Transcript Implementation of the Mental Health Act 2007

Implementation of the
Mental Health Act 2007
Hospital Managers
Session 1
Goals and Objectives
Domestics
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Emergency procedures
Expected finish times
Refreshment breaks
Lunch arrangements
Venue facilities.
Role of Facilitator
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Guide you through the course
Maximise your participation
Challenge / support / advise
Provide information
Collate feedback / outcomes.
Ground Rules
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Commitment
Courtesy
Honesty
Responsibility
Time keeping.
Objectives (1)
This workshop will enable you to:
• Define the processes and good practice that
should be adopted when considering whether
to exercise the power of discharge
• Explain the new simplified single definition of
mental disorder and the revised criteria for
detention for treatment
• Explain the provisions of supervised
community treatment and the hospital
manager's role in considering a patient’s
discharge from supervised community
treatment
Objectives (2)
• Explain the role of the independent mental
health advocate, and how this might impact of
the running on hearings
• Explain the changes in professional roles and
the impact for evidence-giving in these roles
• Explain the impact of the new duties in relation
to Domestic Violence, Crime and Victims Act
2004 for evidence-giving and hearings.
Timetable
Start 9.15
• Goals and objectives
• Mental Health Act 2007
• Discharge of patients
 Coffee 10.50
• Supervised community treatment (SCT)
• Professional roles
• Referrals to the MRHT for Wales
• Provisions for young people
• Independent mental health advocacy
• Domestic Violence, Crime and Victims Act 2004
• Review and evaluation
Close 13.00
Session 2
Mental Health Act 2007
Why was this review necessary?
• To help ensure that people with serious mental
disorders receive treatment necessary to protect
them and the public from harm
• To simplify and modernise the definition of
mental disorder and the criteria for detention
• To bring mental health legislation into line with
modern service provisions
• To strengthen patient safeguards and tackle
human rights incompatibilities.
The Mental Health Act 1983
• Reception, care and treatment of mentally
disordered people
• The circumstances for detention for treatment
without consent
• Sets out the processes and the safeguards for
patients
• Main purpose is to ensure that people with
serious mental disorders can be treated
irrespective of their consent where it is
necessary to prevent them from harming
themselves or others.
The Mental Heath Act 2007
Introduced amendments to several earlier
Acts:
– The Mental Health Act 1983
– The Mental Capacity Act 2005
– The Domestic Violence, Crime and
Victims Act 2004.
Activity – Changes to the Mental
Health Act 1983
In pairs using the information in your
participant pack:
– identify the significant changes to the
1983 Act, and
– the impact these changes will have on
your role.
Mental Health Act 1983 Code of
Practice for Wales
• Is designed to guide practitioners in
discharging their powers and duties under
the Mental Health Act
• Chapter 27 deals with the hospital
manager’s power of discharge under
section 23 of the 1983 Act.
Guiding principles
Guiding principles grouped under three
broad headings:
•The empowerment principles
•The equity principles
•The effectiveness and efficiency principles
Activity
In small groups discuss …
What you would need to consider to
ensure these principles are applied in
practice.
Session 3
Discharge of Patients
Discharge of patients
Under the 1983 Act the hospital managers
are part of the group (along with RC, the
nearest relative and the MHRT for Wales)
with the power of discharge.
The amendments brought in by the 2007
Act:
• do not change the exercise of this power
• extends the power to cover a new group of
patients.
Discharge of patients
The Act:
• Covers the discharge of community
patients – those who have been
discharged onto SCT under a community
treatment order.
Discharge of patients
Review Panels
• Must have three or more members
• The Act does not define either the criteria
or the procedure for reviewing a patient's
detention
• Hospital managers should consider
whether the criteria for admission or
continued detention under the Act are
satisfied.
Criteria for detention
• The person must be suffering from a mental
disorder of a nature or degree which makes it
appropriate for them to receive medical
treatment in hospital, and
• It is necessary for their own health or safety or
for the protection of other persons that he or she
should receive such treatment and it cannot be
provided unless the person is detained, and
• Appropriate medical treatment is available for
the person.
Criteria for detention
Main changes
• Definition of mental disorder
• Appropriate medical treatment.
Definition of mental disorder
• The definition of mental disorder has been
changed to 'any disorder or disability of the mind'
• Replaces the previous wording of 'mental illness,
arrested or incomplete development of mind,
psychopathic disorder and any other disorder or
disability of mind'
• Abolishes the four categories of mental disorder
that were previously used
• This new definition provides a single, simple
definition rather than specifying categories of
disorder.
Definition of mental disorder
• Includes clinically recognised mental illnesses
• Encompasses forms of personality disorder
• Disabilities of the brain would not be classified
as mental disorders unless they give rise to a
disability or disorder of the mind as well
• The overall effect of this then is to widen the
application of the provisions to all mental
disorders.
Learning disability
• In general does come under the definition
of mental disorder
• A person can only be detained for
treatment (or discharged on to SCT)
where it is associated with abnormally
aggressive or seriously irresponsible
conduct
• No change to the previous position.
Exclusions
The 1983 Act formerly provided that:
“the definition of mental disorder should not be
construed as implying that a person may be dealt
with as suffering from mental disorder by reason
only of promiscuity or other immoral conduct,
sexual deviancy or dependence on alcohol or
drugs”.
Replaced with a single exclusion stating that
'dependence on alcohol or drugs is not considered
to be a disorder or disability of the mind'.
Appropriate medical treatment test
Needs to cover the question of:
• whether proposed medical treatment is
clinically appropriate for the nature and
degree of the patient’s mental disorder,
and
• all other factors relating to the patient’s
circumstances.
Appropriate medical treatment test
Other factors to take into account:
• implications for the patient's family and social
relationships
• the patient's gender, gender-identity, and sexual
orientation
• their culture and ethnicity
• the patient’s physical health
• the consequences of not providing treatment
• any implications for the patient’s education or
work.
Appropriate medical treatment test
The criteria cannot be met unless medical
treatment:
– is available to the patient in question
– and is appropriate given the nature and
degree of the patient’s mental disorder
– and takes account of all other circumstances
of the case.
What is meant by ‘medical
treatment’?
The definition of medical treatment has been
amended to read:
– “Medical treatment includes nursing, psychological
intervention and specialist mental health habilitation,
rehabilitation and care”
The Act now stipulates that medical treatment:
– “shall be construed as a reference to medical
treatment the purpose of which is to alleviate, or
prevent a worsening of, the disorder or one or more
of its symptoms or manifestations”.
When does the appropriate
treatment test apply?
• Under section 3 of the 1983 Act, and
related sections of Part 3
• As part of the criteria for CTOs, which are
covered by a new section (section 17A) of
the Act
• Used as part of the corresponding grounds
for renewal and discharge.
When does the appropriate
treatment test not apply?
The test does not apply to:
• Section 2 or section 4 of the 1983 Act
(admission for assessment).
Other criteria – Patients own health
and safety
Admission to hospital under section 3
Typical factors that may be taken into account when
making such an assessment. These include:
– Any evidence suggesting that the patient’s
mental health will deteriorate without treatment
– The views of the patient on the likely course of
the disorder and the possibility of it improving
– The possible impact of any future deterioration or
lack of improvement on carers, close friends, or
family - especially those living with the patient
– Whether there are other methods of coping with
an expected deterioration or lack of
improvement.
Other criteria – Protection of other
persons
There are two separate issues to consider:
1. The nature of the potential risks
2. The likelihood of such harm occurring
Need to arrive at a balanced view of the
acceptability of the risks.
Discharge by hospital managers
The Hospital Managers:
• may undertake a review at any time at their discretion
• must review a patient's detention when the RC submits a
report under section 20(3) renewing detention
• must consider holding a review when they receive a
request from a patient
• must consider holding a review when the RC makes a
report under section 25(1) barring a nearest relative’s
application for the patient's discharge.
Discharge by hospital managers
When reviewing the case of a patient detained in
hospital for treatment (section 3 or 37), the review
panel should consider the following questions:
– Is the patient still suffering from mental disorder?
– If so, is the disorder of a nature or degree which
makes treatment in a hospital appropriate?
– Is detention in hospital for treatment still
necessary in the interests of the patient's health
or safety, or for the protection of other people?
– Is appropriate medical treatment available for the
patient?
Discharge by hospital managers
Where the RC has made a report under
section 25(1) barring a nearest relative’s
application for the patient's discharge, the
review panel should also ask:
– Would the patient, if discharged, be
likely to act in a manner dangerous to
other persons or to him or herself?
Discharge by hospital managers
N.B.
• These questions should be asked in the
order given
• The panel must order the discharge of the
patient unless they are satisfied, on the
basis of all the questions asked, that
continued detention is appropriate.
Activity
In your groups read through the case study
about Jane and answer the questions.
Use the Code of Practice and information in
your participant pack for reference.
Session 4
Supervised Community Treatment
Supervised community treatment
(SCT)
• SCT provides for some patients to live in the
community while still being subject to powers
under the 1983 Act to ensure they continue with
the medical treatment that they need
• The aim of SCT to break the cycle in which
some patients leave hospital and do not
continue with their treatment
• SCT replaces after-care under supervision.
Supervised community treatment
• An individual may be discharged onto SCT, this
is achieved by way of a CTO
• Only those patients who are detained in hospital
for treatment (under section 3 or an unrestricted
order under Part 3 of the Act) can be discharged
onto SCT
• In order for a patient to be eligible for SCT,
various criteria need to be met.
Supervised community treatment
Patients who are discharged onto SCT will be
subject to conditions whilst living in the community
– Most conditions will depend on individual
circumstances but must be for the purpose of
ensuring the patient receives medical
treatment, or to prevent risk of harm to the
patient or others
– The conditions will form part of the patient's
CTO which is made by their RC.
Supervised community treatment
• May be recalled to hospital for treatment
should this become necessary (either inpatient or out-patient care)
• May resume living in the community or,
• If they need to be treated as an in-patient
again, their RC may revoke the CTO
• After-care under supervision has now
been abolished.
Making a community treatment order
The RC and AMHP must be satisfied that the
following five criteria are met:
1. Must be suffering from mental disorder which
makes medical treatment appropriate
2. Need medical treatment for their mental disorder
either for their own health or safety, or for the
protection of others
3. Must be possible to receive the treatment needed
without having to be detained in hospital
4. Have the power for the patient to be recalled to
hospital for treatment should this become
appropriate
5. Appropriate medical treatment is available.
Making a community treatment order
• When making decisions, the RC must consider
the risk that the patient’s condition will
deteriorate after discharge from hospital
• In considering that risk, the RC must have
regard to the patient’s history of mental disorder
and any other relevant factors
• If the RC and the AMHP cannot come to an
agreement, then the CTO cannot be made.
Conditions of the CTO
There are two conditions that must appear in all
CTOs:
– Patient’s must make themselves available for
medical examinations as required for the
purposes of determining whether the CTO
should be extended
– They must make themselves available for
medical examinations to allow a SOAD to
make a Part 4A certificate.
Conditions of the CTO
Further conditions will be set as required with the
intention of:
– ensuring that the patient receives medical
treatment, and/or
– preventing risk of harm to the patient’s health
or safety, and/or
– protecting other persons.
Conditions of the CTO
• The RC and an AMHP must agree the conditions
• The RC may subsequently vary the conditions,
or suspend any of them without the agreement
of an AMHP.
Community treatment order
How long does the CTO last for?
• May initially last for up to six months from the date when
the order was made
• Can then be extended for a further six months and,
following that, it can be extended for periods of one year
at a time
• To be extended, the RC must examine the patient and
provide a report to the hospital managers confirming that
the necessary criteria are met
• An AMHP must agree that the criteria for extension of the
CTO are satisfied, and that it is appropriate to extend the
CTO, before the report can be made.
Community treatment order
A CTO comes to an end if:
• the period of the CTO runs out and the CTO is
not extended, or
• the patient is discharged from the applicable
powers of the 1983 Act, or
• the RC revokes the CTO following the patient's
recall to hospital.
Recall to hospital
A community patient may be recalled temporarily
to hospital if the RC decides:
– that the patient needs to receive treatment for
his or her mental disorder in a hospital, and
– that without this treatment there would be a
risk of harm to the patient’s health or safety, or
to other people.
Both conditions must be met.
Recall to hospital
If the criteria for recall are met, the patient can also
be recalled :
– even if the they are complying with the
conditions set out in the CTO
– if they fail to comply with the condition that
they must make themselves available for
examination.
Revocation of the CTO
• The RC may revoke the patient’s CTO if the
patient meets the normal criteria for detention for
treatment in hospital
• This will require an AMHP’s agreement that it is
appropriate to do so
• The authority to detain the patient is revived
(unless the patient is a Part 3 patient)
• Considered a new period of detention and the
patient has the normal rights of appeal.
Expiry of a CTO
A community patient will be discharged
absolutely from liability to recall on the
expiry of the CTO, if the order has not
previously ceased to be in force.
Discharge from SCT
Orders for discharge
• Under section 23 of the Act, the patient can be
discharged from SCT in the following ways:
– by the RC at any time
– by the hospital managers, using their powers
of discharge
– by the hospital managers following application
by the patient’s nearest relative giving not less
than 72 hours notice (Part 2 patients only).
Discharge from SCT
Restriction on discharge of community patients by
a nearest relative
• The nearest relative must give 72 hours notice in
writing to the hospital managers if they wish to
make such an order
• The RC can bar the order for discharge from
taking effect, using their powers under section
25(1), by making a report that certifies that the
patient is likely to act in a dangerous manner to
themselves or others if discharged from SCT.
Discharge by hospital managers
using powers under section 23
Reviewing SCT
The Hospital Managers:
– may undertake a review of the patient's case at any
time at their discretion
– must review a patient's case when the RC submits a
report under section 20(3) renewing CTO
– should consider holding a review when they receive a
request from a patient
– should consider holding a review when the RC makes
a report under section 25(1) barring a NR's
application for the patient’s discharge.
Discharge by hospital managers
using powers under section 23
Where a patient is subject to SCT, the hospital review panel
should consider the following questions:
– Is the patient still suffering from mental disorder?
– If so, is the disorder of a nature or degree which
makes appropriate for them to receive medical
treatment?
– If so, is it necessary in the interest of patient’s health
and safety or for the protection of other people?
– Can such treatment be provided without being
detained in hospital but subject to being liable to
recall?
– Is appropriate medical treatment available for the
patient?
Discharge by hospital managers
using powers under section 23
• These should be considered in the order
given
• Unless satisfied that all these questions
can be answered positively, the panel
should direct the discharge of the patient.
Discharge by hospital managers
using powers under section 23
Where the RC has made a report barring discharge by the
nearest relative, the hospital managers should also
consider the following question:
– If discharged, would the patient be likely to act in a
manner dangerous to other persons or to him or
herself?
If, on consideration of the report and other evidence, the
Hospital Managers disagree with the RC and decide the
answer to this question is "no",
– they should discharge the patient.
Activity
In your groups read through the case study
about John and answer the questions.
Use the Code of Practice and information in
your participant pack for reference.
Session 5
Professional roles
Professional roles
The 2007 Act has:
• broadened the group of practitioners who can
take on the roles which are central to the
operation of the 1983 Act
• it replaces the role of the responsible medical
officer (RMO) with that of the responsible
clinician (RC)
• it replaces the role of the approved social
worker' (ASW) with that of the approved mental
health professional' (AMHP).
Professional roles –
Approved Clinician
The criteria set out in the 'Directions' for a person
to be 'approved' are that:
– they fulfil the professional requirements
– they are able to demonstrate that they
possess the relevant competencies, and
– they have completed within the last two years
a course for the initial training of ACs.
Professional roles –
Approved Clinicians
To fulfil the professional requirements, a
person must be one of:
– a registered medical practitioner
– a chartered psychologist
– a first level nurse whose field of practice is
mental health or learning disabilities nursing
– an occupational therapist
– a registered social worker.
Professional roles –
Approved Clinicians
Responsibilities under Part 2 of the Act
• The RC has taken over the duties previously fulfilled by
the RMO
• The RC has also taken on a similar role in respect of
SCT
– Where the patient is liable to be detained or a
community patient, the RC is defined as the AC with
overall responsibility for the patient's case
– Where the patient is subject to guardianship, the RC
is defined as the AC authorised by the responsible
Local Social Services Authority to act.
Professional roles –
Approved Clinicians
Responsibilities under Part 3 of the Act
• Where a patient is concerned in criminal
proceedings, the RC has again taken over
the duties previously fulfilled by the RMO
• Certain functions previously restricted to
registered medical practitioners can now
be exercised also by ACs.
Professional roles –
Responsible Clinician
• The RC may be any practitioner who has been
approved for that purpose - i.e. an approved
clinician (AC)
• Not restricted to medical practitioners. May be
undertaken by practitioners from other
professions, such as nursing, psychology,
occupational therapy and social work.
• The functions that RCs have taken over from
RMOs have been supplemented by new
functions in relation to SCT.
Professional roles – Approved
Mental Health Professionals
Functions of the AMHP
The AMHP has taken over the duties and functions
of the ASW
– making applications for admission and
detention in hospital under Part 2 of the 1983
Act
– making applications for guardianship
– new functions in relation to SCT
– LSSAs have a duty to arrange for an AMHP
to consider the patient's case on their behalf.
Professional roles – Approved
Mental Health Professionals
Who may be an AMHP?
• Social workers
• A wider group of professionals that they
have the right skills, experience and
training
• There is no requirement that an AMHP be
an employee of an LSSA.
Professional roles – Approved
Mental Health Professionals
How is an AMHP 'approved'?
• LSSAs will approve AMHPs
• Before doing so they must be satisfied that the
individual:
– has appropriate competence in dealing with persons
who are suffering from mental disorder, and
– Meets requirements set out in Regulations setting out
conditions for approval, factors as to competency and
requirements for training
• The Care Council for Wales must approve courses for
the training of AMHPs in Wales, regardless of the
trainees' profession.
Professional roles – Approved
Mental Health Professionals
To fulfil the professional requirements set out in the
Regulations, a person must be one of:
– a registered social worker
– a chartered psychologist
– a first level nurse whose field of practice is
mental health or learning disabilities nursing
– an occupational therapist.
Session 6
Referrals to the Mental Health
Review Tribunal for Wales by
Hospital Managers
The Mental Health Review Tribunal
The MHRT for Wales reviews a patient's case on:
• application from the patient or the patient's
nearest relative
• referral by hospital managers if the MHRT for
Wales has not reviewed the case within a given
period
• referral from the Welsh Ministers (in nonrestricted cases)
• referral from the Secretary of State for Justice
(restricted cases).
Patients for whom Hospital
Managers must make a referral
• Patients admitted to a hospital in pursuance of
an application for admission for assessment
• Patients admitted to a hospital in pursuance of
an application for admission for treatment
• Community patients
• Patients whose CTO is revoked
• Patients transferred from guardianship to a
hospital.
Periods after which hospital
managers must make a referral
Six months after detention from the day on which:
– the patient was first detained for assessment (under
section 2) or for treatment (under section 3), or
– The patient is admitted following revocation of a CTO,
or
– the patient was detained in hospital following a
transfer from guardianship
After 3 years without review (or one year for patients aged
under 18 years) and the MHRT for Wales has not reviewed
the case in that time.
Key changes
1. Hospital managers were only under a
duty to make a referral to the MHRT for
Wales upon the renewal of patient's
detention
2. The requirement to refer a patient aged
under 18 years after one year represents
an extension to the previous age limit of
16 years.
Following revocation of CTO
• The RC may recall the patient to hospital
where appropriate
• The RC may revoke the patient's CTO.
This will require an AMHP's agreement
that it is appropriate
• The managers of the hospital have a
statutory duty to refer the patient's case to
the MHRT for Wales as soon as possible
after the order is revoked.
Session 7
Provisions for Young People
Informal admission of patients aged 16
or 17 with the capacity to consent
• Decisions cannot be overridden by a person with
parental responsibility for them
• This means that:
– If the patient consents, they can be admitted to
hospital and their consent cannot be overridden by a
person with parental responsibility
– If the patient does not consent, they cannot be
informally admitted on the basis of consent from a
person with parental responsibility
• The young person could nevertheless be admitted to
hospital for compulsory treatment if they meet the
relevant criteria.
Accommodation for patients
aged under 18
Hospital managers are under a duty to:
• Ensure that, subject to their needs,
patients under 18 are accommodated in
an environment that is suitable for their
age.
Accommodation for patients
aged under 18
The decision should be taken on the basis of:
• What is suitable for a patient of this age?
• Is there something about this patient or the
circumstances that suggests the use of an
environment that would not normally be suitable
for a patient of this age?
• Consultation with a suitable person with
experience in child and adolescent mental
health services cases.
Session 8
Independent Mental Health
Advocates
Qualifying patients
• Patients who qualify for advocacy support are essentially
those who are:
– liable to be detained under the Act (excluding those
subject to sections 4, 5(2), 5(4), 135 or 136), or
– subject to guardianship, or
– a community patient
– informal patients being considered for section 57 or 58A
treatments
• Qualifying patients must be informed that they are eligible for
the services provided by an IMHA as soon as is practicable
• An IMHA will meet with a patient on the request of the patient,
the nearest relative, the RC or an AMHP.
How does the IMHA support the
patient?
Includes help in obtaining information about and
understanding:
– the provisions under which the patient qualifies
for an IMHA
– any conditions or restrictions to which affect the
patient
– the medical treatment the patient is receiving or is
being proposed or discussed
– the legal authority for providing the treatment
– the requirements of the Act which apply to
treatment.
How does the IMHA support the
patient?
The IMHA may also:
• support the patient to exercise their rights
under the Act, including by representing
them
• support to ensure they can participate in
decisions about care and .
Independent mental health
advocates
IMHA has a right to:
– access any hospital or local authority records
relating to the patient (with patient consent)
– meet patients in private and to visit and
interview anyone professionally concerned
with the patient’s medical treatment
It is important to note also that the hospital
managers cannot withhold correspondence
between patients and their advocates.
Independent mental health
advocates
Who can act as an IMHA?
– Must be approved by the Local Health Board or
are employed by a provider of advocacy services
to act as an IMHA.
Before approving any person as an IMHA a Local
Health Board must be satisfied that the person:
– has appropriate experience or training
– is of integrity and good character
– will act independently of any person who instructs
them to act as an IMHA or is professionally
concerned with the medical treatment of the
qualifying patient.
Activity
Hospital manager hearings
In pairs using the information in your participant
pack:
– identify the likely impact of these changes on
your role
– what you will need to consider.
Hospital manager hearings
• Expect to see IMHAs supporting patients
at such hearings
• Hospital managers will need to consider:
– Whether you will take evidence at the
hearing
– How you will respond if the patient
wishes to speak without professionals
present.
Session 9
Domestic Violence, Crime and
Victims Act 2004
Domestic Violence, Crime and
Victims Act 2004
Will apply where:
• the offender is made subject to a hospital order
without restrictions, or
• the offender is made subject to a hospital and
limitation direction and the limitation direction
subsequently ceases to have effect, or
• the offender is transferred from prison to hospital
under a transfer direction without a restriction
direction, or where the restriction direction is
removed.
Victims’ rights
Right to make representations and receive
information
The local probation board must establish whether the
victim wishes:
– to make representations as to whether the
patient should be subject to conditions in the
event of discharge from hospital
– to receive information about those conditions in
the event of the patient’s discharge
Domestic Violence, Crime and
Victims Act 2004
The Hospital Managers must:
• inform the victim if the offender is being
considered for discharge or is to be
discharged
• inform the victim whether the patient is to
be subject to a CTO including any
conditions.
Session 10
Review, Action Planning and
Evaluation
Review and action planning
• Review of your issues and goals
• Review of course objectives.
Course objectives
Do you now feel able to:
• Define the processes and good practice that
should be adopted when considering whether to
exercise the power of discharge
• Explain the new simplified single definition of
mental disorder and the revised criteria for
detention for treatment
• Explain the provisions of supervised community
treatment and the hospital manager's role in
considering a patient’s discharge from
supervised community treatment
Course objectives
• Explain the role of the independent mental
health advocate, and how this might impact of
the running on hearings
• Explain the changes in professional roles and
the impact for evidence-giving in these roles
• Explain the impact of the new duties in relation
to Domestic Violence, Crime and Victims Act
2004 for evidence-giving and hearings.
Review and action planning
Complete your action plan.
Evaluation
Please complete the course evaluation form.
Thank you.