Mental Health (care and treatment) (Scotland) Act 2003: Code of Practice Volume 1

Chapter 11: Social Circumstances Reports (section 231)

Introduction

This chapter examines the preparation of a social circumstances report (" SCR") under section 231 of the Act. It begins by describing the provisions of section 231 of the Act and the associated regulations which set out when an SCR must be prepared; what it must contain; and who it must be sent to.

The chapter then provides a range of best practice guidance with respect to, for example, the purpose of an SCR; when it would be acceptable not to prepare an SCR; and the difference between an SCR and a proposed care plan.

Overview of the statutory provisions

01 Section 231(1) of the Act states that wherever a "relevant event" occurs in respect of a patient, the patient's designated MHO must prepare an SCR within 21 days of the "relevant event" occurring. Within those same timescales, the MHO must send a copy of the report to the patient's RMO and the Commission. (There is no form prescribed in regulations for this but a pro-forma ( SCR1) is available on the Scottish Executive's website at: www.scotland.gov.uk/health/mentalhealthlaw .)

02 Where the MHO considers that providing an SCR would serve 'little, or no, practical purpose', the MHO must, in terms of section 231(2) of the Act, record the reasons for this and send a report to the patient's RMO and to the Commission. (There is no form prescribed in regulations for this but a pro-forma ( SCR1) is available on the Scottish Executive's website at: www.scotland.gov.uk/health/mentalhealthlaw )

03 Section 232 of the Act defines a "relevant event" as:

• the granting of a short-term detention certificate;

• the making of an interim compulsory treatment order;

• the making of a compulsory treatment order;

• the making of an assessment order;

• the making of a treatment order;

• the making of an interim compulsion order;

• the making of a compulsion order;

• the making of a hospital direction; or

• the making of a transfer for treatment direction.

04 Regulations made under section 231(3) of the Act (The Mental Health (Social Circumstances Reports) (Scotland) Regulations 2005 ( SSI No. 310)) prescribe that the following categories of information must be provided in an SCR:

• the reasons behind the use of compulsory powers;

• the views of patient with respect to the use of compulsory powers;

• if the patient is unable to give a view, and only if available to the MHO, the views of the patient's named person, carer, guardian and welfare attorney with respect to the use of compulsory powers;

• the patient's current state of mental health;

• the patient's current state of physical health;

• the patient's mental health history;

• an assessment of risk of harm to the patient and to others;

• the patient's personal history including details of employment, finances, and accommodation prior to the use of compulsory powers;

• details of the family situation, including whether the patient has children, dependants and caring responsibilities;

• details of the patient's regular social contacts: e.g. supportive friends, involvement with voluntary organisation, church attendance, etc.;

• the patient's ability to care for him/herself;

• the care being provided to the patient prior to the use of compulsory powers taking place;

• any matters which would require the local authority to inquire under section 33 of the Act;

• any alternatives to the use of compulsory powers which were considered and ruled out;

• the patient's history of offending, including any consideration of victims and/or those affected;

• the patient's history of substance misuse, if any;

• any relevant ethnic, cultural and religious factors;

• whether the patient has difficulty in communicating; and

• the care planning which has been put in place to deal with any of the above issues.

What is the purpose of an SCR?

05 The purpose of an SCR is to:

• provide the RMO with information which may assist in the assessment of the patient (including an assessment of potential risks) and in the planning of future care and treatment either on a formal or an informal basis;

• advise the RMO of the outcome of the MHO's assessment which should identify, at an early point, those aspects of a person's health and welfare as well as any support needs of carers which the MHO feels should be addressed in constructing future care plans;

• inform the Commission of the patient's circumstances prior to their being subject to compulsory powers and whether any alternative courses of action might have been considered or could be considered in the near future, and what these courses of action might have been or are; and

• alert the Commission to concerns with respect to any circumstances which fall within its remit and with respect to which it might wish to make further enquiries when carrying out its functions and duties under the Act.

06 An SCR should reflect the MHO's assessment and the information on which it is based. It should bridge the gap between specialist psychiatric services and local authority assessment and care management services, processes and resources. It should:

• bring together in one document relevant information from diverse sources, both historical and current;

• analyse the interaction between a person's mental disorder and their personal and social circumstances;

• comment on whether the MHO believes that compulsory powers have been used appropriately and on how and whether those powers should continue to be used; and

• propose recommendations for the future care and treatment of the patient.

Whom should the MHO interview and/or consult in preparing an SCR?

07 The patient is the most important person in this process. It is essential that the MHO makes all reasonable efforts to meet with and interview the patient for the purpose of preparing an SCR. Interviews with the patient are fundamental to good professional practice in carrying out the assessment relevant to an SCR. Only in exceptional circumstances would an MHO be able to finalise an SCR without having interviewed the patient at least once. The MHO will need to exercise his/her communication skills and draw upon his/her knowledge and experience to establish a therapeutic relationship with the patient during the process of assessment. This will enable him/her to contribute good quality information to the RMO and the rest of the multi-disciplinary team in order to assist in their own assessment and decision-making about the future care and treatment of the patient. For this reason, it is important that local authorities, in responding to their duties under section 229 of the Act appoint a "designated mental health officer", try to ensure continuity of care and limit changes of designated MHO to the greatest extent possible.

08 There may be occasions where a patient does not wish to or is not able to cooperate with the MHO in this process. When this is the case, it should be stated in the SCR. The MHO should, nevertheless, continue to prepare the SCR using all available information. It would be standard practice to interview involved relatives and/or primary carers, where appropriate, while preparing the SCR.

09 The patient might, however, state that he/she does not wish a carer or relative to be interviewed. In such cases, the MHO should weigh up the advantages and disadvantages of over-riding these wishes. This is a judgement call which should be discussed with the patient's RMO and other members of the multi-disciplinary team. Decisions will be informed by the nature of the relationship between the patient and the carer or relative; the nature of the illness and the impact on the behaviour of the patient; and the perceived potential value of the views of the relative or carer. There may, for instance, be situations where the patient's behaviour towards the primary carer or relative was a cause of major concern on their part prior to becoming subject to compulsory powers admission, and it may be that it would be difficult to assess and plan future care without their involvement. Where a decision is taken to over-ride the patient's wishes, the patient should be informed of this decision, the reasons for the decision; and the fact that the MHO will still be bound to protect the patient's confidentiality.

10 Persons who would normally be consulted by the MHO include all key members of the multi-disciplinary team involved with the service user; the patient's GP or other members of the Primary Care Team; any social work colleagues who have otherwise been involved with the patient and/or a close member of their family or their carer ( e.g. in Community Care, Criminal Justice or a Children and Families Team), their primary carer; relatives and key staff involved in service provision in the voluntary sector.

11 The MHO should always discuss with the patient whether they would find it helpful to have their named person and/or independent advocate (where they have one) involved in any interviews with the MHO in the course of preparing the SCR.

In what circumstances might preparing an SCR serve "little, or no, practical purpose"?

12 As described in paragraph 1 above, section 231(1) of the Act states that an SCR must be prepared subsequent to the occurrence of any "relevant event". Administrative and workforce constraints alone do not absolve local authorities from this statutory duty. An MHO is only permitted not to prepare an SCR where he/she can demonstrate that preparing an SCR would serve little or no practical purpose. The effect of such a view is that the MHO does not believe that the processes allied to the preparation of an SCR (for example, interviewing the patient; consulting with relevant others; and pulling together all relevant information, including the MHO's assessment) will assist the RMO in the assessment and care planning of the patient or does not believe that information relating to the patient should be brought to the attention of the Commission.

13 There are situations, however, in which it will be evident that preparing an SCR would serve little or no practical purpose. An SCR, for example, may have been prepared following admission to hospital on the authority of a short-term detention certificate and the patient is subsequently detained under a CTO ( i.e. a further "relevant event"). Similarly, a patient may be made subject to an assessment order for which an SCR is prepared and subsequently is made subject to a compulsion order. These situations will be generally fairly straightforward. Other situations require finer judgements. In some circumstances a patient will be admitted to hospital on the authority of a short-term detention certificate which is then revoked shortly afterwards. This could happen for any number of reasons. For example, the person may become well again quite quickly as in a case where the patient's mental state was considerably worsened by the effects of drugs or alcohol at the time of admission to hospital. In other cases, even though the certificate has been revoked, the person may still remain in hospital on a voluntary basis. In both these situations, it would be best practice for the MHO to discuss the situation with the RMO to determine whether it would be helpful to prepare an SCR. MHOs should also consider that there will be situations where they are not able to engage in constructive discussions with the patient and, sometimes, a carer or involved relative, despite efforts.

14 There may be occasions where the MHO's ability to prepare a thorough SCR will be in some way compromised. The MHO should always remember that, as a general rule, there will be value in putting together a report with limited information rather than not preparing an SCR at all. This could happen, for example, where a report had previously been completed, within the previous 3 to 6 months. It would be best practice to build upon the previous SCR and focus on the relevant information/ developments in the intervening period and how this affects the assessment and care planning. Such an SCR should therefore focus on the factors which played a part in the breakdown of the previous care plan and how the care and support being given to the patient might be adjusted in future to take account of this. Even in such cases it would be best practice to repeat information from the first report (if necessary, by cutting and pasting) to ensure that all information is pulled together in the latest report so that it can stand on its own as a useful management tool.

15 Local authorities should set up systems to monitor the level and quality of its provision of SCRs. Such systems should monitor, on a routine basis, the reasons stated by MHOs as to why providing a report would serve little, or no, practical purpose.

What is the difference between an SCR, a proposed care plan and a Mental Health Officer's report which both accompany the application for a Compulsory Treatment Order?

16 The MHO report for the CTO application should focus on the assessed needs of the individual and whether the MHO believes the criteria for compulsory powers are satisfied. A proposed care plan, while commenting on assessed needs, focuses almost exclusively on future care plans. Together these documents will contain much, but not all, the information included in an SCR. It should be possible to use much of the information from an SCR to help complete an MHO's report and a proposed care plan so that there should not be any wasted effort if the decision is taken to proceed with a CTO application well after an MHO has begun the process of completing an SCR. The main added value of the SCR is that it summarises information on the personal and social circumstances of the individual, as well as the care and treatment history of the patient and places this in the context of the current admission and future care planning.

17 The SCR should examine how the patient has managed his/her illness in the past; what has triggered acute episodes in the past; what has/has not worked, and why. The SCR may contain extraneous details which, while important historically in understanding the patient and his/her current situation, are not pertinent to the CTO application and the powers being sought. For example, there may be information on previous relationships, financial information, previous minor offences etc. which are not seen as relevant to the CTO application and in which it might be best to respect the patient's right to privacy and confidentiality. Personal information should only be shared with the Tribunal in applications when such information is relevant to the application. The SCR will also include information primarily for the attention of the Mental Welfare Commission which would not normally be included in these other reports.

What is the difference between an SCR and a report requested by the Sheriff Court in considering imposing a Compulsion Order?

18 The basic difference is the purpose for which the reports are being prepared. An SCR, as stated above, is prepared primarily to assist the RMO in assessment and care planning and to give relevant information to the Mental Welfare Commission. A report prepared in response to a request from the Sheriff Court when a Compulsion Order is being considered is to assist the court in determining an appropriate disposal: i.e. whether a Compulsion Order would be appropriate or an alternative mental health disposal. Such reports will have to address relevant social circumstances, assess risk and take account of the views of others and to this extent may well contain much of the material that would normally be found in an SCR. They would not, by their nature, contain all the information usually found in an SCR which is written, with a different purpose, for a different audience. Like an application for a CTO, the MHO should not include personal detailed information on the patient which is not relevant to the decision the court has to make.

Can an MHO trainee prepare an SCR?

19 The Act is structured in such a way to ensure that the specialist knowledge and expertise of the MHO is brought to bear in the assessment and care planning of persons subject to compulsory powers under the Act. The SCR should be a reflection of the MHO's assessment as well as a reference document which pulls together valuable, relevant information on the personal and social circumstances of the individual. As stated earlier, it should be founded on the basic professional practice of interviewing the patient and relevant others and consultation with the multi-disciplinary team. These are not activities that can be transferred to someone who does not as yet have the required expertise. MHO trainees do, of course, need to secure experience to be able to demonstrate the competencies necessary to receive the Mental Health Social Work Award and be appointed to act as an MHO. Ideally an MHO trainee should shadow an MHO who is interviewing and consulting others in preparing an SCR. The trainee might even, on their own, undertake further interviews and discussions with others in the multi-disciplinary team and use these as a basis for further discussions with the MHO preparing the SCR. The trainee might even gain useful experience from preparing a draft SCR based on the joint work which was undertaken with the MHO. The completed SCR, however, has to be owned and signed by the MHO. It is they who will remain accountable for both the content of the report and the practice upon which it was based.