1. NHS North Yorkshire and York1 The MCA & The MHA The main features GP Registrars 12 December 2012 Chris Brace

2. NHS North Yorkshire and York2 Different Purposes The Mental Health Act 1983 and the Mental Capacity Act 2005 are different legal instruments with different powers and safeguards

3. NHS North Yorkshire and York3 Aims The Mental Capacity Act 2005 exists to empower and protect incapacitous adults. This Act provides a coherent framework for decision making for incapable adults that did not exist in the common law. The Mental Health Act 1983 provides a legal framework for the treatment of patients with mental disorder, without which there would be a risk of harm to the patient’s health or safety or a risk of harm to others. “Mental disorder” is a threshold in both

4. NHS North Yorkshire and York4 MHA If the criteria are met the Mental Health Act can be applied to a person with capacity without that persons consent or may be applied to a non compliant or dissenting patient who lacks capacity and for whom detention is necessary.

5. NHS North Yorkshire and York5 Application of the MHA 1983 The Mental Health Act should be applied where a patient… S.2(2)(a) is suffering from mental disorder of a nature or degree that warrants detention in hospital for assessment (followed by medical treatment)… (b) …ought to be detained in the interests of his own health or safety or for the protection of others (s1(2) “mental disorder” means any disorder or disability of the mind

6. NHS North Yorkshire and York6 Application of the MCA 2005 The Act and 2007 amendments only applies to adults (over 16yrs MCA over 18 DoLS) who lack capacity. “Best interests decisions” are only made in the absence of capacitous consent or refusal. Mental capacity is specific to the decision that has to be made

7. NHS North Yorkshire and York7 MCA continued S.2 A person lacks capacity in relation to a matter if…*unable to make a decision…because of an impairment of or disturbance in the functioning of the mind or brain.

8. NHS North Yorkshire and York8 S.3 *unable to- -Understand information relevant to the decision -retain that information -use the information in the decision making process -communicate the decision

9. NHS North Yorkshire and York9 Physical Treatment Under the MHA The Act includes treatment of physical health problems only to the extent that such treatment is part of, or ancillary to, treatment for mental disorder (eg – treating wounds self-inflicted as a result of mental disorder). Otherwise, the Act does not regulate medical treatment for physical health problems. MHA Code, paragraph 23.4

10. NHS North Yorkshire and York10 Physical Treatment Under the MCA If the patient lacks the capacity to consent to the particular treatment proposed:- - Check records for Welfare LPA - Is there an ADRT If there is no authority to refuse the treatment a best interests decision is made by the person proposing the treatment.

11. NHS North Yorkshire and York11 Best Interests The Mental Capacity Act (s4) clarifies best interests decision making: Section 5 clarifies common law decision making and acts which are undertaken in connection with care and treatment Section 6 sets limits to section 5 acts particularly in the area of restraint, as well as clarifying the priority given to Lasting Power of Attorney.

12. NHS North Yorkshire and York12 Treatment not permitted under the MCA Treatment to which section 57 MHA applies, that is: treatment requiring consent and a second opinion ECT to a detained patient What about ECT for incapacitous informal patients? Treatment for mental disorder to a detained (MHA) patient Treatment to a SCT patient whilst in the community.

13. NHS North Yorkshire and York13 MHA - Capacity and Consent MHA Code, 23.27-23.36 For patients over 16, capacity assessed as per MCA For patients under 16, competence assessed as per the ‘ Gillick ’ (or ‘ Fraser ’ ) rules “ Competence means that the child has sufficient understanding and intelligence to enable them to fully understand what is involved in a proposed treatment ” maturity comes into it. –Reference Guide, 17.17 Even though treatment may be given compulsorily, “ the patient ’ s consent should still be sought before [it] is given, wherever practicable ” –MHA Code, 23.37

14. NHS North Yorkshire and York14 overlap The Mental Health Act provides a legal framework for detention for the purpose of treating mental disorder, using compulsion where necessary. Treatment for physical disorder cannot be given without consent under the Mental Health Act. However a patient may be detained for the assessment and or treatment of their mental disorder and if, and only if, the patient lacks capacity to decide on physical treatment a best interests decision may be made under the Mental Capacity Act 2005

15. NHS North Yorkshire and York15 DoL MHA MCA Treatment overlap MHA Part IV Detention overlap – Eligibility. With the Kind Permission of Neil Allen, Thirty Nine Essex Street Chambers

16. NHS North Yorkshire and York16 Which Act to use? You cannot pick and choose between the MHA and MCA. If the Mental Health Act could be used it should be used. The Mental Health Act has primacy. This is underlined in GJ v The Foundation Trust

17. NHS North Yorkshire and York17 However.. if the patient does not meet the threshold criteria in s2 and or s3 (see slide 5) of the Mental Health Act, and the nature of the restrictions on their liberty which are necessary to provide care amount to a deprivation of liberty, an application for DoLS should be made.

18. DoLS: What are the Deprivation of Liberty Safeguards The safeguards (inserted into the MCA) provide legal protection through the use of prescribed procedures for people who lack capacity and for whom deprivation of liberty in a hospital or care home may be necessary and, for whom the Mental Health Act would not be appropriate. NHS North Yorkshire and York18

19. NHS North Yorkshire and York19 The outline procedure for authorising detention under (MCA) DoLS Managing Authority (hospital/care home) identifies a potential Deprivation of Liberty applies for authorised deprivation of liberty to the Supervisory Body (Primary Care Trust / Local Authority). The supervisory body arranges the following assessments: Age, Mental Health, Mental Capacity, Best interest, Eligibility, No refusals. Authorisation may be granted for up to one year

20. DoLS Assessors Mental Health Assessor – a registered medical practitioner who has undertaken additional training for the role. Best Interest Assessor (BIA) – a health or social care professional who has undertaken additional training for the role. CPD requirements – annual refresher.

21. NHS North Yorkshire and York21 Outline procedures for admitting to the Mental Health Act Two registered medical practitioners (one of whom is approved under section 12 (2) examine the patient. May make a medical recommendation(s) for detention under s.2 or s.3. An Approved Mental Health Professional assesses the patient and consults with their nearest relative and, may make an application (for detention) founded on the medical recommendation(s). The application (pink section papers) are received on behalf of the hospital managers (Trust Board) The patient and their nearest relative are informed of their rights.

22. Section 12 MHA Specifies the requirements that apply to medical reccomendations Subsection (2) provides for the Secretary of State to approve doctors who have special experience in the diagnosis and treatment of mental disorder. Approval delegated to Strategic Health Authorities (NCB post April 2013) NHS North Yorkshire and York22