Presentation to London

1
Presentation to London South East MHA
Administrators Mental Heath Act 1983 As amended
by the Mental Health Act 2007!

• Presentation by
• Yens Marsen-Luther
• National Lead MHA Administration

2
The main changes to the 1983 Act are

• 1. Definition of mental disorder
• 2. Criteria for detention
• 3. Professional roles
• 4. Nearest relative
• 5. Supervised Community Treatment
• 6. Mental Health Review Tribunals
• 7. Age-appropriate services
• 8. Advocacy
• 9. Electro-convulsive Therapy
• 10. Other Changes to the MHA 1983

3
Main Changes 1Section 1 Mental Disorder

• The Bill abolishes the four forms of mental
  disorder in the 1983 Act.
• It simplifies the existing definition of mental
  disorder Mental disorder means any disorder or
  disability of mind.
• It removes three of the exceptions in section
  1(3) immorality, promiscuity and sexual
  deviancy leaving in only dependence on
  alcohol or drugs.

4
Consequences

• The definition of mental disorder is widened by
  removing the previous references to immorality,
  promiscuity and sexual deviancy.
• Therefore, so too are the Acts short-term
  holding powers, such as the polices power to
  detain citizens under section 136 and the power
  to enter private premises under section 135.
• The repeal of the category of psychopathic
  disorder extends the group of people who are
  liable to potentially indefinite detention or
  compulsion, e.g. under section 3.
• In the case of people categorised by doctors as
  having a personality disorder, their long-term
  detention no longer requires the existence of a
  persistent disorder or disability of mind that
  results in abnormally aggressive or seriously
  irresponsible conduct.
• Nor need their condition be treatable.

5
The new section 1

• 1.(2) In this Act
• mental disorder any disorder or disability of
  mind and mentally disordered" shall be construed
  accordingly
• (2A) But a person with learning disability shall
  not be considered by reason of that disability to
  be
• (a) suffering from mental disorder for the
  purposes of the provisions mentioned in
  subsection (2B) below or
• (b) requiring treatment in hospital for mental
  disorder for the purposes of sections 17E and 50
  to 53 below,
• unless that disability is associated with
  abnormally aggressive or seriously irresponsible
  conduct on his part.
• (2B) The provisions are
• (a) sections 3, 7, 17A, 20 and 20A below
• (b) sections 35 to 38, 45A, 47, 48 and 51 below
  and
• (c) section 72(1)(b) and (c) and (4) below.
• (3) Dependence on alcohol or drugs is not
  considered to be a disorder or disability of mind
  for the purposes of subsection (2) above.
• (4) In subsection (2A) above, learning
  disability means a state of arrested or
  incomplete development of mind which includes
  significant impairment of intelligence and social
  functioning.

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Section 3

• The four forms of mental disorder have been
  abolished.
• Consequently, a person with a personality
  disorder may be placed under section 3 even
  though s/he would not today satisfy the criteria
  for having a psychopathic disorder.
• The treatability test is abolished, and replaced
  by an appropriate medical treatment test, which
  now applies to all patients.
• According to the Act, references to appropriate
  medical treatment are references to medical
  treatment which is appropriate in the patients
  case, taking into account the nature and degree
  of their mental disorder and all other
  circumstances of his case.
• Although it is no longer necessary that the
  treatment is likely to alleviate the patients
  condition, or prevent it from worsening, the
  purpose of any treatment provided must still be
  to alleviate, or prevent a worsening of, the
  disorder, or one or more of its symptoms or
  manifestations.
• Treatment need not be under medical supervision,
  or involve a doctor, and may consist only of
  specialist care or psychological intervention.
• The renewal and tribunal discharge criteria are
  modified accordingly.

s3
7
The new section 3 criteria 2 -

• 3.(1) A patient maybe admitted to a hospital and
  detained there for the period allowed by the
  following provisions of this Act in pursuance of
  an application (in this Act referred to as an
  application for admission for treatment) made in
  accordance with this section.
• (2) An application for admission for treatment
  may be made in respect of a patient on the
  grounds that
• (a) he is suffering from mental disorder of a
  nature or degree which makes it appropriate for
  him to receive medical treatment in a hospital
  and
• (b) repealed treatability test
• (c) it is necessary for the health or safety of
  the patient or for the protection of other
  persons that he should receive such treatment and
  it cannot be provided unless he is detained under
  this section and
• (d) appropriate medical treatment is available
  for him.
• (3) An application for admission for treatment
  shall be founded on the written recommendations
  in the prescribed form of two registered medical
  practitioners, including in each case a statement
  that in the opinion of the practitioner the
  conditions set out in subsection (2) above are
  complied with and each such recommendation shall
  include-
• (a) such particulars as may be prescribed of the
  grounds for that opinion so far as it relates to
  the conditions set out in paragraphs (a) and (d)
  of that subsection and
• (b) a statement of the reasons for that opinion
  so far as it relates to the conditions set out in
  paragraph (c) of that subsection, specifying
  whether other methods of dealing with the patient
  are available and, if so, why they are not
  appropriate.
• (4) In this Act, references to appropriate
  medical treatment, in relation to a person
  suffering from mental disorder, are references to
  medical treatment which is appropriate in his
  case, taking into account the nature and degree
  of the mental disorder and all other
  circumstances of his case.

8
Form A7 (currently Form 10) Regulation
4(1)(d Mental Health Act 1983 section 3 Joint
medical recommendation for admission for
treatment THIS FORM MUST ONLY BE COMPLETED IF
BOTH DOCTORS ARE PRESENT We, full names and
addresses of both medical practitioners
registered medical practitioners, recommend that
PRINT full name and address of patient be
admitted to a hospital for treatment in
accordance with Part 2 of the Mental Health Act
1983.I PRINT full name and address of first
practitioner last examined this patient on
date.I had previous acquaintance with the
patient before I conducted that examination.I
have been approved by the Secretary of State
under section 12 of the Act as having special
experience in the diagnosis or treatment of
mental disorder.ltDelete if not applicable.gtI
PRINT name and address of second practitioner
9
Form A7 (currently Form 10) Regulation 4(1)(d)
Cont. In our opinion, this patient is suffering
from mental disorder of a nature or degree which
makes it appropriate for the patient to receive
medical treatment in a hospital. In our opinion
this patient is suffering from (complete (a) or
(b)) (a) mental illness/severe mental
impairmentand his his mental disorder is of a
nature or degree which makes it appropriate for
him to receive medical treatment in a hospital
(b) psychopathic disorder/mental impairment
and his mental disorder is of a nature or degree
which makes it appropriate for him to receive
medical treatment in a hospital and such
treatment is likely to alleviate or prevent a
deterioration of his condition. ltDelete the
phrase which does not apply.gt 52
10
Form A7 (currently Form 10) Regulation 4(1)(d)
Cont. This opinion is founded on the following
grounds Give clinical description of the
patients medical condition We are of the
opinion that it is necessary (i) in the
interests of for the patients own health (ii)
in the interests of for the patients own safety
(iii) with a view to for the protection of
other persons ltDelete the indents not
applicablegt that this patient should receive
treatment in hospital, because Reasons should
include whether other methods of care or
treatment (eg out-patient treatment or local
social services authority services) are available
and, if so, why they are not appropriate. Please
continue on a separate sheet if necessary, and
attach it to this form. Such treatment cannot
be provided unless the patient he is detained
under section 3 of the Act, for the following
reasons Reasons should indicate whether other
methods of care or treatment (e.g. out-patient
treatment or local social services authority
services) are available and if so why they are
not appropriate, and why informal admission is
not appropriate. Please continue on a separate
sheet, if necessary, and attach it to this form.

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Form A7 (currently Form 10) Regulation 4(1)(d)
Cont. We are of the opinion that, taking into
account the nature and degree of the mental
disorder from which the patient is suffering and
all the other circumstances of the case,
appropriate medical treatment is available to the
patient at the following hospital (or one of the
following hospitals) Enter name of
hospital(s). If appropriate treatment is
available only in a particular part of the
hospital, say which part. Signed Date Signed
Date
12
Appropriate treatment example

• According to the Briefing Note on the Bill,
  Decision makers will have to consider not only
  the clinical factors, but also, for example,
  whether treatment will be culturally appropriate,
  how far from the patients home the proposed
  service is and what effect it will have on the
  patients contact with family and friends.

Mr Jones is detained under section 3. His
diagnosis is anti-social personality disorder.
His case comes before a tribunal. He argues that
the treatment he is receiving in a private
hospital 150 miles from his home in London does
not constitute appropriate treatment. It is not
culturally appropriate, there is no psychological
input, he has no contact with family and friends
and it is too far from home. Furthermore, it is
not medical treatment because the purpose of his
detention is simply public protection, not
alleviating or preventing a worsening of his
condition.
13
Medical treatment

• 145.(1 ) In this Act, unless the context
  otherwise requires medical treatment includes
  nursing, OUT and also includes care,
  habilitation and rehabilitation under medical
  supervision, psychological intervention and
  specialist mental health habilitation,
  rehabilitation and care
• 145.(3) Any reference in this Act to medical
  treatment, in relation to mental disorder, 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.

14
The Guiding Principles

• The following are new requirements for inclusion
  in the new Code of Practice for the Mental Health
  Act 1983 as amended by the Mental Health Act 2007

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(2A) The code shall include a statement of the
principles which the Secretary of State thinks
should inform decisions under this Act.

• (a) respect for patients' past and present
  wishes and feelings,
• (b) respect for diversity generally including,
  in particular, diversity of religion, culture and
  sexual orientation (within the meaning of section
  35 of the Equality Act 2006),

16

• (c) minimising restrictions on liberty,
• (d) involvement of patients in planning,
  developing and delivering care and treatment
  appropriate to them,
• (e) avoidance of unlawful discrimination,
• (f) effectiveness of treatment,
• (g) views of carers and other interested parties,
  
• (h) patient wellbeing and safety, and
• (i) public safety.

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• The above principles to be included in the Code
  can all be found in the first chapter in the Code
  of Practice.
• They can be departed from but this can only be
  done for good reason which must be noted at the
  time.

18
Form H3 (currently Form 14) Regulation 4(4)
Mental Health Act 1983 sections 2, 3, 4 and 5(2)
Record of receipt of medical recommendation(s)
and formal admission to detention in hospital
(To be attached to the medical recommendation(s)
and the application for admission or report)
PART 1 Name and address of hospital or mental
nursing home PRINT full name of patient
Delete the three of (a), (b), (c) and (d) which
do not apply. (a) The above named patient was
admitted to this hospital on date of admission
to hospital at time in pursuance of an
application for admission under section state
section of the Mental Health Act 1983 (b) The
above named patient was admitted to this hospital
on date of admission to hospital at time in
pursuance of a transfer from guardianship. (c)
An application for the admission of the above
named patient (who had already been admitted to
this hospital) under section state section of
the Mental Health Act 1983, which appeared to me
to be duly made and founded on the necessary
recommendation(s), was received by me on behalf
of the managers on date at time and the
patient was accordingly treated as admitted from
that time.
19
Form H3 (currently Form 14) Regulation 4(4)
Cont. Statutory documentation relating to this
patients liability to be detained under the
Mental Health Act 1983 was received by me on
behalf of the managers and the patient was
consequently detained under section on date
. (d) I received a report furnished under
section 5(2) of the Mental Health Act 1983 in
respect of the above named patient on behalf of
the managers on date at time at which report
furnished. Signed on behalf of the managers
PRINT NAME Date
20
Form H3 (currently Form 14) Regulation 4(4)
Cont. PART 2 (to be completed only if the
patient was admitted in pursuance of an emergency
application under section 4 of the 1983 Act) On
date at time I received, on behalf of the
managers, the second medical recommendation in
support of the application for the admission of
the above named patient. The patient was given
information in accordance with section 132 of the
Act on date. The patients nearest
relative/the person authorised to exercise the
functions of the nearest relative was informed of
the patients admission on date. ltDelete the
phrase which does not applygt The local social
services authority of the area where the patient
resided immediately before admission is name of
authority. That authority was advised of the
patients admission on date. Signed on behalf
of the managers Date Time
21
New roles AMHPs Clinicians 3 -

• AMHP Nurses, occupational therapists and
  psychologists can all request training to qualify
  as Approved Mental Health Professionals.
• RC Responsible Clinician. Other than medical
  professionals can now pursue training to achieve
  the competencies required to become an approved
  clinician and thereafter be appointed as an RC
  for patients suffering from mental disorder.

22
The nearest relative 4 -

• The Act amends the list of persons who may be a
  patients nearest relative by giving a civil
  partner equal status to a husband or wife.
• It also introduces a new right for a patient to
  apply for an order displacing the nearest
  relative on the same grounds currently in
  existence for other applicants, and on the
  additional ground that the nearest relative is
  unsuitable.
• It changes the requirement that the acting
  nearest relative must, in the courts opinion, be
  a proper person to act to whether the person
  is, in its opinion, a suitable person to act.

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SUPERVISED COMMUNITY TREATMENT - 5 -
24
Introduction

• The supervision application (supervised
  discharge) provisions are repealed.
• In their place is a Supervised Community
  Treatment order.

85.   The SCT provisions will allow some patients
with a mental disorder to live in the community
whilst still subject to powers under the 1983
Act. Patients subject to SCT remain under
compulsion and liable to recall to hospital for
treatment. Only those patients who have been
detained in hospital for treatment will be
eligible for SCT. In order for a patient to be
placed on SCT, various criteria need to be met.
An AMHP also needs to agree that SCT is
appropriate. Patients who are on SCT will be made
subject to conditions whilst living in the
community. Conditions will depend on their
individual and family circumstances. Conditions
will form part of the patient's CTO which is made
by the RC. Patients on SCT may be recalled to
hospital for treatment should this become
necessary. Afterwards they may then resume living
in the community or, if they need to be treated
as an in-patient again, their RC may revoke the
CTO and the patient remains in hospital for the
time being. Explanatory Notes
25
The criteria

• 17A(4) The responsible clinician may not make a
  community treatment order unless
• in his opinion, the relevant criteria are met
  and
• an approved mental health professional states in
  writing
• (i) that he agrees with that
  opinion and
• (ii) that it is appropriate to make
  the order.
• (5) The relevant criteria are
• (a) the patient is suffering from mental disorder
  of a nature or degree which makes it appropriate
  for him to receive medical treatment
• (b) it is necessary for his health or safety or
  for the protection of other persons that he
  should receive such treatment
• (c) subject to his being liable to be recalled as
  mentioned in paragraph (d) below, such treatment
  can be provided without his continuing to be
  detained in a hospital
• (d) it is necessary that the responsible
  clinician should be able to exercise the power
  under section 17E(1) below to recall the patient
  to hospital and
• (e) appropriate medical treatment is available
  for him.

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CTO Statutory Forms

• CTO1 Community treatment orders themselves
  (including the conditions attached to them).
• CTO2 Notification of variations to the conditions
  of community treatment orders.
• CTO3 Notice to patients recalling them to
  hospital. (The Act specifies that this notice
  must be given in writing to the patient.)
• CTO4 Record of the patients detention on recall
  (in other words, the point from which the
  maximum period of 72 hours detention runs
• CTO5 Revocation of a community treatment order
  (which, in effect, revives the original
  authority to detain the patient).

27
CTO Statutory Forms

• CTO6 Authority for the transfer of a recalled
  patient from one hospital to another (where the
  managers are different).
• CTO7 Report by a responsible clinician extending
  a community treatment order with the agreement of
  an approved mental health professional.
• CTO8 Report by a responsible clinician confirming
  that a patient who has been absent without leave
  for more than 28 days should remain a patient on
  supervised community treatment. (This will only
  apply to patients who go absent when recalled to
  hospital).
• CTO9 Assignment of responsibility for a patient
  on supervised community treatment from one set of
  hospital managers to another
• CTO10 Part 4A certificate approving the
  administration of certain types of medical
  treatment to patients on supervised community
  treatment.

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Conditions

• An order shall specify conditions to which the
  patient is to be subject.
• The order shall specify conditions that the
  patient makes her/himself available for the
  purposes of being examined in connection with (1)
  the orders renewal, and (2) the furnishing of a
  consent to treatment certificate.
• The patient may be recalled to hospital if s/he
  fails to comply with either of these two
  conditions.

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Conditions cont.

• It may only specify such other conditions as the
  responsible clinician and an AMHP agree are
  necessary or appropriate for the purpose of (a)
  ensuring that the patient receives medical
  treatment (b) preventing risk of harm to the
  patients health or safety (c) protecting other
  persons.
• If a community patient fails to comply with any
  of these additional conditions, that failure may
  be taken into account for the purposes of
  exercising the power of recall.
• The conditions may be varied or suspended from
  time to time.

30
POWER OF RECALL

• The power of recall shall be exercisable by
  notice in writing to the patient.
• A recalled patient may be transferred to another
  hospital.
• Where a community patient is recalled, the RC may
  revoke the community treatment order if s/he is
  of the opinion that the section 3 conditions are
  satisfied and an AMHP agrees with that opinion
  and that it is appropriate to revoke the order.
• The effect is that the managers have the same
  power to detain the patient under s.6(2) as if
  s/he had never been discharged and for section
  20 renewal purposes the patient is deemed to have
  been admitted under section 3 on the day the
  order is revoked.
• The patient shall be released after 72 hours if
  by then the patient has not been released and nor
  has the order has not been revoked.

31
Consent

• SCT Patients are treated under Part 4A of the MHA
  83
• They should be consenting and will require a SOAD
  report to confirm that any treatment under
  section 58 is appropriate
• On recall they will be subject to Section 62A
• On revocation under 17F they will be subject to
  Part 4 again

32
Mental Health Review Tribunals - 6 -
33
Changes to MHRT under 2007 Act

• Mental Health Review Tribunal (MHRT) it
  introduces an order-making power to reduce the
  time before a case has to be referred to the MHRT
  by the hospital managers.
• It also introduces a single Tribunal for England,
  the one in Wales remaining in being.
• It changes the referral period after 6 months to
  include any time that may have previously been
  spent on Section 2
• It extends the annual referral for those under 16
  to adolescents who are under 18

34
AGE APROPRIATE SERVICES 7 -
35
AGE APROPRIATE SERVICES

• Age Appropriate Services it requires 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).
• This is due to be introduced in 2010

36
AGE APROPRIATE SERVICES

• Section 131A also provides that any patient under
  18 who is admitted informally or under the Acts
  powers, the hospital managers will consult with a
  person who appears to them to have knowledge or
  experience of cases involving minors.

37
Advocacy - 8 -
38
Independent Mental Health AdvocateIMHA

• The 2007 Act section130A-D places a duty on the
  appropriate national authority to make
  arrangements for help to be provided by
  independent mental health advocates.
• It is not clear what if any funding will be
  available for this

39
IMHA

• Advocates will have an unfettered right to meet
  with patients in private and to meet with
  professionals. They will have access to patients
  records only where a capable patient gives
  consent, or, in the case of incapable patients
  where such access would not conflict with a
  decision made by a deputy, donee, court etc and
  the person holding the records agrees that such
  access is appropriate.

40
Electro-convulsive Therapy 9 -
41
ECT (Section 58A) 9 -
s58
42
Urgent ECT (Section 62)
s62
43
Other Amendments to the Mental Health Act 1983
44
Sections 135 136

• 135.(3A) A constable, an approved mental health
  professional or a person authorised by either of
  them for the purposes of this subsection may,
  before the end of the period of 72 hours
  mentioned in subsection (3) above, take a person
  detained in a place of safety under that
  subsection to one or more other places of safety.

s135/6
45
Offender provisions
Part III
46
Extend the rights of victims by amending the
Domestic Violence, Crime and Victims Act 2004

• Arrangements will need to be put in place to
  ensure that patients who have been subject to
  court proceedings dealt with by the above Act are
  identified so that hospital managers are able to
  notify their victims of appeal hearings taking
  place and any leave arrangements that are being
  considered by contacting the appropriate court
  liaison officer, who would deal with this by
  advising the victim.

47
Section 17 Amendment

• There is a new requirement to consider the use of
  SCT before granting S 17 Leave for 7days or more!
• Current local forms will need to reflect this
  requirement by ensuring that where or when leave
  of 7 days is granted that the RC can record the
  reason for not using SCT.
• There will also be a need to monitor the use of
  longer term section leave.

48
New forms for discharge by responsible clinicians
.

• 2.14 Adopting the criteria set out above, there
  would be no reason to introduce a statutory form.
  However, in the discussions led by the Care
  Services Improvement Partnership, many people
  argued such a form would be of value. The
  Department has therefore included two draft forms
  to that effect, and would particularly welcome
  comments on whether responsible clinicians should
  be required to use them. A possible alternative
  (with these and other forms), would be for the
  Department or someone else to make available
  a model form which could be used if organisations
  wished.

49
What Products will the Administration Work-stream
deliver

• We will be providing a Training work book for
  Administrators and Hospital Managers
• We will be commissioning a new Statutory Forms
  Manual in conjunction with IMHAP which will
  include Court Order Forms. Two copies will be
  made available to each Trust free and during the
  first six months further copies will be available
  at cost price plus a handling fee.
• We will be providing one days training for
  Administrators and one days training for Hospital
  Managers
• We may be providing an Administration Manual

50
What Needs to be Done by MHA Administration?

• Ensure that new consent regulations for CAMHS
  which came into force in January are adhered to
• Prepare/revise local forms for
• a) Section 17 leave 7days or more
• b) Suspension of CTO conditions include
  distribution requirements
• c) Monitoring forms for change of place of safety
• d) Medical recommendation Statutory Forms need to
  have appropriate treatment added to form
• e) Ensure that diary dates are amended to reflect
  changes to the 83 Act
• f) Training of Hospital Managers provide numbers
  for attendance at national training event in
  July/September

51
What Needs to be Done by MHA Administration? Cont.

• g) access to electronic records for
• i) MHRT ii) IMHA iii) Hospital Managers
• h) Preparing for Hearings for Patients on SCT
• i) Preparing for MHAC visits to SCT Patients
• j) Ensuring that new policy for SCT includes
  communication requirements for MHAA
• k) Introducing a Policy for MHRT Hearings to
  ensure compliance with Regulation 6 and
  recommendations of MHRT Improvement Pilot
• l) Training for Trainers to ensure that MHAA is
  seen as the key MHA training resource where
  appropriate

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THANK YOU!
Yens.marsen-luther_at_londondevelopmentcentre.org