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Assessment of mental capacity: who can do it?

  • Ankush Singhal (a1), Alok Kumar (a2), Ravindra B. Belgamwar (a3) and Richard E. Hodgson (a4)
Abstract
Aims and Methods

To determine the point prevalence of mental incapacity and the ‘Bournewood gap’ in general adult and old age mental health in-patients. The correlation of mental capacity assessment between doctors and nurses was investigated. Data were gathered on one census day for all general adult and old age psychiatric in-patients at three hospital sites.

Results

Half the sample lacked capacity and one third fell into the ‘Bournewood gap’. The capacity assessment by nurses and doctors correlated highly (κ=0.719, P=0.0001).

Clinical Implications

‘Bournewood gap’ patients should have their needs assessed in order to identify and protect their rights. Appropriately trained mental health nursing staff can undertake this assessment.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Cairns, R., Maddock, C., Buchanan, A., et al (2005) Reliability of mental capacity assessments in psychiatric in-patients. British Journal of Psychiatry, 187, 372378.
Department of Health (2005a) Bournewood Consultation. The Approach to be Taken in Response to the Judgement of the European Court of Human Rights in the ‘Bournewood’ Case. Department of Health. http://www.dh.gov.uk/assetRoot/04/10/86/41/04108641.pdf
Department of Health (2005b) New Ways of Working for Psychiatrists: Enhancing Effective, Person-centered Services through New Ways of Working in Multidisciplinary and Multiagency Contexts: Final Report 'But Not The End of The Story. Department of Health. http://www.dh.gov.uk/assetRoot/04/12/23/43/04122343.pdf
Department of Health (2006) Background to Independent Mental Capacity Advocate (IMCA) Service. Department of Health. http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/SocialCare/IMCA/IMCAArticle/fs/en?CONTENT_ID=4134876&chk=XUvRNL
Eastman, N. & Peay, J. (1998) Bournewood: an indefensible gap in mental health law. BMJ, 317, 9495.
House of Lords (1998) R. v. Bournewood Community Mental Health NHS Trust ex part L. House of Lords Judgment. 25 June 1998. TSO (The Stationery Office).
Raymont, V., Bingley, W., Buchanan, A., et al (2004) Prevalence of mental incapacity in medical inpatients and associated risk factors: cross-sectional study. Lancet, 364, 14211427.
H.L. v. UK, European Court of Human Rights, C [2004] J 4269.
L. v. Bournewood Community and Mental Health NHS Trust [1998] 2 WLR 764.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Assessment of mental capacity: who can do it?

  • Ankush Singhal (a1), Alok Kumar (a2), Ravindra B. Belgamwar (a3) and Richard E. Hodgson (a4)
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eLetters

Assessment of mental capacity: who can do it, or who should do it?

Schalk W. du Toit, Specialty Registrar ST4 General Adult Psychiatry
19 February 2008

I was interested to read about the discrepancy in the number of capacity assessments, carried out by doctors on general adult and old age psychiatry wards. (Singhal et al, Psychiatric Bulletin, January 2008, 32, 17-19) Although the authors gave no explanation, the result could be because patients on the general adult wards, who probably lacked capacity,were more likely to be detained under the Mental Health Act and therefore fell outside the Bournewood gap.

This result does however support my belief that doctors on general adult psychiatry wards do not assess their patient’s capacity (to consent to treatment) often enough.

I took part in conducting a survey (Hill et al, 2006) in which consultant and trainee psychiatrists were asked, “What are the key elements in the assessment of a patient’s capacity?” Over a third of the 95 participants could only identify 2 or less of the 5 points in testing decision-making capacity. (England & Wales Mental Capacity Act 2005 and Re C test) This suggested an inadequate level of knowledge, and I believe that as doctors we could become even more de-skilled, should we rely entirely on our nursing colleagues to fulfil this role in future.

The authors make the point that, “Appropriately trained mental healthnursing staff can undertake this assessment.” I am sure they can, but should they?

I believe it is appropriate that as prescribing doctors, we should beassessing our patient’s capacity to consent to the proposed treatment, andnot merely delegate these duties to other healthcare professionals. This makes sense from an ethical and medico-legal perspective.

Hill SA, Mather GI, James AJ. Assessing decision-making capacity: a survey of psychiatrists' knowledge. Medicine Science and the Law. Jan 2006; 46 (1): 66-8

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