Long-Term Segregation Under the Mental Health Act: A Care Staff Guide

Long-term segregation is one of the most restrictive practices in mental health and learning disability services. It means a patient is not allowed to mix freely with other patients on a long-term basis, and it can go on for weeks or months. Because it can cause real harm, it is closely scrutinised by regulators, commissioners and advocates. This guide explains what it is, how it differs from seclusion, and what staff should expect in terms of safeguards and reviews.

It is general information, not legal advice. Always follow the Mental Health Act Code of Practice and your own organisation's policy, because the detailed requirements are set out there and in local procedures.

Seclusion and long-term segregation are different

The Mental Health Act Code of Practice defines seclusion as the supervised confinement and isolation of a patient, away from other patients, in an area from which they are prevented from leaving. It is meant for short periods, to contain severely disturbed behaviour that is likely to cause harm to others.

Long-term segregation is different. NHS policies that follow the Code describe it as a situation where a patient is prevented from mixing freely with other patients on a long-term basis because of a sustained risk of harm to others, which is a constant feature of their presentation, and where short-term interventions are not enough. A key difference is that the person usually keeps contact with staff, and therapeutic engagement is meant to continue. If a person is, in effect, being secluded for days on end, a team needs to stop and ask whether the practice is lawful, and whether the right label and safeguards are in place.

Why it matters

People in long-term segregation are often autistic, have a learning disability or have complex mental health needs, and many have already experienced trauma. Long periods away from others can worsen distress and behaviour, and can slow recovery. For that reason the Code, regulators and the NHS expect it to be used rarely, for as short a time as possible, and always alongside a plan for ending it. Our guide to restraint and seclusion training covers the wider framework around restrictive practice.

Safeguards staff should expect

Local policies built on the Code of Practice typically include the following safeguards:

• a clear decision, made by a multidisciplinary team that includes the responsible clinician, with family or carers, the commissioner and an advocate involved wherever possible
• regular therapeutic observation and continuous staff engagement
• access to food, drink, hygiene, fresh air, activities and contact with others as far as risk allows
• respect for privacy, dignity, and cultural and spiritual needs
• a written plan with the aim of ending segregation, and a record of what would need to change
• the least restrictive and most homelike environment that can be provided
• a proportionality assessment that considers the person's human rights

Reviews and oversight

The Code expects regular review, and local policy sets out the exact timetable. As an example, one NHS mental health trust's policy requires a daily review by a doctor, a weekly multidisciplinary review, a monthly senior manager review, and a three-monthly external review with the commissioner and an independent mental health advocate. Other trusts set their own timetables, so check your own policy rather than assuming this schedule applies to you.

Every review should be documented, and should ask the same questions. Is segregation still necessary? What has been tried? What is the person saying? What would a lower level of restriction look like? Our guide to the Independent Mental Health Advocate explains how advocates can support patients through this.

The role of care staff

Care and nursing staff are often the people who spend the most time with the person. That makes their observations central to every review. Staff should:

• record what the person says and does, including positive moments, not only incidents
• keep up engagement, so that the person is not simply left alone
• report any sign of distress, self-harm or deterioration in physical health at once
• support the written plan for ending segregation, including small steps such as time with one other person
• raise concerns if the practice seems to have drifted without review

An approach built on positive behaviour support helps teams understand what is driving behaviour and reduce the need for segregation in the first place.

Warning signs that practice has drifted

• Reviews are late, or are signed off without the person being seen.
• The plan for ending segregation is vague, or has no dates.
• The person has little contact with staff beyond essential care.
• The commissioner, family or advocate have not been told.
• The environment is bare, unsafe or institutional.
• Staff describe the arrangement as permanent.

Frequently asked questions

Is long-term segregation the same as seclusion?

No. Seclusion is short-term confinement, while long-term segregation is a sustained arrangement to reduce a continuing risk to others, with ongoing staff contact and a plan to end it.

Who decides?

The decision involves the multidisciplinary team led by the responsible clinician, with input from the patient, family or carers, the commissioner and an advocate.

Can a patient challenge it?

Yes. Patients can raise concerns with an advocate, ask for review, and use the usual rights of complaint and appeal. Detained patients may also have the right to apply to a tribunal.

Where can teams find training?

See the CPD hub for professional development options for care and healthcare teams.

Learnsignal will update this guide as the Code of Practice and Mental Health Act reforms are put into practice.