Doctors recommend. The applicant applies. Mixing those up causes most paperwork errors.
Who does what under the Mental Health Act?
Each step of a detention belongs to someone different. Doctors examine and recommend. The applicant, an or the nearest relative, decides whether to apply. The hospital managers accept the application and hold the authority to detain.
After that, the responsible clinician runs the case. A checks treatment given without consent, and the tribunal reviews the detention. Keeping the jobs apart is the safeguard.
What is an AMHP?
An approved mental health professional is approved by a local authority that's satisfied they're competent to work with people with mental disorder (s114). Social workers, mental health or learning disability nurses, occupational therapists and chartered psychologists can qualify. A doctor can't (s114(2)).
Approval lasts five years at a time, with at least 18 hours of relevant training each year (Reference Guide 30.14 and 30.15). AMHPs act for a local authority, but nobody can tell them whether to apply. The decision is their own (Code 14.52).
Before applying, they must interview the patient in a suitable manner. They must be satisfied that hospital is the most appropriate way to give the care and treatment needed (s13(2)). They inform the nearest relative about s2, and consult them before s3, which they can't make over an objection (s11(3) and (4)).
What is a section 12 doctor?
A section 12 doctor is approved as having special experience in diagnosing or treating mental disorder (s12(2)). For s2, s3 or guardianship, one of the two medical recommendations must come from one. Approval lasts up to five years (2015 Instructions, paragraph 5).
If the s12 doctor doesn't know the patient, the other recommendation should, if practicable, come from a doctor who does (s12(2)). Some previous knowledge of the case is enough (Code 14.73). Separate examinations can't be more than five days apart (s12(1)).
A doctor who's an approved clinician is automatically treated as s12 approved (s12(2A)). An who isn't a doctor isn't, and can't give a medical recommendation.
What is an approved clinician?
An approved clinician is approved, by a body acting for the Secretary of State, to carry out the Act's AC functions (Reference Guide 30.38 and 30.39). Doctors, practitioner psychologists, mental health or learning disability nurses, occupational therapists and social workers can all be approved (Reference Guide 30.41).
Approval lasts five years. You need an approved induction course in the two years before applying. You must also show the relevant competencies, unless you're on the Specialist Register in psychiatry or in your final year of training (2015 AC Instructions, paragraphs 3 and 4).
The competencies cover assessment and risk, treatment, assessing capacity to consent, care planning and leading a team (AC Instructions, Schedule 2). An AC can be a responsible clinician or be in charge of a treatment. When in charge of an inpatient's treatment, they can use the s5(2) holding power.
What does a responsible clinician do?
The is the approved clinician with overall responsibility for a detained or patient's case (s34(1)). Hospital managers should have protocols to allocate the available AC with the most appropriate expertise, with cover when they're away (Code 36.3).
- Leave. Grants s17 leave, with any conditions they think necessary (s17(1)).
- Renewal. Examines the patient in the last two months of the period and reports to the managers. Someone of another profession, involved in the treatment, must agree in writing (s20(3) and (5A)).
- Discharge. Can discharge the patient from detention or a CTO (s23).
- CTOs. Makes a CTO only with an AMHP's written agreement (s17A(4)), and can recall the patient to hospital (s17E).
- Barring. Can bar a nearest relative's discharge by reporting, within 72 hours of their notice, that the patient would be likely to act dangerously (s25).
An RC needn't be a psychiatrist. Where psychological therapy is central, a psychologist may be the right RC (Code 36.5). If the RC can't take charge of a treatment, such as a drug they can't prescribe, another clinician does and keeps them informed (Code 36.10 and 36.11).
Responsible clinician vs approved clinician vs section 12 doctor
| Section 12 doctor | Approved clinician | Responsible clinician | |
|---|---|---|---|
| What it is | A doctor with special experience in mental disorder | A professional approved for the Act's AC functions | The AC in overall charge of one patient's case |
| Who can be one | Doctors only | Doctors, psychologists, nurses, OTs and social workers | Any approved clinician |
| How you get it | Approval, for up to 5 years | Approval, for 5 years | Allocation by the hospital managers |
| Medical recommendations | Yes | Only if they're a doctor | Only if they're a doctor |
| Typical tasks | Assessments and recommendations for s2 and s3 | In charge of a treatment, s5(2), consent certificates on Form T2 | Leave, renewal, discharge, CTOs |
The nearest relative
The nearest relative comes from the list in s26: spouse or civil partner first, then children, parents, siblings and so on. It isn't the same as next of kin. The patient can't simply choose them, though a court can displace an unsuitable one (s29).
- Applying. They can apply themselves (s11(1)), or require the local authority to have an AMHP consider the case. If the AMHP decides not to apply, they must give reasons in writing (s13(4)).
- Being told and consulted. They're informed of a s2 application and consulted before s3 or guardianship, which an AMHP can't make over their objection (s11(3) and (4)).
- Discharge. They can order discharge from s2, s3 or a CTO on 72 hours' written notice, unless the RC bars it (s23 and s25).
Who counts, and how to displace them, is set out under the nearest relative.
What does a SOAD do?
A second opinion appointed doctor is appointed by , the Act's regulatory authority in England, to give the independent certificates requires (s58(3) and s145(1)). In Wales, the Welsh Ministers appoint them.
You'll need one for medication after three months if the patient refuses or lacks capacity (Form T3). You'll also need one for when they lack capacity, and for CTO patients' Form CTO11 certificates. Before certifying, the SOAD consults a nurse and someone who's neither a nurse nor a doctor (s58(4)).
SOADs can visit, interview and examine the patient in private, and inspect their treatment records (s119(2)). Consent to treatment under Part 4 covers when each certificate applies.
Who are the hospital managers?
In an NHS hospital the managers are the trust itself; in an independent hospital, whoever is registered to run it (Code 37.2). They hold the authority to detain, and must make sure patients are detained only as the Act allows (Code 37.3).
In practice they delegate. Staff check and receive the papers (Code 37.12), and tell patients about their rights and about IMHAs, orally and in writing (s132; Code 37.14). Discharge decisions go to managers' panels of three or more people who aren't employees (Code 37.7 and 38.4 to 38.6).
Managers can't discharge patients held under s5, s135 or s136, or remanded under s35, s36 or s38. Restricted patients need the Justice Secretary's consent (Code 38.2).
Becoming a section 12 doctor or AC as a trainee
Membership of the Royal College of Psychiatrists is one route to s12 approval. Another is four years' full-time experience in a psychiatric training post or similar, with at least two supervised assessments for medical recommendations in the previous 12 months (2015 Instructions, Schedule).
Either way, you need an approved induction course in the 12 months before applying. You also need CPD evidence, from your programme director if you're in training, and two referees, one a s12 approved consultant psychiatrist (paragraph 3).
You can apply for AC approval in your final year of higher training. Unless you'll be acting up or working as a locum consultant, it takes effect once you show the approving body you've joined the Specialist Register (2015 AC Instructions, paragraph 4(2)).
Mistakes people make
- Leaving the bed to the AMHP. If the doctors think admission is needed, finding a suitable bed is their job, unless local arrangements say otherwise (Code 14.77).
- Assuming a non-medical RC can recommend. An RC who isn't a doctor can grant leave, renew and discharge, but can't give a medical recommendation for detention.
- Treating next of kin as the nearest relative. Work it out from s26 each time, and check whether a court has appointed someone else.
- Letting approval lapse. Section 12 approval lasts up to five years, and you must stop acting as a s12 doctor once it expires (2015 Instructions, paragraph 6). Diary the date.
- Not knowing who the RC is. It should always be easy to find out, with cover for nights and leave (Code 36.3).
The rules in brief
- AMHP. Makes most applications, after interviewing the patient and considering alternatives. Often a social worker, but nurses, OTs and psychologists can be AMHPs too. Never a doctor.
- Section 12 doctor. Approved for up to five years as having special experience in mental disorder. One of the two recommending doctors must be one.
- Approved clinician (AC). Approved for five years to act as an approved clinician: they can be a responsible clinician, or in charge of a treatment under Part 4. Psychiatrists, and some nurses, psychologists, OTs and social workers.
- Responsible clinician (RC). The AC in overall charge of a detained or CTO patient. Grants leave, renews, discharges.
- Nearest relative. A statutory role chosen by a list, not next of kin.
- SOAD. A second opinion appointed doctor, appointed by CQC, who certifies treatment under Part 4.
- Hospital managers. The trust, or an independent hospital's registered provider. They hold the authority to detain, give rights information and can discharge.
Read more: MHA Code of Practice 2015, chapter 14: Applications for detention in hospital · Section 12 approval instructions 2015 · Approved clinician approval instructions 2015
Questions trainees ask
What is a responsible clinician?
The approved clinician with overall responsibility for a detained or patient's case (s34(1)). They grant leave, renew detention, discharge, and make and recall CTOs.
What's the difference between an RC and an AC?
An approved clinician is approved to carry out the Act's roles, such as being in charge of a treatment or acting as a responsible clinician. The is the AC in overall charge of a particular detained or CTO patient.
Who can be a responsible clinician?
Any approved clinician: a psychiatrist, or an approved psychologist, nurse, occupational therapist or social worker. The hospital should allocate the AC whose expertise best fits the patient's main needs (Code 36.3).
Can a doctor be an AMHP?
No. AMHPs are usually social workers, and can be nurses, occupational therapists or psychologists, but not doctors.
What's the difference between an approved clinician and a section 12 doctor?
A section 12 doctor is approved as having special experience in mental disorder, and one of the two recommendations for detention must come from one. An approved clinician can take charge of treatment or be an RC, and an AC who's a doctor is automatically treated as s12 approved.
How long does approved clinician approval last?
Five years. First approval needs an approved induction course in the two years before you apply; re-approval needs a refresher course in the previous 12 months.
What does a SOAD do?
A second opinion appointed doctor, appointed by , independently certifies treatment that says needs a second opinion. That includes medication after three months for a patient who refuses or lacks capacity, and for a patient who lacks capacity.
Who are the hospital managers?
The NHS trust that runs the hospital, or the registered provider of an independent hospital (Code 37.2). They hold the authority to detain, and their power to discharge is used by panels of people who aren't employees.
Test yourself
Who can make an application for admission under s3?
Show the answer
B. Doctors recommend; the applicant applies. The applicant is an AMHP or the nearest relative.
Quick-fire
Section 12 approval lasts up to
Show the answer
5 years