In the liminal spaces of mental health law - what to do when section 136 expires?

The pressure on mental health services has not gone unremarked and is of widespread concern in England and Wales. This can have implications when a bed is being sought for a patient who has undergone a Mental Health Act assessment and is deemed to meet the criteria for being formally admitted to hospital. Once the 24 h period for assessment under section 136 of the Act has lapsed, the ongoing detention of the patient can lead to a legal grey area. Through a fictional example this paper examines the relevant case law and statute that may be used to continue the detention and explores the ethical problems that this may cause.

Accident and emergency department attendance rates of people experiencing homelessness by GP registration: a retrospective analysis.

BACKGROUND: People experiencing homelessness are known to have complex health needs and to be high users of hospital accident and emergency (A&E) departments. It is unclear whether access to a day-time specialist homeless medical practice, as opposed to routine general practice, influences A&E attendance rates. AIM: This study investigated whether registration with a specialist homeless service would alter A&E attendance rates in a single geographical region in Scotland. DESIGN & SETTING: A health board area with a specialist service for people experiencing homelessness was selected. Data were obtained from the hospital records of 4408 A&E attendances by people experiencing homelessness at NHS Lothian (based on a broad definition of homelessness and including those in temporary accommodation) between January 2015 and July 2017. METHOD: The attendances were compared between people registered with a specialist service and those registered with a mainstream GP. RESULTS: The reasons for attendance and urgency of attendance were broadly similar between the two groups. Repeat attendance was similarly high in both groups. Almost 70% in both groups attended with problems deemed urgent, very urgent, or requiring immediate resuscitation. The patients registered with the specialist homeless service were more likely to be older and male; however, this did not affect the frequency of attendance. CONCLUSION: People experiencing homelessness attending A&E mainly do so for urgent or very urgent problems. This was not related to the type of day-time primary care service they had access to. Strategies to reduce attendances, such as out-of-hours mobile medical units, should be explored.

Homeless mortality data from East London.

BACKGROUND: The rate of homeless mortality is known to be significantly below the national average, with mortality rates varying geographically. This study aims to look at the rates and causes of homeless mortality within East London. QUESTION: To characterise homeless mortality of patients registered in two specialist homeless practices, between 2001 and 2016 in the London boroughs of Tower Hamlets and Hackney, by age at death and cause of death. STUDY DESIGN: A retrospective study of general practice electronic patient records. METHODS: Electronic patient records across two general practice surgeries specialising in care for the homeless in East London were examined and their mortality data extracted. RESULTS: Two hundred and three deaths recorded in the two general practice surgeries were examined. The average age at death was 47 years, with the highest numbers of deaths being attributed to substance misuse, liver disease and cardiac-related deaths. Those dying of cardiac-related causes died at an average of 51, those dying of liver-related causes died at an average age of 49 years and those dying from substance misuse died at an average age of 38. CONCLUSIONS: Those dying of substance misuse-related causes died much younger than the average homeless patient did.

Patient-accessible tool for shared decision making in cardiovascular primary prevention: balancing longevity benefits against medication disutility.

BACKGROUND: Primary prevention guidelines focus on risk, often assuming negligible aversion to medication, yet most patients discontinue primary prevention statins within 3 years. We quantify real-world distribution of medication disutility and separately calculate the average utilities for a range of risk strata. METHOD AND RESULTS: We randomly sampled 360 members of the general public in London. Medication aversion was quantified as the gain in lifespan required by each individual to offset the inconvenience (disutility) of taking an idealized daily preventative tablet. In parallel, we constructed tables of expected gain in lifespan (utility) from initiating statin therapy for each age group, sex, and cardiovascular risk profile in the population. This allowed comparison of the widths of the distributions of medication disutility and of group-average expectation of longevity gain. Observed medication disutility ranged from 1 day to >10 years of life being required by subjects (median, 6 months; interquartile range, 1-36 months) to make daily preventative therapy worthwhile. Average expected longevity benefit from statins at ages ≥50 years ranges from 3.6 months (low-risk women) to 24.3 months (high-risk men). CONCLUSION: We can no longer assume that medication disutility is almost zero. Over one-quarter of subjects had disutility exceeding the group-average longevity gain from statins expected even for the highest-risk (ie, highest-gain) group. Future primary prevention studies might explore medication disutility in larger populations. Patients may differ more in disutility than in prospectively definable utility (which provides only group-average estimates). Consultations could be enriched by assessing disutility and exploring its reasons.