Voting Rights of Patients with Mental illness or intellectual disability​​​​​​​

Dr Maria Clarke - Retired Honorary Clinical Senior Lecturer Imperial College London

Dr Masum Khwaja – Chair London s12/AC London Approval Panel & Consultant Psychiatrist CNWL NHS FT

Please feel free to use CNWL voting rights resources to promote voting rights in your own organisation.

“This is all about civil rights for all citizens; something I’m passionate about and why this is a very important initiative.” – Claire Murdoch, CNWL Chief Executive

The right to vote is a powerful symbol of inclusion or exclusion from society and is enshrined in the European Convention on Human Rights.

Historically mental health patients and those living with intellectual disability have been socially isolated, marginalised and disenfranchised.

Supporting the voting rights of patients promotes social inclusion and citizenship, and challenges discriminatory and stigmatising attitudes all of which are likely to promote recovery.

Voting sends the clear message that the opinion of a person living with mental illness or intellectual disability is of equal value to that of anyone else.

Voting offers patients a political voice and an opportunity to influence government policy. A vote in this context is more than a choice of party or candidate; it is a motivation for politicians to understand and support issues relevant to those with mental illness.

Emerging evidence, although limited, points to an important relationship between civic engagement and improved mental health, suggesting that voting as a form of civic engagement is a social determinant of mental health.

Many people, staff and patients, remain unaware that a lack of mental capacity is not a legal incapacity to vote. Persons who meet the other registration qualifications are eligible for registration regardless of their mental capacity.

The Representation of Peoples Act 2000, and Electoral Administration Act 2006 removed most of the legal barriers to voting for patients with mental health and/or intellectual disability, so that now all patients, bar the relatively small number of forensic patients convicted of a criminal offence and ordered to hospital by the courts, can vote.

Despite these changes in the law a significant number of mental health patients remain effectively disenfranchised by either a lack of knowledge of their eligibility to vote or of the voting process or by self-stigmatising attitudinal barriers (e.g. believing that their opinion is of little worth) and/or by symptoms such as anxiety or depression that may prevent them from registering or casting their vote.

A significant number of professionals also remain ignorant of the rights of patients to vote.

We urge organisations and individuals, working with patients with mental health problems or intellectual disability, to pro-actively support patients who want to exercise their democratic right to vote and help them to register and to cast their vote.

In 2012 we published a paper in The Psychiatrist titled 'Uptake and knowledge of voting rights by adult inpatients during the 2010 UK General Election'

The paper showed that in-patients in Westminster were half as likely to register to vote and those who did register were half as likely to cast their vote as the general population. This translated as a voting rate of only a quarter that of the general population. Patients on long stay rehabilitation wards were particularly disenfranchised. Only 12 per cent had made an active decision not to register to vote. The other 88% cited a lack of relevant knowledge as they were either unaware of their eligibility to vote or did not know how to register to vote. Results also indicated engagement in the political process in that 66 per cent of patients who were eligible to vote stated that they were interested in voting. Three barriers to voting were postulated: informational, psychological and physical.

The paper has been mentioned in the CQC report Monitoring the Mental Health Act in 2011/12  (now archived – if access please see second chapter entitled Participation and Respect, voting on page 31).

Voter ID is undoubtedly a significant additional barrier to voting that is likely to disproportionately impact on more disadvantaged groups in society including mental health patients, and other disabled groups, who are less likely to have, or to apply for, the required photo ID.

Voter ID was introduced in 4 May 2023 and requires voters in England to show photo ID at polling stations before being allowed to vote in local elections, police and crime commissioner elections, parliamentary by-elections and recall petitions. From October 2023 voter ID also applies to UK general elections.

Voter ID is yet one more reason why it’s important that patients, carers, advocacy and service user groups, as well as professional bodies and staff working in mental health services continue to raise awareness of the importance of voting rights, and push for the development of local and national strategies to actively support people with mental health difficulties to register and vote.

Building up to the 2015 General Election we developed a CNWL strategy to promote voting rights in our inpatient units and community teams.

We produced a  Trust Voting rights policy.

We then developed educational, promotional and informational resources such as posters, staff quizzes, patient and staff information leaflets, and a  Voting rights film.

We produced a Voting Rights Recovery college module for patients and staff that utilised material available from Rock Enrol - engaging young people in democracy.

We worked closely with our communications department to develop a weblink to voting rights resources for staff and patients.

A campaign to support patients to register and to cast their vote should they wish to do so was formally launched by our CEO Claire Murdoch a few months prior to the 2015 general election.

Throughout the campaign we tried to encourage staff to systematically enquire whether patients under their care would like help to register and to cast their vote and if they did then to ensure that a support plan was in place to help them do so. 

With services under pressure we weren't able to survey the numbers we had initially intended. Despite this we produced a few useful surveys that were presented as posters at the European Congress of Psychiatry in Madrid in 2016 and published in The Journal of the European Psychiatric Association.

The limited number of people surveyed and the lack of previous surveys for comparison limited the interpretation of the findings. However, in general, the results together with informal feedback from staff and patients were promising in that patient awareness of their right to vote and staff knowledge of patients voting rights had improved in some areas since the 2012 general election.

Knowledge and uptake of voting rights by psychiatric inpatients in Westminster, London during the 2015 UK General Election

Knowledge and uptake of voting rights by adults with mental illness living in supported accommodation in Westminster (London) during the 2015 UK general election

Knowledge of patients’ voting rights amongst mental health professionals working in the London Borough of Westminster during the 2015 UK General Election

CNWL, jointly with the Royal College of Psychiatrists, have continued to promote voting rights prior to local and national elections and we will be again prior to the 2024 General Election 2024 on 4 July.

We strongly believe that voting rights promotion strategy should be co-produced with patients and other stakeholders.

Coproduction of the CNWL voting rights strategy formed the basis of a presentation at the Royal Society of Medicine’s in July 2017. Rough preparation slides of the presentation are available here: How coproduction is the key to the NHS five year forward view.

In 2016/17 Dr Maria Clarke and Dr Masum Khwaja joined the Cabinet Office's multiagency Accessibility of Elections working group, on which they represented the Royal College of Psychiatrists.

Members of the working group include, amongst others, civil servants, senior representatives from the electoral commission, Centre for Mental Health, Mencap, United response, Rethink Mental Illness, Scope and RNIB.

Information about the working group can be found on page five of the February 2017 ARENA  article. ARENA is a journal that offers help and advice for those involved in electoral administration.

The working group has now moved from the Cabinet office to the Department for Levelling Up, Housing & Communities. Dr Maria Clarke retired in 2023 and has been replaced by Dr Saima Ali and Dr Alexis Theodorou. 

 

Survey (2017/18) was sent to MDs of NHS MH Trusts. The survey showed that only 9% of MHTs had a VR policy despite 66% considering voting rights promotion as very important/essential. Almost half of Trusts did not implement any voting rights initiatives prior to the 2015 GE (49%) or 2017 GE (47%). 

The survey was presented as a poster at the 2019 RCPsych congress.

The survey was repeated in 2021 and the survey results showed a considerable increase in positive attitudes towards voting rights for patients. This time 24% of Trusts said that they had a voting rights policy and 39% said that they intended to develop one.

Furthermore, 78% said that it was extremely important for their organisations to promote voting rights and only 2% said it was unimportant. 90% said that staff should support patients to register to vote and to cast their vote. The survey will hopefully be submitted for publication later this year.

Our 2012 paper was mentioned in the CQC report Monitoring the Mental Health Act in 2011/12 . 

CQC confirmed in 2020 that: ‘Voting registration – and enabling patients to exercise their voting rights – remains one of our areas of focus in monitoring the Mental Health Act and wider inspection.’

 

Together with CNWL Clinical Director for Rehabiliation Dr Shirish Bhaktal we facilitated research conducted by Benjamin Cubbs Coldron (University of Nottingham). The research was published in July 2020  in the Journal of Psychiatric Nursing: Supporting political rights for people in psychiatric rehabilitation: “Appropriate” political action in medicalized environments

Presentations at the World Congress of the RCPsych Rehabilitation & Social Psychiatry Faculty and the World Association of Social Psychiatry (WASP) - January 2023 London 

 

1.  Promoting Voting Rights for Mental Health Patients in a London Rehabilitation Unit - Tejal Patel 
URL: https://www.slideshare.net/MasumKhwaja/wasp-rcpsych-conference-17123-tejal-promoting-voting-rights-for-mental-health-patients-in-a-london-rehabilitation-unitpptx 

 

2. National Survey of Promotion of Voting Rights by Mental Health Trusts in England - Dr Saima Ali and Dr Alexis Theodorou 

URL: https://www.slideshare.net/MasumKhwaja/wasp-rcpsych-conference-saima-alexis-national-survey-of-promotion-of-voting-rights-by-mental-health-trusts-in-england-17123pptx 

 

3.  Promoting Voting Rights for Mental Health Patients - Masum Khwaja

URL: https://www.slideshare.net/MasumKhwaja/wasp-rcpsych-conference-masum-promoting-voting-rights-for-mental-health-patients-1712023pptx 

 

The Big Issue published a short opinion piece in March 2015. It isn't easily accessible online and so has been reproduced below.

The Big Issue- Vote for Good Mental Health

The right to vote is a fundamental human right and is enshrined in the European Convention on Human Rights. Diverse representation from all parts of the community is necessary if we are to build a fairer society. Yet those with mental health problems, despite having the right to vote, often don’t register or cast their vote. A significant number of mental health patients/service users remain unaware of their eligibility to vote, do not know how to register to vote, lack confidence to cast their vote or believe it is of no value to do so.

A survey of mentally ill in-patients in Westminster at the time of the 2010 general election revealed that in-patients who were eligible to vote were half as likely to register as the general election and half as likely to cast their vote once registered.

The Central and North West London Foundation Trust and the Royal College of psychiatrists are launching a campaign to promote the voting rights of people living with mental health problems. The message – that the opinion of a person with mental health illness is of equal value as that of others – challenges the stigma many people with mental health problems endure.

Voting gives mental health patients/service users a political voice and an opportunity to influence government policy. It is a powerful symbol of inclusion or exclusion from society. We should all support this campaign – it will create a healthier society for all of us.

 

 

We produced a film on voting rights; the film is available online and we have encouraged other organisations to use the film in their promotional work on voting rights.

Do you know your voting rights?

Promotion of citizenship as an intrinsic therapeutic focus and activity routinely undertaken by services supporting people with mental illness and intellectual impairment. This should include supporting patients to register to vote and to cast their vote if they wish to do so.

A national network of interested professionals and service users.

Further promotional work is required to establish a deeper understanding of the benefits of promoting voting rights amongst patients, carers and clinical staff - some whom still do not appreciate the relevance of the issue to their clinical work with patients.

Produce a continuing professional development module for the Royal College of Psychiatrists which will promote the knowledge of voting rights of those living with mental illness amongst psychiatrists.

Survey of carer’s knowledge of the voting rights of patients with the intention that this may offer insight into the feasibility of using carers to support patients to register and to vote.

If you would like further information or have any questions, please email Dr Masum Khwaja, Dr Alexis Theodorou or Dr Saima Ali. 

For information on how rehabilitation services in CNWL implemented voting rights in previous elections please contact Tejal Patel (Head OT rehabilitation services).

Saima and Alexis are not CNWL employees but, as Masum, are representatives of the RCPsych at the Accessibility to Elections government working group. Saima is a forensic ST and Alexis a Consultant Psychiatrist.

 

Dr Masum Khwaja: masum.khwaja@nhs.net

Dr Alexis Theodorou: alexis.theodorou@nhs.net

Dr Saima Ali: saima.ali10@nhs.net

Tejal Patel: tejal.patel@nhs.net