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HOSPITAL ADMISSION, DISCHARGE and AFTERCARE

ADMISSION TO HOSPITAL

Most people with a mental illness receive medical treatment and personal support at home from their GP and Community Mental Health Team(CMHT). Generally people are only admitted to hospital when they become extremely unwell or when they are in crisis.

If a person needs treatment in hospital a referral is usually made by their GP or CMHT. If a person is not already known to the local mental health services they may be admitted urgently for assessment. A person can be admitted to hospital either "informally" or "formally".

A person is admitted informally when they want to receive treatment in hospital and agree to their admission. Such people are referred to as "voluntary" or "informal" patients. Voluntary patients can of course discharge themselves and leave hospital at any time without the agreement of staff. However, there is provision to stop a voluntary patient discharging themselves if they are seriously, mentally unwell (see Section 5 of the Mental Health Act below).

A person becomes a formal patient when they are admitted to hospital under a section of the Mental Health Act. This compels them to remain in hospital (even if they don't want to) for set periods and to be assessed or receive treatment. For more information see the page on the Mental Health Act.

ON THE WARD

Some hospitals have single sex wards; in others there are no separate wards for men and women although sleeping, toilet and bathing arrangements will always be single sex. A voluntary patient can check this out before hand; if the admission is an emergency this may be more difficult.

Arrival on the ward can be a very distressing and confusing time. Ward staff will be aware of this and will ensure that they help the person settle for example by showing them around the ward. Nursing staff and medical staff dress in everyday clothes and can be identified by their name badge.

Soon after admission the person will be interviewed by a member of the nursing staff and by the ward doctor; the person will be asked about past history as well as full details of their current problems. This information is taken to ensure that the help and support offered while in hospital is appropriate. The patient will also be asked if they have brought any medication with them.

A keyworker (sometimes called a primary nurse, named nurse or care co-ordinator) is introduced to each new patient within a few days of admission. The role of the keyworker includes co-ordinating nursing care and providing relevant information, for example a person's rights under the Mental Health Act.

Daily activity -  Activity on the ward will depend on the type of ward and the needs of the individual patients.

Medication - Will usually be given out at set times, often around mealtimes and bedtime.

Meals - There may be a choice of menu for main meals and special diets will be catered for.

Drinks - There is usually a kitchen on each ward where drinks or toast can be made in between meals

Visiting - On the majority of wards arrangements for visiting are fairly flexible with some wards have unrestricted visiting. Visiting for some individuals may be restricted if the treatment team feel that this is beneficial to the patients recovery.

Ward round - Ward rounds usually take place weekly and offer an opportunity for professionals involved in the person's treatment to discuss their care and treatment plan. Patients should be fully involved in these discussions and important relatives and carers should be invited.

Smoking - Smoking is only allowed in designated areas within each ward.

Care and Treatment Planning - The latest guidance for professionals working with people detained in hospital under the Mental Heatlh Act states that, during a person's stay in hospital they should ensure that the person's full range of needs are assessed, and a multi-disciplinary plan drawn up to meet those needs. This plan should be drawn up together with the person and their carers, and it should be clear which professional is co-ordinating the implementation of the plan. Currently this guidance applies specifically to people detained on the ward under a Section, but good practice suggests it is relevant for all patients.

The Welsh Mental Health Act Code of Practice includes significant information about many of these ward arrangements.

DETENTION IN HOSPITAL UNDER THE MENTAL HEALTH ACT

The Mental Health Act (legally the Mental Health Act 1983 as amended by the Mental Health Act 2007) sets out the situations where a person may be compulsorily admitted to hospital for assessment and treatment, and also where a person may receive compulsory treatment at home. Some of the most commonly used sections are referred to here:

Section 2 allows for a person to be admitted to hospital for assessment, although the Act also makes it clear that the person may be given treatment, with their consent, under this section.

An application for admission for assessment is usually made by an Approved Mental Health Professional, and has to be supported by two Doctors (one of whom must have approval under the Act and one should know the person). An application can also be made by the person's Nearest Relative. The person making the application for assessment must have seen the person within the past fortnight, and the doctors must have seen the individual within a week of each other.

The doctors must confirm that:

•  the person is suffering from a mental disorder of a nature or degree which warrants admission to hospital for assessment followed by medical treatment; and 
•  the person should be detained in the interests of their own health and safety or with a view to the protection of others.

Detention under this Section can be for up to 28 days, and cannot be extended.

Section 3 allows for a person to be admitted to hospital for treatment.

The application process is similar to that for Section 2, but with the doctors confirming:-

• the person is suffering from a mental disorder of a nature or degree which makes it appropriate to seek medical treatment in hospital;
• it is necessary for the health or safety of the individual or for the protection of others that they should receive such treatment and it cannot be provided unless they are detained, and
• appropriate medical treatment is available for that person.

Detention under Section 3 is for an initial period of six months, and this can then be renewed for a further period of six months and then for periods of one year.

Sections 4 and 5 allow for a person to be admitted to hospital in emergency situations.

Section 4 should only be used where a person needs to be admitted to hospital as a matter of "urgent necessity". An application for admission under Section 4 is made by an Approved Mental Health Professional, or the person's Nearest Relative, and is supported by one doctor, usually the person's GP.

Both the person making the application and the doctor must have seen the person in the previous 24 hours, but the emergency application can be signed before or after the medical recommendation. Admission to hospital must be made within 24 hours of the form being signed.

Detention under Section 4 lasts for 72 hours and cannot be extended. However, Section 4 detention can be converted to detention under Section 2 or Section 3 by obtaining a second medical opinion within the 72 hour period.

Section 5 relates to detention of a person already in hospital. It allows for a person already in hospital to be detained in hospital in an emergency situation to give time to consider an application under Section 2 and Section 3. Application for detention under Section 5 can be made by the individual's doctor in the hospital or by some grades of nurses.

Detention lasts for 72 hours when made by a doctor or for 6 hours or until a doctor arrives when made by a nurse. If the doctor arrives and decides to make a Section 5 order, the nurse's 6 hours are included in the 72 hours.

RIGHTS OF APPEAL TO A MENTAL HEALTH REVIEW TRIBUNAL

People who are detained in hospital under the Mental Health Act have rights of appeal against their detention to a Mental Health Review Tribunal (MHRT).

Section 2 Patients have a right to appeal during the first 14 days of their Section.

Section 3 Patients have a right to appeal once during their initial 6 months of detention, once during their second 6 months of detention, and yearly thereafter. If a patient does not initiate an appeal for themselves, Hospital Managers automatically refer their case to an MHRT during their first 6 months of detention, and then every three years subsequently.

HOSPITAL DISCHARGE UNDER THE MENTAL HEALTH ACT 

Planning for a person's discharge should begin as soon as possible after a person's admission. As part of a discharge care plan, continued support should be provided where necessary by a range of mental health professionals in the community, and can include support from both statutory and voluntary agencies. This team of professionals could include, in addition to a person's GP, Community Psychiatric Nurses (CPNs), Social Workers, Psychologists, Occupational Therapists (OTs) and support workers.

This team can provide a range of services encompassing monitoring and administering medication; providing 'talking therapies' and giving long-term support. It is usual for a follow-up appointment to be arranged following discharge.

Section 2 and Section 3 Discharge from detention under Sections 2 and 3 can be authorised by:
• the Responsible Clinician (RC)
• the Hospital Managers
• the person's Nearest Relative who has to give 72 hours notice of their intention to discharge the patient thus allowing the patient's RC to consider the  intention and stop the discharge by reporting to the Hospital Managers
• a Mental Health Review Tribunal

Section 4 and Section 5
Discharge from detention under Section 4 can only be authorised by the person's Responsible Clinician (RC).

AFTERCARE UNDER THE MENTAL HEALTH ACT

People who have been detained in hospital for treatment (usually under Section 3 and also under Section 37) are entitled to receive "statutory after-care" under Section 117. Planning for a person's after-care should begin as soon as after their admission to hospital as possible and, in practice, this will usually be a continuation of care planning for the person under the Care Programme Approach (CPA).

A person's RC is responsible for ensuring a person's needs are fully indentified and assessed, and that a Care Plan is drawn up and implemented on discharge, to meet their needs. This should be done jointly together with the person's important relatives and/or carers, with primary and secondary health services, and with social services. Voluntary sector providers should also be included where appropriate. A care co-ordinator will be appointed to maintain regular contact with the person and ensure that the Care Plan is kept under review.

TREATMENT AT HOME UNDER THE MENTAL HEALTH ACT

People can be required to accept treatment when they return home through a provision in the Mental Health Act known as Supervised Community Treatment (SCT), if they:

- have been detained in hospital for treatment, usually under Section 3,
- continue to need treatment but no longer need to be in hospital, and
- are believed to be at risk of not complying with their treatment.

Where a person is subject to SCT, they are given an individual Community Treatment Order (CTO) which sets out the conditions for their continued treatment.

FURTHER INFORMATION

All the major documents relatin gto the Mental Health Act and the Code of Practice, including information leaflets, are available on the  Health of Wales Information Service (HOWIS) website whcih can be accessed by this link:

www.wales.nhs.uk/mentalhealthact1983

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