Psychiatric Bulletin (2004) 28: 248-250. doi: 10.1192/pb.28.7.248
© 2004 The Royal College of Psychiatrists
Psychiatric Bulletin (2004) 28: 248-250
© 2004 The Royal College of Psychiatrists
Difficulties with use of the Mental Health (Scotland) Act 1984 by general practitioners in rural Scotland
Millia Begum, Psychiatric Senior House Officer
Argyll and Bute Hospital, Lochgilphead, Argyll, PA31 8LD
Rebecca Helliwell, General Practice Vocational Senior House Officer
Argyll and Bute Hospital
Angus Mackay, Physician Superintendent, Director of Mental Health Services for Lomond
and Argyll
Argyll and Bute Hospital
Declaration of interest
None.
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Abstract
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AIMS AND METHOD
Anecdotal evidence suggests that considerable difficulties are experienced
in rural areas by isolated general practitioners, when detaining patients
under the Mental Health (Scotland) Act 1984. The aim of this study was to
identify the range and extent of these difficulties in a structured way, and
to identify ways of responding to them. A postal questionnaire was sent to 85
general practitioners in a sparsely populated area of Scotland to assess their
experience of emergency detention.
RESULTS
The questionnaire response rate was 62%. Considerable difficulties were
recorded from those who responded, notably their lack of support with clinical
management during the delay between the patient’s detention and the
arrival of psychiatric staff, the lack of satisfactory places of safety for
the patient during this period, and the difficult logistics of safe and
satisfactory transport to hospital.
CLINICAL IMPLICATIONS
Rural general practitioners and their patients appear to be disadvantaged
through lack of coordinated help in the management of inherently difficult and
risky clinical situations. Even without additional resources, the process
could be improved through coordinated, multi-agency action plans which take
account of local conditions.
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Introduction
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The emergency detention of a mentally ill person in the community is
difficult under most circumstances, but especially so when the place of
assessment by the general practitioner is remote not only from the hospital to
which the patient is being referred, but also from professional support. This
situation is typical of many rural areas in Scotland, and the difficulties
encountered by general practitioners in such areas have been commented upon by
the Mental Welfare Commission for Scotland
(2001). As the percentage of
people with mental health problems being cared for in the community rises, and
with the increasing emphasis on the principle of ‘reciprocity’
(attention to patients’ rights and amenity in proportion to the extent
to which liberty is restricted), an understanding of - and attention to - the
particular problems of rural areas becomes more important.
This paper reports the results of a survey of all general practitioners in
the district of Argyll and Bute, a scattered rural catchment area some 7000
km2 in size on the west coast of Scotland, including several
offshore islands. The psychiatric hospital for this district is situated in
Lochgilphead, and is up to 130 km distant from some of its catchment
boundaries. The survey concentrated on experiences with emergency detention of
patients under the Mental Health (Scotland) Act 1984, but also sought views
about elective admission and the management of patients living in the
community on extended leave during long-term detention.
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Method
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A questionnaire survey was conducted of all 85 general practitioners in the
Argyll and Bute Mental Health Directorate catchment area. The two-page
questionnaire comprised 18 questions, and had a two-part structure: the first
part addressed practical issues encountered during emergency detention, and
the second addressed practitioners’ experiences with clinical
responsibility for patients on extended leave (copies of the questionnaire are
available from the authors upon request). The questionnaires were sent by
post, and were followed up by polite telephone reminders to non-responders 2
weeks later.
For most of the numerical data, simple percentages were calculated and
given the non-normal distribution of other data. The median and range are
given.
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Results
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The response rate was 62%, which compares favourably with previous surveys
of this topic (Mental Welfare Commission
for Scotland, 2001). The 53 respondents were experienced general
practitioners, with a median of 10 years’practice in their current
location (range 2 months to 33 years), but their actual experience of the
process of detention was generally very limited. The great majority (86%)
reported ready availability of the appropriate forms and guidance notes. Most
detentions occurred in the patient’s own home, but over a third of
respondents had detained a patient in one of the small community hospitals
scattered throughout the district, and a quarter had done so in a police
station (Table 1). Other sites
reported were fields, roads, and campsites for travelling people. Almost all
the respondents stated that they informed patients when they were being
detained, although a third expressed concern over their personal safety and
stated that this worry tended to deter them from detaining a patient. Nearly
half of the respondents were unaccompanied at the time of assessment and
detention.
The most common problems reported by these general practitioners concerned
what to do with the patient between the time of detention and the arrival of
psychiatric staff to escort the patient to hospital, and the lack of timely
availability of a mental health officer. Strong opinions were expressed on
issues such as difficulties in finding a local place of safety during the
interim period, the need to resort to police custody, the risk of patients
absconding, and the usual lack of availability of trained staff to be with the
patient over this period.
According to the terms of the Mental Health (Scotland) Act 1984, consent to
detention by the qualified doctor should be sought either from a mental health
officer (an accredited member of the local authority social work department)
or from the nearest relative. However, the majority experienced difficulty in
obtaining timely assessment by a mental health officer, and nearly half tended
to seek consent from an available relative. Only a small minority of doctors
had proceeded without such consent - provision for which is made in the Act,
if attempts to obtain consent have been made. On the thorny issue of whether
detention had ever been used as a mechanism to secure hospital admission and
provision of an ambulance and psychiatric nurse escort when the statutory
requirements for informed consent had not been met, only one respondent
admitted to this procedurally inappropriate, but in some ways understandable,
tactic.
Experiences with long-term detention were sought within two categories:
first, the provision of the medical opinion for non-emergency detention (under
section 18 of the Scottish Act, the intended route to involuntary admission to
hospital), and, second, experiences with patients on extended leave from
hospital while under long-term detention. Nearly half of the respondents (24;
45%) had been involved in providing an opinion in relation to detention under
section 18, but the discouragement from this involvement is powerful; in
addition to making a full psychiatric assessment and completing the necessary
paperwork, the doctor may be required to justify the decision at a sheriff
court, which may be a long way from the practice. It was therefore hardly
surprising that 45% of respondents expressed reluctance to become involved in
this non-emergency admission process. Asked about their perception of a
general practitioner’s clinical responsibility towards a patient on
extended leave, more than two-thirds saw no difference between such patients
and their other patients, but nearly a third felt that there was a
difference.
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Discussion
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The detention of an individual on the grounds of mental illness is a
serious matter and it is an individual’s right to have this procedure
conducted in as sensitive, dignified and safe a way as possible. These rights
should not be compromised by geographical remoteness, but they become more
difficult to uphold in practice. This survey of general practitioners across a
scattered rural catchment area on the west coast of Scotland is, to our
knowledge, the first such study to be published, although a similar topic was
recently addressed, through questionnaire, by the Mental Welfare Commission
for Scotland (2001). The
Commission’s findings were broadly in agreement with ours, and raise
serious issues regarding the implementation of the Mental Health (Scotland)
Act 1984 in rural areas with poor access to psychiatric in-patient places and
to appropriate and speedy professional support. By far the biggest problem
encountered is the management of the often lengthy delay following the
decision to detain until the patient can be safely escorted to hospital. Who
is responsible for the patient during this period? How can a single-handed
general practitioner actually guarantee the safe and satisfactory care of the
patient during this time? How, within feasible resources, can patients’
rights be honoured? Answers to these questions are difficult, but are
important and urgently needed. A report from the Remote and Rural Areas
Resource Initiative (RARARI) in Scotland suggests that local protocols
describing a psychiatric emergency plan should be drawn up by National Health
Service (NHS) boards and endorsed by all appropriate agencies and professional
groups (Remote and Rural Areas Resource
Initiative, 2003). The report urges that the plan should include
statements defining the skills and competencies required of relevant staff,
minimum staffing levels, and clear arrangements on the availability of mental
health officers. However, the resource implications are considerable, given
the cost inefficiency of having specialist staff readily available in remote
and sparsely populated areas. Many of the general practitioners surveyed
mentioned that the only available place of safety for patients awaiting
psychiatric nurse escort was the local police cell. Not only is this
unacceptable from the point of view of patients and their families, it is an
arrangement about which the police feel very uncomfortable. Even local
community hospitals may not have safe and private areas that are suitable for
the purpose. The logistics of transport is an associated and frequent problem.
Ambulances will not carry detained patients without a psychiatric nurse
escort, leading to an inevitable delay while the psychiatric nurse travels by
ambulance from the base hospital. Several respondents mentioned that
helicopters could not be used because of local aviation protocols and safety
issues. One person commented that most detentions are planned on the basis of
completing the form as late as possible, in order to minimise the delay
period. As in any situation involving several agencies, it is crucial to be
clear about the assignation of clinical responsibility. Until the moment when
the patient is collected for transfer by psychiatric staff, this must in our
opinion be the patient’s general practitioner, and that this
responsibility should extend to medical preparation of the patient for
transfer.
A large number of respondents (43; 82%) had problems gaining access to a
mental health officer. This, as well as ready access to specialist advice,
might be solved to some extent by video linkage between outlying practices and
the psychiatric base unit. As far as non-emergency use of the power of
detention is concerned, the main problem is again one of access, with general
practitioners being reluctant to become involved in a process that might
require them to absent themselves from their practice in order to provide an
opinion in court. This undoubtedly explains the tendency for general
practitioners to use emergency admission under section 24 rather than planned
admission (section 18), but it is contrary to the intentions of Parliament
when the Act was formulated. Patients on extended leave tend to be seen as no
different from any other patients in terms of the general clinical
responsibility of the primary care doctor, but this is not so for a sizeable
minority. Although it was not possible on the basis of our questionnaire to
explore this issue, it is to be hoped that this finding does not reflect a
feeling that a detained patient on leave is the responsibility solely of the
psychiatric service, rather than one shared with the primary care team.
We are conscious that the respondents to our questionnaire were confined to
one particular rural district, Argyll and Bute. However, we have no reason to
believe that the nature and extent of the difficulties we have described are
peculiar to this district and cannot reasonably be generalised to other rural
catchment areas. This assumption is supported by the RARARI report.
The impending implementation of a new Mental Health Act for Scotland
(during the course of 2005) will not substantially affect the use of emergency
detention by a general practitioner, apart from the fact that the practitioner
will be required to consult, where practicable, a mental health officer but
not a nearest relative. This will helpfully exclude family members from the
perhaps distressing detention process, but it will place more onus on local
authorities to provide reasonable access to mental health officers. The
General Medical Services contract for general practitioners represents another
forthcoming change that may increase the difficulties experienced in remote
and rural settings. If rural practitioners opt out of 24-hour on-call
responsibility, there may be a need for out-of-hours cover to be provided in
ways that would reduce the availability of a medical practitioner who is
familiar with the patient and the family. In these new circumstances it will
be particularly important that a multi-agency plan is in place for occasions
on which the Mental Health (Scotland) Act 1984 may have to be invoked.
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Conclusions
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There has always been ample anecdotal evidence of compromises to
patients’ rights during the process of detention in remote areas. This
small survey represents a structured record of the real difficulties
encountered by rural general practitioners, which render these compromises
virtually inevitable. Solutions must be found in order to honour the principle
of reciprocity, and this will require a serious commitment to proper
resourcing of support for primary care teams from both the psychiatric service
and from local authorities. Locally-based community mental health teams are an
essential feature of the solution, enhanced by local psychiatric emergency
plans of the sort recommended by RARARI, through which all potentially
interested parties (such as primary care staff, the psychiatric service, the
local authority, the police, the ambulance service and ferry operators) are
consulted and signed up. Primary care and remote communities have for long
been left to find any port in a storm.
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Acknowledgments
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We would like to thank the many general practitioners in Argyll and Bute
who took the time and trouble to complete our questionnaire. We are also
grateful to Mrs Fiona Broderick for excellent secretarial support.
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References
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MENTAL WELFARE COMMISSION FOR SCOTLAND (2001)
Annual Report (2000-2001). Edinburgh: Mental Welfare
Commission for Scotland.
REMOTE AND RURAL AREAS RESOURCE INITIATIVE (2003) Bid 79 Report
. Recommendations for the safe management
of acutely disturbed psychiatric patients in Scotland’s remote and rural
areas. Isle of Arran: RARARI.
Top
Abstract
Introduction
