Compulsory Hospitalisation

Voluntary means of dealing with the patient's mental health problems must have been exhausted before these legally sanctioned methods of detention may be used. The patient must have a mental disorder, i.e. any disorder or disability of mind, but alcohol or drug addiction are insufficient on their own to detain a person under the Mental Health Act. The patient's mental disorder must require hospital detention for assessment or treatment, or to protect the interests of the patient or others. The Mental Health Act 1983 gives a statutory framework for non-consensual detention of patients in hospital. The 1983 Mental Health Act has been amended by The Mental Health Act 2007.

The Mental Capacity Act (2005) gives the power to have a person lacking capacity who is neglecting himself and becoming undernourished to be admitted to hospital for treatment. The Mental Capacity Act (2005) does not apply to any treatment for mental disorder which is being given in accordance with the rules about compulsory treatment set out in Mental Health Act.

The main changes made to the 1983 Mental Health Act by the 2007 Mental Health Act are:

• Definition of mental disorder: a single definition of mental disorder applies throughout the Act.
• Criteria for detention: it introduces a new “appropriate medical treatment” test which will apply to all the longer-term powers of detention. It is now not possible for patients to be compulsorily detained or their detention continued unless medical treatment which is appropriate to the patient’s mental disorder and all other circumstances is available to that patient.
• Professional roles: it broadens the group of practitioners who can take on the functions previously performed by the approved social worker (ASW) and responsible medical officer (RMO).
• Nearest relative: it gives to patients the right to make an application to the county court to displace their nearest relative and enables county courts to displace a nearest relative who it thinks is not suitable to act as such.
• Nearest relative: the provisions for determining the nearest relative have been amended to include civil partners amongst the list of relatives.
• Supervised community treatment (SCT): it introduces SCT for patients following a period of detention in hospital. This allows patients with a mental disorder to be discharged from detention subject to the possibility of recall to hospital if necessary.
• Electro-convulsive therapy: it introduces new safeguards for patients:
  • If a detained patient has capacity, then they can decide whether they wish to have electroconvulsive therapy - except in emergencies.
  • A detained patient with a valid advance decision opposed to being given ECT cannot be treated by it, except in an emergency.
• Tribunal: it reduces the periods after which hospital managers must refer certain patients’ cases to the Tribunal if they do not apply themselves and introduces an order-making power to make further reductions in due course.
• Advocacy: it will place a duty on the appropriate national authority to make arrangements for help to be provided by independent mental health advocates.
• Age-appropriate services: it will require hospital managers to ensure that patients aged under 18 admitted to hospital for mental disorder are accommodated in an environment that is suitable for their age (subject to their needs) - to be implemented in April 2010.

Professional roles

• Applicant Approved Social Worker (ASW) is to be replaced by Approved Mental Health Professional (AMHP). An AMHP is a person from any health profession/social work approved to act in that role by a local social services authority. A registered medical practitioner may not be an AMHP.
• Medical recommendations are to be made by 2 doctors, one of the two being Section 12 approved (all Medical Approved Clinicians are deemed also to be approved).
• Approved Clinician: an approved clinician is a person approved by the appropriate national authority to act as an approved clinician for the purposes of the Act. The power to approve is delegated. To act as a patient's responsible clinician, a professional must first be approved as an approved clinician. The approved clinician in charge of a particular episode or type of treatment may or may not be the Responsible Clinician.
• Responsible Clinician (RC): a patient's Responsible Clinician is defined as the approved clinician with overall responsibility for the patient's case. All patients subject to detention or Supervised Community Treatment have a Responsible Clinician, who may be a Nurse, Occupational Therapist, Psychiatrist, Psychologist or Social Worker.

Supervised Community Treatment (Community Treatment Order)

• The Mental Health Act 2007 states that Supervised Community Treatment should be considered when:
  • The patient is suffering from a mental disorder of a nature or degree which makes it appropriate for them to receive medical treatment.
  • It is necessary for their health or safety or for the protection of other persons that they should receive such treatment.
  • Such treatment can be provided without them continuing to be detained in a hospital.
  • Appropriate medical treatment is available for the patient.
  • It is necessary for their health or safety or for the protection of other persons that the responsible clinician should be able to exercise the power to recall the patient to hospital.
• The Responsible Clinician should consider what risk there would be of a deterioration of the patient's condition if they were not detained in a hospital (e.g. as a result of not complying with the medical treatment required for their mental disorder).

• A GP has detailed knowledge of the patient that aids the decision as to whether compulsory powers should be used. A GP’s role also includes arranging or carrying out assessments for possible compulsory admission to hospital.
• After making an initial assessment, the next step is to discuss the case with a psychiatrist and if necessary request a domiciliary visit by an approved psychiatrist, if it is required.
• If the psychiatrist feels that a patient needs admission to hospital but informal admission is not appropriate, an AMHP or nearest relative (NR) should be contacted to make arrangements for a formal ‘application’ to be made.
• Detention of a patient for treatment of a mental health disorder requires a formal ‘application’ by either the NR or preferably the AMHP.
• In situations where the process needs to take place rapidly and it is not practical for a psychiatrist to come to examine the patient before compulsory admission, then the GP can approach the AMHP or NR directly.
• Informal admission should always be considered as first option.
• Medical recommendations for the application to compulsorily admit:
  • Before an application can be made for admission to hospital, two doctors (who have both examined the patient) both need to give a ‘medical recommendation’. One doctor must be approved under the MHA, usually a consultant psychiatrist (but a GP can apply to become approved under Section 12(2) of the MHA). If possible, one doctor (e.g. the GP) should have met the patient before.
  • However an application for an emergency admission requires only one medical recommendation, which can be provided by a GP.
• Occasionally GPs are asked to examine a patient in hospital and provide a second medical recommendation to detain a patient who is already voluntarily admitted, or is already detained under another Section (e.g. Section 4, emergency admission).
• A medical recommendation should not be given if there are any conflicts of interest.
• The ‘responsible clinician’ replaces the role of ‘responsible medical officer’ being in overall charge of the care of the sectioned patient. This person has powers to grant leave and discharge.

• The period of assessment (and treatment) lapses after 28 days (not renewable).
• Patient's appeals must be sent within 14 days to the mental health tribunal (composed of a doctor, lay person and lawyer).
• An AMHP (or the nearest relative) makes the application on the recommendation of 2 doctors, one of whom is 'approved' under Section 12(2) of the Act (in practice a consultant psychiatrist or SpR of sufficient experience). The second medical recommendation is given by a doctor who knows the patient personally in a professional capacity. If this is not possible, the Code of Practice recommends that the second doctor should be an 'approved' doctor.

• The exact mental disorder must be stated.
• Detention is renewable for a further 6 months (annually thereafter).
• 2 doctors must sign the appropriate forms and know why treatment in the community is contraindicated. They must have seen the patient within 24 hours. They must state that treatment is likely to benefit the patient, or prevent deterioration; or that it is necessary for the health or safety of the patient or the protection of others.

• The admission to hospital must be an urgent necessity.
• May be used if admission under Section 2 would cause undesirable delay (admission must follow the recommendation rapidly).
• An AMHP or the nearest relative makes the application after recommendation from one doctor (eg the GP).
• The GP should keep a supply of the relevant forms, as the social worker may be unobtainable.
• It is usually converted to a Section 2 on arrival in hospital following the recommendation of the duty psychiatrist. If the second recommendation is not completed, the patient should be discharged as soon as the decision not to convert to Section 2 is made. The Section should not be allowed to lapse.

• The doctor in charge (or, in the case of a consultant psychiatrist, his or her deputy) applies to the hospital administrator, day or night, so it is often helpful to obtain early joint care for these patients with a consultant psychiatrist.
• A patient in an A&E department is not in a ward, so cannot be detained under this Section. Common law is all that is available to provide temporary restraint for someone who is a manifest danger either to himself or to others' while awaiting an assessment by a psychiatrist.
• Plan where the patient is to go before the 72 hours has elapsed, e.g. by liaising with psychiatrists for admission under Section 2.

• Any authorised psychiatric nurse may use force to detain a voluntary 'mental' patient who is taking his own discharge against medical advice, if such a discharge would be likely to involve serious harm to the patient (e.g. suicide) or others.
• During the 6 hours the nurse must find the necessary personnel to sign a Section 5(2) application or allow the patient's discharge.

• Enables patients to receive community care where it cannot be provided without the use of compulsory powers.
• Application is made by an AMHP or Nearest Relative and also needs two medical recommendations.
• The guardian, usually a social worker, can require the patient to live in a specified place, to attend at specified places for treatment and to allow authorised persons access.

• The patient continues to suffer from a mental disorder and would benefit from continued hospital treatment.
• Further admission is needed for the health or safety of the patient - which cannot be achieved except by forced detention.

• This is as a result of The Mental Health (Patients in the Community) Act 1995, which has been incorporated within the 1983 Act.
• It allows formal supervision to ensure that a patient who has been detained for treatment under the Act receives follow up care.
• The application is made at the time of detention for treatment by the RMO. It is supported by an AMHP and a doctor involved in the patients treatment in the community.
• A supervisor is appointed who can convey the patient to a place where treatment is given.

• Section 117 requires the provision of after-care for patients who have been detained on the longer term Sections (3,37,47 or 48).
• The CPA is not part of the Act but stipulates that no patient should be discharged without planned after-care: the systematic assessment of health and social needs, an agreed care plan, the allocation of a keyworker and regular reviews of progress.

• Allows police to arrest a person 'in a place to which the public have access' and who is believed to be suffering from a mental disorder.
• The patient must be conveyed to a 'place of safety' (usually a designated A&E department) for assessment by a doctor (usually a psychiatrist) and an approved social worker.
• The patient must be discharged after assessment or detained under Section 2 or 3.

• This empowers an approved social worker who believes that someone is being ill-treated or is neglecting himself to apply to a magistrate to search for and admit such patients.
• The AMHP or a registered medical practitioner must accompany the police.