The cost of Mental Health Review Tribunals *

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Stephen Blumenthal and Simon Wessely
There has been a substantial increase in the number of Mental Health Review Tribunals (MHRTs) and hence the cost of administering the tribunal system.We report an estimate of the cost of MHRTstaking account, for the first time, of both direct and indirect costs to the various government departments.We estimate that the total cost is currently Â£12,274,380per annum.
The annual number of applications for Mental Health Review Tribunal (MHRT) hearings has risen dramatically since they were introduced in the present form by the Mental Health Act (1983).In 1984 there were approximately 3,000 applications for tribunals.This number has in creased three-fold since then, and the projected figure for 1993 was almost 10,000 applications, resulting in around 5,000 tribunal hearings.
There has been no comprehensive analysis of the costing of tribunals.Previous estimates, for example the Palmer report (Palmer et al, 1991), take account only of the direct costs to the Department of Health by presenting the budget set aside for the administration of tribunals.No mention is made of the indirect expenditure by either the Department of Health or other government departments involved.

The study
We were commissioned by the Department of Health to provide a report on MHRT delay.The methodology included sending questionnaires to the individuals and agencies involved.This gave us an opportunity to estimate the direct and indirect costs of MHRTs.Respondents were questioned about their Mental Health Act workload in terms of writing tribunal reports and attending hearings.A breakdown of those involved in MHRTs is given in Table 1.
The building-block approach to costing has been used (Allen & Beecham, 1993).This model involves four stages: the describing of service elements, identifying activities and calculating service units, identifying cost implications, and calculating the total cost.*The study was funded by the Department of Health.The views expressed are the authors' own.
Information was also obtained from interviews with representatives from government depart ments involved with the administration of MHRTs: Department of Health, Home Office and Lord Chancellor's Department.

Department of Health: direct expenditure
The direct expenditure on MHRTs for 1992/3 was Â£4,061,200 (Department of Health, 1993a).This represents the cost of running the four regional tribunal offices, including the salaries of clerks and office staff.It also includes the fees and expenses of tribunal members and some witnesses but excludes the cost of judges.Direct expenditure are given in Table 2.

National Health Service
The costs to the NHS include the time doctors spend writing tribunal reports and attending MHRTs, and the time spent arranging hearings for the hospital administration departments.The latter expenditure is difficult to quantify al though work involved in the administration of the Mental Health Act takes up an increasingly large part of administrators' and clinicians' time.
We calculated the total cost of the RMOs' report by estimating the number of reports that are prepared for tribunals and multiplying this by the approximate number of hours spent prepar ing a report.Our survey data suggest that the average report takes two hours to prepare taking account of both restricted and unrestricted cases.A psychiatric report was submitted in approximately 75% of the total number of tri bunal applications in this study, although not all of these reached the stage of having a hearing.Hence if there are 10,000 tribunal applications this year, about 7,500 medical reports will be prepared, even if not all are used.
Attendance at the tribunal adds further indi rect costs.We found that the average time spent attending tribunal hearings is a further two hours, again taking account of restricted and unrestricted cases.Approximately 5,000 cases will reach a tribunal, thus involving an average of 10,000 hours of RMO time (or his or her deputy).The total number of consultant hours (25,000 including report writing and attendance) was then multiplied by the average cost of a consult ant per hour.This is Â£45.12 which includes salaries, secretarial support and overheads (Netton & Smart, 1993).The annual cost of medical time to the NHS is therefore Â£1,128,000.
There is also the cost of Mental Health Act administration to the health service.Each tribu nal takes approximately four hours of adminis trative time.The unit cost per hour is around Â£13.10 including salaries and overheads.The total cost of administration is therefore Â£524,000 per year.
Further expenditure is incurred in holding the tribunal hearing.It is estimated that the capital costs of a typical psychiatric in-patient to the NHS is Â£91.30per day (Netton & Smart, 1993).We have used this as the basis for calculating the hourly cost (Â£3.80).A standard tribunal hearing takes approximately two hours and there are about 5,000 of these per year.The annual capital cost of the MHRT is Â£38,000.

Social services
The social service cost, in terms of social worker time, was calculated in a similar fashion.Again, approximately 75% of applicants had social cir cumstance reports prepared, leading to 5,000 hearings attended by a social worker.Our data show that an average of two hours was spent preparing a social circumstance report and a further two hours attending the tribunal hearing, taking account of both restricted and un restricted cases.In addition, a social worker in a local authority would spend approximately four hours interviewing the patient and his or her relatives.We recognise that this does vary par ticularly for social workers in special hospitals and regional secure units.
The total number of social worker hours (55,000) was then multiplied by the average cost of a social worker per hour (Â£18.70)(Netton & Smart, 1993).We estimate that the annual cost of social work time to local authorities is Â£1,028,500.

Home Office
Restricted cases are reviewed by C3 Division in the Home Office on behalf of the Home Secretary.The department is divided in two, and MHRTs are dealt with by the division dealing specifically with Mental Health Act work.Tribunals take up approximately one third of this part of the department's workload.
C3 Division employs approximately 40 staff.The total cost in salaries is approximately Â£lm Mental Health Review Tribunals per annum, and support and accommodation account for about Â£lm more (Home Office, per sonal communication).Tribunal expenditure by the Home Office is therefore about Â£667,000.

Lord Chancellor's Department
Judges are seconded from the Lord Chancellor's Department (LCD).According to the LCD.there are approximately 35 judges who are involved with MHRT work.Our survey of judges indicated that they spend an average of 18 hours per week involved in tribunal work.The average salary of a judge is Â£65,000 per annum which amounts to approximately Â£270per day and Â£34per hour.This is a conservative estimate as the tribunal offices pay retired judges Â£306per day (Depart ment of Health, 1993b).The Â£34 per hour is doubled when account is taken of the additional administrative costs, support staff and capital expenditure.We estimate the cost of MHRTs to the LCD to be Â£2,227,680.

Legal aid
Legal aid for 1992/3 totalled Â£2,600,000 for MHRTs.Approximately Â£450.000 of this was spent on independent psychiatric reports.The average legal aid bill for an individual case was Â£562.

Total cost
We calculate the total cost of holding Mental Health Review Tribunals to be Â£12,274,380.A breakdown of the costs is given in Table 1.

Conclusions
The cost of administering the MHRT system has risen dramatically since tribunals were intro duced in their present form by the 1983 Act.
Estimates of cost have avoided the less obvious aspects of expenditure on the MHA 1983, even though Mental Health Act work takes up an increasing amount of the workload of psy chiatrists, social workers, judges and the Home Office.
This analysis of the cost of MHRTs was not the main remit of the study on tribunal delay and there are thus several inaccuracies.A more thorough investigation is required detailing fur ther the costs to health and social services, the Home Office and Lord Chancellor's Department.The role and cost of the Special Hospital Services Authority and the Council on Tribunals needs to be examined in more detail.It is anticipated that such an analysis would reveal further costs in the administration of the system.
Safeguarding the rights of detained patients is essential for a just system.However, it does not come cheap.

Table 1 .
Contributions to the cost of MHRTs

Table 2 .
Direct costs of MHRTs