• 'I called the police a few months ago and found them sympathetic and helpful, but they are also very aware of the extra danger that involving them can cause to me'
• 'police are helpful but should be used as a last resort as it must be extremely stressful for the person concerned and for others involved e.g. children'
• 'police and hospital were first regarded as friends but when police took him into hospital to prevent him cycling round the streets, he became paranoid about the police'
• 'police are sympathetic and doing their job but the trauma for the patient was immense and long-lasting and affected future contact with all medical services. Handcuffs do not get forgotten or forgiven'

Police involvement could be seen as a failure of mental health services

• 'section and admission could not have been made without the police'
• 'in the past they have been very helpful, but at present, although there have been a number of incidents involving the police which have been reported to the psychiatrist, he still does not think her condition is bad enough to have her sectioned'
• 'police involvement would not have been necessary if the GP had listened to me and acted earlier'
• 'police involvement made no difference. The doctor contacted the police before he arrived to see the patient'

The table above shows the psychiatric hospital as the preferred choice for most groups with Accident and Emergency Department rated lowest.

Some thought that the initial 72 hours was too short and suggested a change from 72 hours to 1 week.

Many thought that there should be more regular reviews:

• '6 months and 1 year are too long' reviews are too far apart. Monthly reviews would be better or at least a 3-month stage'

It was suggested that flexibility was needed.

• 'each individual case should be assessed and a time limit agreed at the initial detention, then re-assessed when the time limit is up. Further detention if required and so on until detention is no longer necessary'
• 'should be an interim period in accommodation in community while still under section before being catapulted into the community'

5.6 Review/legal challenge

We asked respondents if they thought current arrangements for review/legal challenge were satisfactory.

When respondents were asked whether current arrangements for review/challenge were satisfactory, 41.8% (40% of carers, 41.5% of service users) said YES and 43.4% were unsure.

The remaining 14.8% respondents were not satisfied and from them was a strong plea for advocacy.

• 'there should be a legal right to advocacy to help challenge detention'
• 'there should be a right to advocacy, independent of NHS'
• 'clear information and advocacy support must be provided within 24 hours of a detention order being made'

It was thought that the courts and the Mental Welfare Commission were not necessarily the right bodies to investigate challenges to detention.

• 'the MWC is seen as toothless by service users and on the side of psychiatrists. There is a need for an independent body but the Commission's role, powers and make-up should be reviewed'
• 'the MWC needs stiffening up'
• 'the sheriff hasn't the relevant experience'
• 'the system could surely make it easier to challenge rather than having to go through the courts'

Suggestions were made of others being involved.

• 'only people with a good knowledge of mental illness should be involved in these cases'
• 'an immediate interim challenge to the Health Council with an early (7day) decision would be less stressful than a court hearing, which could then follow if appropriate'
• 'there should be an independent person to oversee patient's rights are not being abused'
• 'they should be entitled to see a lawyer as soon as they are detained. Their GP should be informed if slhe has not yet been'

Information about procedures and legal aid should be given.

• 'the service user and the next-of-kin should be told about all available ways of challenging sections'
• 'there needs to be an automatic right to legal aid, not means-tested, as the state is detaining people who have not committed a crime, so I think these are special circumstances'

5.7 Review of 72 hour section

When we asked whether it should be possible for a person detained under a 72 hour section to require the detention to be reviewed in some way, 26.2% respondents thought not and 35.1 % were unsure. The 38.7% who answered YES were asked to suggest how this could be done. A professional commented:

• 'I think psychiatrists have a duty (i.e. with S20 approval) to review a patient on Sections 24/25 after admission and to decide whether detention is appropriate or not. Practicalities i.e. weekend admissions etc may make this difficult.'

Some people thought that there was insufficient time for review while another suggested 48 hours was quite long enough.

A number of suggestions were made as to how the current situation regarding review could be improved.

Advocacy was asked for by several respondents and this could be very helpful in any review.

Several suggestions were made as to who should do this review.

• 'a second opinion from an MHO and other medical'
• 'a care plan co-ordinator'
• 'appeal by a carer through the GP'

A carer could initiate a review

• 'through the GP'
• 'the carer's views should be taken into account as to whether the section is necessary'
• 'psychiatrists should meet both carer and advocate'

Legal and MWC help was indicated

• 'working with the duty doctor, there should be a legal adviser'
• 'legal right to advocacy plus more staff for the MWC, to include coverage over weekend and holidays. Also the service user should have the right to compensation and sanctions against doctors who use power inappropriately'
• 'more money for the MWC to ensure that increased demand for review can be met'

Some people would like a new independent body

• 'because the psychiatric profession will not undermine another professional. We need a truly independent body to be enlisted throughout Scotland'
• 'give a nominated group from hospital or community, powers to hear the case very quickly and make a decision'

5.8 Compulsory treatment in the community

The question put was " Do you think compulsory treatment in the community to prevent relapse/deterioration is a good idea?"

61% of all respondents said YES, 13% said NO but a substantial number were less emphatic with 23% replying PERHAPS and 3% replying UNSURE.

Combining the figures for YES and PERHAPS shows the figures for those who thought it was possibly a good idea. We then find that 91% of carers, 77% of service users and 72% of NSF(Scotland) staff thought that compulsory treatment was possibly a good idea. (Note that NSF(S) staff work closely with both service users and carers in the community).

When the question of whether compulsory treatment would prevent people from relapsing was answered, 88% of carers, 74% of service users and 82% of staff thought this was possible. However, 15% of users thought that it would not prevent relapse.

Whether compulsory treatment would mean that people would get help before they deteriorated was also answered very positively. 87% of carers, 74% of service users and 83% of staff thought it possible that people would get this help.

The above results indicate a favourable view of compulsory treatment but important drawbacks were noted as follows:

When asked if compulsory treatment would require excess compulsion, the highest score was for the option PERHAPS.

67% of carers, 46% of service users and 89% of staff thought it possible that excess compulsion would be necessary.

Would compulsory treatment stop people with mental health problems from contacting mental health professionals?

66% of carers, 51% of service users and 94% of staff thought it possibly would. There was real uncertainty here with, for instance, service users saying PERHAPS 16% and UNSURE 22%

Would compulsory treatment mean that black and ethnic minority groups could experience discrimination? The highest score was for the option NO 33%. 34% of carers. 32% of service users and 59% of staff thought it possible.

Respondents were asked to make comments on the whole idea of compulsory treatment, which they interpreted as compulsory treatment in the community in the form of Community Treatment Orders (CTO).

Despite the positive votes for CT0s, all groups wrote about their many misgivings about the issue. Imposing a CTO on someone would presumably relate to previous episodes of a service user becoming ill after stopping medication.

The order could be used to keep someone out of hospital when they really needed asylum and re-assessment in hospital rather than more medication in the community. Doubts about CT0s were expressed by all groups - service users, carers and staff.

• 'more helpful for staff to see the service user often enough to have on-going assessment, build therapeutic relations so that hospital admissions were properly considered to benefit the individual, rather than to satisfy public prejudice'
• 'what is really needed is better community care 24 hours per day, 7 days per week'
• 'there should be more social workers, crisis intervention out-of-hours, follow-up visits to the person's home, more supportive housing, enough workers to prevent relapse'
• 'imposing a CTO is a response to public hysteria in particular cases. It could lead to over-medication'

Some respondents were definitely against the idea of a CTO

• 'it would make me fearful if someone came into my house to inject me, making my home into a hospital. It will not be done to help the patient and is a breach of civil liberties'
• 'very unfair, unethical way of dealing with mental illness which almost criminalises it'

  Some were more positive and thought the idea of a CTO

• 'a good idea as it might stop hospital detention'
• 'if treatment is shown to work, then it is a good thing'
• 'If you are a danger to yourself or others, you must be made to take treatment'
• ' would be a good idea if it meant regular visits from a CPN (say fortnightly) or other mental health professional to check on medication, as my son so often forgets to take his'

And finally:

• 'professionals must win the trust of service users, not give up if a user does not want to let them in or talk which is the best way to prevent relapses. CT0s only if all other measures fail'
• 'how do you ensure that compulsory treatment is carried out i.e. the full dosage of medication is taken?'
• 'only if all parties agree e.g. GP, CPN, service user, possibly carer and only at times of extreme crisis'
• 'safeguards must be built in to protect against abuse'

Where should the treatment specified in a CTO be carried out?

Locations are listed below in order of preference (some respondents ticked more than 1 box)