Care Quality Commission report

Last week the Care Quality Commission (CQC), which has taken over the functions previously carried out by the Mental Health Act Commission, published their first annual report on the administration of the Mental Health Act in England. It is also the first complete year (April 2009 to March 2010) of the new legislation regarding electroconvulsive therapy (ECT), which since November 2008 has given detained patients who retain capacity the right to refuse treatment, unless their psychiatrist thinks they need it urgently.

The report contains four and a half short pages on ECT, and starts in a confusing way by saying:

“Electro-convulsive therapy (ECT) treatment of detained patients or patients subject to community treatment orders must be certified by a SOAD, unless urgent powers of treatment are invoked”.

In fact, if a detained patient consents to treatment, and is deemed to have capacity, there is no need for a SOAD (second opinion appointed doctor) to become involved. This is pointed out in a footnote but would have been better in the text.

The report goes on to say that there has been “a general decline in the number of requests for ECT certification over the past five years”. The figures are as follows:

2005/06    1,926

2006/07    1,818

2007/08    1,730

2008/09   1,606

2009/10   1,339

Three of the requests in 2009/10 concerned patients living in the community. The rest concerned patients detained in hospital.

Prior to November 2008, ECT could be given to capable but refusing patients under section 58, and they accounted for about 40 per cent of those treated without consent. So you would have expected the figures to fall by about that amount between 2006/08 (the last complete year of the old system) and 2009/10 (the first complete year of the new system). They have actually fallen by rather less, as psychiatrists have been switching people from the capable but refusing category to the incapable category.

Over forty per cent of the people treated without their consent under section 58A of the Mental Health Act were women over the age of 65. At the other end of the age-range, there were two requests to use ECT on people under 18 years of age – one was authorised. Since November 2008 the law requires psychiatrists to seek authorisation before giving ECT to anyone under the age of 18, even if they consent to treatment. According to the report:

“We received no requests to arrange ECT second opinions for informal patients under the age of 18, although we cannot assume that all clinicians caring for such patients will know that certification is required, and therefore cannot say with certainty that no such treatments were given”.

Couldn’t someone tell the clinicians?

There has been a significant increase in the numbers of people receiving ECT under section 62, that is without either consent or a second opinion. This is spite of the fact that the new legislation from November 2008 was supposed to restrict the circumstances in which section 62 can be used. A third of all patients for whom a SOAD visit was requested had already received at least one treatment before the visit, something which the CQC admits to being concerned about. Yet they then devote half a page to a complaint from a psychiatrist who finds the legislation too restrictive.

In more than 98 per cent of cases, the SOAD authorised the use of ECT.

Other news from the report: deep brain stimulation remains unregulated; and psychosurgery has returned to England, with one operation in Bristol, after more than a decade in which no operations were carried out (although its use continued in Scotland and Wales).

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