Mental Health Act assessment: how an application is made

What is a Mental Health Act assessment?

It's how professionals decide whether someone should be detained in hospital under section 2, section 3 or section 4. The aim is to work out whether the criteria are met and, if so, whether an application should be made (Code 14.33). Usually that means an AMHP and two doctors.

It isn't the same as a mental health assessment, which can be any clinical review. An MHA assessment is about detention, so it must look at the alternatives, such as crisis and home treatment teams (Code 14.34).

How to request a Mental Health Act assessment

• The local authority. If it has reason to think an application may be needed, it must arrange for an AMHP to consider the case (s13(1)). Councils should run a 24-hour AMHP service (Code 14.35).
• The nearest relative can require the council to do this. If the AMHP then decides not to apply, they must give the reasons in writing (s13(4), Code 14.102).
• Doctors approached by a nearest relative should tell them about that right (Code 14.32).

More on the nearest relative.

Who does what

• The AMHP coordinates the assessment and decides whether to apply (Code 14.41). They act for a council, but nobody can tell them what to decide. They bring a social perspective and look for alternatives (Code 14.52).
• Who can be an AMHP. A registered social worker, a mental health or learning disability nurse, an occupational therapist or a chartered psychologist (Reference Guide 30.11). Never a doctor (s114(2)).
• The two doctors each decide whether to recommend. One must be s12 approved, and approved clinicians count automatically (s12(2), (2A)). The other should know the patient if practicable, and some previous knowledge of the case is enough (Code 14.73).

What happens at a Mental Health Act assessment

1. The AMHP introduces everyone, explains each person's role and carries ID (Code 14.51).
2. The patient can have a friend or advocate there, unless it's too urgent (Code 14.53). They should usually get the chance to speak to the AMHP alone (Code 14.54).
3. Communication needs are met, for example with a signer or a professional interpreter (Code 14.42).
4. Each doctor examines the patient directly and considers all the relevant information, including what family and other professionals know (Code 14.71).
5. Unless there's good reason, the AMHP sees the patient with at least one doctor. Both doctors discuss the case with the AMHP (Code 14.45, 14.46).
6. Everyone considers capacity and the alternatives: informal admission, the MCA, care in the community or guardianship (Code 14.11, 14.12).
7. The AMHP tells the patient the decision and the reasons, then the nearest relative, the doctors, any care coordinator and the GP (Code 14.100).

If they're intoxicated, wait for it to wear off if you can (Code 14.56). Avoid interviewing through a closed door unless others are at serious risk. If you can't get in, consider a s135 warrant (Code 14.55).

Mental Health Act assessment time limits

The Act sets no length for the assessment itself. What it fixes are these dates, so check them before anyone signs.

What the medical recommendations must say

• Symptoms and behaviour, not just a diagnosis (Code 14.75).
• For s3, why nothing less will do. Whether other methods of care are available and, if so, why they aren't appropriate (s3(3)(b)). That means outpatient care, informal admission or the MCA, for example (Reference Guide 8.43).
• For s3, the hospital. That appropriate treatment is available, ideally knowing which hospital (Code 14.76).
• For s4, the urgency. The doctor verifies the statement that it's urgently necessary (s4(3)).

If the doctors recommend admission, finding the bed is their job, not the applicant's, unless local arrangements say otherwise (Code 14.77).

Conflicts of interest

An application made with a conflict of interest is invalid (s11(1A), s12(3), Reference Guide 8.55, 8.56). The 2008 Conflicts of Interest Regulations cover:

• Money. A financial interest in the outcome. A fee paid whatever the outcome doesn't count (Code 39.6).
• Family. Being a close relative of the patient, of another assessor, or of a nearest relative who is applying. In-laws count, and so does living with any of them as a couple (Reference Guide 8.55, 8.56).
• Work. A line management, employment or close business link with the patient, another assessor or a nearest relative who is applying (Code 39.7, 39.9).
• One team. All three assessors in the same clinical team, or an assessor who works in the same team as the patient (Code 39.9). In urgent necessity, all three can be from one team (Code 39.12).
• Independent hospitals. Both recommendations can't come from doctors on the staff of the independent hospital the patient is going to (Code 39.4).

When the AMHP decides not to apply

Nobody has to apply just because the criteria are met (Code 14.103). The AMHP must be satisfied that detention is the most appropriate way of giving the care and treatment the person needs (s13(2)). If it isn't, they record why and put an alternative plan in place (Code 14.104).

They should tell the nearest relative that they can apply instead (Code 14.101). If the professionals disagree, they talk it through and agree a plan with a risk assessment, even a temporary one. Nobody abandons the patient (Code 14.109, 14.110).

After the decision: getting to hospital

• A named hospital. The application must name a specific hospital, not just a provider (Code 14.89). Don't move the patient until the hospital has agreed to take them (Code 14.91).
• Authority to convey. The completed application lets the applicant, or anyone they authorise, take the patient there, with reasonable force if needed (s6(1), Code 17.13). The patient is in legal custody on the way (s137).
• The police should help if violence is likely, ideally alongside an ambulance (Code 17.14). More on police powers.
• The AMHP's report. An outline report goes to the hospital on admission, with the reasons and practical details. It doesn't replace the AMHP's full report (Code 14.93, 14.95).
• On arrival. The receiving officer checks the papers with the AMHP, and the admission is recorded on Form H3 (Code 35.9, reg 4(4)).

Mistakes in the forms

• Correctable within 14 days. Blank spaces other than the signature or the doctor's reasons, alternatives left undeleted, and misspelt names or addresses. The person who signed corrects them, with the managers' consent (s15(1), Reference Guide 31.23).
• Replaceable. A recommendation that's insufficient, for example signed after the application or with thin reasons, can be replaced by a new one within the 14 days (s15(2), Reference Guide 31.30).
• Fatal. An unsigned application or recommendation, an application by someone not entitled to make it, or a recommendation from a doctor with a conflict of interest (Reference Guide 31.19).

After a fatal defect, the patient can only be held by a new application, or meanwhile under s5 if they're already in hospital. Otherwise the managers should discharge them (Code 35.13).

A worked example

The 5 clear days after 3 March are 4 to 8 March, so 9 March is the last day for the second examination. If the AMHP applies on 9 March, both recommendations must be dated 9 March or earlier. Ms B must then reach hospital by 22 March. If the s12 doctor slips to 10 March, the GP or another doctor must examine her again.