By Steve Chamberlain
The Covid-19 pandemic is causing major disruption in multiple areas of our lives and the Coronavirus Act 2020 gives the government considerable additional powers to restrict movement and amend legislation in an effort to control and contain the spread of the disease.
Mental health services are particularly affected by schedule 8, which gives ministers the power to amend the Mental Health Act 1983 (MHA) if the situation deteriorates and local authorities and the NHS are at risk of being unable to fulfil their statutory responsibilities. It is important to note that schedule 8 will not be enacted without further ministerial order. So for the time being we are working with the MHA as it stands.
There has already been considerable discussion about how to respond to existing duties in the context of the risks of infection to both professionals and the public in the course of statutory assessment processes.
MHA assessments are required when it is considered that a person is sufficiently mentally disordered to need compulsory admission to hospital for their health or safety, or to protect others. An assessment typically requires the person to be assessed by two doctors and an approved mental health professional (AMHP).
The assessment could take place in the person’s own home, in a psychiatric ward, a general hospital ward, a police station or wherever the person happens to be. The nature of the assessment is almost inevitably highly pressured and emotionally laden, as the person will be in mental health crisis, there will be significant risks and a decision is being considered to deprive someone of their liberty.
Quality of communication crucial
This makes the quality of the communication crucial, in order to ensure a thorough and lawful assessment. The whole process of the MHA assessment is governed by rules set out in the MHA and its code of practice. Before making a decision whether or not to detain a person, the AMHP must interview them “in a suitable manner” (section 13(2), MHA).
AMHPs have always considered a face-to-face interview to be the only way to interview “in a suitable manner”. But with the onset of the Covid-19 pandemic and the risks of infection, increasing consideration is being given to video interviews. However, while they are being used in other contexts there are no guidelines for MHA assessments.
MHA assessments throw up particular challenges. The AMHP has overall responsibility for co-ordinating the assessment (code of practice, 14.41). It is their job to ensure the various professionals and agencies are involved in a timely manner. They must also ensure to the best of their ability the person is aware of the process, of their rights and is given the opportunity to express their wishes and feelings. All this while a person is experiencing a mental health crisis.
When a person is exhibiting possible symptoms of Covid-19, they pose a particular infection risk to the professionals present. Even without symptoms, we are told that people can be infectious, so an apparently healthy person provides no guarantee against infection. Equally, professionals may pose a similar risk to the individual. Government policy is clear. To reduce infection we must maintain distancing guidelines.
MHA assessments frequently take place in uncontrolled and cramped environments: people’s front rooms, police cells, A&E side rooms. It can be difficult to guarantee a suitable distance, particularly when a person in mental health crisis may be acting unpredictably.
Are video assessments the answer?
So how about completing assessments by video link? Is that the answer?
As far as I’m aware, no one had piloted or tried video interviewing prior to this pandemic, but it appears that it is starting to happen in some areas, and in limited circumstances. Just within the past two weeks, some services have been starting to produce guidelines for their staff.
I’ve never been comfortable with the idea of video interviewing in this context, but no one has ever needed to consider it seriously before now. Or maybe I’m a dinosaur stuck in the 20th century.
Starting with the basics, the doctor must “personally examine” the patient and the AMHP has to be satisfied that they can interview in a suitable manner, and to defend that if challenged, in court if need be. The definition of “personally examine” continues to be discussed, but I will currently focus on the role of the AMHP.
I believe there are circumstances when this would be possible using video, and other times when it would be out of the question.
There appear to be three main issues:
- Technology (hardware and adequate reception)
- Sufficient support for the interviewee
- The impact on the interviewee of the use of technology
Hardware is a major issue for many services, but perhaps only because it has never been considered. The purchase of a tablet is fairly cheap in the current scheme of things. Many services have wifi capability providing reception.
What about data protection? The NHS has recently issued guidance about information governance in the context of Covid-19 Advice to health and care professionals includes encouragement of videoconferencing, including the use of commercial products such as Skype or WhatsApp. The guidance goes on to remind professionals to be cautious about confidentiality issues as with any other communication.
The support issue is trickier. Increasing numbers of people are highly IT literate but an MHA assessment is very different to a simple conversation.
To look at two rather extreme examples, there would be no question of being able to video interview a person with advanced dementia who was on their own with no support.
However, for someone with a ‘trusted other’ (either professional or informal), who could support the person and ensure the AMHP is able to communicate verbally and maintain good visual contact, then I don’t see why it can’t work.
This could happen in a variety of environments: psychiatric ward, general hospital ward, police station, even someone’s own home. The ‘trusted other’ would need to be able to cope with the process and the AMHP would need to be proactive in managing it.
Thirdly it depends on the impact of the technology on the individual.
The AMHP will need assess whether the process of communication via video will impact negatively on the person’s responses and their reactions. For example, if someone has delusional thinking which focuses on technology, I think it would be very difficult to interview the person by video, and to consider it to be “in a suitable manner”. On the other hand, being interviewed by a person (or a team) in full PPE may be equally or more disturbing.
I’m becoming more accepting of the possibility of video interviews for MHA assessments, but only in the right context and with effective support. I think the demands of the current crisis are such that it is inevitable that video interviewing will happen with increasing frequency, and by the time we come out at the other end we will have developed some guidelines.
Steve Chamberlain is chair of the AMHPs leads network. He is writing in a personal capacity.