been changed dramatically during the course of the project We do not know whether there has been any change since then, although we have no reason toassume that the picture would look very different 4 years later. Our analysis leads us to conclude that the changes required to make any major impact on the overall experience of recipients of mental health services go well beyond a reorganization of ASWs. However, changes that are within the power of agencies charged with implementing the Act can make an impact on outcomes, and it has been our aim in disseminating the results of this project in a variety of ways to assist that process.

In presenting the findings of this project we have had to go beyond analysis of data collected on the monitoring forms in order to provide some context for those findings and also to understand their meanings. In Chapter 2 we start by considering why mental health legislation exists and how it has changed as different views of the appropriate response to mental disorder have achieved prominence. Also in this chapter we consider evidence concerning the place occupied by mental health work within social services departments and what this implies for the ability of such departments to implement the new Act We develop this theme in Chapter 3 where we consider the intentions, hopes, and expectations of those who campaigned for a change in the law, and the reactions of those who would have to implement it. Chapter 4 sets out our major findings concerning assessments for compulsory detention and the outcomes of those assessments—the core of the 1983 Act. We compare our findings with available information about detention under the 1959 Act (which the 1983 Act revised and replaced) and also provide comparisons between different local authority areas. Chapter 5 contains our findings in relation to other sections of the Act, which provide further insights into the way mental health work is perceived and organized within social services. In Chapter 6 our attention is focused on those people who were assessed by social workers during the year in which we were collecting data, some of whom ended up in hospital and some of whom received some alternative form of care. We compare outcomes for different groups of people and consider other...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• ACKNOWLEDGEMENTS
• CHAPTER 1: COLLABORATION IN THE STUDY OF NEW LEGISLATION
• CHAPTER 2: THE SOCIAL CONTEXT OF THE 1983 MENTAL HEALTH ACT
• CHAPTER 3: GREAT EXPECTATIONS OR MUCH ADO ABOUT NOTHING?
• CHAPTER 4: LEGISLATION IN ACTION: THE EVIDENCE OF CHANGE
• CHAPTER 5: ONE STEP FORWARD....
• CHAPTER 6: THE SOCIAL PERSPECTIVE ON MENTAL DISORDER AND MENTAL HEALTH PRACTICE
• CHAPTER 7: BEYOND SECTIONING
• APPENDICES
• REFERENCES