Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0139cOlder People, Clinicians andMental Health RegulationElaine MurphyQueen Mary College, University of London, London, UKThe Mental Health Act 1983 (England and Wales) made nomention of age, applying to children and those of advancedyears just the same as to younger adults. Similarly, the MentalHealth Act Commission created by the 1983 Act to ‘‘keepunder review the operation of the Act’’ as it related to detainedpatients also had no responsibilities specific to older people.The old Commission had an awkwardly circumscribed role withfew real powers. It visited hospitals and registered nursinghomes to meet patients and ensure that the conditions in whichthey were detained were of an acceptable standard. TheCommission also investigated complaints relating to detainedpatients and monitored the consent to treatment safeguards inPart IV of the Act, appointing independent doctors to givesecond opinions.In December 2000, after 10 years of discussion and consultationabout the failings of the 1983 Act, the government publishedproposals for a new Mental Health Act 1 , which will have a verysignificant impact on the practice of geriatric psychiatrists. Itcontains new safeguards for the care and treatment of people withlong-term mental disorders in institutional care, providingobligatory second opinions for those who are unable, throughmental incapacity, to consent to treatment. In effect, this willcover all those with dementia in long-term care and many otherolder psychiatric patients. The new Act also replaces the oldCommission with a new Commission for Mental Health, whichwill have wide powers in relation to overseeing the new legislationbut will not be a visitorial or inspectorial body. For the first time,the new Commission will have a responsibility to ensure thatprofessionals are trained properly in the legislation. This willsurely require far closer working relationships with professionaltraining and accreditation agencies. The old visitorial function,however, will be handed over to the new National Care StandardsCommission and the Commission for Health Improvement. Thus,clinicians can expect even more inspection and regulation, ratherthan less, under the new regulations.The central regulatory system is usually dated back to 1833,when the Factory Inspectorate was established. The Times 2pronounced that this new system contained ‘‘the seeds of mightychanges’’, although the Editor was ‘‘no enthusiast’’ for centralregulation but acknowledged that an inspectorate offeredadvantages ‘‘if inspectors or visitors of strong capacity, ofenlightened humanity and moral courage’’ were appointed. TheLunacy Commission of 1845, chaired by the indefatigable 7th Earlof Shaftesbury for 40 years until his death in office, achievedconsiderable influence with government and changes in localasylums and workhouses because the Commission remainedsmall, elite and adopted a coherent, unifying set of policies in itsearly years 3 .Modern mental health commissions are similar to the LunacyCommission in being only as effective as their members are.Ministers have not always been convinced of this simple truth andhave sometimes seen Commission appointments as a convenientreward for other fields of endeavour or as an opportunity topromote other laudable government objectives. Since its inceptionin 1984, the old Commission, a multiprofessional body, struggledto attract members of distinction from the professions ofpsychiatry and law and yet, to achieve credibility and respectfrom psychiatric services, the quality, training and behaviour ofmembers was crucial. Over the years there was a steadyimprovement in the administrative efficiency of the organizationand a significant step up in quality of the recruits. The newCommission will need to learn some of the lessons learnt if it is toachieve early credibility. Being a good commissioner requiresenormous tact, humility and an ever-present awareness that anurturing, developmental, encouraging approach achieves farmore and is less alienating to professional staff than a heavyhanded‘‘policing’’ approach.The notion underpinning regulatory bodies dies hard. The ideais that the Secretary of State employs a team of quasi-independent‘‘eyes and ears’’ to act as the conduit for information to centralgovernment and to channel edicts from the centre to the field. Theproliferation of statutory commissions and non-statutory regulatorybodies (so-called QUANGOS) in the late twentieth and earlytwenty-first centuries would suggest that faith in these institutionsas movers and shakers of social improvement remains undimmedin governments today. The zeal with which agencies areestablished falls away as soon as it is realized that inspectorsand monitors cannot substitute for good local managers. Inmental health services, good hospital unit management andimprovements of standards of training and clinical work throughprofessional bodies, such as the Royal College of Psychiatrists andthe National Boards for nursing education, are more likely toeffect permanent improvements in standards of care. ‘‘Watchdogs’’and Commissions inevitably disappoint ministers and theusual cycle of events is that a commission’s powers areprogressively reduced and in due course frequently disbandedon the grounds of economy. As the numbers of factories grewbeyond what it was reasonable to inspect, the Factory Inspectorate’ssweeping powers to make statutory regulations and act aslocal magistrates were abolished in 1844. The Board of Controlsimilarly found its powers diminished from those of itspredecessor, the old ‘‘dead duck’’ Lunacy Commission, and wasPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd