Sunday, 8 January 2012

The Mental Health Act: A Lightning Tour

The Mental Health Act 1983 could conceivably be compared to a department store (at least, I’ve conceived it). There are 10 Parts to the Act, just like there are different floors in a department store, of varying importance and relevance to AMHP practice. As a bit of a MHA train spotter, I have tried to read all of the Act, even the really boring bits – and there are plenty of them – just so that you don’t have to.

Each Part contains different aspects of Mental Health law – just like a department store, if a department store contained law instead of goods.

Bear with me. Let’s see how it runs.

Part I could be compared to the foyer of a department store. It’s by far the smallest part of the Act, and consists of a short and sweet introduction defining mental disorder (which since the changes in the 2007 Act is now defined as “any disorder or disability of the mind”), as well as a useful reminder that people with learning difficulties are largely excluded from the Act.

Once you’ve negotiated the foyer, we enter Part II, which contains the bread and butter matters of most concern to AMHP’s and patients. It’s a bit like Harrod’s main food hall – bustling with people, with a lot of activity going on, and a lot of transactions taking place. Part II is predominantly concerned with the powers and duties defined in the Mental Health Act – these of course relate mainly to detention under Sec.2, 3, or 4, Guardianship, and more recently Supervised Community Treatment. In fact, probably less than 25% of the Mental Health Act impacts on AMHP practice on a day to day basis. AMHP’s will therefore spend much of their professional time with issues relating to Part II.

The lift then takes us to Part III -- although this is an important part of the Act, it is not necessarily directly of relevance to AMHP’s , unless they work in a forensic setting, as it relates mainly to the powers of criminal courts to detain mentally disordered offenders.

Next up is Part IV, the medical floor – the equivalent of the orthopaedic bed and surgical appliance department (or maybe not) -- concerned with Consent to Treatment, which is predominantly to do with the strictly medical aspects of the MHA. It includes directions relating to Electro-convulsive Therapy (ECT) and other treatments such as “any surgical operation for destroying brain tissue or for destroying the functioning of brain tissue”. While psychosurgery was far from uncommon in the 1950’s and 1960’s, and I have in my earlier years working with people with mental illness come across patients with leucotomy scars on their foreheads, I am not sure that any such procedures are still in use.

The lift doors open next on Part V, which concerns itself with Mental Health Review Tribunals, while Part VI is a dim and murky floor, as it gets into seriously arcane and convoluted territory, relating to “Removal and Return of Patients within the UK”. It contains the rules relating to transfers and extractions of patients between England, Scotland, Wales and Northern Ireland – as well as the Channel Islands and the Isle of Man.

Section 86 appears to stray into Roswell UFO territory, as it refers to “Removal of aliens”. Unfortunately, this does not relate to transfer arrangements for ET back to his home planet, but to patients who are non-British nationals and “the conveyance of the patient to his destination in that country or territory and for his detention in any place or on board any ship or aircraft until his arrival at any specified port or place in any such country or territory”.

Of course, AMHP’s really don’t need to know any of this stuff – until, that is, a patient who has absconded from Jersey turns up in Llanelli.

Part VIII relates to the “Miscellaneous Functions of Local Authorities and the Secretary of State”, perhaps comparable to the lingerie department, since it clothes the Act in some of the necessary accoutrements that make the Act work. Among other things, it establishes that “a local social services authority may approve a person to act as an approved mental health professional for the purposes of this Act.” Sec.115 gives an AMHP the important power to “enter and inspect any premises (other than a hospital) in which a mentally disordered patient is living, if he has reasonable cause to believe that the patient is not under proper care.” It also includes Sec.117 and the duty to provide aftercare.

Part IX created a number of offences relating directly to practice under the MHA and to people with mental disorders within the meaning of the Act.

Part X, the very top of the department store, along with the roof garden, contains everything that doesn’t fit on any of the other floors, being called “Miscellaneous and Supplementary”. It’s a bit of a rag bag, containing the new rules relating to Independent Mental Health Advocates, as well as the essential Sec.131, which establishes the principal of the supremacy of informal admission (“Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital or registered establishment in pursuance of arrangements made in that behalf and without any application, order or direction rendering him liable to be detained under this Act, or from remaining in any hospital or registered establishment in pursuance of such arrangements after he has ceased to be so liable to be detained.”)

Part X also refers to the duties of Hospital Managers (including the withholding of “postal packets”), as well as the important Sec.135 (warrants to search for and remove patients) and Sec.136 (police powers relating to mentally disordered persons in public places). It also contains Sec.141, relating to mentally disordered MP’s, which I covered in my last post.

If you’re still reading this post, you’re probably wondering what happened to Part VII – why didn’t the lift stop at that floor?

Well, there’s a simple answer, which is that there is no longer any Part VII. It used to contain the rules relating to the Court of Protection, but it was repealed in its entirety by the Mental Capacity Act 2005.

When I first started to work on this post, I was intending to devote it to Part IX, relating to offences, but decided that it was necessary to put it into the context of the Act as a whole.

Next time, then, I will be taking a closer look at the implications of Part IX. Wouldn’t you just love to get obstructive relatives arrested when you’re trying to undertake an assessment under the MHA in a person’s home? Maybe you can.


  1. very good thanks a whistle stop tour of the act which has given me a basic foundation of understanding ready for my AMHP course

  2. "Next up is Part IV, the medical floor... concerned with Consent to Treatment, which is predominantly to do with the strictly medical aspects of the MHA. It includes directions relating to Electro-convulsive Therapy (ECT) and other treatments such as “any surgical operation for destroying brain tissue or for destroying the functioning of brain tissue”. While psychosurgery was far from uncommon in the 1950’s and 1960’s... I am not sure that any such procedures are still in use."

    IIRC, a couple of hospitals in the UK do still carry out - very rare - psychosurgical procedures like anterior cingulotomies and/or capsulotomies. In England & Wales, I don't believe they can be done at all without the patient's informed consent, even on a detained patient. Mind you, I bow to your more detailed knowledge of the Act's arcana if you know better; my knowledge of this obscure topic is based on an essay on psychosurgery I wrote over decade ago, so may well be outdated. Fortunately it's not an area of practice one frequently comes across...!

    I have the feeling the legal situation in Scotland is/was a little looser, but I really can't remember any details.

    Leaving psychosurgery aside, this month's BJPsych has a couple of articles about the efficacy of trans-cranial direct current stimulation in depression. This involves passing weak electric currents through the brain, and without the characteristic seizure activity of ECT, so I presume would not technically be covered by the sections of the Act pertaining to ECT. If this treatment ends up becoming more widespread in the future, I wonder how the Act would interpret it? Is there anything in it already about it?

    Just a random thought brought on by the coincidence of reading those journal article recently, and then this blog post. :)

  3. More on psychosurgery - s57 is one of the few bits of the Act that apply to any patient, whether or not detained or otherwise liable to the Act. There are a very few places in England or Wales undertaking such procedures. One was authorised by CQC in England in 2009-10, none in Wales, and none in England in 2010-11 (Wales yet to publish). In the previous years operations were occurring only in Wales, but low numbers.

    Informed consent is bascally required (ie patient will need capacity). Theorectically yuo can use s62 to but it is very unlikely you could claim that it is "immediately necessary to save the patient’s life" nor can yuo use the provision of the MCA to authorise for someone who lacks capacity.

    Scotland has very similar legal requirements and approves a couple of treatments most years - possibly because their legislation actually covers newer treatments such as deep brain stimulation

  4. Thanks for your illuminating comments, Anonymous!