Transcript Document

Mental Health Act 1983
Dr Nicola Guy, Head of Mental Health
Act Code Review
https://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983
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Purpose Of the Presentation
• Background
• Why we have revised the Code of Practice
• What did people say
• Key changes
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Review of the Mental Health Act 1983 Code of Practice
Background
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Review of the Mental Health Act 1983 Code of Practice
Background and context
• New Code comes into effect in England from 1 April 2015. It does not
alter existing legislation.
• The Code of Practice was last published in 2008. Needed to ensure that
the Code is up to date and relevant in today’s current health and care
system, ensuring appropriate advice is given on the Act and that
appropriate safeguards are in place for patients.
• Health Select Committee report on the post-legislative scrutiny of the
2007 Mental Health Act.
• Commitments in Transforming Care: a national response to
Winterbourne View Hospital (2012) and Closing the Gap: priorities for
essential change in mental health (2014)
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Review of the Mental Health Act 1983 Code of Practice
What we wanted to achieve
• Patients, their families and carers are:
- clear about their rights and involved in decisions about care and
treatment;
- treated with dignity and respect;
- can expect the best care and appropriate support; and
- know how to challenge if they don’t receive it
• Professionals are supported to improve their practice
• Improvements to care, treatment and outcomes and helping to achieve
‘parity’ with physical healthcare
• To reflect changes in legislation, case law, policy and professional
practice
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Review of the Mental Health Act 1983 Code of Practice
View from a Service
User – Jan Rogers
https://www.youtube.com/embed/cpsV
J1mhkyE
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Review of the Mental Health Act 1983 Code of Practice
Key challenges
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Review of the Mental Health Act 1983 Code of Practice
Key challenges in the review
• Improving care, treatment and outcomes
• How can professionals be supported to improve the way
they provide care and support
• Making the system work as effectively and efficiently as
possible
• How best to ensure patients, their families and carers:
- are clear about their rights and involved in decisions
about care and treatment
- are treated with dignity and respect
- can expect the best care and appropriate support; and
- know how to challenge if they don’t receive it
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Engagement
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Engagement activity
• Engagement with patients, their families & carers and
professionals seeking views on changes
• 10 week public consultation on the proposed changes,
including events on inpatient wards and community
settings
• Established a Steering Group and Expert Reference
Group
• Specific engagements e.g. Yorkshire and London
AMHPs conference, Royal College of Psychiatrists and
College of Social Work event
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Review of the Mental Health Act 1983 Code of Practice
Engagement activity
• We received over 344 responses to the consultation,
– 142 responses from organisations or groups
– 162 from individuals predominantly from patients,
former patients, NHS managers and health
professionals.
– Of the 162 responses from individuals, 141 provided
information about their gender. Of these, 49% were
men and 51% were women
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Review of the Mental Health Act 1983 Code of Practice
What did people say?
• Need for clarity on what roles and responsibilities are,
what good looks like and what you can do if things go
wrong
• There was broad agreement that the proposed guiding
principles of the Code provided a sound framework, but
some queries about status and specific wording
• Guidance about children, young people and other
vulnerable groups was clearer than previously
• Need for stronger guidance in relationship to review
and discharge and to support individuals with a learning
disability
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Review of the Mental Health Act 1983 Code of Practice
What did people say?
• Emphasise the roles of family members, carers and
advocates in processes and decisions
• Place more emphasis on the need for staff awareness
and training
• Place more emphasis on the duty of commissioners
and providers to ensure an appropriate number of beds
and resources in order to implement the Code, and on
the role of organisations such as CQC, scrutiny
committees and Health and Wellbeing Boards in
monitoring
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The Revised Code
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Review of the Mental Health Act 1983 Code of Practice
Aims
• To provide stronger protection for patients and clarify roles,
rights and responsibilities. This includes:
• Involving the patient and where appropriate, their families
and carers in discussions about the patient’s care at every
stage
• Providing personalised care
• Minimizing the use of inappropriate blanket restrictions,
restrictive interventions and the use of police cells as places
of safety.
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Review of the Mental Health Act 1983 Code of Practice
The main changes include:
• 5 new guiding principles
• New chapters on care planning, human rights, equality
and health inequalities
• Consideration of when to use the Mental Health Act
and when to use the Mental Capacity Act 2005 and
Deprivation of Liberty Safeguards
• New section on if things go wrong - provides
information on resources when there is poor quality of
care or when safeguards of the Act are not applied
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Continued:
• New sections on physical health care, blanket
restrictions, duties to support patients with dementia
and immigration detainees
• Significantly updated chapters on the appropriate use
of restrictive interventions, particularly seclusion and
long-term segregation, police powers and places of
safety
• Further guidance on how to support children and young
people, and those with a learning disability or autism
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Changes to the Code
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Global Changes to the Code
• Easier to read and navigate
• Plainer English
• Restructuring that the Code so that it follows an individual’s
journey of care
• More cross -references
• We updated the Reference Guide and made materials
available in alternative formats e.g. easy read
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Executive Summary and Introduction
• New section introduced to summarise what is in each chapter
• Each cluster of chapters has a mini introduction to set in context
and guide the reader
• Refreshed and /or introduced new annexes, cross references and
index
• Clarified who Code applies to
• Clarified use of terms ‘must’, ‘should’ and ‘may/could/can’
• Information in relation to complaints, safeguarding and
whistleblowing
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Chapter 1 - Guiding Principles
5 new Guiding Principles:
1.
2.
3.
4.
5.
Least restrictive option and Maximising Independence
Empowerment and Involvement
Respect and Dignity
Purpose and Effectiveness
Efficiency and Equity
• These principles focus on an individual patient’s recovery, better
reflect the health and care system, and clarify the roles of all
professionals in ensuring high quality and safe care for individuals
subject to the Act.
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Chapter 2 - Mental disorder definition
• Additional guidance for professionals conducting mental
health assessments of those with learning disabilities and/or
autistic spectrum disorders
We ask them to:
• Record their reasons for concluding the individual’s conduct
is abnormally aggressive or seriously irresponsible
• Why it relates to the person’s learning disability and is not
attributable to other factors such as an unmet physical
health, social or emotional need.
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Human rights, equality and
health inequalities
• New chapter (3) and guidance throughout the Code
• Supports the new, overarching principles and equality and
human rights issues throughout the Code.
• CCGs and providers should have Human Rights and
Equality Policy
• New guidance on promoting good physical healthcare (see
also chapter 24) and reducing health inequalities
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View from a Carer –
Jeremy Coke-Smyth
https://www.youtube.com/embed/IFe0Aa4U
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Chapter 4- Information for patients, nearest
relatives, carers and others
• Throughout the Code we have strengthened the
empowerment and involvement principle, to reflect feedback
and policy in the Care Act 2014 on carers
We have included guidance:
• that patients are informed they may seek legal advice on
their detention and CTO, and that they should be provided
with assistance if required.
• additional guidance on early discussion with patients about
what information they are happy to share and what they
would like kept private, and how to complain.
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Review of the Mental Health Act 1983 Code of Practice
Chapter 5 - The nearest relative
• Throughout the Code, we make it clearer that families,
carers and ‘nearest relatives’ should be involved in decisions
about care and treatment.
• We have strengthened the Code to reflect that professionals
should involve the main carer if they are not the patient’s
nearest relative.
• Clarified the particular decision in relation to which a person
may lack capacity, i.e. the decision to make an application to
displace their nearest relative
• Guidance on what to do if there is no nearest relative
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Chapter 6 - Independent Mental Health
Advocates
• New guidance reminding local authorities of their statutory
duty to commission IMHA services, including having due
regard to diversity and equality issues as required by
regulations under the Act and under the Equality Act 2010.
• New guidance on ensuring IMHAs have appropriate
knowledge/skills to support with additional requirements
(e.g. learning disability, sensory impairment, or do not speak
English)
• New guidance making opt out for qualifying patients lacking
capacity
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Chapter 7 - Attorneys and deputies
• No significant changes.
• Gives guidance on the effect of the Act on the powers of
donees of lasting power of attorney (attorneys) and court
appointed deputies under the Mental Capacity Act 2005
(MCA).
• Attorney and deputies can take decisions in relation to the
welfare, property or affairs of a person subject to the Act that
they are otherwise authorised to take, with two exceptions
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Chapter 8 - Privacy, safety and dignity
New guidance on:
• blanket restrictions, including locked door policies
Further guidance on:
• patient access to and use of internet
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Chapter 9 - Wishes expressed in advance
• No significant changes but more reference to this chapter in
other chapters
• Wishes expressed in advance will be promoted via the
accessibility and awareness project as a key way of
involving patients in discussions about care and treatment
when they are well
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Chapter 10 - Confidentiality and information
sharing
• New guidance about consulting with organisation’s Caldicott
Guardian
• It is good practice for independent sector providers to have a
Caldicott Guardian
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Chapter 11 - Visiting patients in hospital
• The revised Code emphasises the need for privacy for visits
and phone calls
• Further guidance to support and enable families, carers and
friends to visit
• Additional guidance advising professionals to consider
implications for families and carers of placing patients long
distances from home
• Chapter balances requirements of helping people visit
patients with findings of Saville Review and need to protect
patients
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Chapter 12 - The Tribunal
• No significant changes.
• Guidance on the role of the Tribunal and related duties on
hospital managers and others.
• Hospital managers and the local authority have a duty to
ensure that patients understand their rights to apply for a
Tribunal hearing.
• Hospital managers have various duties to refer patients to
the Tribunal.
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Chapter 13 - Mental capacity and
deprivation of liberty
• New chapter to explain interface between MHA and Mental
Capacity Act 2005 (MCA) at point of admission
• Guidance on use of when the Mental Health Act and the
MCA can be used, including when they may be used
concurrently
• Who is ineligible for a deprivation of liberty authorisation
under the MCA
• Case studies and flowcharts to aid decision-making
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Chapter 14 - Applications for detention in
hospital
• Additional guidance has been added, in particular
a) commissioning services under the Act, and reference
to the s140 duty on CCGs to notify local authorities of
arrangements for urgent admissions and admissions of
children and young people
b) where to locate a patient
c) Support for immigration detainees and people with
dementia
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Chapter 15 - Emergency applications for
detention
• New guidance that, if an AMHP makes an application for
detention, the nearest relative should be informed at the
same time, or within a reasonable time afterwards, unless
the patient requests otherwise
• We have included factors which should be considered in
deciding whether to inform the nearest relative against the
patient’s wishes.
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Chapter 16 - Police powers and places
of safety
• Findings of the review of the s135 and s136 legislation.
• Numerous clarifications for police officers including the relevance
of PACE Code of Practice C
• Clarification of the roles of the AMHP and doctor who accompanies
a police constable executing a warrant issued under s135 (1).
• Clarifications for the arrangements AMHPs should have in place
when patients are detained far from home
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Chapter 16 continued
• Provides a greater focus on identifying a place of safety before
executing a warrant; ensuring an AMHP contributes to the
assessment, and reducing the use of police stations as a place of
safety
• Detention in a police station under section 136 should not exceed
a maximum period of 24 hours.
• Police stations should not to be used for u18s, 136 suites attached
to an adult ward: may be used for an under 18
• Local policies on use of police powers and places of safety
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Chapter 17 - Transport of patients
• New footnote referring to the national protocol under the Crisis
Care Concordat, ambulance trusts in England agreed that where
people are detained under section 136, they would aim to respond
within 30 minutes.
• Give good practice guidance that patients should be informed as
soon as possible of the reasons for any planned transfers, and
supported to discuss a planned transfer with family, friends or
carers
• Provide that commissioners should consider what assistance can
be given as part of the care package to support family or friends to
visit patients in out of area placements, particularly for patients
under 18
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Chapter 18 - Holding powers
• There are no significant changes to this chapter
• Paragraph 18.2 to add that decision makers should always
consider whether a less restrictive alternative to detention is
available. This aligns with the least restrictive option and
maximising independence guiding principle.
• In the Transfer to other hospitals section, we have clarified the
wording regarding a patient’s capacity (or lack of capacity) to
consent to a transfer to another hospital.
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Chapter 19 - Children and young people
under the age of 18
• We have changed the term ‘zone of parental control’ to ‘scope
of parental responsibility’.
• Interface with the Children Acts, MCA and DoLS (for young
people), and assessing competence and capacity.
• Police cells should not be used as a place of safety for under
18s unless there are exceptional circumstances which make
this course of action absolutely necessary and this should be
reflected clearly in the local policy for section 136
• Updated guidance on consent of a person with parental
responsibility as it relates to deprivation of liberty.
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Chapter 20 - People with learning
disabilities or autistic spectrum conditions
• This chapter has been updated to reflect current terminology
and practice, and address some major concerns raised by
practices at Winterbourne View.
• Strengthening the code to recognise that ‘hospitals are not
homes’ that the least restrictive way of achieving the
proposed assessment or treatment must be identified
• New requirements that professionals record on the relevant
forms their reasons for coming to the conclusion that the
individual’s conduct is abnormally aggressive or seriously
irresponsible
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Chapter 20 continued:
• Placing greater emphasis on the helpful role that can be
played by families and friends
• Clarifying which parts of the chapter referred to learning
disability only, to autism only, and to both learning disability
and autism.
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Chapter 21 - People with personality
disorders
• We have not made any significant changes
• This chapter has been updated to reflect the development of
services which can provide appropriate treatment for these
disorders.
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Chapter 22 - Patients concerned with
criminal proceedings
• Additional guidance in relation to transporting part 3 patients, including
to and from court and urgent hospital transfers, and in relation to
sections 47/49 and 48/49, including supporting immigration detainees .
• Further guidance on conditional discharge of restricted part 3 patients,
including those convicted of very serious crimes.
• New section on multi-agency protection arrangements (MAPPA) to
clarify the role of health services in assessing and managing the risk of
MAPPA eligible part 3 patients.
• References to restricted patients grouped together and crossreferencing improved
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Review of the Mental Health Act 1983 Code of Practice
Chapter 23 - The appropriate medical
treatment test
• In response to comments from the CQC, we have further
clarified guidance on appropriate medical treatment and
availability
• This chapter provides guidance on the application of the
appropriate medical treatment test and the criteria for
detention or a community treatment order (CTO) under the
Act.
• It includes guidance on appropriate treatment for people with
dementia.
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Chapter 24 - Medical treatment
• Amended to refer to part 4A consent certificates (Form CTO
12), introduced by regulations since the Code was
published.
• Further guidance about initial three month period during
which medication for mental disorder can be given without
consent/certification.
• New Guidance on promoting good physical healthcare, diet,
nutrition and physical activity and reducing impact of comorbidities
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Chapter 25 - Treatments subject to special
rules and procedures
• Amended to refer to part 4A consent certificates (Form CTO
12) in response to comments from the CQC and Law
Society and to reflect changes in regulations.
• Further guidance about statutory consultees (the people
whom a SOAD must consult before issuing certificates
approving treatment).
• Clarification of the circumstances in which a certificate
authorising treatment issued by an approved clinician under
section 58 or section 58A will cease to authorise treatment
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View from Maggie
Atkinson – Service User
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Chapter 26 - Safe and therapeutic responses
to disturbed behaviour
• This chapter reinforces and complements the new DH
guidance Positive and Proactive Care: reducing the need for
restrictive interventions (published April 2014).
• It provides additional information on the use of restrictive
interventions for patients receiving treatment for a mental
disorder in a hospital and who are liable to present with
behavioural disturbances, regardless of their age and
whether or not they are detained under the Act
• Additional guidance on the appropriate environment for long
term segregation, and guidance on when the procedure for
seclusion should commence within long term seclusion.
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Chapter 26 continued
• Additional paragraphs introduced on security measures in
response to stakeholder comments regarding security needs and
security measures.
• Amendments have been made to ensure the greater involvement
of IMHAs in developing positive behaviour support plans including
consultation prior to the planned use of mechanical restraint,
involvement in seclusion and long term segregation reviews.
• Further clarity is given on the nature of restrictive intervention
reduction programmes. It is complemented by the fuller guidance
in Positive and Proactive Care.
• Revisions of terminology and phraseology to improve clarity.
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Review of the Mental Health Act 1983 Code of Practice
Chapter 27 - Leave of absence
• Clarification that s17 leave should normally be of short duration
• Further guidance on leave for Part 3 restricted patients,
escorted leave to Northern Ireland and the inclusion of a
photograph in a patient’s notes to help identify the patient if
necessary.
• Guidance on differences when considering leave of absence for
restricted patients have been developed and agreed with MoJ.
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Review of the Mental Health Act 1983 Code of Practice
Chapter 28 - Absence without leave
• No significant changes
• Provides guidance on action to be taken when patients are
absent without leave (AWOL) or have otherwise absconded
from legal custody under the Act, including on when patients
are to be considered to be AWOL.
• Hospital managers should have policies in place outlining
actions necessary in this eventuality and guidance is
provided about the matters that should be covered by such
policies.
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Chapter 29 - Community Treatment
Orders
• Clarification inserted to underline that the conditions of a
CTO must not deprive the patient of their liberty.
• Reiterates point made in chapter 4 that written reasons for
revocation of CTO should be given to patient and (where
appropriate) their nearest relative
• Hospital managers should notify the patient and (where
appropriate) their nearest relative when they have referred
the patient’s case to the Tribunal
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Chapter 30 – Guardianship
• No significant changes
• This chapter provides guidance on:
-
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purpose of guardianship,
assessing a patient for guardianship,
responsibilities of local authorities, and
components of effective guardianship.
Review of the Mental Health Act 1983 Code of Practice
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Chapter 31 - Guardianship, leave of
absence or CTO
• No significant changes
• Reflect accurate terminology - ‘DoL order’ changed to ‘Court
of Protection order’.
• Clarified guidance on whether a CTO or leave of absence
should be used, including to make decisions more
accountable and transparent and to discourage
inappropriate use of long-term section 17 leave
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Chapter 32 - Detention and CTO, renewal,
extension and discharge
• Clarifies that the responsible clinician (RC) must make the
decision on renewal on the basis of clinical factors only.
• Make it clearer that reviews must take place and ‘de facto’
detention not occur
• New guidance on documenting decisions and sharing with
patients and as appropriate carers and nearest relative
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Chapter 32 continued
New guidance:
• Responsible clinicians should ensure that before renewing
the patient’s detention the second professional is given
enough notice to be able to interview or examine the patient
if appropriate.
• Wider multidisciplinary team should be included when
making decisions about discharge, extending the period of a
CTO or extending s17 leave.
• Hospital managers should ensure that they have systems in
place or notices and discharge orders served on the hospital
to be considered without delay by hospital managers or their
authorised officers
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Chapter 33 - After-care
• This new chapter updates the Code to reflect the changes in
the Care Act 2014 and stakeholder views about better care
planning and after-care. It brings together information about
care planning previously in separate chapters.
• References to Care Act guidance included.
• New guidance that after-care services may be reinstated if it
becomes obvious that they have been withdrawn
prematurely, e.g., where a patient’s mental condition begins
to deteriorate immediately after services are withdrawn.
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Chapter 33 - continued
• New definition of mental health after-care
• Choice of accommodation and top-up payments
• After-care remains free of charge
• People wanted much more detailed info about how MHA
aftercare under S117 of MHA and S75 Care Act work
together
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Chapter 33 - continued
This includes:
• Under the Care Act every mental health patient and carer has a
right to a needs assessment and a care and support or
support plan (though qualifying patients may then get services
under section 117)
• There is nothing in the Care Act that excludes mentally ill people
from any of its provisions which is good news for those who have
not been detained under a section that qualifies them for section
117
• No one has to accept section 117 services, a few people who
qualify see them as discriminatory and may prefer to opt for
services provided under the Care Act)
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Chapter 34 - Care Programme Approach
• This new chapter updates the Code to reflect the changes in the
Care Act 2014 and stakeholder views about better care planning
and after-care
• Additional guidance that professionals with specialist expertise
should be involved in planning for people with autistic spectrum
disorder or learning disabilities.
• CPA chapter highlights importance of multi-agency care planning
and delivery in keeping patients out of hospital
• The Welsh Government expects to revise the Welsh Mental Health
Act Code of Practice in 2015.
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Chapter 35 - Receipt and scrutiny of
documents
• No significant changes
• New guidance that the patient should be informed of their
discharge by hospital managers under section 23 both orally
and in writing, and in an accessible format for the patient
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Chapter 36 - Allocating or changing a
responsible clinician
• No significant changes
• New point that, if the patient requests a change in RC, their
reasons should be established to inform an appropriate
response
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Chapter 37 Functions of Hospital
Managers
• Revised guidance advising on communication of information
relating to part 3 patients who have committed sexual or
violent crimes.
• New guidance that hospital mangers should obtain a copy of
the AMHP report.
• Further information about giving patients notice of decisions
to withhold their post and their right to ask the CQC to
review such decisions.
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Chapter 38 - Hospital Managers’ power of
discharge
• Changes seek to increase transparency, accountability and
scrutiny and, as appropriate, involvement of carers
• Further guidance about involving the patient in the hospital
managers’ hearing, sharing the formal record of the decision and
reasons with the patient, and offering patients an opportunity to
discuss the hearing.
• Additional guidance on supporting individuals with communication
difficulties or limited capacity and the skills/experience of hospital
managers’ panel members
• Further guidance on process for contested or uncontested cases
• Guidance on what to do if ‘de facto’ detention occurs
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Review of the Mental Health Act 1983 Code of Practice
Chapter 39 - Conflicts of interest
• New guidance that it is good practice for recommendations
to be from doctors from a different organisation/ trust site
• New guidance stating that providers in close proximity may
create and maintain shared list of second recommendation
doctors.
• By working together providers should ensure that
safeguards at admission are enhanced and also that there is
no untimely delay or impact on the patient.
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Review of the Mental Health Act 1983 Code of Practice
Chapter 40 - Support for Victims
• Clarification of the operation of the Victim Contact Scheme,
especially in relation to non-statutory victims
• Clarification on support for victims of unrestricted patients
• Additional guidance to support victims who are also family,
carers or friends
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Code of Practice 2015 is available at:
https://www.gov.uk/government/publications/code-of-practice-mentalhealth-act-1983
Hard copies available to order from the Government Stationary Office:
http://www.tsoshop.co.uk/bookstore.asp?FO=1160007&DI=642031
Reference Guide is available at:
www.gov.uk/government/publications/reference-guide-to-the-mentalhealth-act-1983
Supporting documentation, is available at:
https://www.gov.uk/government/consultations/changes-to-mentalhealth-act-1983-code-of-practice
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No voice unheard, no right ignored
Please also see the link below for the consultation No voice unheard,
no right ignored
The document seeks to explores views on a number of issues related
to supporting people with learning disability, autism and mental health
conditions.
This includes some relating to the Mental Health Act which were
raised during the recent consultation on the revised Mental Health Act
Code of Practice. The consultation started on 6 March and ends on
the 29 May 2015:
https://www.gov.uk/government/consultations/strengtheningrights-for-people-with-learning-disabilities
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Review of the Mental Health Act 1983 Code of Practice