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Introducing the Programme (Part I)

Part I: The importance of creating a cultural shift in mental health inpatient settings

Welcome to the first blog post in our 2-part series. We are the Programme Delivery Team responsible for the Mental Health Act Quality Improvement (MHA QI) programme, a collaborative effort commissioned by NHS England and delivered by The PSC, The Virginia Mason Institute (VMI), and independent lived experience practitioners.

- Part I focuses on the MHA reforms, and the rationale behind incorporating coaching on the national MHA QI programme, as part of the transformative process.

- Part II delves into the importance of co-production and the essential role of lived experiences in shaping the design and delivery of the programme.

Introducing the Programme (Part I)

What is the national Mental Health Act QI Programme?

The national MHA QI (Mental Health Act Quality Improvement) programme aims to improve the equity of experience for individuals from ethnically diverse backgrounds and those with learning disabilities & autism when detained under the Mental Health Act in hospitals across England.

Over 50 NHS Trust-run services will be involved, receiving coaching at different levels of the organisation to promote cultural change, enhance leadership capacity, and empower staff teams to co-produce and implement change ideas in line with the programme's aim.

Background on the Mental Health Act

The Mental Health Act (MHA) 1983, the legislation governing mental health care in England and Wales, has long been in need of comprehensive reform. The Act allows individuals to be detained and treated for their mental health in hospitals against their wishes.

The rationale for the much-needed MHA reforms is as follows:

  • Outdated Legislation: The Mental Health Act 1983 was based on earlier legislation and has not evolved to reflect modern mental health care practices and attitudes. Practices such as using police cells as ‘safe spaces’ or limited access to advocacy services, are severely outdated.
  • Rising Rates of Detention: In the ten year period between 2005/06 and 2015/16, the number of detentions increased by 40% from 45,484 to 63,622. Even though detentions under the Mental Health Act have recently fallen, overall numbers remain consistently high, with 53,337 people detained in 2021/22. This has led to calls for the government to review the threshold/need for detention more frequently.
  • Inequalities in Mental Health Care: The 2018 Independent Review identified disparities faced by people from ethnically diverse backgrounds and those with learning disabilities and autism, highlighting the urgent need for change.
  1. A disproportionate number of BAME individuals are detained under the MHA. For example, Black people are over four times more likely to be detained under the act and over ten times more likely to be subject to a Community Treatment Order (CTO).
  2. People with a learning disability or autism are at a particular disadvantage, as professionals do not always have the time nor skills to understand how best to work with these patients. The vast majority (90%) of autistic people who are detained in hospitals are put there under the MHA.

In response to these concerns, an independent review in 2018 proposed over 150 reforms.

This independent review crucially stated that: “We intend to shift the balance of power between patients and professionals. To make it easier for a patient’s wishes to be respected both in the present and the future....”

The Government published the Reforming the Mental Health Act White Paper in August 2021, which sets out proposed changes to the MHA and wider reforms of policy and practice around it based on the recommendations from the Independent Review in 2018.

Guiding principles of the Mental Health Act reforms

  1. Choice and Autonomy - Ensure that service users’ views and choices are respected
  2. Least Restriction - Using the act’s powers in the least restrictive way possible
  3. Therapeutic Benefit - Ensure that patients are supported to get better
  4. The Person as an Individual - Viewing and treating patients as individuals


The role of non-legislative change in putting into practice principles of the MHA reforms

The government has recognised that legislative changes, while vital, are only part of the equation. Without a shift in the mindset and practices within mental health care settings, the desired improvements from the reforms may not be fully realised.

The primary goal of the national MHA QI programme is to facilitate this cultural shift, to enhance the cultural appropriateness of care for those detained under the MHA. Furthermore, this programme places a strong emphasis on addressing inequity of experience for people from ethnically diverse backgrounds, and people with a learning disability and autistic people - supporting Trusts to embed a a ‘locally-led, centrally supported’ approach to QI.

Coaching on this programme can play a vital role in facilitating this process, empowering leaders, staff, and patients to work together towards a more equitable and compassionate mental health care system for those detained under the MHA. This involves executive and service leadership & frontline delivery coaching, focusing on:

  • Co-producing alongside lived experience
  • Supporting Cultural Change
  • Building Leadership Capacity
  • Engaging Staff Teams

From a systemic lens, this coaching will ensure that staff work alongside patients to explore and understand the barriers that compromise equity in the settings they work in. Only then will we be able to observe improved care planning, reduced inequalities and increased dignity and respect for those detained under the MHA, particularly for groups experiencing significant inequalities under the MHA - people from ethnically diverse backgrounds, and people with a learning disability and autistic people.

From an individual and patient carer lens, the approach emphasises empowering patients and their carers to openly share their distinct experiences and diverse needs with the staff on the ward. Through this collaborative effort, patients, their carers, and lived experience practitioners work together with the staff to ensure that the support provided caters to the individual and diverse requirements of each person, focusing on their recovery journey.

A pivotal aspect of this approach involves placing patient and carer voices and perspectives at the core of the relationships formed with healthcare providers, and when necessary, advocacy support.

“Board members told us that culture is key. For a person to feel safe, the experience and culture of care needs to be kind, compassionate and hopeful, so they can make the progress that supports them to achieve a good quality of life back in their community. Staff also need to feel safe and supported to speak up early when a service does not meet the standards they want to deliver.” - Dr Geraldine Strathdee, independent chair of the Rapid review into data on mental health inpatient settings

Overall, the MHA reforms represent a significant step towards creating a mental health care system that places greater emphasis on patient autonomy and dignity.

Our second article will go into further detail about the role of co-production and lived experience on this programme, and our coaching approach.

Author: Akhila Potluru

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