MH Act (Mental Health)
Most patients who require inpatient care will agree to hospital admission and become 'informal' patients.
However, a minority of patients - about 5% - will require compulsory admission and detention.
The majority of such patients are detained under the Mental Health Act of 1983
and are often termed 'sectioned' -
in reference to the Section of the Mental Health Act under which they are detained.
All compulsorily detained patients
should be suffering from a mental disorder
which merits detention in hospital
in the interests of their own health or safety,
or the safety of others.
Notes:
The Mental Health Act 1983
has been amended by the Mental Health Act 2007
(but is still termed the Mental Health Act 1983)
the Mental Health Act 2007 has changed the definition of
Mental Disorders covered by the Mental Health Act
now defined as
"any disorder or disability of the mind"
simplified definition
now applies to all sections of the Act
potentially means some people previously excluded are now included
e.g. there may be some people with an acquired brain injury who were not covered by the term
"mental impairment or severe mental impairment"
who could now benefit from the protections of the Act
Four forms of mental disorder terminology have been removed from the act
(mental illness, mental impairment, severe mental impairment and psychopathic disorder)
There are two exemptions specifically referred to:
Learning Disability
a person with learning disability
may be only detained if that disability is associated with abnormally aggressive or seriously irresponsible conduct.
This does not, of course, preclude the use of compulsion for people who have another form of mental disorder
(such as a mental illness) in addition to their learning disability
applies to all those sections that relate to longer-term compulsory treatment
or care for a mental disorder
(in particular section 3, section 7 (Guardianship), section 17A (Supervised Community Treatment)
and forensic sections under Part 3 of the Act)
Dependence on alcohol or drugs
refers only to dependence and
does not exclude the effects of substances, such as intoxication, psychosis and delirium
Sexual issues
note that the previous exemptions for "promiscuity or other immoral act"
have not been included in the amendments made by the 2007 Mental Health Act
This means that persons diagnosed with paedophilia can be detained in hospital by virtue of that alone
The Act makes it clear that professionals, including doctors,
are expected to follow the guidance of the Code of Practice,
or explain why they haven't done so
The 2007 Act provides a new provision to allow Supervised Community Treatment.
This allows a patient detained on a treatment order to receive their treatment in the community rather than as an in-patient
allow a small number of patients who currently disengage from support once discharged from hospital to be cared for in the community,
subject to the possibility of being recalled to hospital if necessary.
This is to ensure they continue to get the treatment they need.
There is no lower age limit
Sectioning in general practice
To admit someone over 16
who will not agree to an informal (voluntary) admission
and who is a danger to themselves or to others,
the procedures of the 1983 Act must be used:
There are five sections of the Mental Health Act
that may affect GPs in the emergency situation:
Section four - Emergency admission - up to 3 days (72 hours)
Used to admit a patient when only one doctor can be found
This doctor may be the GP
The AMHP makes the application
and the doctor makes the recommendation
Detention is limited to 72 hours
To allow a full Mental Health Act assessment
Section two - Admission for assessment - up to 28 days
Allows admission and assessment of a patient for up to 28 days
Treatment can be given for mental disorder without consent
Application is made by THREE professionals
The Approved Mental Health Professional (AMHP) (Approved social worker or other)
Two doctors make written recommendations
- Doctor with approval of secretary of state section 12
- Doctor who knows the patient
The AMHP takes the lead role in a Mental Health Act Assessment
before the Mental Health Act 2007
- this role was taken by a social worker who had undergone specialist training - an Approved Social Worker (ASW)
- this role has now been extended to other clinicians
(e.g. community psychiatric nurses) who have undergone special training
The AMHP will act on behalf of the nearest relative
by coordinating the assessment
and making the formal application
One doctor (usually a psychiatrist)
should have approval from the Secretary of State under Section 12
The other doctor is a doctor who has previous knowledge of the patient
(usually the GP)
Section three - Admission for treatment - up to 6 months
for patients who are already known to the service
or who have already been assessed under Section 2
lasts for up to 6 months
can be renewed thereafter
Application is made by the same professionals as in a section two
Section 135 - Forced entry required
allows for a magistrate to authorise forced entry to a property
where it is believed that a person is suffering from a mental disorder
Once the GP has alerted the services to the situation
The AMHP will guide the process
Section 136 - Police safety
A police officer can detain, to a place of safety,
a person in a public place who they believe may be suffering from a mental disorder
This action allows a full Mental Health Act assessment to take place
to which the GP may be called
in most areas, the "place of Safety" is the police station
- however some Trusts have introduced dedicated Place of Safety sites within the hospital
Making arrangements for admission
1. Assess the patient and obtain the consent of the family
- if possible, avoid asking the family to be responsible for signing section papers
as they are likely to be the long-term carers and need the patient's trust
2. POLICE NEEDED?
Contact the police if there is a risk of violence or of the patient absconding
The police have a legal duty to ensure a sectioned patient gets to hospital and so warn them if they are likely to be needed
3. APMH
Contact the approved mental health worker / duty social worker
The APMH will coordinate the proceedings
- Contact hospital to arrange the bed and arrange the psychiatrist's attendance if at all possible
- if you are not from the patient's practice eg on call for a GP co-operative, an approved GP must also be called
- Arrange transport to hospital
Code of practice (Mental Health Act 1983)
The Act makes it clear that professionals, including doctors,
are expected to follow the guidance of the Code of Practice,
or explain why they haven't done so.
The Guiding Principles:
Purpose
Decisions under the Act must be taken
with a view to
minimising the undesirable effects of mental disorder,
by maximising the safety and well-being (mental and physical) of patients,
promoting their recovery
and protecting other people from harm
Respect
People taking decisions under the Act must recognise and respect
the diverse needs, values and circumstances of each patient,
including their race, religion, culture, gender, age, sexual orientation and any disability
Must consider the patient's views, wishes and feelings (whether expressed at the time or in advance),
so far as they are reasonably ascertainable,
and follow those wishes wherever practicable
and consistent with the purpose of the decision
Must be no unlawful discrimination
Participation
Patients must be given the opportunity to be involved,
as far as is practicable in the circumstances,
in planning, developing and reviewing their own treatment and care
to help ensure that it is delivered in a way
that is as appropriate and effective for them as possible
Involvement of carers, family members and other people who have an interest in the patient's welfare
should be encouraged (unless there are particular reasons to the contrary)
and their views taken seriously
Effectiveness, Efficiency and Equity
People taking decisions under the Act
must seek to use the resources available to them and to patients
in the most effective, efficient and equitable way,
to meet the needs of patients
and achieve the purpose for which the decision was taken
Least restriction
People taking action without a patient's consent must attempt to keep to a minimum
the restrictions they impose on the patient's liberty, having regard to the purpose for which the restrictions are imposed
Nearest relative (section 26 of Mental Health Act)
The nearest relative according to Section 26 of the Act
is the first surviving person in the following list:
1) husband or wife (or co-habitee for more than 6 months)
2) son or daughter (if aged over 18 years)
3) Father or mother
4) brother or sister (aged over 18 years)
5) grandparent
6) grandchild (aged over 18 years)
7) uncle or aunt (aged over 18 years)
8) nephew or niece (Aged over 18 years)
9) non-relative living with the patient for 5 or more years
The Mental Health Act 2007
has given greater power to patients
if they believe that the person identified under the Act as their nearest relative
is not acting in their best interests
they can now apply to a county court to displace the relative
Section 1 (Mental Health Act)
Section 1 of the Mental Health Act defines mental disorder.
A patient must be suffering from a mental disorder, as defined by the Act,
if they are to be compulsorily detained using the Act.
Section 2 (Mental Health Act)
Section 2 of the Mental Health Act allows compulsory admission for assessment,
or for assessment followed by medical treatment, for a duration of up to 28 days.
An application under Section 2 can be made by a relative or an Approved Mental Health Professional (AMHP)
and must be supported by two medical recommendations
one of which must be from an approved doctor under Section 12 of the Act
ie. having special experience in the diagnosis or treatment of mental disorder
(generally a consultant or senior registrar psychiatrist)
The medical recommendations must agree that the detention
is in the interests of the patient's own safety,
or the safety of others,
or the patient is suffering from mental disorder of a nature or degree
which warrants detention
for assessment,
or assessment followed by treatment,
at least for a limited period.
Appeal to the Mental Health Review Tribunal is allowed within 14 days of admission
The Mental Health Act 2007 has earlier automatic referral to a Mental Health Review Tribunal (Tribunal)
where patients don't apply themselves and new Tribunal system structure
Each medical recommendation shall include a statement that the grounds of the application are complied with
and must be signed on or before the date of the application.
One medical recommendation may be given by a doctor on the staff of the hospital admitting the patient;
this does not extend to nursing homes.
It is often most appropriate for this to be the consultant
who will subsequently treat the patient.
Section 3 (Mental Health Act)
Section 3 is similar to section 2,
only the detention is for treatment and may be for a duration of up to 6 months, although this can be extended.
Grounds:
Patient suffers from a mental disorder (See Above)
AND
it is necessary for the health or safety of the patient
or for the protection of other persons,
AND
such treatment cannot be provided unless they are detained under this Section.
Duration is for 6 months, including the day of admission.
Renewal is from the end of the 6 months
for periods of 6 months
and then for periods of one year
In addition to the Responsible Clinician,
the written agreement of a second professional is needed to renew section 3.
The second professional must
come from a different professional discipline compared with the RC
be involved with the care of the patient
be able to reach independent decisions
have sufficient expertise and experience to make a judgement about whether the criteria for detention continue to be met
Even if the RC disagrees with the view of the 2nd Professional, they should not normally seek to find another professional.
In such circumstances the section 3 would not be renewed
In very exceptional circumstances where a different opinion is sought
this must be brought to the attention of the hospital managers
who are also required to consider and approve the renewal of the section
The patient has the right to appeal to the Mental Health Review Tribunal
within the first 6 months
and then once a year
The Mental Health Act 2007 has stipulated an earlier automatic referral to a Mental Health Review Tribunal
where patients dont apply themselves and new Tribunal system structure
Section 4 (Mental Health Act)
Section 4 allows emergency detainment
for the purpose of assessment for a duration of up to 72 hours.
The application can be made by the nearest relative or an Approved Mental Health Professional (AMHP)
and must be supported by one doctor.
The doctor must have examined the patient within the previous 24 hours.
The recommendation should indicate the urgent nature of the application
such that detention under section 2 would involve unacceptable delay.
A second medical recommendation from an approved doctor, under section 12 of the Act,
received within 72 hours will allow further detention under section 2.
Duration is for not more than 72 hours.
Renewal is not possible.
But by means of a second medical recommendation,
which must be signed and received by the hospital managers within three days of the admission,
Section 4 can be converted into Section 2.
Section 5 (Mental Health Act)
This section is concerned with emergency holding powers, which may be applied to in-patients.
Section 5(2) is concerned with doctors,
whilst section 5(4) gives certain powers to Registered Mental Nurses.
Section 5(2) allows the compulsory detention
of a patient already receiving inpatient treatment
for a duration of up to 72 hours by the doctor in charge of the case.
As for Section 2, the patient must be suffering from a mental disorder and be a potential danger to himself or to others. The detention is to allow time for an application for admission under Section 2 or 3 to be made.
Section 5(4) allows detention of a patient by nursing staff - a Registered Mental Nurse
- for a duration of up to 6 hours while the doctor is found.
The nurse must record the time of detention on a specific form
and also indicate that the patient is a potential danger to himself or to others
and that a doctor was not immediately available to implement Section 5(2).
Consent to treatment(Mental Health Act)
The Mental Health Act deals with the provision of treatment to patients who may be
incapable of giving informed consent or who may refuse to do so.
These provisions do not apply to those
- detained under Section 4,
- under short-term powers
- or when remanded for report.
A distinction is made between consent for medication or ECT,
and consent for surgical operations or proceedures with more lasting effects.
Section 7 (Mental Health Act)
Section 7 is a treatment order, as is Section 3,
but is used when reception into guardianship is more appropriate,
often the local Social Services Department.
The guardian's powers are specified under Section 8.
Section 8 (Mental Health Act)
Section 8 defines the authority of the guardian,
as empowered under Section 7 of the Act.
These are:
being able to require the patient to live at a specified place
being able to require the patient to attend places for treatment, occupation, training or education
being able to ensure that any specified person,
usually a doctor or social worker, can see the patient at home
