Thursday 28 February 2008

Mental Health Act 2007

Parts of the new Mental Health Act 2007 are already with us but most of it comes in to force this October. It's a smaller bit of legislation than the original Act, so it will still be known as the Mental Health Act 1983 (MHA 1983) but this new bit of law ammends some key areas.

Some are widely known. No longer will doctors have to look after detained patients, the Responsible Medical Officer (RMO) role ceases to exist and instead we have Approved Clinicians (who could be nurses, psychologists, occupation therapists etc) who can then act as the Responsible Clinician instead of a psychiatrist. So when detained under section 3, it could be almost anyone looking after you and deciding when you are allowed out, with psychiatrists nowhere to be seen.
Interesting times, eh?

The implications of some changes are less well known. It was, oddly, a carers forum that developed this scenario at me. I then spoke with a lawyer :

A patient, Alex, becomes unwell after drinking alcohol and using cannabis and becomes psychotic. He stops work and is admitted under the MHA 1983 for 6 weeks, having a period of time being detained in hospital for treatment under section 3.
After 6 weeks in hospital he's back home again with his family.
2 weeks after this he's back at work.
Alex then drinks alcohol and use cannabis.
He become psychotic and is admitted, again.
His family are cross that he's psychotic again, why did we let this happen?
This pattern repeats itself over time.

Summary : A patient has serious psychotic episodes as a result of lifestyle choices they elect to make.

Implications : We've detained him under section 3 of the MHA 1983 and have a duty of care. Her Majesty's Government has given us an instrument to provide care for him, in the form of the MHA 1983. From October this year, this extends to Supervised Community Treatment (SCT) that has to be considered for all patients detained under section 3 (and other treatment sections). We have to consider this (as in, the law says so, and when we have to, e.g. when you have more than 7 days leave, so it can't be ignored).

If Alex uses alcohol and cannabis, he becomes psychotic. If Alex doesn't, he doesn't. When we look after him, we are attempting to get him well and keep him well (with advice, psychological therapy, medication, support, whatever). We have to, it's our duty of care for a detained patient (and continues to be our duty through section 117, SCT and under the Care Programme Approach). Some sections (7, 25) specifically require more.

How do we exercise our duty to look after Alex and avert psychosis (with the loss of income, distress to him and his family, time out in hospital and so on) when he's discharged from hospital?

We use a SCT that requires he abstains. We say he has to abstain, since to do otherwise is to cause a relapse. Just the way he could be told he has to take his tablets, family/carers were adamant that mental health services should be directing patients who become psychotic on drugs not to take drugs. Under a SCT what happens if they fail to take their tablets or fail to abstain from cannabis? They're recalled back to hospital by their Responsible Clinician, RC (who could be a CPN, ward nurse, psychologist, OT, whoever). After a couple days and an AMHP (from October what an approved social worker will be) a section 3 starts again (note, no medical recommendation has been made for this and they're there for up to 6 months, now).

The stick : abstain from alcohol and drugs, take your tablets, or you're locked up. Again.

The pressure from carers and family : how can the Responsible Clinician not do this? The RC has a duty of care to Alex. The RC knows if Alex uses alcohol/drugs he becomes psychotic so to support community placement Alex must avoid them. The government's given us a tool to effect this care plan and ensure Alex remains well. To not use a SCT, thus allowing him to become psychotic (which is a forseeable event we can reasonably predict) can be seen as a failure of the RC in their duty of care to Alex and as medical negligence. The family can complain that the RC was able to avert this psychotic episode through use of the SCT but didn't, thus a letter from Bastard, Bugger and Brown Solicitors is on it's way to the Trust to sue their asses for an episode of psychosis that was forseeable and could have been prevented if the RC had used an SCT appropriately.

Mental health services enforcing such things, and there are oh so many things that impact 'pon mental wellbeing that we could enforce . . .
. . . may we live in interesting times.


Shrink Wrapped said...

Interesting times indeed!

How do you feel about other clinicians taking on the RC role?

Anonymous said...

Stuff the RCs! I'm very interested to see how doctors embrace this new world freedom?! No longer the social police of our society and able to actually treat the individual in the context of doctor - patient .. not doctor - court - society - police - car park attendant...
What do the learned shrinks think they'll do with it?
I'll post later on how I'm shitting myself as a potential RC - then having some cocky psychiatrist argue with me why i'm holding back their patient from discharge when it's in his best interests to progress....
Must read more on the new Act first tho...

Unknown said...

How does the clinician whoever they are, in practice, actually stop one from taking alcohol/drugs?

Are they allowed to be in the community?
Also.. what about medical ethics.. I know the mental health act supersedes the patients' right to refuse treatment,does it now extend to the patients right to take harmful substances?

Anonymous said...

random drug screens
yes they can be in the community - just as long as they clear up their mess.
causes of MH issues have not readily been addressed in MHA law - but should - and only to the extent tha they are made aware of the consequences and every other offence they commit after they attain discharge goes to criminal court

Disillusioned said...

Actually, I'd settle for living in boring times quite happily.

(It IS a great curse, though, I have to admit!)

The two weeks on a trolley team said...

so their might not be a psychiatrist deciding when the patient leaves care??? Just puts things on a par with the current situation where there's often no psychiatrist to be seen when one wants a patient taken INTO care ;)

Dr. Thunder

The Shrink said...

Advice is that monitoring could indeed be a necessary part of care within an SCT. Thus, if a patient is thought to need detention under section 3 but could be fine at home if drug free, monitoring for drugs is then appropriate under the SCT and failure to participate in this would be seen in the same terms as failure to participate in clozapine monitoring etc so could result in the patient being recalled to hospital and the section 3 starting again.

Big Brother had nothing on this.

Anonymous said...

Haven't had chance to read up on the MHA changes as yet, but before the post passes into obscurity (by a new and equally engaging post, of course) ....
There are big similarities to this revamp and the MHA I currently work with down under and I'll highlight a few interesting points.
They have civil and criminal (forensic) treatment orders but either can be commuted from in-pt treatment to community. "Conditions" can be applied to either and any breach of these can result in "revocation of leave" - ie re-admission.
MHRT review both sort of detention every 6 months. Big difference is forensic patients have their upper levels of leave determined by MHRT with psychiatrist discretion only within the parameters they set (eg MHRT can set levels of staff escort such as 2:1 or time restrictions such as 'only 4 hours').
The odd thing about these is that the same conditions can be transfered from secure facility to open rehab unit and the MHRT have no control over which sort of facility the patient is placed in - so they coujld determine the patient of high risk; 2:1 escort only one hour - but we can still place them in an open rehab unit - which kind of obviates the MHRT purpose if clinical team can determine level of security.

Civil sections remain the psychs autonomous responsibility.
MHRT conditions of leave can stipulate anything also. There is no MHA Commission or independent reviewers which bothers me a lot tho appeal processes exist (but take several weeks to process). There is also no MHA Code of Practice either which I'm pushing for as the MHA is poorly applied throughout the region.
Frequently MHRT will include "refrain from illicit substances" and, oddly enough, they invariably carry the standard phrase "must not possess a firearm" which is kind of odd when they only have escorted ground leave - lucky the staff knew not to give the patient a firearm on the way to get a diet coke, I say.

In regards the other stuff of AMHP, we have them too. Emergency Orders or recommendation for admission, which can be made by anyone with AMHP approval - including Ambulance Drivers and Police, allows for the removal to the MH team based at the A&E dept. If admitted, this order gets immediately converted to civil section which remains the treating psych responsibility.

I don't have a huge problem with RC's as the realms of mental health often transcend far beyond 'medicine' and the psychiatrist really is a member of the team with whom equal responsibility could be shared. Example with us is that nurses determine the observation levels for our in-patients (on our unit - others yet to follow) and the medics support this as they regard our 'hands on' as more appropriate and the fact that nurses manage the unit - plus they seem comfortable with our clinical ability to make good judgments.

However, in regards MHA2007 provisions, I am concerned that other clinicians are not as disciplined as medical staff in making rational judgment at such a significant level and are liable to make many mistakes by taking things at face value or having the urge to be seen to be 'doing something' by making a decision without thinking it through enough. (Social workers have some exemption from this as they seem mroe geared to making independent decisions - nursing however focuses more on the need to make immediate decisions for immediate needs and does not train people up readily in strategic decision making). The other disciplines also do not seem to have the unity of medical staff in preserving their own - that's not saying medical staff 'cover each others arses' (tho some do) but moreso there seems less allegiance to the 'profession' as a whole and a more individual/personal stance is taken.
I like the theory of RCs but I am very worried about it's practical application. I fear some people will regard it as a 'power thing' (much as some Nurse Practitioners seem to have when "asserting" their independent authority to write scripts etc when the approving physician might question their decision) and some others may make rash or ill-considered judgments that don't consider the 'bigger picture'.
I'd like to see more generic training in 'decision making' to the same level as medical trained staff before RCs are encouraged to utilise their authority.

I would like to know what the pre-requisites are to be an RC are going to be. Have these been determined?

The Shrink said...

"I would like to know what the pre-requisites are to be an RC are going to be. Have these been determined?"


4 days training.

angel said...

Its like new Mental Health which was act on 2007 came in October. It will be known as the Mental Health Act 1983 (MHA 1983) but it a new law ammends some key areas.
The Responsible Medical Officer (RMO)Approved Clinicians.