implementation of the mental health act 2007 hospital managers

Implementation of theMental Health Act 2007

Hospital Managers

Session 1

Goals and Objectives

Domestics

• Emergency procedures

• Expected finish times

• Refreshment breaks

• Lunch arrangements

• Venue facilities.

Role of Facilitator

• Guide you through the course

• Maximise your participation

• Challenge / support / advise

• Provide information

• Collate feedback / outcomes.

Ground Rules

• 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.


The Act:

• Covers the discharge of community patients – those who have been discharged onto SCT under a community treatment order.


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.


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.


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.


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?


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?


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.


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.


• May be recalled to hospital for treatment should this become necessary (either in-patient 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.


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.


• 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

• 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.

Restriction on discharge of community patients by a nearest relative

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.


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?


• 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.


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.


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.


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 AMHPThe 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.


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.


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.


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 non-restricted 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


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

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

Right to make representations and receive information


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.

implementation of the mental health act 2007 hospital managers

Documents

objectives mental health

mental health act chapter

mental capacity act

mental heath act

mental health legislation

victims act

serious mental disorders

treatment necessary