1. Implementation of the Mental Health Act 2007 General Awareness Module

2. Session 1 Goals and Objectives

3. Domestics Emergency procedures Expected finish times Refreshment breaks Venue facilities.

4. Role of Facilitator Guide you through the course Maximise your participation Challenge / support / advise Provide information Collate feedback / outcomes.

5. Ground Rules Commitment Courtesy Honesty Responsibility Time keeping.

6. Objectives This workshop will enable you to: Explain the background to and purpose of the Mental Health Act 2007 Outline the following key changes to the Mental Health Act 1983 Identify and describe the guiding principles in the Mental Health Act 1983 Code of Practice for Wales Define the changes to the Mental Capacity Act 2005.

7. Timetable Start 9.15 Goals and objectives Mental Health Act 2007 Key changes to the 1983 Act Break Mental Health Act 1983 Code of Practice for Wales Deprivation of liberty safeguards Review and evaluation Close 11.45

8. Session 2 Mental Health Act 2007

9. 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.

10. 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.

11. The Mental Health Act 2007 The Mental Health Act 1983 The Mental Capacity Act 2005 The Domestic Violence, Crime and Victims Act 2004. Introduced amendments to several earlier Acts:

12. Key Changes to the Mental Health Act 1983 Key Changes Definition of mental disorder Appropriate medical treatment Supervised Community Treatment Professional Roles Advocacy ECT Power to transfer patients

13. Definition of Mental Disorder The definition of mental disorder has been changed to: 'any disorder or disability of the mind'. The four categories of disorder have been abolished, so there may be a few disorders now covered which previously were outside the scope

14. Definition of Mental Disorder Exclusions: Learning disability unless 'associated with' abnormally aggressive or seriously irresponsible behaviour Dependence on alcohol and drugs.

15. 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:

16. Appropriate medical treatment Availability The test requires that appropriate treatment is actually available for the patient. It is not enough for appropriate treatment to exist in theory for the patient's condition.

17. 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 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”.

18. 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 provides that an RC will be an approved clinician (AC) with overall responsibility for a patient’s case. –it replaces the role of the approved social worker (ASW) with that of the approved mental health professional (AMHP).

19. Professional roles - Approved Clinician (AC) Approved by the Welsh ministers and delegated to Local health Boards Requirements set out in the Mental Health Act 1983 Approved Clinician Directions 2008

20. Professional roles - Approved Clinician (AC) For a person to be 'approved', they must meet the following criteria: –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 approved clinicians.

21. Professional roles – Responsible Clinician May be any practitioner provided that that person has been approved for that purpose - i.e. an approved clinician (AC). In addition to the functions which RCs have taken over from RMOs, they also have new functions in relation to SCT.

22. Professional roles – Responsible Clinician Responsibilities under Part 2 of the Act: Where a patient is subject to compulsory admission to hospital or guardianship, the duties previously fulfilled by the RMO. Similar role in respect of SCT. Renewing a patient's detention or extending their CTO. Responsibilities under Part 3 of the Act: Where a patient is concerned in criminal proceedings, the duties previously fulfilled by the RMO. Certain functions previously restricted to registered medical practitioners can now be exercised also by ACs.

23. Professional roles – Responsible Clinician Who will be the RC? In all cases the RC will be the AC with overall responsibility for the patient’s case. This is set out in section 34(1) of the 1983 Act. If the RC is not qualified to make decisions about a particular treatment then another appropriately qualified professional will take charge of that matter, with the RC continuing to retain overall responsibility for the patient's case.

24. Professional roles – Approved mental health professionals Functions of the AMHP As has already been noted, the AMHP has taken over duties and functions of the ASW. This includes functions such as: –making applications for admission and detention in hospital under Part 2 of the 1983 Act –making applications for guardianship. Like RCs, the AMHPs also have certain new functions in relation to SCT.

25. Professional roles – Approved mental health professionals Who may be an AMHP? Social workers A wider group of professionals if they have the right skills, experience and training.

26. Professional roles – Approved mental health professionals How is an AMHP approved? Local Social Services Authorities (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 (see below) setting out conditions for approval, factors as to competency and requirements for training.

27. Professional roles – Approved mental health professionals To fulfil the professional requirements set out in the Mental Health (Approval of Persons to be Approved Mental Health Professionals) (Wales) Regulations 2008, a person must be a: a registered social worker or a chartered psychologist or a first level nurse whose field of practice is mental health or learning disabilities nursing or an occupational therapist.

28. 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.

29. Supervised community treatment (SCT) 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.

30. Supervised community treatment (SCT) Patients discharged onto SCT may be recalled to hospital for treatment should this become necessary May be for either in-patient or out-patient care. 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.

31. Making a Community Treatment Order Criteria The RC and AMHP must be satisfied that the following criteria as set out in section 17A of the Act are met: (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... 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) to recall the patient to hospital (e) appropriate medical treatment is available for him.

32. Conditions of a CTO There are two conditions that must appear in all CTOs. The patient: 1.Must make themselves available for medical examinations as required for the purposes of determining whether the CTO should be extended 2.Must make themselves available for medical examinations to allow a second opinion approved doctor (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.

33. Conditions of a CTO 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.

34. Community Treatment Order How long does it last? Initially last for 6 months from the date when the order was made. The order can then be extended for a further 6 months and, following that, it can be extended for periods of one year at a time.

35. Community Treatment Order - Extension The RC must: examine the patient provide a report to the hospital managers confirming that the necessary criteria are met. The AMHP must agree: that the criteria for extension of the CTO are satisfied, that it is appropriate to extend the CTO, before the report can be made.

36. Community Treatment Order – 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. The RC can recall a patient only for a maximum of 72 hours without revoking the CTO.

37. Community Treatment Order – Revocation If the RC decides that the patient meets the normal criteria for detention for treatment in hospital, –the RC may revoke the patient’s CTO –an AMHP’s agreement is required –if the AMHP does not agree, the patient will remain on SCT –the authority to detain the patient is revived and considered a new period of detention and the patient has the normal rights of appeal.

38. Role of the patient's nearest relative Rights in connection with the care and treatment of a mentally disordered patient, including –the right to apply for admission to hospital –the right to block an admission for treatment –the right to discharge a patient from compulsion –the right to certain information that has been given to the patient.

39. Nearest relative Who may act as the nearest relative? husband or wife, civil partner son or daughter father or mother brother or sister grandparent grandchild uncle or aunt nephew or niece.

40. Nearest relative - Displacement The 1983 Act allowed various parties to apply for an order displacing the nearest relative on grounds such as: –the nearest relative is too ill to act –the nearest relative unreasonably blocks admission –the nearest relative has discharged (or is likely to discharge) the patient without due regard.

41. Nearest relative - Displacement The 2007 Act has changed in two ways: 1.Not a suitable person 2.Right for a patient to apply

42. 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.

43. Independent Mental Health Advocates (IMHA) Qualifying patients: persons who are liable to be detained under the Act (excluding those subject to sections 4, 5(2), 5(4), 135 or 136) patients subject to guardianship community patients (i.e. those on SCT)

44. How does the IMHA support 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, and the reasons for it –the legal authority for providing the treatment –the requirements of the Act which apply to treatment.

45. How does the IMHA help the patient? The IMHA may also: support the patient to exercise their rights under the Act, including by representing them support patients in other ways to ensure they can participate in decisions about care and treatment.

46. Independent Mental Health Advocates The IMHA has a right to access and inspect: any hospital or local authority records relating to the patient. such records relevant to the support the advocate will provide to the patient.

47. Independent Mental Health Advocates Who can act as an IMHA? –Person approved by the Local Health Board or –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.

48. Electro-convulsive therapy 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.

49. 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.

50. 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.

51. 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.

52. 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.

53. Places of safety – Existing powers Under section 135(2) the police can, on the authority of a magistrate: –enter premises (if need be by force) and –remove a patient who is liable under the Mental Health Act to be taken or retaken into custody.

54. 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.

55. 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.

56. Activity In groups, discuss the implications for your role of these changes.

57. Session 3 Mental Health Act 1983 Code of Practice for Wales

58. Guiding principles Guiding principles grouped under three broad headings: The empowerment principles The equity principles The effectiveness and efficiency principles

59. Guiding principles Should be considered whenever a decision has to be made about a course of action under the Act Work together to form a balanced set of considerations which should inform all decision-making.

60. 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

61. 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

62. 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

63. Session 4 Changes to the Mental Capacity Act 2005 and introduction of Deprivation of liberty safeguards

64. 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 1983. These safeguards are referred to as deprivation of liberty safeguards and are expected to commence in April 2009.

65. Deprivation of liberty safeguards They come into play when: someone who has a mental disorder, and who lacks capacity to make decisions for themselves, is (or is to be) deprived of their liberty in a hospital or care home Except where that person: is detained under the provisions of the Mental Health Act 1983, or is under 18 years of age.

66. Deprivation of liberty safeguards Where all the above conditions are met: The hospital or care home must seek authorisation for its actions from a 'supervisory body'. Without such authorisation being granted, the deprivation of liberty may not proceed.

67. Deprivation of liberty safeguards Authorisation for the deprivation of liberty will be given by the supervisory body only if it is satisfied that: –it is in the person's best interests, and –there is no less restrictive alternative available. The deprivation may continue only for the shortest period that is necessary.

68. Deprivation of liberty safeguards Deprivation of liberty is not specifically defined in the Mental Capacity Act. Legal interpretation of deprivation of liberty will be a question for the courts There can be no simple definition that would apply in all cases: –It will depend very much on the circumstances of the particular individual. –The person must definitely have been deprived of their liberty; if their liberty has been only restricted, then their case will not come within these safeguards.

69. Deprivation of liberty safeguards The following factors might well be considered by the courts to be relevant: –The person is not allowed to leave the home or hospital. –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.

70. Deprivation of liberty safeguards The question of whether a person is being deprived of their liberty will need to be kept under review and addressed explicitly whenever a change is made to their care plan.

71. Deprivation of liberty safeguards – Standard authorisations Qualifying requirements: 1.Age 2.Mental health 3.Mental capacity 4.Best interests 5.Eligibility 6.'No refusals'.

72. Deprivation of liberty safeguards – Standard authorisations The managing authority of a hospital or care home must request authorisation from the supervisory body if a person is to be deprived of their liberty as a resident in that hospital or care home. The supervisory body will then conduct a series of assessments to verify that the person meets the six qualifying requirements. These assessments must be made as soon as possible after the application. If any of the assessments conclude that the person does not meet the criteria, the supervisory body must turn down the request for authorisation.

73. Deprivation of liberty safeguards – Urgent authorisations –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.

74. 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.

75. Activity In groups discuss how the introduction of deprivation of liberty safeguards will impact on your role

76. Session 5 Review, Action Planning and Evaluation

77. Review and Action Planning Review of your issues and goals Review of course objectives.

78. 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

79. Review and Action Planning Complete the action plan

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

81. Evaluation Please complete the course evaluation form Thank you