Section 25 of the Mental Health Act

Having lost interest in UK nursing a few years ago (just after the s25 mallarky) I have little experience of it in practice. However, from the debate around it, I understand the main thrust at the time to have come from the Christopher Clunis report (someone add a link to The Zeto Trust please) and was an attempt to amend the errors of the application of s117 “aftercare”.

The MHA s25D is the part I believe you refer to in your post and a copy resides at: http://www.markwalton.net/Orig...../s25d.asp? on the Mark Walton page.

My understanding is that the point of the s25D was to ensure services basically didn’t have an excuse anymore for patients in the community who refused treatment (medication, attending appointments, etc) to prevent these dangerous homicidal persons roaming the community unattended. Of course it probably gets abused by hospitals as a way of enforcing community services accepting ‘difficult to manage’ patients back into the community.

The medico-political debate kinda went:

How does a compulsory community treatment provision actually help us to improve the provision of services?

In-hospital RMO’s determine/apply s25D but can community services refuse to accept as supervisors?
(Health Authorities must accept a s25 referral before it can become active - s25A 6;7;8)
(8) Where a Health Authority accept a supervision application in respect of a patient the Health Authority shall—

Compulsory community treatment just makes it harder for the”therapeutic alliance” with the worker.

If they need ‘compulsory’ treatment then they’re obviously not well enough to be in the community.

The MHA Code of Practice (DoH 1999) gives no guidance on this part of the Act itself, however, the supplemental Mental Health (Patients in the Community) Act 1995 (c. 52); [inserted into s25 of the MHA 1983]
( http://www.opsi.gov.uk/ACTS/ac.....2_en_1.htm ) lays out some pretty step by step (idiots guide to supervision in the community) instructions.

It specifies:
25B Making of supervision application

(1) The responsible medical officer shall not make a supervision application unless—

(a) subsection (2) below is complied with; and

(b) the responsible medical officer has considered the matters specified in subsection (4) below.

(2) This subsection is complied with if—

(a) the following persons have been consulted about the making of the supervision application—

(i) the patient;

etc….

As we know, the meaning of ‘consulting’ the patient is nothing like ‘consent from’ the patient, and usually requires the RMO to simply ‘tell’ the patient this is how it’s going to be.

ASW’s are a breed to themselves. (Do they still wear cordorouys and drive Morris Minors?) ASW’s advocate strongly for patient autonomy so, ergo, they are likely to want the patient’s agreement. (I actually like their grounding balance to the dichotomy of care/custody - it allows me to think ‘high risk’ for everyone)

Essentially, as I understand it, s25 IS compulsory treatment in the community and consultation only is required - which is not the same as consent, concordance, confabulation or constantinople.

Your colleagues probably only heard the first syllable “con” and thought of the first word that came into their head to do with psychiatry. So, of course, that wasn’t consent.

They were probably thinking of concorde - flying away somewhere exotic - drinking pina coladas - whilst doing a 1-1 suicide special watch - which I don’t do of course - as I now live in exotic tropical Australia

Hope this helps

The whole point of section 25 is to TRY and ensure compliance with treatment and care. People can still choose not to comply. In fact, non-compliance seems to be normal human behaviour - how many people take the full course of antibiotics, for instance; how many smokers refuse to give up despite all the marvellous medical advice against it etc. Some service users object to the notion of “compliance” as it suggests a few things: -

1) Doctor is always right
2) They are either compliant or non-compliant, with no gradations inbetween
3) The drugs are the only important thing in their wellness

“Concordance” is meant to reflect that the service user and treatment/care providers are in agreement. In practice, it just seems to mean the same old notion of compliance IME.

Section 25 is a waste of time! It is a bit of paperwork to cover peoples back if something goes wrong, as with Clunis. It does nothing to enforce either “compliance” or “concordance”. Bottom line is you still have to readmit under section 3 if things go tits up, and you could have done that anyway without a section 25. I’ve known a couple of consultants who find it better to send the patient on extended (like 3 months) periods of section 17 leave from hospital, rather than bother with section25.

“I’ve known a couple of consultants who find it better to send the patient on extended (like 3 months) periods of section 17 leave from hospital rather than bother with section25.

This is illegal.

Is it illegal? Perhaps bending the law a bit, maybe immoral, but if it is illegal, how come it happens without the Mental Health Act commissoners saying owt?

Perhaps I should have added that within that extended leave, the person still has regular, usually weekly, trips back to hospital to see their consultant.

Please expand, E!

If a person is well enough to go on so much leave, then they really should be discharged. Section 3 is not intended to be a de facto community supervision order.

It is illegal in the same way that if an individual is admitted informally and the admitting doctor writes in the margin of the admitting notes.

“If the patient tries to leave then consider for sec 5:2″

i.e. you are informal up to the moment you try to exercise your democratic right to leave. I suspect that if the Mental Health Act commissioners got to hear about either practice they would have something to say on the matter.

To correct my earlier posting; s25 (just like s17) does not actually allow for the enforceabliity of medication in the community. It allows for the enforced transportation to a place of treatment. Of course, then refusing to accept medication treatment (at the day centre or hospital) makes it a very freedom-challenging decision for the pt to go against the treatment.

I can’t see how not using s25 is illegal, since it is meant to enhance the s117 provisions by making named people responsible for the services aswell as giving them the authority to monitor, convey or recall patients.

s25 is only applicable in the following criteria (aswell as mental illness etc of course): s25A(3) b & c -
# there would be a substantial risk of serious harm to the health or safety of the patient, or the safety of other persons, or of the patient being seriously exploited, if she/he were not to receive the aftercare services provided and
# being subject to supervised discharge is likely to help to secure that the patient does actually receive the aftercare services.

If a pt falls short of this then there is no reason to not apply s17 leave instead alongside s117 planning. That’s the way it always worked and that part of the Act wasn’t broken. It was when no-one turned up for s117 meetings to decide how best to monitor very sick Johnny who was only ill when he defaulted on medication.

s25 allows for the pts discharge from hospital into the community. s17 leave requires a bed to remain available. The technical differences are merely a bed-numbers game. When RMO’s determine to use medium/long term s17 instead of s25 it’s usually because there’s no-one to take on the s25 responsibility rather than they specifically don’t meet the criteria. s17 however, still remains the hospital staff’s problem rather than s25 - community staff.

If that becomes the hardened rule then, in the absence of being able to facilitate s25, the patient would remain in hospital until someone becomes available to supervise. I doubt the MHAC would be too pleased with that practice either.

s25 is essentially informal treatment in the community - right up until you refuse. Then you become a recall candidate.

Just like the “consider for s5(2)” note in the margin - there’s nothing wrong with that. A good medic will avoid detention where-ever possible. All sections are judgment calls - there is no hard and fast right or wrong. That notation simply says : They’re close to sectionable but I’d rather not at this time.

Of course it may mean: “They ought to be sectioned, but that means paperwork”; either way, the patient gets the least restrictive of the two choices.

The oddity for me was s25 seemed to be trying to fix the leaky s117 holes by pouring more water into the Act, not plugging the holes.

It did nothing to actually address the function of the community services (funding, practice, organisation, etc) just made it more complex (and ergo, harder) for hospital/community to facilitate. Remember, this part of the Act was designed to prevent/minimise the risk of seriously and dangerously ill persons (who had become reasonably stable) to be simply discharged without follow up.

The statistical danger of compulsory community supervision is much like the ‘efficacy’ of the emergence of tin helmets by World War II. It didn’t stop them shooting at you - but it did increase the number of head injuries dramatically (since less people were dying from the same head shots).

People discharged on s25 are effectively considered a ‘higher risk’ than others simply on sporadic s17 leave. Not using a s25 means your patients are less risk = less money/services needed.

Alternatively, discharge everyone on s25, means you have a high risk, high acuity community need - more money/services.

Regardless of the purpose and rights or wrongs of s25 supervised discharge, at the end, interpretation and application comes down to the clinical decision of the acute ward RMO who will decide on the same criteria they have always decided on - Do I need that bed for someone else more than this one? If so - discharge - by whatever means. (If likely to get sued/be liable for damage by this person? Consider s25 or someone else first)

E, I see that “consider for 5(2)/5(4)” written in admission notes quite often!

Indeed, one SHO wrote that in ALL his admission notes, even for planned detox/change of medications admissions. He also immediately placed all those admitted on 15 minute “supportive observations, regardless - he was
a bit of a numpty.

It may or may not be illegal to do this, but it is surely unneccessary, as
once someone is admitted any RMN or SHO would identify if a 5(2)/5(4)
was needed.

Interesting topic, Mr.Ian’s post makes me wonder if the use of repeated S17 v. S25 is down to shortages in the community team v. bed shortages.

I am not a lawyer so it’s more that possible I may not have my facts quite straight on this one. (Where is the good Dr C when you need him? Things have gone awfully quiet over at http://nhsblogdoc.blogspot.com in recent weeks). Sec 25 allows for the care coordinator to “take and convey” a patient who is no longer compliant with the conditions of Sec 25 to a place of safety (i.e. Hospital psych ward) and there to have him assessed by the RMO and re admitted under sec 3 if necessary. The only advantage of this arrangement being the supposed ease with which this can be done, (ie no need for a full MH assessment with ASW and second sec12 approved doctor, just the RMO and care coordinator). The problem is if push comes to shove, and the patient physically refuses to be “taken and conveyed” anywhere you are a bit stuffed. I once asked a Police officer if he would be prepared to break down a door to remove a patient who was physically resisting being taken back to hospital because I as care coordinator had told him (the police officer) that the patient was in breach of his sec 25 conditions, and his response was “not without a magistrates warrant” which takes you back to square one. (Incidentally the police officer had never heard of sec 25 and I suspect ten years on from their original introduction few will have).

The question of the illegality or otherwise of keeping patients on sec 17 leave and then recalling the patient to hospital every 6 months to renew the section. This was a practice that was popular with some psychiatrists prior to sec 25 being introduced, and sec 25 was in brought in partly to make this practice unnecessary. I think it may come under the heading of habeas corpus (unlawful imprisonment) certainly the MH act states somewhere that a patient must be kept in the least restrictive manner consistent with their best interests and that of others and as beakie puts it “If a person is well enough to go on so much leave, then they really should be discharged (from sec 3)”. I have always seen sec 25 as a half way stage between sec 3 and being informal in the community but a MH tribunal I attended recently did not seem to see it that way (why not?). Keeping someone on sec 3 in any form for longer that is necessary is at the very least bad practice and if not habeas corpus then is probably contravening their civil liberties or basic human rights.

Writing “consider for detention under sec 5:2 if patient tries to leave” is a clear case of habeas corpus because the implication is that if the individual tries to leave they will be stopped, so they are not really free to leave at all, which is an obvious pre requisite for them giving informed consent to stay in the first place. Having a nurse stood by the exit stopping people from leaving amounts to the same thing as locking the door which if the person is not formally detained is illegal.

I’ve not posted ’cause I’m muddled ’bout what’s being talked through here!

Section 25 does indeed give powers to convey and I’ve found police to treat this in the same way as a patient detained under section 3 who refuses to come in to hospital. The Mental Health Act 1983 section 25 necessitates that patients have to attend. In legal terms you “can not frustrate the will of Parliament” unless you use another statutory instrument, thus they just bring them in and that’s that.

As to section 5(2) I agree it’s bad form and unlawful to document your intention to use 5(2) routinely.

There will be occasions when a patient is at high risk who’s agreeable when assessed but has lability of mood and behaviour (e.g. in a known psychotic manic patient with an established relapse signature and clinical course). In this scenario to consider the clinical course and understand that a disturbed behavioural repetiore and insistance on leaving is likely to unfold, it’s plainly common sense to generate a management plan for this eventuality.

As such, to convey in the notes that within the meaning of the MHA 1983 that the patient has a mental disorder, this is of a nature or degree that warrants hospital inpatient care, and community/less restrictive options could not address clinical need seems simply good practice, stating the current assessment and formulation at that point in time.

You can not direct that a section 5(2) should be used since if you truly thought the patient should be detained and direct that then you should crack on and do it properly rather than have them defacto detained but without the safeguards of the MHA 1983.

MHA 1983 code of Practice directs us such that we’re obliged to manage them “in the least restrictive setting” so we can’t detain them on section 5(2) just ’cause they’re detainable and may leave in the future.

To convey thoughts that, for specific patients at specific times with the rich amount of clinical information you have that in high risk scenario of self discharge you’d feel that MHA 1983 “should be considered” has to be good practice.

The nature of the original post was a question really on the meaning and application of s25. The rest of the postings have, inevitably I guess, circulated around the reasons why s25 may be problematic and discussion which includes the wider aspects of the MHA such as s117, s17 and further into s5(2)/5(4).

The issue I believe is inherently brought with the sought purpose and angle of interpretation someone is seeking to apply to that part of the Act; ie s25 - are we protecting patient, public or staff?

Returning to my original comments, s25 was all about a man known to the services who left hospital care with a slap dash s117 plan. His case worker tried to engage him (I never read the full report but I think essentially he just went transient), there were no legal powers to direct anyone to do anything and the case worker could not enforce his/her clinical judgment upon the consultant. It was therefore all left to common law duty of care stuff outside of the Act which left no one obliged until he killed a random tube passenger, Jonathon Zito, in a fit of paranoia.

s25 does not allow for treatment to be enforced.
It does allow for a person to be conveyed against their will to a treatment centre – where enforced basket weaving will ensue (that’s covered under the OT Compulsory Useless Skills Act 1504).

Under s25 a patient cannot refuse to be examined by a doctor.

Re-admission, if felt necessary, appears to be done under the normal provisions of s2, s3 or a dodgy s4. Scotland has it slightly different, with provision for recall for 7 days within their s35 supervised discharge.

The MHA in Queensland has in place community treatment orders. Either civil (cITO) of criminal (cFO – Forensic Order) which is essentially s3 community or s37 community treatment, respectively.

Rule of thumb here is (as I’ve seen no contrary or supporting legal provision anywhere) that community services can refuse to take a cFO into their area which would be the same as Health Authority not accepting a s25 discharge. (Qld is about the size of 10 UK’s broken into 11 districts – most the services are ‘down south’ tho [sound familiar, uk?] ). ITO’s can just get discharged (thrown out) at any time to any place – there is no aftercare mandate (vis s117 uk MHA) in the Qld MHA.

The s25 similarities in Qld are only relevant to a cFO. However, the MHRT (same line up as UK) actually set the conditions of community leave, subject to approval of recommended discharge plan. (They also set them for FO in-patients too, even down to the staffing ratios such as 2:1 grounds or 1:1 community if they feel so inclined – psychs can only amend ITO leave). The leave conditions are sometimes a little harsh or pedantic, are based on perceived risk and have no seeming limitations. If they had a Human Rights Bill here, they would probably be in breach (eg Not to change addresses without approval of the treating psychiatrist – they never say “not to kill myself or anyone else” - should I tell them about ‘no harm contracts’?).

Taking the two MHA versions (Qld & UK) into consideration, it might provide a different slant away from the thinking of the MHA being there for protection of the unwell person or the staff.

The primary reason behind the MHA is as always, since the 1714 Vagrancy Act (http://www.mdx.ac.uk/WWW/STUDY/Law.htm#12Annec23), the need to legally contain those who cause the public unrest.

Those who may commit offences out of madness scare the hell out of Jo Public. And Jo Public demands some protection from the seemingly uncontrollable will of those so possessed.

s25 is not, and has never been, about improving community services for those who need it. It does offer a tinge of protection to in-patient (or ‘the offloading’) staff if a s25 order is in place. It offers a minimal amount of powers to the community staff so that they may carry out their ‘monitoring’ and necessary interventions when it gets a bit scary.

As I wrote before, the aim is to make (emphasise, capitalise, underline and bold “MAKE”) the community services provide a further level of protection that is in writing and aims to minimise the risk of harm being done. Preventing harm to self I think is a secondary gain/intent/concern.

In response to E: I think the MHRT regard the MHA as either it’s on or it’s off. They don’t deal with informal patients so perhaps it doesn’t compute – if you’re under the Act in any way, you’re detained, albeit it in the community. For the sake of furthering the notion tho, I suppose s25 is not quite half way between s3 and informal because s25 is quite strictly monitored. It is better than involuntary in-patient status, but s17 leave is getting closer to informal than s25. So maybe 1/3 the way?

And Habeas Corpus (Lat: bring me the body) is the remedy for unlawful imprisonment, not the act itself. Unlawful imprisonment is called “employment”.

I also picked up this handy hint from Dave Sheppard’s page: http://www.davesheppard.co.uk/...../s17.shtml
“It used to be accepted that you could not be recalled from leave just to renew your section and then let you out on leave again. For a section to be renewed you have to be in need of inpatient treatment. But following a legal ruling, the Code of Practice now says that your section can be renewed whilst you are on leave.”

Not sure what that ruling was based on, but apparently, renewing s17 is an accepted legal practice now.

Dammit, let’s s17 the world and be done with the risk assessment.

employment is a waste of good drinking time