Chamber and committees

http://reports.mwcscot.org.uk/.

The following tables have been produced from information held by the Mental Welfare Commission and detail the number of patients who have been detained since the introduction of the Mental Health (Care and Treatment ) (Scotland) Act 2003.

(a) Detained Patients by Order of a Court or Tribunal

(b) A medical Practitioner Authorising Emergency Detention

(c) Short-Term Detention Certificate in Each Year Since the Introduction of the Mental Health (Care and Treatment) (Scotland) Act 2003

Notes on data:

Figures cover period 1 April to 31 March for each year.

*Implementation of the Act commenced in October 2005.

In addition, several pieces of research were commissioned by ministers, including An exploration of the early operation of the Mental Health Tribunal for Scotland and Experiences of the early Implementation of the Mental Health (Care and Treatment) Act 2003: A Cohort Study.

There are no plans at present to commission a research project specifically around auditing the transcripts of all tribunal hearings to date.

If a patient is concerned that one of the criteria for a Compulsory Treatment Order or an Interim Compulsory Treatment Order have not been met they can appeal.

However, it may be noted that the 2001 Millan Report, on which the Mental Health (Care and Treatment) (Scotland) Act 2003 was based, recommended (recommendation 8.24) that short term detention should be used in preference to emergency detention wherever practicable.

It may also be noted that the Code of Practice states that a short-term detention certificate is the preferred gateway order because, as compared with an emergency detention certificate, it can only be granted by an approved medical practitioner; the consent of a mental health officer in the granting of the short-term certificate is mandatory, and it confers on the patient and the patient''s named person a more extensive set of rights including the right to make an application to the tribunal to revoke the certificate.

In the explanatory notes to the act it makes the point that the criteria for a short-term certificate and a CTO are similar but that one important distinction is that a  short-term certificate may be used in circumstances where the nature and effect of the patient''s mental disorder is not clear and, therefore the approved medical practitioner must only be satisfied that it is necessary to detain the patient for the purpose of either determining what treatment should be given or for administering medical treatment.

There are still cases where it is appropriate to consider a CTO application in the first instance. This does provide for a thorough examination of the criteria and affords the patient greater rights. A balance has to be struck in protecting the rights of the individual while ensuring speedy access to treatment where there would be risks in delaying.

Psychological therapies, rehabilitation and support have been effective in improving social functioning in patients and are used in conjunction with medication to improve overall quality of life.

It is important to note that serious side effects are uncommon and there is no evidence for a world wide epidemic of iatrogenic illness directly related to antipsychotic prescribing. People with schizophrenia have an increased risk of mortality due to cancer, and cardiovascular and endocrine conditions. However, there are complex reasons for this, some related to smoking, lack of exercise, poor attendance at screening and keep well clinics in primary care, poor diet, high risk behaviours and possibly the illness itself.

Whilst there is some uncertainty about the precise relationship between schizophrenia, metabolic problems and antipsychotic medication there is agreement that routine physical health screening of people prescribed antipsychotic drugs is required. This issue is picked up in the NICE (2009) Guidance which makes specific monitoring recommendations. Scotland has further addressed this issue in Improving the Physical Health and Wellbeing of those Experiencing Mental Illness December 2008 published by the Scottish Government, the SIGN guideline for schizophrenia published October 1998 and the Integrated Care Pathway for Schizophrenia published December 2007 which provides standards for care and monitoring of the disorder. The Quality of Outcomes Framework (QOF) in primary care is now trying to reduce these inequalities by specific screening programmes on physical health in severe mental illness.

It is also important to note that since the 1960s and the introduction of antipsychotic medication, there has been widespread closure of asylums across the UK and Europe. This has been directly attributed to our ability to control the symptoms of psychotic disorders with medication. This has led to most patients being treated in the community rather than hospital.

As indicated in Volume 2 of the Code of Practice to the Mental Health (Care and Treatment) (Scotland) Act 2003, the concept of impaired decision making is separate to that of incapacity as defined under the Adults with Incapacity (Scotland) Act 2000. However, when assessing a person''s decision-making ability, it is likely that similar factors will be considered to those taken into account when assessing incapacity. Such factors could involve consideration of the extent to which the person''s mental disorder might adversely affect their ability to believe, understand and retain information concerning their care and treatment, to make decisions based on that information, and to communicate those decisions to others.

Under the act the onus rests on the practitioner to demonstrate that he/she considers it likely that the criteria for detention, including that of significantly impaired decision-making ability (SIDMA) is met. Moreover, SIDMA must always be linked to the patient''s mental disorder.

As the test of significantly impaired decision-making ability (SIDMA) is part of the criteria for civil compulsory measures, the patient has the right of appeal under the act against the certificate or order in question.

All prescriptions need to be signed by a doctor and each administration requires to be initialled on a drug prescribing sheet which is stored in the case-note.

There would be no reason on the grounds of privacy and confidentiality why an individual should not be informed of the names of those who prescribe and administer their medication. This is an integral part of the medical record and it is fundamental that the patient knows the name of the person who treated them. The prescriber actively treats the patient. It is not a passive relationship.

In addition, identification of the person prescribing and administering the medication may not always be a formal process; it can be as simple as the medical professional in question introducing them self to the patient.

The Patient Rights (Scotland) Bill, introduced to Parliament on 17 March 2010, includes a schedule of Healthcare Principles. Principle 2 is that ˜Patients are treated with dignity and respect''; there are also Principles on Patient Participation, which emphasise such information and support as is necessary to enable a patient to participate as fully as possible in decisions relating to the patient''s health and wellbeing. The Bill legislates for a duty on relevant NHS bodies to have regard to the health care principles in so far as they are relevant to the function being performed.

The Mental Health Tribunal for Scotland is the independent organisation responsible for making decisions about the care and treatment for a person subject to compulsory powers under the 2003 act. Statutory protections for patients are built into the 2003 act, with a requirement on relevant medical personnel to submit a care plan to the tribunal setting out the medical treatment which it is proposed to give or is being given, to review patients'' cases and providing rights of appeal to the tribunal for revocation of an order. In particular, prior to granting a short-term detention certificate the registered medical practitioner and/or tribunal, as the case may be, is required under the 2003 act to consider the question of whether the patient''s ability to make decisions about the provision of medical treatment is significantly impaired. This is a clinical judgment.

72 deaths of people subject to mental health legislation were reported to the Commission during 2009. Most of these deaths were of individuals who were over the age of 60 and were due to natural causes. All of these deaths were reported to the Procurator Fiscal. The commission does not investigate suicides of people known to mental health services unless there is an allegation of deficiency of care. However, in all cases where there is an incident review, the commission requests a copy when it is complete. The commission will investigate if it is not satisfied that the local investigation has been performed with sufficient rigour.

All deaths by suicide of psychiatric patients, formal or informal, in contact with psychiatric services are subject to a health board critical incident review and then become part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). The recommendations at a service level from the NCISH are then fed back to health boards for implementation. We believe this has reduced the inpatient suicide numbers significantly in last five year report. The Scottish Government continues to fund this process through Manchester University in conjunction with the National Patient Safety Agency.

NHS critical incident reviews are also independently quality assured through NHS Quality Improvement Scotland.

The Cullen report Review of Fatal Accident Inquiry Legislation which was published on 3 November 2009 made a recommendation regarding deaths of people detained under the Mental Health (Care and Treatment) (Scotland) Act 2003. The report''s recommendations are currently being considered by the Scottish Government.