Sunday, 7 October 2007


The Mental Health Act 1983 is, obviously, the law. It's a "statutory instrument" that contains provision to detain people with mental health problems and unmet needs in hospital (even though they don't wish to be there). There's a Code of Practice that tells us how we're to use the MHA 1983.

A couple points are worthy of mention.


When I was a trainee doctor, we'd get shredded for talking of "sectioning" someone. We were instead to speak of "detaining someone under section blah" which at the time seemed pedantic thought control. One Royal College examiner said he'd failed a candidate for such talk. With hindsight it's sitting increasingly well with me, but p'raps I'm simply becoming more pedantic as time marches on. Being less glib and more professional is important, though.

Being detained

I've never detained anyone. Well, technically not. I've made medical recommendations. Approved Social Workers have made applications to hospital managers for a patient to be detained. Hospital Managers have agreed to detain the patient in their hospital.


It shouldn't be.

Nurses have to be the patient's advocate, the NMC says so. Curiously, the GMC doesn't have anything like that directing doctors but most of us do feel we have such a role. As such, when we're advocating that a patient has a right to get the help they need and deserve it's useful to be part of the decision making process rather than be painted wholly as the prison warden. We don't detain people, we make recommendations for their care then social workers and hospital managers detain them if that's necessary. As such we can continue to focus on their care. A seemingly tiny point, but such things shift the culture and philosophy of mental health units from paternalistic/abusive to collaborative/clinically driven.

Anyway, I'm a civilian. Should I be locking people up?

Least restrictive setting

We've got to manage patients in the least restrictive setting. Hospital in-patient care should be for folk who have needs that can only be addressed through hospital care and increasingly these are far and few between . . . what can be done in a hospital that teams can't do in the community? There are assessments and interventions, of course. But typically it's rare that there's specific work that a hospital admission does that couldn't be done in the community (which is self evident, given that 1/4 of the population will at some point in their lives experience mental illness, but so few reach Secondary Care services let alone in-patient admission).

Hands up who thinks detaining people is just about hospitals? A not uncommon scenario for me is of someone with dementia who's been diagnosed and treatment's been optomised but they can't manage in the community despite having lots of support. One elderly lady this Summer became more confused at night, thinking since it was light that 9.00pm was 9.00am. She was helped to bed at 8.00pm by home care and would then rise to wander around the street through the night - living on a busy main road made this particularly unsafe. She'd been active at night for many months, it got worse, what were we to do? She was adamant that she wanted to stay at home.

Section 7 of the MHA 1983 lets the local Social Services authority force someone to reside at a specific address (e.g. you now live at Care Home X). As this is then the law, if they leave police are obliged to return them to this property. They're also compelled to attend out-patient clinics, any medical reviews and even non-medical meetings such as job centre attendance, going to a specific place of work, or having to attend specific evening classes as well as having no choice where they live.

All this seems pretty heavy, doesn't it? What I find more perturbing is that the protection patients have within the MHA 1983 are pretty good. The Mental Capacity Act 2005 is far more widely reaching (e.g. allowing community treatment orders against the patient's wishes) but has none of the scrutiny, no need for 2 doctors/doctors with specialist training and experience, no rights of appeal to hospital managers and a Mental Health Review Tribunal and no review dates. Scary.


Calavera said...

My oh my, this brings back memories of studying Medical Law and Ethics in my second year. We had essays to write on these sorts of topics and questions about under what circumstances we could detain patients under the MHA, and all the time I just thought, "I can't ever imagine myself doing that, though."

Oh and by the way, I meant to comment on this on your last entry, but now I'm too lazy to open up a new comment window, but I just wanted to say that I think it's great that you're so 'pro-teaching' and that you make proper time to give your team some extra teaching. That really is awesome, and I've come to really appreciate that sort of attitude and approach in doctors after struggling through some attachments as a third year!

It's the type of attitude that I hope that I will have as a doctor, one day in the future! (Hopefully. Making the sweeping assumption that I actually eventually get there.)


~Miss Smack said...

Our mental health system over here is most probably like most countries. Underresourced, under trained and under-funded.

People are dying left, right and centre.

Such a shame.

The Shrink said...

Cal, the use of the MHA 1983 is simple enough . . . I do anything and everything I can before I entertain it :-) Happen that's why I have so very few detained patients compared to peers, but it does make me wonder if I'm overly harsh in not facilitating care that people could deserve at times despite their insistence to the contrary.

And teaching matters. Not seen a GP since I had an ear infection at medical school (and was delerious, seeing furniture move and all sorts). But some day my nearest and dearest or I may need a doctor, best get 'em as skilled as possible, eh?

Miss Smack . . . very grim.

Mental health services in the UK have patchy funding with some being under resourced but in fairness many are adequately resourced.

It seems to be how the resources are used (with politicians and the Deptartment of Health determining this, not clinicians) that's giving most patients a raw deal.

The big gap, generally, is psychological therapies since they work but are costly.

Ho hum.