Introduction
Since 2006, The Mental Health Act 2001 (MHA, 2001) has been fully operational in Irish mental health approved centres. The Act gives a legislative basis for mental health-care practice, which is consistent with international law, the European Convention on Human Rights and best practice. Since its introduction, patients detained under MHA 2001 have had rights to independent review by a tribunal, appointed by MHA 2001, and rights and privileges protected under this legislation. This paper describes a structured template that facilitates review of the operation of MHA 2001 in our service.
St Patrick's University Hospital is the oldest independent provider of mental health care in Ireland. St Patrick's aspires to provide the highest quality mental health-care to promote mental health and to advocate for the rights of those who suffer from mental illness. It is in this context that the dashboard, along with other quality initiatives, has been implemented. The organisation provides a range of mental health services including campus-based inpatient care on two sites in three approved centres: St Patrick's University Hospital, James's Street, Dublin 8; Willow Grove Adolescent Unit, James's Street, Dublin 8; and St Edmundsbury Hospital, Lucan, Co. Dublin. It also provides a comprehensive range of day-care programmes; a number of community clinics called “Dean Clinics” and a range of technology-based supports. St Patrick's works with over 3000 people each year and accounts for circa 12% of the country's total inpatient needs.
Included in this paper is the dashboard considered by the Clinical Governance Committee of St Patrick's University Hospital for the entire year 2012, displayed how it is viewed on a weekly basis by the Clinical Governance Committee but also including end of year validation of information (Fig. 1).
Fig. 1 Involuntary Admission Dashboard 2012.
Background
An appropriately governed approved centre must have structured processes in place to adequately monitor its activities vis-à-vis MHA 2001. There are a number of elements of this MHA 2001 that require such monitoring (Fig. 2).
Fig. 2 Mental Health Act 2001 Key elements for dashboard monitoring.
Where a patient is detained under the MHA 2001, an independent tribunal made up of a legal member (Barrister or Solicitor who will act as Chair), a lay person and a consultant psychiatrist is held within a set time according to Section 17 (Referral of admission order and renewal order to a tribunal) of the MHA 2001 and a proper independent adjudication is made. Cases such as this may be revoked or affirmed. In addition, a number of rights to independent review and challenge to the detention are enshrined in the MHA 2001.
It is essential that the operation of MHA 2001 is fully in accordance with best practice. There have been a number of challenges in the High Court which are documented in case law (bailii.org). These challenges have been brought before the Courts as a result of errors in adherence to the Mental Health Act 2001. After more than 5 years’ experience of operating the MHA 2001, a wealth of clinical understanding and skill has been accrued. The Clinical Governance Committee decided to combine this awareness of the operation of the Act and prepare an inter-disciplinary template, which will allow us to monitor our compliance across our health service as a whole.
Methods
As defined by Few (Reference Few2007) ‘A dashboard is a visual display of the most important information needed to achieve one of more objectives; consolidated and arranged on a single screen so the information can be monitored at a glance’. With this in mind, the MHA Administrator prepared an involuntary admission dashboard with issues in relation to the volume of and oversight of the Act 2001, combined in an easy format for review by the Clinical Governance Committee. The Clinical Governance Committee at St Patrick's University Hospital Services includes nursing, psychiatry, social work, pharmacy and administrative support. The Committee met to combine their awareness of the agendas arising over the first 5 years of the operation of the MHA 2001 in a common template. Through audit and monitoring, the MHA Administrator collected data with regard to the common sentinel events that occur in relation to compliance and combined these into a single data sheet, which allowed the Committee to review our operation of the MHA 2001 on a weekly basis across three approved centres within our mental health service.
The Clinical Governance Committee then used this to monitor our services compliance on a week-to-week basis.
Result
The dashboard shows the most important performance indicators to be monitored. This allowed the organisation, via the Clinical Governance Committee, to review data in a contemporaneous manner. In all, the dashboard was reviewed on 48 occasions by the Committee during 2012. As of 31 December 2012, the dashboard demonstrated that there were in total 80 involuntary admissions, of which 31 patients were detained under Section 14, 40 patients were detained under Section 24 and nine patients were transferred into the Hospital under Section 21 of the Act 2001. There were no patients at the hospital with an involuntary status of >3 months as of 31 December 2012. In total, there were 72 Mental Health Tribunals held, at which 11 patients were discharged at tribunal under Section 18 of the MHA 2001. A total of five patients underwent electroconvulsive therapy under Section 59 (ECT) of the MHA 2001. There were five Section 60 (administration of medicine) reviews carried out. Involuntary admissions accounted for 3.4% of our total admissions YTD in 2012. This is significantly lower than the national average for approved centres, which is 10%, as reported by Daly & Walsh (Reference Daly and Walsh2010). All of this information is displayed on a single sheet (Fig. 1).
Discussion
Combined experience of the operation of MHA 2001 has added greatly to our understanding of its use. An inter-disciplinary review also enabled us to highlight key events and issues that can cause concern in terms of the Act's operation. The result was the drafting of a dashboard that allowed continuing monitoring of our operation and also accurate noting of our compliance with the obligations enshrined in the MHA 2001.
For example, the Organisation monitors, on a weekly basis, via the Clinical Governance Committee, the number of times Section 23(1) (power to prevent voluntary patient from leaving the approved centre) is implemented, how many times this action leads to an involuntary admission and the percentage of involuntary compared with voluntary admissions. We can then compare our practice to the national average.
The organisation also monitors, in the same way, the number of times Section 14(2) (admission order) is implemented and how many times this action leads to an involuntary admission. We also monitor the use of assisted admissions under Section 13 (removal of persons to approved centres) and Section 63 of the Health (Miscellaneous Provisions) Act (2009) is also monitored.
Section 20 (application for transfer of patient) is monitored via an organisational-based form to be signed off by the clinical director, following a request for transfer of a patient under the MHA 2001. Transfers to St Patrick's may only proceed on completion of this form by the clinical director (Fig. 3).
Fig. 3 Clinical Director consent for Transfer S20/21 MHA 2001.
All transfers to and from the hospital, under Section 21 (transfer of patient) are then monitored via the dashboard.
The current status of each patient in terms of renewal orders/tribunal hearings and transfers is easily viewed on the dashboard.
The dashboard also highlights the number of Section 60 (administration of medication) reviews required in a particular month and how many have been complete. This information is then collated throughout the year and made available to the Inspectorate during the inspection process.
Appeals to the circuit court under Section 19 (appeal to the circuit court) is also monitored.
The organisation monitors Section 28 (discharge of patients) in terms of revocations and the stage at which these revocations were made, that is, revoked prior first tribunal, revoked at tribunal and post-tribunal/prior second tribunal.
The use of this structured monitoring process allows us not only to measure basic adherence to the Act 2001 but also to measure activities that impact directly on the care and treatment of our service users.
Although clinical care and proper adherence to best practice continues to be a clinical and professional matter, the use of structured monitoring tools allows for coherent observation of matters in a way that would not be possible by random or purely clinical means.
