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Inexperienced trainees doing more Section 136 emergency assessments

  • Liz Tate (a1)
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Abstract
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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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1 Waddell, L, Crawford, C. Junior doctors are performing fewer emergency assessments – a cause for concern. Psychiatrist 2010; 34: 268–70.
2 Department of Health. Reducing Junior Doctors' Hours Continuing Action to Meet New Deal Standards Rest Periods and Working Arrangements, Improving Catering and Accommodation for Juniors, Other Action Points (HSC 1998/240). Department of Health, 1998.
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BJPsych Bulletin
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Inexperienced trainees doing more Section 136 emergency assessments

  • Liz Tate (a1)
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eLetters

MISCONCEPTIONS AROUND SECTION 136 OF THE MENTAL HEALTH ACT

Khurram Sadiq, Locum Consultant Psychiatrist Trafford
08 November 2010

I would like to draw Dr Huda’s attention to the fact that when a junior surgical trainee would not be required to carry out a surgery until appropriately trained, then how may a psychiatric trainee in his/her early training be giventhe responsibility to deal with the complex Section 136 assessments. This is not a counsel of perfection but a reality check. The eyes do not see what the mind does not know, hence great deal of risk involved in letting the junior doctors review these assessments with out adequate safeguarding in the form of prompt support and supervisions.

Code of Practice clearly implies that the Section 136 be assessed by Section 12(2) approved doctors as a desirable outcome and in circumstances where the practice deviates from the guidelines, a reason is to be documented. The other aspect is that although the section 136 assessments are overseen by junior doctors they are still to be seen by the section 12(2) approved doctors and the AHMP. This arrangement of involving a junior doctor followed by the section 12(2) approved doctors per protocol actually bears more burdens on

the resources with the duplication of resources and time constraints.

Although Dr Huda has quoted that most Section 136 assessments do not require a Section 12(2) doctor to come out as they are in relation to alcohol, but there is no evidence to back the argument hence a here say! All the previous evidence based suggests that there is a high conversion rate of the assessments to admission that can be as high as 80%(1).

In the letter I am baffled by the deviation of the subject from the trainees assessment of Section 136 to emergency assessments. Although section 136 is part of emergency assessments but is by no means the only emergency assessment. I agree that it is not possible to omit the junior doctors for

covering the emergency assessments but can be provided with adequate support and supervision in order to understand and learn from these complex scenarios.

I agree to disagree with Dr Huda on the argument about the senior psychiatrists need for rest because of the prearranged commitments whilst being on call. On call is a contractual obligation that would include section 136 assessment and mental health act assessments. Also part of the job contract are the fixed obligations related to the job like the ward rounds, multidisciplinary team meetings and doing out patient clinics. If there isa problem regarding the clash between duties then these concerns could either be dealt with early swaps or if still unresolved then should be discussed with either the local management or in the LNC settings. Letting the inexperienced junior doctors to be the bearer of that clash may be putting the junior doctor as well as the patient at high risk.

It persistently amazes me that there is such a misperception of the process of the Section 136 of mental health act despite of having a very clear cut protocol(2). We should not forget that Section 136 is a very important part of mental health act and hence a legality and a very frequent occurrence at the same time. The code of Practice clearly stipulates the process and a frequent deviation from the guidelines means a Pandora box that is not far away from being opened.

References:1.Turner.T, Ness.M, and Imison.C (1992). Mentally disordered persons found in public places. Diagnostic and special aspects of police referrals

(Section 136). Psychol Med. 22. 765-7742. Code of Practice: Mental Health Act Manual 1983. Department of Health. 2nd Impression. London. TSO. 2008

Khurram SadiqLocum Consultant PsychiatristTrafford

Sylvia KhanST3 PsychiatryTrafford
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Conflict of interest: None Declared

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A counsel of perfection

Ahmed S Huda, Consultant Psychiatrist
09 October 2010

Dr Tate advocates that only experienced junior doctors undertake S.136 assessments. If they are not experienced then the senior doctor comes in to do the S.136 assessment. This is a counsel of perfection.

Junior doctors, particularly if they are inexperienced, are expected to consult with senior doctors about emergencies they see. This includes S.136 patients as well as other patients including A & E referrals whomay be suicidal and/or homicidal. The argument put forward is that, even if they have access to senior advice, the junior doctor may make inadequate assessments would apply to all assessments they make. The further argument would be that in a perfect world, no junior doctor shouldbe expected to see any of these assessments before we were sure they couldmake adequate assessments possibly after a period of weeks or months of the on the job experience, supervision and training.

Unfortunately we live in an imperfect world. Junior doctors now have extensive induction to try and give them enough know how to perform adequate assessments early on. However many hospitals will often have GP trainees with no experience of psychiatry. There are also far too few psychiatry trainees to fill all the junior posts (meaning gaps in the rotawhich may or may not be filled with locums with varying degrees of experience). There is the EWTD directive which limits the on call hours a junior doctor may do.

All these "real world" factors mean that it is simply not possible toensure that inexperienced junior doctors do not do see emergency assessments before we are satisfied after weeks/ months of work experiencethat they can be "trusted". Most hospitals do not have an abundance of experienced junior doctors to do the oncalls for the first two months or how long it takes before we can be satisfied with the quality of the doctor that is new to psychiatry.The alternative is that the S.12 approved doctor comes in for every S.136 or indeed every emergency assessment by an inexperienced doctor. (It should not matter if a homicidal or suicidal patient is on a S.136 or informal.) Fine in theory and Dr Tate is welcome to do this in her own practice until the day she retires. However, our local experience is that most S.136 patients do not require a S.12 doctor to come in, the clinical problem frequently being caused by alcohol/substance dependency and/or personality disorder. The resultant fatigue on the senior doctor and sometimes the disruption to regular duties the next day (sometimes leadingto cancellation of clinics or ward rounds) being far more counter-productive to the care of patients and the service than any putative gain of not having to rely on the assessment of an inexperienced doctor.After all, if a patient has a pre-arranged outpatient appointment to see asenior psychiatrist or waiting to see them at a ward round they also deserve to see the senior psychiatrist rather than be told "sorry they've had to cancel, they been up all night in A &E/ S.136 room".

A proper risk assessment of the situation bearing in mind the real world factors outlined above would suggest the continued practice of senior advice available by phone, junior doctor induction, and when drawing up rotas trying to ensure inexperienced doctors are doing as little of the oncall as possible until they have completed essentail induction topics as assessing mental state, risk assessment and managementand the Mental Health Act.
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Conflict of interest: None Declared

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