Implementation of the Mental Health Act 2007 Core Module

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 This workshop will enable you to: Explain the background to and purpose of the Mental Health Act 2007 including the role of the Regulations Outline the key changes to the Mental Health Act 1983 Outline the key content of the Mental Health Act 1983 Code of Practice for Wales (the Code) Identify and describe the guiding principles in the Code Outline the changes to the Mental Capacity Act 2005 Outline the principal changes to the Domestic Violence, Crime and Victims Act 2004.

Timetable Start 9.15 Goals and objectives Mental Health Act 2007 and Code of Practice Coffee Criteria for detention Supervised community treatment MHRT for Wales and IMHA Provision for young people ECT Power to take and convey and places of safety Lunch Deprivation of liberty safeguards Domestic Violence, Crime and Victims Act Review and evaluation Close 15.00

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 Health Act 2007 The Mental Health Act 1983 The Mental Capacity Act 2005 The Domestic Violence, Crime and Victims Act Introduced amendments to several earlier Acts:

Activity identify the significant changes to the Act, and the impact of these changes on your role Changes to the Mental Health Act In pairs, using the information in your participant pack:

Session 3 Mental Health Act 1983 Code of Practice for Wales

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?

Empowerment principles 1.Patient well-being and safety should be at the heart of decision-making 2.Retaining the independence, wherever practicable, and promoting the recovery of the patient should be central to all interventions under the Act 3.Patients should be involved in the planning, development and delivery of their care and treatment to the fullest extent possible 4.Practitioners performing functions under the Act should pay particular attention to ensuring the maintenance of the rights and dignity of patients, and their carers and families, while also ensuring their safety and that of others

Equity principles 5.Practitioners must respect the diverse needs, values and circumstances of each patient 6.The views, needs and wishes of patients’ carers and families should be taken into account in assessing and delivering care and treatment 7.Practitioners should ensure that effective communication takes place between themselves, patients and others

Effectiveness and efficiency principles 8.Any person made subject to compulsion under the Act should be provided with evidence based treatment and care, the purpose of which should be to alleviate, or prevent a worsening of, that person's mental disorder, or any of its symptoms or manifestations. 9.Practitioners should ensure that the services they provide are in line with the Welsh Assembly Government’s strategies for mental health and learning disability

Session 4 Criteria for detention

The criteria remain generally much as before Also apply to the new provisions for supervised community treatment (SCT) Addition that 'appropriate medical treatment' must be available for the patient 'Treatability test' has been removed.

Appropriate treatment test is available to the patient which is appropriate it considers the nature and degree of the patient’s mental disorder takes account of all other circumstances of the patient’s case. The criteria cannot be met unless medical treatment:

Medical Treatment 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 new rules also stipulate that the purpose of medical treatment, “is to alleviate, or prevent a worsening of, the disorder or one or more of its symptoms or manifestations”.

Activity In your groups, read through the cases for Maggie, Morgan and Jim and then decide whether in your view: –the person has a mental disorder –whether detention under the 1983 Act would be possible. Please give reasons for your answers

Appropriate treatment test When does the appropriate treatment test apply? Section 3 –criteria for detention under section 3 of the 1983 Act Related sections of Part 3 and corresponding criteria for renewal and discharge –section 36 - remand for treatment –section 48 - transfer of unsentenced prisoners –section 51(6) - hospital orders where it is impractical or inappropriate to bring a detainee before the court.

Appropriate treatment test When does the appropriate treatment test apply? –Section 17A - as part of the criteria for community treatment orders. 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).

Session 5 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.

Activity In groups, read through the case study and answer the questions using the information in your participant pack.

Patients 16 or over Those with capacity to consent to treatment can only be treated if they consent Those who lack the capacity to consent to treatment can be treated without their consent Force cannot be used to administer treatment if the patient objects to it, except in emergencies Force is permissible if the patient does not object to treatment If the treatment cannot be given to the patient if it conflicts with a valid and applicable advance decision made under the Mental Capacity Act.

Children aged under 16 Children aged under 16 can be made subject to a CTO A child with capacity to consent to treatment can only be treated if they consent A child who lacks the capacity to consent to treatment can be treated without their consent Advance decision should not arise though, since these cannot in general be made by children under 16.

Emergency treatment for patients lacking capacity Force can be used to give treatment only if: it is immediately necessary it needs to be given to prevent harm to the patient, and it is a proportionate response to the likelihood of the patient suffering harm and to the seriousness of the harm.

Emergency treatment Treatment can be classed as immediately necessary if it is intended to: –save the patients life, or –prevent a serious deterioration of their condition, or –alleviate serious suffering by the patient, or –prevent the patient from behaving violently or being a danger to himself or others and represents the minimum interference necessary. Note provisos

Session 6 Mental Health Review Tribunal for Wales and Independent mental health advocates

Referrals 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.

Referrals 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.

Referrals After 3 years without review –Hospital managers were only under a duty to make a referral to the MHRT upon the renewal of patient's detention –The requirement to refer a patient aged under 18 years after one year represents an extension to the previous age limit of 16 years

Referrals On revocation of a CTO –Statutory duty to refer to MHRT for Wales as soon as possible after the order is revoked. –Note this is in addition to the duty to refer six months after the patient’s admittance following revocation of the CTO

Qualifying Patients Patients who qualify for advocacy support are essentially those who are: –liable to be detained under the Act, or –subject to guardianship, or –a community patient. 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 responsible clinician or an AMHP.

Independent mental health advocates How does the IMHA help the patient? Includes help in obtaining information about and understanding: –the patient’s rights under the Act –the provisions of the Act under which the patient qualifies for an IMHA –any conditions or restrictions which affect the patient –the medical treatment the patient is receiving or is being proposed or discussed –why it is given, proposed or discussed –the legal authority for providing the treatment –the requirements of the Act which apply to treatment.

Independent mental health advocates How does the IMHA support the patient? The IMHA may also give: help in obtaining information about and understanding any rights which may be exercised, and help (by way of representation or otherwise) in exercising those rights.

Independent mental health advocates IMHA has a right to: –access and inspect 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 hospital managers cannot withhold correspondence between patients and their advocates.

Session 7 Provisions for young people

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. Informal admission of patients aged 16 or 17 with the capacity of consent

Provisions for young people 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. 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? –Consult a suitable person with experience in child and adolescent mental health services cases. Accommodation for patients aged under 18

Session 8 Electro-convulsive therapy

New safeguards New safeguards for patients introduced: Abolition of the power to impose ECT on a detained patient who has the capacity to consent, other than in an emergency situation ECT can only be given when the patient gives consent, or is incapable of giving consent.

Consent to ECT Patients capable of consent Detained adult patient: –consent must be certified by either the AC in charge of their treatment or by a SOAD. Detained or informal patient not subject to a CTO under 18 years of age: –a SOAD must certify their consent and that it is appropriate for the treatment to be given.

Consent to ECT Patients incapable of consent The SOAD must certify that: –the patient is not capable of understanding the nature, purpose and likely effects of the treatment, and –it is appropriate for the patient to receive the treatment. These provisions apply to all detained patients (adults and children) and informal child patients not subject to a CTO.

Consultation by SOAD Before issuing a certificate, the SOAD must first consult two other persons: –A nurse concerned with the patient's medical treatment, and –Another person professionally concerned with the patient’s medical treatment who is neither a nurse nor a doctor. The patient’s RC and the person in charge of their treatment (if they are not the RC) are specifically excluded from being a person the SOAD must consult.

Certification not possible The SOAD may not give the certificate if giving the treatment would conflict with: –a valid and applicable advance decision of the patient not to receive the treatment –a decision made by a deputy or done as defined by the Mental Capacity Act 2005 –an order of the Court of Protection.

Urgent treatment Emergency ECT has been extended to patients who are not consenting. The conditions that must be met before ECT may be given in an exceptional emergency are that the treatment: –is immediately necessary to save the patient’s life, or –is immediately necessary to prevent a serious deterioration of his or her condition and is not irreversible.

Electro-convulsive therapy These are that the treatment (not being irreversible or hazardous): –is immediately necessary to alleviate serious suffering by the patient, or –is immediately necessary and represents the minimum interference necessary to prevent the patient from behaving violently or being a danger to himself or to others. Conditions that may not be used for authorising ECT

Session 9 Power to take and convey

A patient who is liable to be detained can be taken into custody and returned to the place where they are required to reside, as named in their care plan. Changes: –Extended to Community patients –Patient being “returned” to a place can be taken there for the first time –Extends powers to include new guardianship patients –Not confined to being returned after absconding or failing to return voluntarily.

Power to take and convey Who can exercise this power? an AMHP an officer on the staff of the hospital a constable (in effect any police officer) anyone authorised in writing by the RC or the hospital managers.

Session 10 Places of safety

Existing powers Under section 135(1), the police can, on the authority of a magistrate, enter premises and remove to a place of safety a person who: –is thought to have a mental disorder, and –has been or is being ill-treated or neglected, or –if living alone, is unable to care for himself. A place of safety includes a hospital, a care home and a police station.

Places of safety Under section 136, the police can remove from a public place to a place of safety a person who: –appears to have a mental disorder, and –appears to need immediate help. Under either section, the person can be detained at the place of safety for up to 72 hours.

New power to transfer The 2007 Act has amended both section135 and section 136 so as to enable a person detained at a place of safety to be transferred to another place of safety Their detention remains subject to the overall time limit of 72 hours.

Session 11 Changes to the Mental Capacity Act 2005 and introduction of Deprivation of liberty safeguards

Mental Capacity Act 2005 The Mental Capacity Act 2005 has been amended to: –provide additional safeguards for people who lack capacity to consent, and –whose care or treatment necessarily involves a deprivation of liberty, but –who either are not, or cannot be, detained under the Mental Health Act These safeguards are referred to as deprivation of liberty safeguards.

Deprivation of liberty safeguards Definition of deprivation of liberty Defined in the legislation as having the same meaning as in Article 5(1) of the ECHR. –What is meant by deprivation of liberty in that context? –How can we decide whether a particular set of circumstances amounts to actual deprivation of someone's liberty or whether it is just a restriction of liberty?

Deprivation of liberty safeguards The difference between restriction or deprivation of liberty is one of degree or intensity rather than of nature or substance No simple definition can be produced that would apply in every case Every case must be assessed on its own terms.

Deprivation of liberty safeguards Case law Based on existing case law, the following factors might well be considered: –The person is not allowed to leave the facility –The person has no, or very limited, choice about their life within the care home or hospital –The person is prevented from maintaining contact with the world outside the care home or hospital.

Activity In small groups, using the information in the participant pack, analyse the case study and discuss responses to questions.

Procedures – requesting authorisation A request for authorisation must be made if a person: –meets or is likely to meet all of the qualifying requirements –is, or is likely to be, detained as a resident in that hospital or care home in circumstances which amount to deprivation of their liberty. Assessments must be made as soon as possible after application Regulations may specify the time period for completion Existing equivalent assessments may be used if carried out within the last year.

Deprivation of liberty safeguards If the person does not meet the eligibility requirements for an authorisation to be issued: –The supervisory body must turn down the request for authorisation –The assessment process will be discontinued.

Procedures – After authorisation is granted Representative is appointed who will: maintain contact with the relevant person support and represent them in matters concerning the authorisation, including requesting a review or applying to the Court of Protection on their behalf.

Urgent authorisation The need is so urgent that it is appropriate to begin before the request is made, or The need has become so urgent that it is appropriate to begin before the request is dealt with. An urgent authorisation can never be issued without a request for a standard authorisation being made.

Urgent authorisation How long does an urgent authorisation last? Maximum of 7 days In exceptional circumstances it is extended to 14 days Can be extended by up to a further 7 days if there are exceptional reasons At the end of the period specified or earlier.

Methods of appeal and review The supervisory body may review a standard authorisation at any time and must do so if requested to by any of: –the relevant person (the patient) –the relevant person's representative –the managing authority of the care home or hospital.

Methods of appeal and review The qualifying requirements are reviewable if: the relevant person does not meet one or more of the qualifying requirements, or the reason that they meet one of the qualifying requirements is not the reason stated in the authorisation, or there has been a change in the relevant person's case (this applies to the best interests requirement only).

Methods of appeal and review The supervisory body must decide if any of the qualifying requirements appear to be reviewable. –If one or more of the age, mental health, mental capacity, objections element of eligibility or no refusals requirements are reviewable, the supervisory body must commission a review assessment –If the best interests assessment appears to be reviewable the supervisory body must obtain a best interests review assessment.

Methods of appeal and review When the review is complete, the supervisory body must inform –the managing authority of the hospital or care home –the relevant person, and –their representative.

Session 12 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.

Victim’s 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 –inform the hospital managers of the victim’s wishes.

Domestic Violence, Crime and Victims Act 2004 The hospital managers must: forward representations to the relevant people for making decisions on discharge or community treatment orders. pass any information received from them to the victim 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.

Responsibilities Hospital managers must be informed by: the RC and the MHRT if the patient is to be discharged the RCs whether they are to make a community treatment order the RCs about information regarding any conditions and when the order will end.

Session 13 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: Explain the background to and purpose of the Mental Health Act 2007 including the role of the Regulations Outline the key changes to the Mental Health Act 1983 Outline the key content of the Mental Health Act 1983 Code of Practice for Wales (the Code) Identify and describe the guiding principles in the Code Outline the changes to the Mental Capacity Act 2005 Outline the principal changes to the Domestic Violence, Crime and Victims Act 2004.

Review and Action Planning Complete the action plan

Sources of further study Sources of further information and study: Specific modules.

Evaluation Please complete the course evaluation form Thank you