Saturday, 13 October 2007

Loose ends

Here are a couple of follow-up reports. You may recall the cheerful but vague young man who has been calling frequently for small prescriptions of diazepam and codeine. Last week I told him that it was time for him to tail off the diazepam, but he could have another two week supply of codeine as he had just learned that he had to go away urgently. Yesterday he came to see Martha, who learned that events had moved on and he no longer had to go away urgently, but for some reason he still needed more codeine. Now Martha may look as though a strong gust of wind might blow her away, but under her gentle exterior there is a determined streak a mile wide. It soon became apparent that she was not going to prescribe him anything and he left with almost indecent haste. We wait with interest to see if he will consult the other doctors in the practice about even more remarkable and unforeseen events.

And at the start of last week I attended a Mental Health Assessment on a man with schizophrenia who had not been taking his medication and was becoming socially withdrawn and neglecting himself. At that time he was happy to be admitted to hospital “informally”, which means voluntarily. However although his condition improved while he was in hospital, because of the support and because he was taking his medication, he had become increasingly unwilling to stay. So he had been detained temporarily under section 5.2 of the Mental Health Act, which allows patients to be kept in hospital against their will for a few days until a proper Assessment can be carried out. And yesterday afternoon I toddled off to the hospital to carry out another Assessment.

The interview room was depressing. There were no windows, and the walls and ceiling were painted the same dreary pale blue. There was an old desk, an examination couch and assorted chairs, while a battered electronic organ completed the furniture. We were quite a large gathering: a young social worker was being supervised by an Approved one, the locum consultant psychiatrist was accompanied by a medical student, and I was the elderly GP: an exotic creature looking like a fish out of water in the hospital environment. Finally our patient arrived, looking less dishevelled than when I last saw him.

Fortunately the situation was quite clear cut. He evidently had active schizophrenia which had improved since admission and would undoubtedly deteriorate again if he left hospital at present, which he fully intended to do. There was no doubt that detention under the Act was possible and desirable. The locum consultant didn't seem to have much time to talk to the medical student, so while she filled in the pink form I did a bit of impromptu teaching. In this case Section Two was inappropriate for that only allows detention for diagnosis, for up to 28 days. We knew the diagnosis. What was required was Section Three which allows detention for treatment, for up to six months although most patients revert to “informal” status long before then.

I will be able to claim another fee, though nothing like the amount that GPs apparently get in the Shrink's area. The whole thing took two hours, including travelling time and waiting for the consultant to turn up, so the mental health authorities were getting my services at a bargain rate.


Anonymous said...

This was an interesting post.
My father was detained once, by two doctors, if I remember correctly. He was admitted to St George's Hospital and stayed about six months. At the time, I think it was difficult to get him out. (This all happened in the sixties)
Presumably, you have another meeting later and look at the situation, but just wondered how you revert to 'informal' status?

Anonymous said...

Annehelene - the psychiatrist looking after the patient will determine when they can have the section removed. This can be when they are getting better, complying with treatment, have good insight into their illness and situation, are willing to engage with the mental health services, etc. Alternatively the patient can apply to the hospital managers to have the section discharged or have a full tribunal. If either of these are successful (from the patient's point of view) then they revert to informal status and are free to discharge themselves from hospital if they wish.

There is one thing I haven't included as I am unsure which sections they can influence (pretty sure Section 2 but not sure about Section 3 or any others) and that is the patient's nearest relative can request discharge from a section. This can be challenged by the responsible medical officer but I'm not sure of the ins and outs of this.

I think this is all correct (am merely a medical student so have used your question as a mini test and answered as best I can without referring to my notes). Hopefully Dr Brown or the Shrink or someone more knowledgable will be able to tell us more!

Ms Medic said...

Thank you for teaching the student! We do appreciate it, since it makes such a difference to the rate we pick stuff up.
Annehelene, the only bit I can clarify above Kelly's neat description of the situation is that you can ask for 2 reviews within the first 6 months of a section 3, and then 1 per 6-month period after that.

The Shrink said...

Dr Brown, you do determine the Mental Health Act fee yourself (although conventionally the LMC or PCT will give a concensus figure) so if it's not work you're keen to do you could tell the ASW organising the assessment you do it for £4000 each assessment ;-)

Anne Helene, erm . . . what Kelly said :-)

Discharge by a Nearest Relative can be over-ruled by the Responsible Medical Officer who has 72 hours to issue a barring certificate under section 25.

The only other scenario for a 6 month detention when RMO/nearest relative/hospital managers/review tribunal can't discharge a patient from formal detention under a section of the MHA 1983 is if the patient has a section 41 Restriction Order imposed by a Court (along with their section 37 rather than section 3) since thr Home Office then need to agree to the discharge too.

Anonymous said...

Thanks Kelly, ms medic and the shrink for answering my query. Much appreciated.