Practical tips for the busy
GP
When called to see a patient who is mentally
unwell your assessment should include whether:
o the patient is suffering from a psychiatric
problem
o the mental disorder is sufficiently serious to
need further assessment and/or treatment in
hospital
o the patient needs to be compulsorily admitted in
the interests of his / her own health, or for the protection of
others
o voluntary admission is an
option.
-
You can
contact the duty approved mental health professional (AMHP)
during and outside office hours by ringing the general telephone
number for the Social Services Department or local
council.
-
If you
think the patient needs hospital admission, the AMHP will make the
arrangements for the patient to be formally assessed for admission.
You will usually be asked to carry out an examination and provide a
written medical recommendation.
-
If you
think a patient needs emergency admission, this can be done under
Section 4 of the MHA, and only requires an AMHP (or NR) and one
medical recommendation.
-
Medical
recommendations need to be written on statutory
forms.
The Mental Health Acts 1983 and
2007 (England and Wales)
Scope of the
guidance
This EGP Update item is only relevant to GPs
practising in England and Wales; as there is new changing
information in relation to the Mental Health Act
legislation.
The item is based on two Department of Health
(England) publications ‘The Mental Health Act 1983: Guidance
for general practitioners - medical examinations and medical
recommendations under the Act’ and ‘Mental Health Act
2007 – overview’ (see Original source material).
These Acts cover England and Wales, but not Scotland and
Northern Ireland. (The current mental health legislation in
Scotland is:
The
Mental Health (Care and Treatment) (Scotland) Act
2003which is still current, although some amendments
have been made.
The
Mental Health (Northern Ireland) Order
1986governs the treatment of people with mental health
problems in Northern Ireland.)
The basis of the 1983 Mental Health Act (MHA) is
to allow the compulsory detention of a patient with a mental health
disorder and their subsequent treatment in hospital for the
disorder without their consent. The 2007 MHA makes various
amendments to the 1983 Act.
Source
Department of Health, The Mental Health Act
1983: Guidance for general practitioners - medical examinations and
medical recommendations under the Act. London: DH;
2007.
This EGP Update item aims to clarify the
GP’s role in undertaking mental health assessments under the
1983 and 2007 MHAs. Amendments made by the 2007 Act are in bold
below.
Key
points
1.
Definitions
-
The
2007 MHA revises the definition of mental illness as ‘any
disorder or disability of the mind’ so that a single
definition applies throughout.
2. Role of the
GP
-
A GP has
detailed knowledge of the patient, especially their medical history
and personal situation, that aids the decision as to whether
compulsory powers should be used. A GP’s role could also
include arranging or carrying out assessments for possible
compulsory admission to hospital for assessment and/or
treatment.
3. Initiating the
process
-
This
usually starts with the GP being approached by a worried relative
or carer. However, sometimes a patient may be detained by the
police to enable him / her to be examined by a medical practitioner
(often the GP) and interviewed by an Approved Social Worker
(ASW).
-
After
making an 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 ASW or nearest relative
(NR) should be contacted to make arrangements for a formal
‘application’ to be made.
-
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 ASW or NR
directly.
-
Informal
admission should always be considered as first
option.
4. Role of the ASW: The 2007
MHA, changes the definition of ASW to any person approved by Social
Services.
-
Detention
of a patient for treatment of a mental health disorder requires a
formal ‘application’ by either the NR or preferably the
ASW. The 2007 MHA gives patients or courts the right to displace
their NR (where there are reasonable grounds to do so) and adds
civil partners to the list of relatives.
-
The
‘approved mental health professional’ is the new name
for the former approved social worker.
5. 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. This 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.
6. Sections of the
MHA
-
Section
2: admission to hospital for up to 28 days for
assessment
-
Section
3: admission to hospital for up to 6 months for
treatment
-
There
is a three part treatment test:
-
the
patient must be suffering from a mental
disorder
-
it
must be necessary for the health or safety of the patient or for
the protection of other persons that s/he should receive such
treatment and it cannot be provided unless they are detained under
this section
-
appropriate medical treatment is available to
the patient.
-
Section
4: admission on an emergency basis for up to 72 hours; only one
medical practitioner required.
-
Section
136: detention by the police to enable examination by a medical
practitioner and interview by an ASW
7. After detention in
hospital
The 2007 MHA introduces supervised community
treatment (SCT) for patients following a period of detention in
hospital. This allows a small number of patients with a mental
disorder to live in the community, whilst ensuring that they
continue to take medication for their mental disorder – so
long as their compulsory supervision is in line with the treatment
test.
1. The consultation
