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The use of emergency detention certificates

 

Emergency detention by age and gender, 1 April 2009 to 31 March 2010

 

AR-09-10-Table2

Our interest in this

An emergency detention certificate (EDC) can be issued by any registered medical practitioner. There should be consent from a mental health officer (MHO) if possible. We collect information on the age and gender of people detained in this way. We look for differences in the way EDCs are used for men and for women and any trends in the use of this power for different age groups. Last year, we found a trend in the use of emergency detention: it fell for men but not for women. We were interested to see if this trend continued.

What we found

The total number of EDCs fell by 3%

       Gender

  • EDCs for men fell by 1%
  • EDCs for women fell by 5%

More women than men are detained under an EDC, except in the 18-24 age group. This has always been the case but the gap has closed slightly since we reported reported on this last year.  We will continue to monitor and report on gender differences in care and treatment.

       Age

  • EDCs for people aged 65 and over rose by 6%
  • Since 2007-8, there has been a 22% increase in the use of EDCs in this age group
  • The increase is proportionately slightly greater for men

Over the past three years, we have commented on an increasing tendency to use mental health legislation for older adults. The use of EDCs in this age group contrasts with a reduction in their use for younger people. As yet, the increase is not statisitically significant. We think the increased use of the 2003 Act for older people reflects the attention given to the rights of people with dementia. If the person cannot consent to hospital admission and is voicing or showing resistance, detention may be more proper than informal admission. Also, it may be that services are trying to manage people with dementia for longer in the community and need to intervene quickly when services are insufficient to deal with the risks faced by the person with dementia. The lack of a power to intervene quickly to provide emergency social care under the Adults with Incapacity (Scotland) Act 2000 may also be an issue here.

At the other end of the age spectrum, the use of EDCs for people under the age of 18 continues to fall.

 

EDCs with and without MHO consent by NHS Board, 2009-10

 

 AR-09-10-Table3

 

Our interest in this

Emergency detention should only be used where granting a short-term detention certificate would involve too much of a delay. We look at the extent to which emergency detention is used to detain people already in hospital or to admit them from the community. We hear of anxiety from some people that, although they agree to be in hospital, they may be detained if they want to leave. We want to find out how often this happens. In previous years, around half of EDCs were granted for people who were already in hospital.

We place great importance on the role of the mental health officer (MHO) in the decision to detain a person. The MHO provides the important safeguard of looking critically at the proposal to detain the person and can help to look at alternative ways to support the person without needing to use compulsory admission. Where the person needs to be admitted, the MHO can help to explain the process and make arrangements to make admission easier and to safeguard the person's property and possessions. The 2003 Act requires either consent from an MHO or an explanation of why this was not possible. We would like to see consent in as many cases as possible. We look to see whether there is more likely to be MHO consent in some NHS Board areas than others.

What we found

As with previous years, Ayrshire and Arran, Lanarkshire and Greater Glasgow and Clyde had relatively low rates of MHO consent to emergency detention. These NHS Boards must work with their local authority partners to address this. Rural areas have significant challenges but the rate of MHO consent in Highland and Grampian show what can be achieved.

Fife and Lothian have very high levels of MHO consent, this suggests that they are providng a good 24 hour MHO service.

 

EDCs by pre-detention status and MH0 consent to detention 2009-10

 

AR-09-10-Table4

Our interest in this

We usually find that detention of a person already in hospital is less likely to involve MHO consent. This is probably because the person is stating an immediate wish to leave and the medical practitioner has conducted an examination, decided that the person should be detained but cannot wait for the MHO. We have concerns that people can be detained for up to 72 hours without MHO consent.

What we found

Again, people who are already in hospital are much less likely to have consent from an MHO when detained under EDC. Overall, it appeared that the use of EDC for people already in hospital was becoming progressively higher than the use for people in the community.

 

EDCs for people in hospital and from the community by gender 2009-10

 

Fig-4a-EDCs-Gender

 

Significantly more women than men are admitted from the community, compared with the gender balance of detention of people already in hospital (p=0.03). This reinforces our view that services respond differently to women in the community at times of mental health crisis. Possible explanations include response to deliberate self-harm by the use of emergency detention and the possibility that men may be  even more likely to be dealt with by criminal justice procedures.

We looked at the use of EDC for people in hospital versus people in the community over the last three years.

Fig-4b-EDCs-Hospital

It is heartening that fewer people are admitted from the community under EDC. Since 2007 the overall drop in the use of EDC has been 16% for people who are admitted from the community. Its use for people in hospital actually rose slightly over the same time. This is highly significant (p=0.002). We think this is because the need to detain a person urgently in hospital may mean that it must be done before both an approved medical practitioner and MHO can attend. We have recommended changes to the use of nurses' power to detain and to the duration of EDCs as part of the review of the 2003 Act. Unless these changes are made, we expect that the use of EDC for people already in hospital will not fall. This is a matter of significant concern to us.

EDCs by time of granting of certificate and MHO consent to detention, 2009-10


 

AR-09-10-Table5

Granting of EDCs vs STDCs, in hours and out of hours 2009-10

 

Fig-5

Our interest in this

While short-term detention should be the usual route into compulsory treatment, emergency detention is still used, mostly outside office hours. We think it is important that there is consent from an MHO wherever possible. We want to find out if MHO consent is available outside office hours.

What we found

Overall, most EDCs have MHO consent. There is no great difference in the rate of MHO consent for people detained within and outside office hours.

 

Duration of emergency detention certificates granted 2009-10*

Table 6

*these figures include people admitted while on community based compulsory orders, but exclude 25 people where we have been unable to determine the duration of the EDC

 

Our interest in this

Short-term detention should be the usual route for admission to hospital under the 2003 Act.  This involves mental health specialists - an approved medical practitioner (AMP) and a social work mental health officer (MHO). Emergency detention certificates (EDCs) can be granted for up to 72 hours. An AMP or MHO is not necessarily involved and there is no right of appeal.

The Act says that hospital managers should arrange for an AMP to examine the person as soon as possible after admission. We think this should happen within 24 hours. Usually, this should result in a decision to either revoke the certificate, or to detain the person under a short-term detention certificate. We do not think that the certificate should run for the full 72 hours and then expire in such circumstances. We look at all EDCs and measure the time until they are either superseded or revoked to make sure that there is evidence of early expert assessment.

What we found

This year, we found that only 18% of EDCs appear to run for the full 72 hours and then expire. This is much lower than in previous years. We are pleased to see this although we think the number should be lower still. It may be that we are not always notified if the order is revoked earlier.

Ideally, EDCs should be revoked or superseded by a short-term detention certificate within the first 24 hours. This happened for 44% of people subject to an EDC this year.  This is an increase on previous years. Hospital managers must do their best to ensure that, where the order is not revoked or superseded, there is at least an assessment by an AMP within the first 24 hours.