White paper on Reforming the Mental Health Act

Main proposed reforms

1. New guiding principles up front in the Act
2. Change criteria for detention under sections 2 and 3 and for use of Community Treatment Order (CTO), but not for Part III detained patients, so that detention and CTO (a) must provide a therapeutic benefit and (b) can take place only if there is a substantial likelihood of significant harm
3. More frequent Mental Health Tribunals (MHTs), although some differences for Part III cases
4. Power for MHTs to grant leave, transfers and community services as well as discharge, including making recommendations for restricted patients which Justice Secretary must consider
5. Removal of the role of hospital managers
6. Advance Choice Documents (ACDs) must be taken into account by services and be offered to all people who have previously been detained.
7. Detailed Care and Treatment Reviews (CTRs), and Care, Education and Treatment Reviews (CETRs) for children, young, autistic and learning disabled people, to be put on a statutory footing and must be in place by day 7 of detention and signed off by clinical/medical director by day 14 and become living documents to be amended and reviewed. Responsible Clinician (RC) should incorporate recommendations from any CETR panel.
8. Patients refusing their medication treatment must have it certified by second opinion approved doctor (SOAD) at day 14, and by 2 months if they do not have relevant capacity, rather than 3 months
9. Wishes of patients with capacity who are refusing treatment should be respected even in urgent circumstances
10. MHT judge (sitting alone) can require the Responsible Clinician (RC) to reconsider a specific treatment decision in a Tribunal hearing, following preliminary ‘permission to appeal’ stage, of a patient refusing treatment or of a patient that lacks the relevant capacity if challenge has been made by Independent Mental Health Advocate (IMHA) or Nominated Person
11. Nearest Relative replaced with Nominated Person (NP), including a Gillick competent adolescent being able to choose their NP, and has additional powers, including being able to object to CTO, although power to block admission and CTO can be overruled, possibly by MHT judge (sitting alone) rather than County Court.
12. Expansion of role of Independent Mental Health Advocates (IMHAs), including power to appeal to Tribunal on the patient’s behalf
13. Pilot programme of culturally sensitive advocates to respond appropriately to diverse needs of individuals from BAME backgrounds
14. Community supervising clinician must also agree CTO as well as inpatient RC and Approved Mental Health Practitioner (AMHP)
15. Expectation that CTOs will end after 2 years set out in guidance in Code of Practice.
16. MHT will have power to check justification for CTO conditions and recommend reconsideration if they believe they are overly restrictive.
17. Recall of CTO patient only possible when there is a substantial risk of significant harm and patient can be recalled to another appropriate location if hospital treatment not needed.
18. Impact of reforms on CTOs will be monitored for reduction in use and effect on racial disparities for an initial 5 year period
19. Consultation will take place about creating a clearer dividing line between MHA and Mental Capacity Act
20. Provision to enable people in advance to consent to informal admission with ‘get out’ clause to prevent them being confined for longer than they would wish to be
21. Consideration to be given to extending Section 5 as a holding power in A&E
22. Greater alignment between Crown Court and magistrates’ courts in being able to divert people from the criminal justice system
23. Introduce 28 day time limit to transfers from prison or immigration removal centres (IRCs) to mental health inpatient settings
24. Establish a new designated role for someone to manage the process of transferring people from prison or IRC to hospital
25. Consultation to strengthen role of social supervisor of conditionally discharged patients
26. Introduction of option of ‘supervised discharge’ for discharge of a restricted patient with conditions amounting to a deprivation of liberty
27. Autism and learning disability no longer to be considered mental disorders warranting treatment under section 3, although such patients can be admitted under section 2 for assessment of factors driving any abnormally aggressive or seriously irresponsible conduct, and section 3 continued if a mental health condition is the driver.
28. New duty on local commissioners to ensure adequate supply of community services for people with a learning disability and autistic people and to create local ‘at risk’ or ‘support’ registers
29. Consultation with proposals to follow on extending monitoring powers of Care Quality Commission.