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Consent to treatment under part 16 of the Mental Health (Care And Treatment) (Scotland) Act 2003

 

AR-08-09-table-36

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Our interest in these figures

The 2003 Act is designed to provide safeguards for patients in general. Part 16 makes provisions for additional safeguards in relation to medical treatment particularly, but not only, where this is given without the patient's consent. There are specific safeguards for certain forms of medical treatment including electroconvulsive therapy (ECT) and procedures classified as Neurosurgery for Mental Disorder (NMD). Under the 2003 Act certain treatments can only be authorised by an independent doctor, known as a Designated Medical Practitioner (DMP).

Neurosurgery for Mental Disorder (Sections 235 and 236)

The 2003 Act requires that all patients (including informal patients) who are to be put forward for a procedure classified as neurosurgery should first be assessed by a Designated Medical Practitioner (DMP) and two other persons (not medical practitioners) arranged by the Commission.  These three persons assess the individual's capacity to consent to neurosurgery and confirm this consent has been recorded in writing. In addition the DMP also assesses that the treatment is in the person's best interests. All three practitioners sign Form T1 if the treatment is approved.  We seek to follow up progress reports on all patients having neurosurgical procedures at 12 months and again at 24 months from the team providing ongoing care for the person.

The Dundee Advanced Interventions Service (AIS) remains the only centre in Scotland providing neurosurgical treatment and has received referrals from Scotland, England and Eire.  Although the 2003 Act has provision for treatment to be carried out without a patient's consent in certain situations, this has not happened since the Act was implemented.  As the AIS only provides operations for people who are capable of giving informed consent this situation is very unlikely to occur.

Our Neurosurgery for Mental Disorder (NMD) Working Group met on three occasions this year and there was also a useful meeting with the Dundee AIS.  The medical treatment known as Deep Brain Stimulation (DBS) is classified for the purposes of the Act as Neurosurgery and requires the same safeguards under Section 234.  With developments in research and the understanding of DBS we anticipate an increase in referrals to us for assessment and with this in mind the Working Group is in the process of recruiting additional members including DMPs.Additional training is required for all Working Group members to undertake their safeguarding roles in this respect.

Other safeguarded treatments (Sections 237 and 240)

Treatments covered by sections 237 and 240 include ECT, any medicine for the purpose of reducing sex drive, medicine given beyond two months and artificial nutrition.

In November 2007 Responsible Medical Officers (RMOs) were given notice that all patients' treatment should comply with procedures under the 2003 Act by the end of March 2008.  In situations where there was still an old Form 9 or 10 under the previous Act this required to be replaced by Form T2 or T3 which have additional safeguards. Treatment given without consent is authorised by a DMP on Form T3.

In October 2008 new versions of T1, T2 and T3 were introduced (version 6.1) and we are confident that this has reduced some problems which were causing confusion with the completion of forms and rectified some minor errors.  As a result the completion of forms has greatly improved.  Focused audits on specific topics are used to identify training needs for the annual seminar for DMPs.

A number of T2 and T3 forms replacing Forms 9 and 10s were received after the specified date but as far as we are aware all hospitals are now complying with the correct procedures.  The process has been greatly helped by liaison between our case work managers and medical records officers.  We are also grateful to hospital pharmacists who have taken an interest in monitoring this area of practice.

Treatment given with the person's consent under the 2003 Act is authorised by Form T2 and the patient's consent in writing.  Under the procedures of the 2003 Act we do not automatically receive these T2 forms and therefore cannot make comparisons with previous years or the 1984 Act. We have made a recommendation to the Scottish Government that it becomes a requirement of the 2003 Act that we are sent a copy of Form T2. In the meantime we are grateful to colleagues who continue to forward us copies of Form T2.

We received 755 T2 forms: 14 were for ECT, the majority of the rest were for medication beyond 2 months. The remaining forms were either for medication to reduce sex drive or the information provided was incomplete.

Treatment given without consent is authorised by a DMP on Form T3

The number and types of treatments authorised by a Certificate of the DMP is shown in the table above.  The majority of treatments authorised were medication beyond two months. As in previous years about half of the patients receiving ECT objected to it or were resisting the treatment. A third of these required treatment to save life, the rest to alleviate serious suffering and/or prevent serious deterioration.

Children and Young People

We received 14 form T2s for patients who were under 18 at the time of completion and consenting to treatment. There were 24 T3 forms for patients under 18 receiving treatment without consent.  None of the T3s were for ECT, 9 were for artificial nutrition and 15 were for medication beyond 2 months.  In all cases except one, either the RMO or the DMP was a child specialist.In the one case the first DMP was a learning disability specialist but it was quickly identified that the patient was also aged under 18 and we were able to send a second DMP with expertise in both learning disability and child psychiatry.

Designated Medical Practitioners

Seventy-three doctors were available to provide second opinions on safeguarded treatments during the year reported.We held an annual seminar for DMPs in October 2008 which was attended by slightly more than half of the DMPs. A summary of the issues discussed is sent to all DMPs. This meeting included an expert speaker on good practice in prescribing for the elderly and a DMP led discussion on ECT issues.  The new version of Form T3 (version 6.1) was also introduced and a number of good practice points were highlighted.During the year a number of psychiatrists expressed an interest in becoming DMPs and two induction seminars took place in the Spring of 2009.  We are grateful to those doctors who have provided second opinions often at short notice.We have noted that clinicians are finding their own jobs very busy and it is more difficult to identify DMPs willing to travel further afield particularly to the Grampian and Highland regions.

Our recommendations for amendments to Part 16 of the 2003 Act

Following review of the 2003 Act a number of minor amendments we have suggested the following:

  • Duration of Authority to Treat (Forms T1, T2 and T3)

We have recommended to the Mental Health Review Group that each certificate of consent to treatment should have a statutory duration of authority, depending on the nature of the proposed treatment.

  • Section 244 (Additional Safeguards for Informal Patients)

New and potentially controversial or relatively unevaluated treatments for mental disorder emerge from time to time.  The MWC recommends an extension of Ministers' power to make regulations to prescribe conditions that must be satisfied before certain types of medical treatment specified in regulations are given to any patient regardless of age and regardless of whether the giving of medical treatment is or is not authorised by virtue of this Act or the 1995 Act. 

As well as providing regulations for new treatments, this would correct an apparent anomaly whereby regulations pertaining to people under the age of 16, but where treatment is authorised by virtue of the 2003 Act, and who give consent to treatments specified under Section 237 could, in theory, be treated without the requirement for an independent opinion.

  • Neurosurgery for Mental Disorder (Sections 235 and 236):

We were asked to assess two people being considered for NMD during the past year both of whom had experienced severe disabling depressive disorder and were considered to have had a full range of appropriate treatments without success.  In both cases neurosurgery was considered to be in their best interests and the procedures took place within a few months of assessment. The NMD Working Group also considered reports on the progress of a number of people who had undergone procedures in previous years.