Experiences of the 'Nearest Relative' provisions in the compulsory detention of people under the Mental Health Act: a rapid systematic review

The Mental Health Act 1983

The MHA 19831 is a piece of UK legislation that governs the assessment, care, treatment and related matters pertaining to individuals with a ‘diagnosed mental health disorder’ who are detained in hospital via civil or criminal pathways. The MHA 19831 outlines the process by which individuals may be detained and treated, their rights to appeal and the rights of those receiving aftercare. The MHA 19831 also outlines the rights of the family and carers of the person being detained. The MHA 19831 fully applies to England and Wales, and partly applies in Scotland and Northern Ireland.

The Nearest Relative provision

The NR provision of the MHA 19831 was intended as another safeguard to protect the rights of a service user who is being involuntary detained. The NR is an individual assigned to the service user who has several rights and responsibilities relating to the care the service user receives. The NR:

• can make a direct application to a hospital for the detention of the service user

• can object to the detention of the service user under section 3 and, if this occurs, the service user cannot be compulsorily admitted

• receives confidential information about the detained person

• can request that the service user be discharged from sections 2 and 3 and a section 7 guardianship order.

Although a NR can also request the discharge of a service user from a community treatment order (CTO), they are unable to object to the initial imposition of the CTO or the recall of a service user to hospital should they not meet the criteria set by a CTO. 1 For ‘unrestricted’ service users admitted via the criminal pathway on section 37, their NR can apply to the tribunal to request a discharge from their section. 1

Identification of the Nearest Relative

Section 26 of the MHA 19831 defines and differentiates ‘Relatives’ and ‘Nearest Relatives’. ‘Relative’ means anyone in the following hierarchical list:

1. husband, wife or civil partner

2. son or daughter

3. father or mother

4. brother or sister

5. grandparent

6. grandchild

7. uncle or aunt

8. niece or nephew.

Under the MHA 1983,1 the AMHP will proceed through this list from top to bottom until an eligible NR, who meets the criteria required to take up the position, has been identified. To be considered eligible for the NR role a person must be > 18 years of age, living in the UK if this is the service user’s country of residence and, in the case of partnerships, in a relationship with the service user for > 6 months. 1 Ex-partners who have permanently separated from the service user cannot be considered for the role. In circumstances in which two individuals are eligible to fulfil the role (e.g. two siblings), the eldest and/or whole-blood relatives are selected.

Displacement and delegation of the Nearest Relative role

The NR may be ‘displaced’ (i.e. a different person appointed to the role) through application by an AMHP to the County Court. Possible reasons for displacement include when the NR cannot take up their duties because of illness, objects to an admission for treatment (or guardianship application) without good reason, has not considered the service user’s welfare or protection of the public in their application to discharge the service user or is considered unsuitable to act for any other reason. 1 Displacement of the NR is the only way to detain a service user under section 3 of the MHA 19831 if their NR has objected to the detention.

The NR can choose to nominate someone else if they do not wish to take up the responsibilities associated with the role, and may delegate responsibilities to the next eligible NR. 2

The Mental Health (Northern Ireland) Order, 1986

This legislation is broadly similar to the MHA 1983. 1 It specifies that compulsory admission will normally be on the basis of a recommendation by a general practitioner and application by an approved social worker (ASW). 5 The role of the NR is similar to that detailed by the MHA 1983. 1

The Human Rights Act 1998

The Human Rights Act 19986 outlines the rights and freedoms that everyone in the UK is entitled to. 6 These rights are set out in a series of 12 articles, each of which details a different right. Such rights include the right to life, the right to privacy, freedom from torture and inhumane or degrading treatment, and the right to a fair trial. 6 The Act means that people in the UK can seek justice in court if they feel that their rights have been violated and that public bodies, such as hospitals, courts and the police, must respect people’s rights. 7 The Human Rights Act was implemented in the UK in October 2000.

The implementation of the Human Rights Act provides a context for issues relating to information-sharing, and confidentiality in particular, given that the assigned NR is entitled to receive confidential information about the service user. 6 Because all health legislation post 1998 must be compliant with the Human Rights Act,6 we believe that it is of central importance for interpreting and implementing the MHA 1983. 1

The National Service Framework for Mental Health 1999

The National Service Framework for Mental Health8 section 6 outlines the support that carers of individuals with mental ill health should expect. This includes a yearly assessment of their needs and an implementation of a care plan based on this. The framework also advises that carers are provided with information regarding the mental health needs of the person they care for, including an explanation of the person’s care plan.

The Mental Capacity Act 2005

The Mental Capacity Act (MCA)9 is intended to protect individuals aged ≥ 16 years who do not have the capacity to make certain decisions for themselves. The MCA is intended to support professionals to assess the capacity of an individual regarding a specific choice and, if capacity is lacking, make a decision that is in the best interests of that person. 10

The Mental Health (Care and Treatment) (Scotland) Act 2003

The Mental Health (Care and Treatment) (Scotland) Act 2003 (MHCT)11 introduced key changes to the processes involved in the detention of people with ‘mental disorders’ in Scotland. The change of greatest relevance to the present review was the introduction of the ‘Named Person’ (NP) role, in place of NR provision. The Millan Committee was established to review the Mental Health (Scotland) Act 1984, which included NR provision as set out in the MHA 1983. 1,12 The NP was recommended in response to a number of concerns over the suitability of the NR, namely that the appointed NR may not be appropriate for reasons of practicality, lack of genuine interest in the service user or the potential for abuse of powers. 13

Under the MHCT, the powers of the NP are reduced, and the service user has choice over who is appointed and can revoke the NP in writing. 11 If the service user does not nominate a NP, an individual can be appointed by default, turning first to the primary carer, and then to the NR hierarchy set out in the MHA 1983 [with the addition of civil partners as set out in the Mental Health Act 2007 (MHA 2007)]. 1,14 Key differences between the NR and NP are shown in Table 1.

The Mental Health Act 2007

The MHA 19831 was revised in 2007,14 leading to a number of significant changes to the Act. These include changes to professional roles, such as introducing the AMHP to replace the ASW, introducing CTOs to replace supervised discharge, certain definitions, interaction with the Mental Capacity Act 2005 and the structure of mental health tribunals. 14 Of direct relevance to the NR provisions were the following amendments:

• When identifying the NR, those in civil partnerships were considered as being of equal status to people who were married.

• Service users were given the power to displace the NR on grounds of unsuitability. Applications were to be made to a County Court.

Information Sharing and Mental Health: Guidance to Support Information Sharing by Mental Health Services 2009

This Department of Health and Social Care (DHSC) publication15 discusses the rights of service users to know about the information that is held about them by public bodies, and the right of carers and other members of the public to receive enough information to enable them to support the service user and protect themselves. 15 The document also acknowledges the role that carers may play in providing information to services. It recommends criteria that should be fulfilled when sharing information regarding a service user between different parties.

The Mental Health (Wales) Measure 2010 and associated Code of Practice to Parts 2 and 3

The Mental Health (Wales) Measure (MHWM) 201016 details the support people living with a mental health problem should receive in both primary and secondary care. With regard to the NR role, the MHWM 2010 aims to ensure that people receiving secondary mental health services in Wales all have a care and treatment plan. The associated Code of Conduct for parts 2 and 3 of the MHWM 2010 stipulates that the service user should be involved as much as possible with the assessment to inform their care and treatment plan, and their carers and ‘significant others’ should be involved when appropriate. 17

The NHS Five Year Forward View 2014

This policy document18 outlines government proposals regarding new models of care within the NHS. Of particular relevance to the NR role, this document outlines a commitment to improve the support that carers of individuals with long-term conditions receive. The document outlines the goal to improve access to information regarding the service user’s condition, history and care, not only for the service user themselves, but also for any other individuals whom the patient wishes to share this information with.

The Mental Health Act Code of Practice 2015

The Code of Practice provides guidelines for professionals on their roles and responsibilities under the MHA 1983. 1,2 Revisions to the Code were made in 2015, in the light of changes in law and policy since it was first published, and aims to improve protection of the rights of service users, families and carers. It also outlines how to determine when the MHA 19831 should be used instead of the MCA and vice versa. 2

Population

This was defined as people detained under section 2 or 3 of the MHA 1983,1 their family and carers and the individuals involved with their care who work within the remit of the MHA 1983. 1

More specifically, the population may include:

• current service users

• former service users

• service users’ family members and carers

• health and social care professionals

• approved mental health professionals (community nurses, psychologists, occupational therapists, social workers)

• advocates

• police officers.

Studies were included if the individuals were:

• a service user who has experience of being compulsorily detained under section 2 or 3 of the MHA 19831

• carers, relatives related professionals (listed above).

Studies were excluded if the individuals were:

• people who have agreed to a voluntary admission and carers, relatives and relevant professionals involved in their care

• people with mental health difficulties not leading to compulsory detention under the MHA 1983. 1

Phenomenon of interest

This was defined as experiences of, or attitudes towards, the application of the NR provisions of the MHA 1983. 1 This includes any experiences in relation to the involvement of relatives, carers or professionals in the care of or decisions about a compulsorily detained person.

Studies were included if data about experiences were obtained through:

• qualitative means (e.g. interview, focus group)

• a survey or questionnaire.

Context

This was defined as the use of the NR provisions of the MHA 19831 within the UK only.

Studies were included if:

• detention took place under the jurisdiction of England, Wales, Scotland or Northern Ireland

• data were from any time since the publication of the Human Rights Act 1998.

Studies were excluded if:

• detention was not under the jurisdiction of England, Wales, Scotland or Northern Ireland

• detention of an individual was undertaken by forensic services.

Extraction of data relevant to the research question(s)

Participant quotations illustrating the views of service users, carers and NRs and the author interpretation of these views (known as first- and second-order construct data, respectively30) were extracted from the results section of each ‘top tier’ article. The information was placed within a framework based on our five research objectives by one reviewer (LS or MN), and checked by a second reviewer (MN or LS) using Microsoft Excel^®. This information was used to identify which papers contributed towards a range of different research objectives and represented a variety of participant perspectives.

Identification of initial themes

This process was carried out independently by two reviewers (LS and MN) identifying eight ‘top tier’ papers from three studies with the most data relevant to multiple research objectives, accounting for a range of participant perspectives. One of these studies was conducted in England31 and two were conducted in Scotland. 32,33 One reviewer (LS) selected the themes presented in each article that were most relevant to the research objectives. A second reviewer (MN) checked the selection of themes (see Appendix 2), which were then used to revise the stage 1 framework. Studies in the ‘second tier’ of included studies did not influence the identification or development of themes.

Final framework revisions using thematic analysis

The content of each of the themes generated through stage 2 of the synthesis was then re-examined. Within each broad theme, first- and second-order data that appeared to be discussing similar or related concepts were grouped together. This formed the beginnings of descriptive subthemes. The data contained under these subthemes were moved both within and across existing subthemes to reflect changes in their content. Preliminary subthemes were divided and merged and content changed in an inductive, iterative process, in order to capture current or relevant ideas within the included studies that were not represented by the initial framework. As this process evolved and additional interpretation occurred, the names of subheadings and their placement under certain themes were changed in order to reflect the data within them. Towards the end of the process, some theme names were also changed in order to better represent the content of the framework and the reviewer’s understanding of the data.

The synthesis was conducted by one reviewer (LS) within Microsoft Excel^®. The names of emerging subthemes and themes were checked with other members of the review team (MN, SB, JTC and RA), whose feedback was incorporated into the developing themes and subthemes to ensure that their names accurately reflected their content.

Relationship between the themes

A figure representing the relationship between the themes identified through the framework synthesis of the ‘top tier’ papers was then developed through discussion (LS, SB, MN, RA and JTC). The data synthesis process is summarised in Figure 1.

FIGURE 1.

Framework synthesis process for prioritised studies.

End-user involvement

One carer with experience of the NR provisions provided feedback on the themes and subthemes identified by the synthesis and commented on the write-up of the results within this report.

Reflexive statement

The methods utilised within this review were reflective of the expertise and experience within the review team. The team consisted of three systematic reviewers (JTC, MN and LS), an information specialist (SB) and a health economist (RA) with prior experience of conducting systematic reviews for the National Institute for Health Research. This prior experience meant that the team aimed to maintain a rigorous methodology throughout the review, despite the limited time frame available. This is reflected in the decision to retain searching across multiple databases, double screening of references at both title/abstract and full-text level, searches within the grey literature and citation-chasing. The team’s prior experience of managing large numbers of retrieved studies within a set time frame meant that we were able to quickly identify a method to prioritise the studies for inclusion in the main synthesis.

The focus of the review was novel for most members of the team. This meant that the background reading and identification of search terms was informed by objective appraisal of existing literature, albeit restrained by the time available. The team knew of some relevant policy because of previous projects and the experience of one reviewer (LS) of working alongside individuals detained under the MHA 19831 and working in accordance with the MCA. This reviewer utilised her prior experience and knowledge gained through her training as a clinical psychologist and of conducting qualitative synthesis within this review. Her experience provided a lens through which the information included in this review was selected, placed within themes and interpreted. This was balanced by the checking of extracted data by a second reviewer (MN) and incorporation of views from other members of the team and a carer with experience of the MHA 1983. 1 The limited time frame necessitated the use of a framework methodology and a more descriptive analysis, which also limited the potential bias during the synthesis process.

Included sources: prioritised studies

Of the 20 studies that met criteria for inclusion in the review, there were 12 studies, reported across 22 papers,4,31–33,36–38,40,45,46,48,49,51–60 that contained enough relevant and usable data for inclusion in the framework synthesis. Table 2 contains a summary of the foci, sample characteristics and qualitative data collection and analytic methods employed in these studies.

Among the ‘top tier’ studies, there were two PhD theses31,32 and four reports. 33,49,56,60 The three studies from Scotland32,33,56 consisted solely of government reports and subsequent publications in peer-reviewed journals, all focusing on the implementation of the MHCT, with specific regard to the NPs provisions. One study38 was conducted in Northern Ireland and focused on the views of various stakeholders on advocacy services available after compulsory detention. The remaining eight studies, conducted in England, could broadly be grouped as focusing on experiences of CTOs,57,60 interactions with various mental health professionals49,58 or perceptions of the MHA 19831 and the NR provisions and their implications for care. 31,45,46,48

All of the ‘top tier’ studies collected data using interviews. Other data collection methods used included administering questionnaires with space for open responses,31,38,49 observation of group discussions,45,49 and workshop events or group exercises. 31,48,49 There was a mixture of national and local sampling approaches, resulting in sample sizes ranging from 21 carers45 to 998 survey respondents. 49 Interviews were conducted with samples ranging from 2145 to 11556 individuals, from a range of perspectives. Analysis was described as ‘thematic analysis’ (eight studies),32,36–38,46,48,49,57–60 ‘grounded theory’ (two studies)33,45 or ‘framework analysis’ (two studies). 4,31,51–56

Included sources: ‘second tier’ studies

Ten papers, reporting eight studies, met the inclusion criteria for the review but did not contain enough relevant data for synthesis. 20,34,39,41–44,47,50,61 Table 3 contains a summary of the aims, sample characteristics and methods for these 10 papers.

There were eight peer-reviewed journal articles reporting six primary studies34,39,41,43,44,47,50,61 and two survey-based reports. 20,42 Eight papers reported research conducted in England and/or Wales,20,34,41–44,50,61 and two reported research conducted in Northern Ireland. 39,47 The papers by Campbell et al. 39 and Manktelow et al. 47 were based on survey data collected in 1998–9, in the context of the Mental Health (Northern Ireland) Order (1986). 5 Of the studies conducted in England and Wales, only the study by De Maynard41 may have been conducted prior to the 2007 amendments to the MHA 1983,1,14 although the date of data collection was not reported.

Telephone and face-to-face interview and focus groups were used in five studies to capture experiences. 34,39,41,43,50 Survey methods with opportunities for free-text or open responses were used on their own in three studies20,42,61 and used in conjunction with interviews by Campbell et al. 39

The views of service users were captured in seven studies,20,34,39,41–44,47,50 including two focusing on the experiences of black and minority ethnic service users. 41,50 Appointed NR or NPs were specifically sampled only in the study by Banks et al. 34 Other family members or carers (i.e. not necessarily in any formal statutory role) contributed views in five studies. 20,39,42,43,50 Mental health professionals, including AMHPs and ASWs, were sampled in six studies. 20,34,39,42,50,61

Subtheme 1.1: service user vulnerability

This subtheme discusses how the hierarchical nature of the selection process of the NR may leave service users vulnerable to abuse and violation of their privacy. The impact of unconscious carer bias on the process of involuntary detention is also explored, with comparisons made with the NP provision in Scotland.

Subtheme 1.2: not representative of real relationships

This subtheme discusses how selection of the person to fulfil the NR role in England may not be representative of a service user’s family circumstances and may inhibit information-sharing with individuals closest to them or with those who support them.

Author views from three studies conducted in England suggest that service users,31 their carers48,58 and the professionals31 involved with supporting them during involuntary admissions did not find the predetermined hierarchy a convenient or useful method of identifying the most appropriate NR. One service user gave her views on how the NR provision distinguishes between the rights of full and half siblings:

I mean what is a half-sister, half-brother? Because sometimes in our family, my mum’s got six kids. All of them are my mother’s kids and as far as I am concerned they’re all my brothers and sisters.

Service user. 31

Reproduced with permission from Dr Joan Rapaport, Anglia Ruskin University, 2018, personal communication

The above quotation provides an example of how the hierarchy used to identify the NR in England may not always represent the service user’s family circumstances. This is further illustrated by a quotation from an ASW interviewed in the same study:

. . . her father only lived 200 yards away and he was the Nearest Relative as defined by the Act. But the social worker used the mother as the nearest relative on the basis that she was actually offering the care and because it was her mother and so on . . .

ASW. 31

Reproduced with permission from Dr Joan Rapaport, Anglia Ruskin University, 2018, personal communication

The above quotation illustrates how the concept of NR may not always equate to the person who is usually involved with the service user’s care. 58 As well as causing difficulty in the identification of the NR, the use of the strict NR hierarchy can also create difficulties with the sharing of information. 49,58 One woman expresses her frustration with the way information-sharing was restricted to her alone:

After the assessment another social worker contacted us for an update but would not speak with my husband because I am legally the Nearest Relative, it was upsetting at such a difficult time.

NR58

Restricting information-sharing to only one carer/NR has important implications for the level of expectation and responsibility placed on carers by professionals. This may have an impact on the support they feel able to offer the service user and undermine their relationship with professionals, as discussed further in Theme 2: confidentiality and information-sharing and Theme 4: importance of maintaining relationships.

In summary, family structures in the UK in the 21st century are highly diverse and often quite removed from either the simple or the reliably harmonious and caring relationships between close blood relatives that the NR provisions presume. Furthermore, as well as the presumption of the importance of blood relatives in the service user’s life, the NR provisions imply that there is one person who is at the same time (1) their primary or sole carer/usual support, (2) the person the service user would trust to act in their best interests and (3) the person whom they would trust with personal or sensitive information about them.

Subtheme 1.3: displacement

The 2007 amendments to the MHA 19831,14 mean that the service user, a relative, anyone living with the service user or an AMHP can apply to the County Court to displace a person who is unsuitable for the role and nominate someone whom they feel would be more appropriate. Issues discussed within this subtheme include how the displacement process can be exploited by both NRs and professionals and how the displacement process in Scotland can provide service users with an opportunity for choice and autonomy over the care that they receive. Four studies contributed towards the development of this subtheme. 31,32,56,57

Of the studies relevant to the NR provision in England, only Rapaport31 contributed significantly to this subtheme. This paper was published prior to the 2007 amendments of the MHA 1983,1,14 which means that at this time service users could not apply to the County Court for the displacement of their NR. This study highlights how some professionals viewed the process of displacing an unsuitable person from the role of the NR as time-consuming, expensive and having the potential to jeopardise their working relationships with carers. The author also indicates how the tribunal system could be misused by individuals who did not want to be displaced. One ASW illustrated this by discussing how her team had struggled to displace one woman who had inherited the NR role from another person:

She [NR] got the original Nearest Relative to sign them over to her brother, so she was out of the legal loop . . . He continued to object although he was really doing it by proxy for her. She was still pulling all the strings.

ASW. 31

Reproduced with permission from Dr Joan Rapaport, Anglia Ruskin University, 2018, personal communication

In this example, the NR managed to use the tribunal system and use their influence within the wider family to retain influence over the service user’s care. Overall, the lack of available evidence regarding experiences of displacing the NR in England, particularly after the 2007 amendments of the MHA 1983,1,14 limits the conclusions that can be drawn.

In Scotland, service users can make a written application to displace (i.e. change) their NP under the MHCT. 11 This seems to be viewed positively by service users:

You might nominate a friend who you’re very friendly with but they might turn out to be totally unsuitable . . . At least you’re not stuck with someone who’s against you and they can always be revoked.

Service user32 (p. 130).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

This quotation illustrates how the process for displacing a NP in Scotland can avoid the involvement both of someone the service user does not have a good relationship with, or who they feel would not support them in a way that is consistent with their wishes. The displacement process was also viewed positively by the individuals involved with creating government policy interviewed in the same study:

. . . revisiting of it is important and we stress that . . . just because someone ends up with someone who’s down as the default Named Person that should be reviewed and discussed with the person as soon as they’re in a position to do that and not just set in stone.

Policy influencer32 (p. 120).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

This quotation acknowledges that under some circumstances (e.g. an emergency admission), a service user may need to be allocated a NP using the default process. The ability to revisit the decision when they are able provides an important opportunity for the service user to exercise choice and autonomy.

Ridley et al. 56 reflect that by the time participants in their study were interviewed for a second time 1 year later almost one-quarter of the service users had changed their NP. Among the reasons given was that the NP had disagreed with the service user’s wishes. The authors report that carers found the process of being displaced unsettling and that it made them uncertain of their rights and responsibilities. 56 We suggest that this may have important implications for the provision of consistent care and/or maintaining working relationships with professionals in the longer term.

Subtheme 1.4: service user isolation

This subtheme aims to highlight the issues encountered by service users who may not be able, or may not wish to, have someone appointed as a NR in relation to their care/detention.

Author31–33,56,60 and participant31–33,56 views from five studies indicated that the NR provision of the MHA 19831 did not account for the fact that some service users may not have a person to act as their NR. Issues with this situation may arise because of family estrangement60 and relatives living outside the country. 31 A quotation from one service user illustrates how the process of identifying the NR does not account for poor family relationships:

. . . this seems to be geared for, you know, nice families as it were [laughing] you know . . . families where the mother comes round and comes into hospital and says ‘how are you son?’.

Service user. 31

Reproduced with permission from Dr Joan Rapaport, Anglia Ruskin University, 2018, personal communication

Here, the advantages of the NP provision used in Scotland are easily identifiable, in that service users without a partner or family member to act as their NR can choose to nominate a friend instead. Following the introduction of the MHCT, some service users32,56 and professionals6,32,33 disliked the necessity of a service user having to identify a NP. This is illustrated by two quotations, one from a service user and one from the perspective of a person involved in influencing government, or ‘policy influencer’,32 in this area:

If it’s the patient’s right to name a Named Person than that’s their right. If they say: ‘I don’t want anything to do with that,’ then that’s it. End of story.

Service user32 (p. 157).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

. . . Because otherwise it just gets very silly and stops being about the person’s best interests and starts being about obeying the letter of the law . . . and at the end of the day is that going to help the individual?

Policy influencer32 (p. 135).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

In 2015, amendments were made to the MHCT that meant that service users would no longer have to nominate a NP and that one would no longer be allocated to them by default. 64 These changes started to be phased in during June 2017 and, although they have the potential of resolving some of the issues discussed in this subtheme, this review did not identify any evidence evaluating these changes.

Summary

In England, Wales and Northern Ireland, the NR is allocated by default, based on a defined hierarchy. Several issues with this process were identified:

• There were occasions when the assigned NR was a person with a history of an abusive relationship with the service user.

• The arbitrary allocation of a NR may lead to the identification of someone who, in the context of individual family situation and relationships, is not best placed to fulfil the role.

• The role of NR may be allocated to someone who is not involved with the care of the service user.

Introduction of the NP provisions in Scotland11 has given service users the option to identify a NP of their choice. Experience of the NP provision in Scotland has revealed the following issues:

• It is beneficial to be able to allocate a friend or carer of a service user’s choice, and to easily displace a default nomination.

• The choice to opt for no NP or NR was considered favourably. Amendments to the MHCT64 now allow for this, but no evidence was identified to allow discussion of the relative merits and drawbacks of this approach.

Summary

This theme is concerned with issues of confidentiality and the sharing of information about compulsorily detained patients. The NR is entitled to receive certain information about the care of the patient, whereas other individuals, who may in reality be the main carer or the closest family member, are not. As discussed in Theme 1: issues with the identification of the Nearest Relative, there is the potential through the default identification of the NR to lead to information being shared with a recipient who is undesirable in the eyes of the service user. However, even when the NR or NP is identified in line with the wishes of the patient, the following issues were identified:

• Service users valued the opportunity to exercise their right to withhold certain information from their NR, as this gave some sense of control.

• Information shared can be complicated, sensitive and unpleasant. There is a certain level of information that some carers felt was necessary to receive in order to be able to carry out their duties, but it was felt by service users, carers and professionals alike that it might not be beneficial to share too much information.

• There was a desire to improve processes by which carers are involved in discussing information about a patient with professionals. Carers wanted to be able to provide what they felt was useful information about the service user. However, they did not always want the patient to know about such conversations, as this could damage their relationship.

• It was considered useful when professionals took a flexible approach to information-sharing with carers, in particular when this considered the wider context of family dynamics.

• It was also noted that the rights of carers, service users and professionals are complicated and not easily explained.

Subtheme 3.1: being heard

Evidence under this subtheme conveys how carers and NRs value the NR provision of the MHA 19831 as something that empowers them to ask for information and challenge the views of the professionals regarding the care that they provide. NRs also perceive their opinions to carry more weight with professionals than those of a regular carer.

Five studies31,32,45,56,60 highlighted several ways in which the NR/NP provisions enhanced carers’ involvement in planning the care of service users. First, authors of three studies31,32,56 noted how the NR/NP provisions improved carers’ access to information about service users’ current or past care and treatment. This is illustrated by a NP, discussing how their relative’s detention under the MHCT meant that they received more information from services within their role as NP:

Until we had the compulsory order you really were largely on your own and the information didn’t come to you, you had to seek it out and it was hard to come by . . .

NP56

Participants from three studies31,45,60 highlighted how their NR/NP status increased their say in the care their relatives received. One example of this was provided by a man discussing how he managed to prevent the involuntary admission of his partner:

They seemed to need my word, I can never remember exact details, but they seemed to need a yes from me before they could go ahead. The last time it was actually me who refused to give it and made a determined effort to keep Elaine at home . . .

Partner and carer45

A NR from another study perceived that professionals appeared to be more responsive to her requests:

I’ve dealt with something . . . I’ve got the right . . . what I felt about a situation that they were in. And it was responded to, it was wonderful . . . I also had the right then to say that I’ve got the right not to have to keep chasing . . .

NR. 31

Reproduced with permission from Dr Joan Rapaport, Anglia Ruskin University, 2018, personal communication

This quotation suggests that the legislation outlined by the NR provision of the MHA 19831 can enhance the confidence of those within the NR role to give their views on the care of the person they support. However, other individuals did not always make use of the opportunity to discuss, endorse or object that the NR/NP is intended to provide them with. Berzins37 suggested that the class, race and gender of people nominated as NPs may influence their ability to carry out their role. One mental health officer (MHO) illustrates this by talking about the development of a DVD (digital versatile disc), presumably to support individuals detained under the MHCT and their carers:

Those tensions again around disadvantage, around class, race and gender come up and bite you. Have you seen the HUG DVD which is a group of fantastically articulate middle-class people . . . but there is a bit where the middle-class are incredibly adept at appropriating things for themselves.

MHO32 (p. 143).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

The above quotation suggests that the class and/or education level of service users and their carers may affect their ability to first understand the information that is given to them and then make use of this information in order to make their voices heard.

Subtheme 3.2: need for information

This subtheme discusses the information that service users, carers, NRs/NPs and professionals require in order for the service user to benefit from the intended function of the NR/NP provision. The section discusses how carers need some knowledge regarding the different section of the MHA 19831 as well as more specific information regarding the NR/NP role. Authors of three studies32,56,57 indicated the need for service users and carers to be more informed about the MHA 19831 in both England and Wales or the MHCT11 in Scotland. The quotation below highlights one carer’s lack of knowledge regarding the implementation of a CTO:

. . . I couldn’t get a clear grip on that ‘if you don’t do A then B will happen’, what B was. That they would within 24 hours come and chase him? Or that they would call him on the phone . . .

Mother and carer57

Here, the carer wishes to know more about the consequences of a service user not adhering to the conditions associated with their CTO. This viewpoint is contradicted by one example presented by Stroud et al. ,60 who interviewed a service user who felt that they did not need to know the finer details associated with the use of a CTO. This stance may reflect the more limited role of the NR in the implementation of CTOs and also suggests that the level of information provided may need to be tailored to the individual circumstances of the carer/service user.

In addition to improving knowledge about the different sections of the MHA 1983,1 and the different levels of care they define, the authors of five studies31–33,38,56 highlight that service users and/or carers needed more information about the role of the NR/NP:

Are they new may I ask? Or is it that they’ve always been there but hardly anyone knows about it? Because I’m only recently hearing about it as though it’s a new piece of legislation?

Carer. 31

Reproduced with permission from Dr Joan Rapaport, Anglia Ruskin University, 2018, personal communication

The above two quotations suggest that service users and carers need a working knowledge of the parts of the MHA 19831 that are relevant to their circumstances, and may need to be informed of how the NR role can support them in this context. Authors from two studies32,33 highlight how knowledge of the NP role among service users and carers may be particularly limited if the service user has not had a previous involuntary hospital admission. The need for accessible information about the NR/NP role was noted by participants and authors of five studies,31,33,38,56,60 although NRs/NPs may not always understand the information that they are given regarding their responsibilities, as illustrated by one policy influencer commenting on the nomination of a NP following an emergency admission:

. . . you appear at some sort of meeting and somebody says, ‘do you want to be your son’s Named Person?’ but you’re not really listening as you’re far too distressed. You realise it’s something quite important and you care about your son so you say yes . . .

Policy influencer32 (p. 119)

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

This relates to information presented within Theme 2: confidentiality and information-sharing, which cautions against overburdening carers and NRs/NPs with information about the care the service user is receiving.

Finally, authors of two studies48,56 indicate that in some cases, the professionals involved with supporting service users and carers may benefit from more knowledge regarding the NR/NP role and how to incorporate it into the care that they provide. This is illustrated by one woman talking about her involvement as a NP:

It’s made the professionals feel they don’t really know what to do with us as Named Persons . . . now they’ve got to find a place for us, but they’re still not sure about what that is.

NP, friend55

This suggests that professionals involved with supporting service users and their NR during an involuntary admission process could benefit from training and support on what the NR/NP role is, how to inform the NR/NP of their rights and involving them, when appropriate, in the care of the service user they support.

Subtheme 3.3: proactive support and engagement

This subtheme discusses the need for professionals to be proactive in identifying the needs of carers that may affect their ability to provide support to the service user within their NR role. The advantages and disadvantages of the approach by professionals used in Scotland to encourage individuals to identify a NP in advance are also explored.

Authors of three studies31,32,49 acknowledged the importance of identifying the needs of the carers and NR involved with providing support to service users. In addition to the need for information (highlighted above in the previous subtheme), Pinfold et al. 49 reflect on the important role professionals have in providing emotional support and comfort to carers during times of distress, although the demands placed on professionals’ time may not always allow for this. 31 Carers also welcomed practical support, such as guidance with filling in forms and referral to services for their own needs. 49

Authors of two studies in Scotland32,33 highlighted the proactive approach used by some professionals to encourage service users, carers and other professionals to think about nominating a NP in advance. This is illustrated by a member of one tribunal panel discussing how MHOs play an important role in advertising the NP role in Scotland:

. . . my experience of mental health officers is that they’re very actively out there in the community talking to the people who are concerned with the care of people.

Tribunal member33 (p. 53).

© Crown copyright 2009. Contains public sector information licensed under the Open Government Licence v3.0

Although this approach was seen as positive by some professionals, others felt that it represented a potential conflict of interest, and felt that professionals should not become involved in what they regarded as a private agreement between the service user and their nominated NP. 32 One MHO reflects on the potential impact of any reluctance from professionals to support the process of a NP:

If that’s the message then you’re not going to get a high take up. You’ve got to be quite proactive to get people thinking about it.

MHO32 (p. 147).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

Although this quotation illustrates the perception that a proactive approach used by professionals may encourage people to nominate a NP, it conflicts with information presented in Theme 4: importance of maintaining relationships that indicates that some service users may not wish to think about the possibility of being ill in the future. Professionals appear to play an important role in recognising when it may be an appropriate time to discuss the nomination of a NP with a service user. We would suggest that factors that may influence this decision include the length of time they have supported them, the quality of the relationship and the service user’s mental health at the time.

Finally, three studies also indicated that carers and NPs may require additional support during the tribunal process to enable them to fulfil their role, including the provision of accessible information,38,56 as indicated within Subtheme 3.2: need for information, and explicit encouragement to share their views. 33,56 Two studies noted that the scheduling of tribunals during the working day could sometimes exclude carers from taking part (Dawson et al. ,33 Ridley et al. 56). One NP stated:

It’ll go ahead regardless of whether me as Named Person can go.

NP56

We suggest that the above statement indicates that the lack of flexibility in scheduling tribunals according to NPs could lead to the views of carers and NRs/NPs being overlooked within the tribunal process and contribute to NRs/NPs feeling unheard and undervalued, as discussed within Subtheme 4.3: carer/professional relationships. This highlights the need for organisers of the tribunal process to be proactive in ensuring that family members, carers and NRs/NPs are supported to attend when appropriate.

Summary

This theme discusses the ways in which support is needed and can be provided with respect to the compulsory detention of a service user and the role of the NR in their care. The following key points emerged from the evidence:

• The role of the NR or NP is complex and may be poorly understood by service users, carers and professionals alike.

• It should be recognised that the NR or NP, as well as other relatives and carers without statutory roles in the admission or ongoing care, may require emotional and informational support at various stages throughout the process of detention and treatment, and that professionals involved in these processes are well placed to deliver them.

• Carers reflected that being recognised as a NR or NP enabled them to offer better support to the service user throughout the processes of detention/treatment under the MHA 19831 through their improved awareness of their rights under the NR/NP provision and the recognition of these by professionals.

Subtheme 4.1: service user/carer relationships

This subtheme discusses issues that may affect the relationship between service users and their carers and NRs/NPs. The issues include the impact on the carer of the responsibility of taking on the NR/NP role, the ability of the NR/NP to act in the best interests of the service user and how the duties associated with the NR/NP role may be a source of conflict between service users and their carers.

The responsibility of caring for someone with mental health difficulties can be very physically and emotionally challenging for the carer at times, as evidenced by author and participant views included within this review. 31,45,46,56,57 The additional responsibility associated with the NR/NP role can contribute towards the stress of responsibility experienced by carers. Authors from five studies31–33,38,56 indicate that carers and NRs/NPs can feel daunted by the responsibility of their role. This is illustrated by a MHO discussing how some carers experience the process of contributing within a tribunal:

People generally appreciate that sense of, kind of empowerment [. . .]. Again because I’m mainly involved with older people sometimes people feel a bit frightened by the process . . . I think for those people who would actually feel frightened rather than empowered by an involvement.

MHO33 (p. 47)

One service user discussed how they would use the flexibility associated with the NP provision in Scotland (MHCT) to choose a friend as their NP in order to relieve the responsibility from family members:

You know, it’s about taking the pressure off them and that could be beneficial for the family member as well, as they can be so busy caring.

Service user32 (p. 138).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

Under the NR provisions of the MHA 1983,1 the service user cannot choose who is involved in decision-making. This means that service users may feel that they have to place extra responsibility on carers without wanting to, or discuss issues with people they find it hard to communicate with. This has clear implications for service users, who may have to accept care or treatment conditions if their NR/NP perceives them to be in their best interests.

Authors of three studies conducted in Scotland32,33,56 highlight the importance of the NP being able to understand, respect and carry out the wishes of the service user, which is clearly related to the quality of their personal relationship. In Scotland, some service users selected friends to be their NP because they perceived them to be more ‘equal’ in terms of their relationship56 and trusted that they would be more aware and supportive of their wishes when it came to being offered certain treatments. 32 However, some service users were concerned with the possible impact the NP role would have on their relationships with friends, and felt that the closeness associated with good family relationships was necessary to undertake the NP role. 56

Authors of two studies highlighted concerns that both service users and NPs did not fully understand the level of information that would be shared with the NP. 33,37 We suggest that this has the potential to place strain on the services user’s relationship with their NP. The need for adequate information about the NR/NP role is discussed further in Theme 2: enabling use of the Nearest Relative/Named Person role. Participant and author views from seven studies31,33,37,45,46,56,57 indicate that another factor that may affect the quality of the service user–NR relationship was when the NR felt that they needed to express views that conflicted with the service user’s, during a tribunal,32,33,57 prior to admission45,46 or while on a CTO. 57 This is illustrated by the observation of two people involved with influencing government policy:

Their care and friendship is with the person [service user] but they are certainly allowed to have an independent view and that is exactly why they don’t want to go to the tribunal and say it to the person, for fear of the reaction.

Policy influencer32 (p. 154).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

It’s most awkward at the tribunal stage where there’s tension between the user and the apparent Named Person, where the MHO has imposed one and, where that happens, there’s still a great deal of bad feeling, I think, and it really doesn’t seem to suit either party.

Policy influencer32 (p. 159).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

Subtheme 4.2: service user/professional relationships

This subtheme discusses how the disclosure of information to NRs against the service user’s wishes can challenge their relationship with the ASWs, psychiatrists and other service staff who support them. Other issues that may affect the service user’s relationship with services, such as the identification of a NP and preparation of an advance statement (‘. . . a document ‘‘completed by a service user when they are well and judged to be able to make decisions for themselves’’. The documents state how the service user would like to be treated in the future if they later did not have the capacity to decide this for themselves‘65) are also explored.

Along with some of the information presented earlier within Theme 2: confidentiality and information-sharing, author views from two studies indicate how the sharing of information without the consent of the service user has resulted in feelings of anger or distress. 31,49 One service user felt that a request by the service user to not share information with their NR should be respected, even at times when they lacked the capacity to make a fully informed decision:

If a service user thinks the carer is the devil, even if this is false, it is clear it will distress the service user to inform the carer. The approach here is to wait until the paranoia has passed. My view here is to follow the service user wishes . . .

Service user49 (p. 110).

© NCCSDO. Reproduced with permission

This contrasts with the view of a psychiatrist interviewed in the same study:

. . . I think there are times when you really want to tell relatives about the patient’s behaviour. Sometimes you have to say ‘I can’t let you go home unless I tell them this’.

Psychiatrist49 (p. 115).

© NCCSDO. Reproduced with permission

This conflict between the desire of the service user to retain their autonomy and the professional obligation of those who support them to protect both the service user and members of the public from harm could have an undesirable impact on the service user’s future willingness to share information with care professionals or to access services. This interpretation is supported by four service users interviewed by Berzins,32 who said that they provided their psychiatrist with the minimum level of information necessary:

I haven’t told the psychiatrist a lot of things. I don’t really tell them very much at all, just a quick how it’s going and how’s the medication, and this is why I think they‘re not always the best person to make a judgement about your situation.

Service user32 (p. 163).

Reproduced with permission from Dr Kathryn Berzins, University of Glasgow, 2018, personal communication

Service user and author views from two studies indicate that some professionals were reluctant to discuss issues relating to the possibility of a future hospital admission, including the nomination of a NP, for fear of damaging their relationship with the service user. 31,32 Author views from two studies also indicate that there may be issues around staff knowledge on how to implement or access advance statements. 49,56 This is discussed further in Theme 1: enabling use of the Nearest Relative/Named Person role.

Subtheme 4.3: carer/professional relationships

This subtheme explores how the relationship between carers and the professionals who support service users can be influenced by the degree that carers feel listened to, valued and involved in the care of the service users.

Four studies33,45,46,57 present the views of participants and authors that indicate that carers and NRs/NPs do not always feel that professionals consider their needs or views when supporting service users. This appears to be an issue at different stages of the service user’s involuntary hospital admission, including pre-admission and discharge, as illustrated by two carers and a NR below:

When I’ve known he’s going downhill and I have felt that I wasn’t really being listened to enough then and I had tried to speak to the doctor but I’ve never been able to.

NR60 (p. 57).

Reproduced with permission from Dr Julia Stroud, University of Brighton, 2018, personal communication

We were shattered . . . I didn’t really want him to come and spend the night at home already, and one day I went in and it took me completely by surprise Dr X wanted him released that day . . .

Mother and carer46

[The psychiatrist] said at the last meeting was ‘I am going to keep you on your CTO’. And I asked why because I said ‘to be honest with you I don’t want him to go back into hospital [through recalls].’ . . . And she wasn’t taking him off it.

Mother and carer57

Author views from four studies31,45,48,56 indicate that carers can feel excluded from the decisions being made about the care of service users during an involuntary admission. This is illustrated by one carer talking about the admission of their partner to hospital:

You don’t always know at the hospital that this is going to happen. I’ve had times when yes, they’re talking about sectioning and then the next thing I know I get a letter in the post saying it’s happened . . . They’ve decided after I’ve gone home . . .

Partner and carer45

Author and participant views from five studies31,49,56–58 indicate that carers may experience the need to protect service users’ right to privacy as a barrier to their own working relationship with professionals. Although carers perceived that information may not be passed on to them because of the automatic assumption by professionals that service users would not want their information to be shared,58 some carers perceived that confidentiality was used by professionals to deliberately exclude them from discussions about a service user’s care. 49,57 One ASW discusses how the potential for conflict between the views of the NR and ASW limited the information NRs were given about their role:

. . . we have a competing element which may not in our view, be the best interests of the particular client . . . I think that’s the real issue . . . I wonder sometimes whether we fully inform Nearest Relatives about their, about their powers, given the kind of practical conflict.

ASW. 31

Reproduced with permission from Dr Joan Rapaport, Anglia Ruskin University, 2018, personal communication

The perceived power imbalance between carers and professionals was also discussed in relation to carers’ experiences of taking part in tribunals in Scotland. 32,33,56 In addition to the intimidating tribunal setting,32,56 carers noted that, although the tribunal system provided the opportunity for them to air their views and feel listened to, they also perceived that professional voices carried more weight. 32,33,56 One solicitor observed:

I think Named Persons feel as though, in relation to the tribunal process, they’ve got a powerful voice but when it comes with wanting to meet with doctors and to speak to other professionals, sometimes they feel as though that voice isn’t quite as powerful in relation to that.

Solicitor33 (p. 44)

Author views from two studies indicate that carers may refrain from complaining about any treatment to themselves or actions on behalf of the service user they perceive to be unfair because they fear damaging their relationships with professionals. 31,57 However, the same studies provide examples of where, when a mutually respectful and open relationship is cultivated between carers/NRs and professionals, they can work together to have a meaningful impact on the care that service users receive. 31,57,60 Some examples of the benefits of carers/NRs and professionals working together include preventing the inappropriate recall from a CTO of a service user back to hospital57 and the delivery of a person-centred care package to prevent an involuntary hospital admission. 31

This subtheme brings together evidence about perceived power imbalances between professionals and carers, including issues regarding maintaining service user confidentiality, and how these imbalances may have an impact on the ability for professionals and carers to work together to support the service user leading up to and during a hospital admission. However, opportunities for professionals to listen to the views of carers and NRs, either through creating opportunities to meet with them privately (as discussed within Theme 2: confidentiality and information-sharing) or through the tribunal system, may help create a mutually respectful working relationship.

Summary

This theme is concerned with the relationships between professionals, carers (NRs or otherwise) and service users during the treatment of individuals subjected to compulsory detention and treatment. Relationships with professionals can have a significant bearing on the experiences of care, whereas the relationships between service users and carers may last a lifetime. The experience of being compulsorily detained places strain on these relationships. There was evidence of experience of a heavy responsibility on carers and a NR or NP alike, and data from this theme highlighted some of the circumstances in which vital relationships can become strained. The following issues emerged:

• The role of NR confers a lot of responsibility and, in some cases in which the NR is the primary carer, this can be overwhelming.

• Disagreements over treatment decisions, carers feeling ignored or cut out and conflicts with mental health professionals are some of the ways in which relationships can be placed under significant strain.

• Another perceived benefit of the NP provision over the NR provision was the flexibility to choose a friend as a NP because the service user felt that they would be more aware of, and more likely to implement, their wishes than certain family members.

• There were positive reflections on instances when professionals worked closely with carers to optimise care outcomes.

The different factors that may support the development of a constructive working relationship between service users, carers and professionals are discussed in Theme 1: enabling use of the Nearest Relative/Named Person role.

Limitations of the evidence

This review identified and summarised a body of qualitative evidence about the experiences of those involved with the compulsory detention of people with mental health problems in the UK. After initially determining included studies, we prioritised and synthesised those studies that offered the most abundant and the most relevant primary data. We identified 12 such studies; however, when developing the framework, only six or seven contributed significantly (see Table 5). 31–33,45,46,56,57 Although experiences of the use of NP provisions in Scotland were represented by only three studies, these were arguably the richest, coming from a PhD thesis32 and two government reports commissioned to examine the implementation of the MHCT. 33,56 Lengthier reports inevitably have scope to include richer accounts of interview participants, for example, than journal articles. Service users’, carers’, NPs’ and professionals’ experiences of the NP provisions were all well represented by the evidence from Scotland. However, there were no studies offering comparisons with the NR provisions of the MHA 19831 in England and Wales. Although the 2015 amendments to the MHCT allow the service user to opt to not have a NP, there was no evidence relating to this. The amended Act was only implemented in 2017, so published studies of its implementation would not be expected at the time of this report.

The evidence of experiences of the MHA 19831 in England and Wales came from eight studies;31,45,46,48,49,57,58,60 however, only four46,57,58,60 collected data after the implementation of the 2007 MHA 19831 amendments. 14 These amendments were notable in that they introduced the option to withhold information from the NR or to displace the NR through application to County Courts, and gave civil partners equal status to married partners in the hierarchy of relatives. Those four studies represented the views of 55 family caregivers,46,57 21 service users and 19 mental health professionals. 60 Thirty-two NRs were interviewed by Smith,58 but few rich and relevant data from this study featured in our synthesis (see Table 5), and seven NRs were interviewed by Stroud et al. 60 Perspectives on current aspects (since 2007) of the NR provisions of the MHA 19831 in England and Wales are therefore represented by a very small number of participants and may not reflect wider experiences of the current legislation and related practices. The data pertaining to the MHA 19831 in England and Wales prior to the 2007 amendments14 were mainly from three studies offering rich data that featured heavily in the synthesis. 31,45,49 These studies represented the views of 57 carers, 34 service users and 43 mental health professionals through the analysis of interview data (Pinfold et al. 49 also conducted a questionnaire survey of 998 stakeholders).

In summary, the limitations of the available evidence should be considered when drawing conclusions from this review. In particular, although a number of the included qualitative studies provided rich data about the experiences of a variety of stakeholders involved in compulsory detention under the MHA 19831 and MHCT, the samples drawn on were predominantly from England and Scotland, and most evidence predated the 2007 MHA amendments;14 therefore, they may not be completely representative of the wider population experiencing or providing such care in the UK in 2018. Nevertheless, although we cannot claim to have conducted an in-depth analysis that has reached conceptual ‘saturation’, there is reasonable analytical generalisability over time and between localities in terms of the recurrence of a considerable number of common plausible issues.

Experiences of the MHA 19831 in Northern Ireland were investigated in just one study38 included in the synthesis. The evidence from Scotland focused on experiences of implementation of the MHCT, without direct comparison with older legislation or legislation in England and Wales. The evidence from England was again drawn from a handful of small studies, and in particular there was a dearth of evidence attempting to examine experiences of the NR provisions since the MHA 19831 was amended in 2007. 14 At best, the evidence can be considered indicative of issues with the MHA 19831 and MHCT11 legislation that may be experienced by service users and carers in particular, rather than representative of the majority of experiences.

Methodological limitations of the review

This systematic review was conducted within a rapid time frame (6 weeks) and the following limitations resulting directly from this approach should be acknowledged:

• A pragmatic decision was made to prioritise studies that contained more than a few paragraphs of relevant primary qualitative data for inclusion in the framework synthesis. With more time, all included studies would have been considered for inclusion in the synthesis.

• A framework approach was used for the synthesis of included studies. The period available for synthesis of the prioritised studies (1–2 weeks) did not lend itself to the preferred method of synthesis, which would have used an iterative, inductive approach. For this reason, the findings of this review are largely descriptive in nature, and are not able to reflect on the nuance and underlying issues identified by the included studies. In addition, it was not possible to include all coded data in the write-up of the synthesis.

• Citation-chasing was undertaken only on those studies prioritised for inclusion in the synthesis. With more time, all eligible studies would have been searched.

• Critical appraisal was undertaken in full, but only for those studies included in the framework synthesis. This was deemed as an appropriate time-saving approach, as findings from the non-prioritised batch of studies were not synthesised and did not influence the conclusions of the review.

• Three studies, which may have contributed useful information to the synthesis, were retrieved too late for inclusion in the review.

Despite these limitations, the processes of searching, study selection and critical appraisal (for prioritised studies) were conducted rigorously and in line with published international standards. 22 The findings of our synthesis should be considered in the light of these restrictions, and the stated limitations of the evidence base.

Implications

Evidence was scarce and much of it was over 10 years old and comprised samples of individuals from a limited range of localities and services. Studies also suffered from a lack of evidence of rigour when collecting or analysing qualitative data. Despite the general consistency of experiences that contributed to themes across studies, only 12 studies contributed to the synthesis. The timeline of this rapid review prevented further exploration of the evidence; however, drawing further conclusions from the limited evidence pool may have exacerbated the potential for biased, unrepresentative experiences to be captured.

For this reason, the main implications of this review are that the topic of the NR provisions of the MHA 19831 is complex, of significant importance to individuals detained under the MHA 19831 and insufficiently studied to date.

Recommendations for research

It is imperative that high-quality primary research is undertaken to explore the current issues around the NR provisions of the MHA 19831 in England and Wales. There is no population group that has been recently and rigorously sampled to inquire about their experiences of the NR provisions, particularly since the introduction of the 2007 amendments to the MHA 1983. 1 Although all areas and topics related to the NR provisions of the MHA 19831 warrant further investigation, some of the specific directions for primary research include:

• Examination of experiences of the NR/NP in the light of the most recent legislative changes throughout the UK, for example the option to opt for no NP in Scotland.

• Further research is warranted in all areas of the UK. There was very little evidence from Northern Ireland and none from Wales and, although the studies based in Scotland were of good quality, they were few in number and all commissioned by the government. Despite the greater number of studies conducted in England, most of the useful evidence arose from a very small number of studies, and none of these had been conducted since key legislative amendments were made in 2007. 14

• There has been a lack of consideration of the experiences of those who are not married or in a civil partnership.

• The views of mental health professionals and mental health advocates were not well represented.

• A dearth of evidence was uncovered relating to the specific experiences of the NR/NP provisions from the perspective of ethnic minorities.

Qualitative methods may be the most appropriate means of eliciting data about experiences of the NR/NP provisions of the MHA 1983. 1 However, reporting of methodological considerations could be improved.

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