A study of mental health legal advice and information services in Northern Ireland

By Jim Campbell and Debra Wilson

Executive summary

1. Background to the project

The research project described in this report was funded by the Nuffield Foundation and managed by Law Centre (NI). The research was carried out by Jim Campbell and Debra Wilson, School of Social Work, Queens University Belfast.  A committee drawn from health and social care stakeholders was used to advise on the research process.

2. Methodology

The researchers used a range of qualitative and quantitative approaches to gather data, these included focus groups, individual interviews and a questionnaire survey. A number of constituent groups were involved in the research: focus groups with service users and carers (44 people in total),  interviews with three managers of organisations which provide advice or information to mental health service users and carers, interviews with four lawyers who have experience of legal representation at Mental Health Review tribunals (MHRTs), a questionnaire survey of solicitors (300 surveys sent, 30 responses) who undertake mental health legal work, an interview with the president of the MHRT, responses from four hospitals about advice and information they provide to inpatients, a summary of information obtained from two mental health advice and information organisations in Britain and Australia.

3. Focus groups of service users and carers

Many service users and carers were unclear about the rights of people who are admitted to psychiatric hospital. They tended to be unsure about details of mental health law, care, treatment and use of medication and had doubts about the quality of written and verbal information on rights, services and legal procedures. Some respondents were concerned about the lack of planning for discharge and preparation for community living. A few respondents felt that they had been or would be labelled as ‘trouble makers’ if they enquired about rights and services. Nonetheless, a number of service users and carers felt that staff had acted in professional and caring ways, despite shortages of resources.

A minority of the respondents had involvement with the MHRT and expressed mixed feelings about this experience. A number felt that they did not receive adequate information about how to apply to the tribunal and, when they or their relatives attended, they thought that parts of the process and outcomes did not wholly take into account their views. Conversely, some were satisfied that their rights had been protected and that the tribunal was a necessary safeguard against the power of professionals. The respondents made a range of recommendations for changes to the tribunal, including the need for clearer information about how to apply and better accommodation, and suggested that the tribunal should be more willing to take into account the care planning process on discharge.

Service users and carers tended to be more positive about their experiences of using community based advice and information services, despite the fact that these agencies focused on more general advice and advocacy rather than specialist mental health work. A number of these organisations were more frequently used than others. In some cases, local politicians were also helpful in resolving problems such as benefits and housing enquiries. Respondents were particularly satisfied with the service provided by specialist advocacy groups which appeared to be more knowledgeable about mental health law and the needs of people with mental health problems and their carers.

4. Interviews with service managers

These interviews revealed how specialist mental health agencies offer a range of services to users and carers. This mostly involves providing advice and information about rights to services and support in accessing benefits, housing, employment and emotional support.  They are less involved in helping clients deal with MHRTs, although staff often provided advocacy services for hospital patients and their carers. Some statutory organisations and professionals found it difficult to adjust to this relatively new role for voluntary sector organisations, there was sometimes a failure to acknowledge the views and expertise of service users and carers. A number of problems faced these organisations. Even though they had a specialist mental health brief there were deficits in training, particularly in terms of understanding mental health law, advocacy and tribunal work. Agencies have developed a range of contacts with legal representatives and organisations which provide them and their clients with specialist advice. They appear to be working at full capacity and are unable to deal with all requests for help. Problems of funding and part-time work undermined the services which they delivered.

5.  Interviews with lawyers and survey of solicitors

Most lawyers were unaware of information and advice provided to patients on admission to hospital, nor did they know how patients were informed about how to apply to the MHRT.  Many respondents acknowledged the need for better training and resources to enable them to better represent their clients. A recurrent criticism was that legal aid costs were inadequate and undermined the quality of representation they could provide, although these fees are currently under review. Many respondents were concerned about the practice of regrading patients prior to attendance at the tribunal, and believed that this compromised principles of human rights and natural justice. A range of views were expressed about the perceived strengths and weaknesses of the tribunal. A number felt the composition and processes used by the tribunal generally protected the rights of patients, but there was some concern about the status of the medical member, and problems of accessing independent medical opinion.  A number of changes to tribunal processes are being proposed in anticipation of expected recommendations of the Mental Health Review and in response to human rights legislation.

6. Information provided by hospitals

Only a minority of hospital administrators responded to the request by the researchers for information. Of these, one hospital provided an extensive pack of information and literature which was made available to patients and carers. The other respondents provide much less material. What emerged from this exercise was the sense of unevenness and lack of consistency in information giving by hospitals. There appears to be a lack of standardised information and advice, and variation in which professionals or named persons are responsible for carrying this role.

7. Law centre case studies

The two centres which we chose to examine offer two models of delivering legal advice and information to mental health service users and carers. The first, Springfield  Advice and Law Centre at Springfield Hospital, England, offers a complex range of services for people living in both hospital and the community. It appears to be quite well funded through a range of governmental sources and has built up a variety of expertise in its full time workers.  A high proportion of its work involves advice and information on mental health law and MHRTs. The Mental Health Legal Centre, Melbourne, is freestanding and somewhat smaller but, again, is particularly expert in helping service users and carers deal with problems of health, social care and income. A particular focus of the centre is in representing clients who are attending Mental Health Review Boards. Both agencies have managed to develop forms of outreach and networks with communities, voluntary organisations and statutory professionals.

8. Recommendations

Recommendation 1.  Many respondents, services users and carers, felt that their voices were not always heard by professionals and tribunals. It is recommended that organisations which deliver mental health services and tribunals should find ways of developing inputs from service users and carers in order to quality assure these systems.

Recommendation 2. Hospital administrators should work alongside service user and carer groups to ensure that adequate advice and information about rights, care and treatment are available for inpatients and their carers. This information should be accessible and understandable.

Recommendation 3.  Some advice and information services are being provided to service users and carers, in both hospitals and the community. These services and other organisations in the sector have developed relationships with trusts and general information and advice services across Northern Ireland but, to be more effective, they require further training and additional resources.

Recommendation 4.  It is apparent from most responses by lawyers that there are significant gaps in training and education, particularly in preparation for MHRT work. It is recommended that a system of specialist mental health education and training is made available to both legal representatives and tribunal members to further enhance legal representation for people with mental health problems.

Recommendation 5.  There is a widespread concern, expressed by many respondents, that too many patients are regraded as voluntary patients prior to the tribunal and that some patients do not receive adequate information about their rights to apply to the tribunal. These numbers are significantly higher than in the rest of the UK. This practice should be investigated with a view to ending it as soon as possible.

Recommendation 6.  Some lawyers remain concerned about the legal status of the opinion of the medical member of the tribunal. It would be purposeful if this debate was further explored by the current Mental Health Review.

Recommendation 7.  Given the concerns by service users and carers in this research, it is very important that hospital administrators develop a standardised system of information and advice which explicitly highlights service user and carer rights through clear and understandable media. This may take the form of leaflets, booklets, information technology and audio visual material. It is essential that named individuals take responsibility for this role and that inclusive discussions take place with service user and carer groups about how this strategy can be developed and delivered.

Recommendation 8. A message from this research project is that there are clear deficits in professional training, support for voluntary agencies and expertise in providing knowledgeable advice for people with mental health problems in Northern Ireland. There are many hard working individuals and groups that require support and assistance in advising and representing clients, whether they are living in hospitals or in the community. There is a gap in information and advice services which should be filled by a unit or agency able to develop knowledge and expertise in this field. Such a unit should be adequately funded to provide and/or coordinate advice and training for lawyers, service user and carer groups, the tribunal and the broad range of organisations currently offering generic advice and legal information in Northern Ireland.

Recommendation 9.  The findings described in this report are necessarily limited by time and resources available to the researchers. A more detailed mapping of this sector is required to reveal in more detail the range of agencies and views of constituencies involved in providing legal advice and information to people with mental health problems and their carers.