We compliment Rigby and McAlpine on a well-written editorial on Section 12 approval.^{Reference Rigby and McAlpine1} The authors raise several pertinent issues about Mental Health Act (MHA) detentions and note that there has been a 47% increase in the rate of detentions countrywide. They are of the opinion that the increase in detentions is mainly attributable to clinicians not being equipped with the necessary knowledge and training. Rigby and McAlpine suggest more rigorous evidence-based training reinforced by appropriate assessment, including summative assessment using criteria-referenced methods with pass marks determined by the Angoff method. The authors also feel that the approval and revalidation processes need to be more robust.

We, however, are of the opinion that the authors have taken an Occam's razor view by largely attributing the problem to clinicians’ training. In our opinion, increases in detention rates are due to multiple factors, and the ‘fix’ is not as binary as upgrading training of clinicians or making the approval and revalidation processes more robust. The process of MHA assessment requires two doctors, of which one has to be an independent Section 12 doctor, and an approved mental health professional (AMHP), who is usually (but not invariably) a social worker. All three have to agree to detain a patient with a mental disorder. It is pertinent that the final responsibility for detaining someone under an MHA belongs to the AMHP, who then submits an application to a local hospital for an in-patient bed.

We quote verbatim from the 2018 Care Quality Commission report² on the use of the MHA to detain people:

Glover-Thomas, in a recent review, notes that the availability of mental health beds has decreased, thereby delaying the ‘preferred option’ of voluntary admission of patients. Therefore, in circumstances when clinicians deem a patient to be in need of care in hospital, resorting to detention ‘may be the quickest means of opening up services’.^{Reference Glover-Thomas3} This factor – in our view – is consequential in ‘bumping up’ detention rates.

The number of appeals to mental health review tribunals (MHRTs) in England and Wales has risen steadily, from 904 in 1980Reference Webster, Dean and Kessel⁴ to 31 469 in 2014.⁵ This reflects the parallel increase in the number detained. However, the percentage of patients who are successful in obtaining discharge at MHRT hearings is relatively low (only 9% of all hearings in 2013–2014 resulted in discharge⁶), suggesting that patients have been detained appropriately. This, in turn, suggests that training for Section 12 approval is not a factor. However, we agree with Rigby and McAlpine that improvements in training would be beneficial to clinicians in terms of increasing their confidence and knowledge.