Demographic and referral patterns of people detained under Section 136 of the Mental Health Act (1983) in a south London Mental Health Trust from 2005 to 2008

Introduction

Section 136 of the Mental Health Act (1983) (Appendix 1, hereafter S136) is the only section whereby one person – acting without medical evidence or training – has the authority to deprive another person of his or her personal liberty. ^1,2 Previous research into S136 has explored the demographic and diagnostic profiles of individuals detained under S136, reporting a high prevalence of white, single, unemployed men aged in their 20s with a diagnosis of schizophrenia and a previous psychiatric history. ³ The over-representation of black and minority ethnic (BME) individuals in S136 detentions has also been reported in numerous previous studies. ^1,4–6 However, these studies have often collected data from only one metropolitan borough or county and have typically utilized brief data collection periods ranging from six months to two years. Data have been reported from southeast London, ⁷ central London, ⁸ north London ⁹ and rural England. ^10,11 The present study aims to provide more up to date demographic data on individuals detained under S136 in a Mental Health NHS Trust ‘place of safety’, over a longer period (3 years) and across five boroughs within one south London Trust.

Methods

Data were collected from one south London Mental Health NHS Trust consisting of five separate and demographically disparate boroughs. The UK Economic Deprivation Index ¹² ranked the relative deprivation experienced by residents of each of the 354 local authorities in the UK in 2008, with each authority receiving a rank from one (most deprived) to 354 (least deprived). The diversity of the five boroughs in our sample is highlighted by the following rankings obtained by each: Wandsworth, 143; Merton, 210; Sutton, 231; Kingston, 273; and Richmond, 293.

The demographic details of all individuals detained under S136 to the Trust place of safety between 1 October 2005 and 30 September 2008 were examined retrospectively, including the following information: date of detention, date of birth, gender, ethnicity, borough in which detained, time of arrival at place of safety, time assessment was completed, status after assessment (under the Mental Health Act [1983]), and discharge address. Certain data such as presenting behaviours and diagnoses were not available for inclusion in data analysis. Population data for the five boroughs based on mid-2006 estimates were gathered from the Office of National Statistics, and all data analyses were performed using SPSS 15.0 for Windows.

Results

There were a total of 887 detentions over the three-year data collection period, of which 57.4% were men. The ages of individuals detained ranged from 13 to 86 years (X = 37.1, SD = 12.9). As shown in Table 1, black people were over-represented in detentions from each of the five boroughs. Overall, they make up 5.2% of the Trust's general population (0.5% Black British, 2.4% Black African and 2.3% Black Caribbean), yet they accounted for 17.2% of the S136 detentions over the three years (5.1% Black British, 5.0% Black African and 7.1% Black Caribbean). This over-representation was most evident in the borough of Wandsworth, where black people accounted for 29.7% of all detentions (9.7% Black British, 6.7% Black African and 13.3% Black Caribbean) and yet only 7.6% of the general population (0.8% Black British, 3.0% Black African and 3.8% Black Caribbean). Black detainees were 57.9% men and 42.1% women with an average age of 35.2 years (SD = 11.2).

A total of 220 detentions (24.8% of the total) were made on weekdays between the hours of 09:00 and 17:00, 665 detentions (75.0% of the total) were made after 17:00 or on weekends, and time of detention was not recorded in two (0.2%) cases. Individuals detained under S136 are allowed to be held at a place of safety for a period of up to 72 hours; the mean duration spent at the place of safety by individuals in our sample was six hours and 54 minutes (SD = 303.8 minutes). No significant differences in assessment time were found between different ethnicities or genders; however, individuals detained out-of-hours spent significantly longer at the place of safety before a decision was made than those detained during business hours (7 hours and 14 minutes compared with 5 hours and 59 minutes; t(878) = −3.20, P < 0.001). Seventy individuals were detained more than once during the data collection period, accounting for 19.4% of the total number of detentions. One person, a white man in his late 20s, was detained on seven separate occasions over the three years.

As shown in Table 2, significant differences in the outcome of S136 assessments were found between ethnic subgroups; χ ²(25, n = 887) = 59.18, P < 0.001. Black people were more likely than white and Asian people to be further detained under the Mental Health Act (1983), and less likely than white and Asian individuals to be either admitted informally or discharged. A total of 372 (41.2%) detentions resulted in a discharge without hospital admission, while 209 detentions (23.1%) resulted in an informal admission. Of those discharged without hospital admission, 59.2% were men and 40.8% women, with an average age of 35.9 years. Twelve people (1.3%) were discharged out of the catchment area and their status was not recorded. Compulsory admissions accounted for the remaining 34.4% of detentions: 255 (28.2%) under Section 2, 52 (5.9%) under Section 3 and three (0.3%) under Section 4.

Discussion

We retrospectively examined the demographic profiles of 887 consecutive S136 detentions in one south London Trust over a three-year period. Black people (comprising Black British, Black African and Black Caribbean individuals as described above) were over-represented in S136 detentions from each of the five boroughs, and over the three years this averaged out to more than a three-fold over-representation across the Trust (i.e. this ethnic group accounts for 5.2% of the Trust's general population, yet accounted for 17.2% of all S136 detentions). This finding supports previous research that has reported an over-representation of BME people in S136 detentions. ^1,4–6,13 Black people in our sample were also significantly more likely than white people to be further detained under the Mental Health Act (1983) and less likely to be admitted informally or discharged. In addition, this finding reflects research by the Commission for Healthcare Audit and Inspection, which has shown that black people are also over-represented among detentions under all sections of the Act. ¹⁴ This suggests that, in spite of a range of policy initiatives to address this issue, ^3,15–17 there has been no substantial change over the previous decade to the repeated observation that black people are significantly more likely than other ethnic groups to enter mental health services via emergency routes (including S136) rather than through primary care or other planned admission. ^4,18–20 As such it is not unsurprising that the over-representation of black people in S136 detentions corresponds with an increased likelihood that black people are subsequently formally admitted for treatment under the act. However, while black people continue to enter mental health services via S136, it is important that police and interprofessional mental health practice serves to improve the detainee's experience of the S136 treatment pathway by minimizing unnecessary distress and delay while conducting the requisite assessments. The proportion of men and women detained also matches previous studies that have reported men accounting for slightly more than half of all people detained. ^6,9,21

One finding of particular interest was that more than two-fifths (41.2%) of all detentions resulted in a discharge without hospital admission. This rate of discharge was considerably higher than those reported in previous research, in which discharge rates of 32%, ¹⁰ 18%, ⁵ 8%, ⁶ and even as low as 0.5% ²² have been reported. It is likely that some of those discharged S136 detainees in our sample will have been discharged to the support of Community Mental Health, Home Treatment or other mental health teams to which they had already been admitted. Many might also have been intoxicated at detention, as the association between S136 detention and drug and alcohol misuse is historically well documented. ^4,23 However, such a high discharge rate without hospital admission remains extremely high when compared with other similar studies and this may suggest that many individuals are accessing mental health services in south London via the S136 route. This, in turn, further highlights the need to improve the experience for detainees as discussed above. S136 detentions place considerable strain on both police and health services staff, especially nursing staff at the Mental Health Trust's place of safety. Crucially, this results in more time away from other service users. Time devoted to the care and supervision of those detained under S136 may necessitate reliance on agency staff – with the associated financial implications for the Trust. While the use of agency staff is necessary to help ensure safety, their contribution to the overall care and support of service users is inherently limited by their unfamiliarity with service users, policies and procedures of the Trust.

The demand placed on resources by S136 detentions is exacerbated by the timing of detentions and duration of assessments. Exactly three-quarters (75.0%) of all S136 detentions were conducted after 17:00 hours or on the weekends, a finding that supports previous research. Greenberg et al. ¹⁰ reported that only 26.0% of their S136 assessments were conducted during business hours, while the Care Services Improvement Partnership ²⁴ reported that the busiest period for S136 detentions was between 14:00 and 22:00 hours. This raises resource issues for the stakeholder agencies involved, as the heaviest detention periods were also those when locating qualified mental health professionals can be most problematic. Although our value of 75% closely reflects the total proportion of hours in a week outside of business hours (76.2%) and may therefore not be surprising, it does raise implications for staffing levels and the experience and training required for staff working outside of business hours. In addition, while assessments conducted during business hours narrowly met the Trust's six-hour target for completion (mean of 5 hours and 59 minutes), out-of-hours assessments were significantly longer (mean of 7 hours and 14 minutes), placing further demands on police and ward staff resources at the place of safety.

DECLARATIONS OF INTEREST

None.