The paper by Wadoo et al Reference Wadoo, Shah, Jehaanandan, Laing, Agarwal and Kinderman1 highlights that junior doctors have a lack of knowledge about mental health legislation. It is not the first study to do so and other studies highlight many different areas where knowledge of law is lacking. Reference Buller, Storer and Bennett2–Reference Schofield4 However, this is an important area to highlight.
Wadoo et al Reference Wadoo, Shah, Jehaanandan, Laing, Agarwal and Kinderman1 state that as theirs is a semi-quantitative study methodologically it is difficult to replicate it. However, it shows what other studies before it have shown: that there is a lack of knowledge regarding mental health law – in this case, specific aspects of the Mental Health Act 1983. This lack of knowledge is not necessarily limited to junior trainees and within the study there are hints of this as it shows that in-service training either had no effects on knowledge or in some areas those that received it faired worse in their knowledge.
The phenomenon of senior colleagues not understanding or being up to date with certain parts of the Mental Health Act 1983 and the Mental Capacity Act 2005 is seen on many of the teaching courses I have been involved with. It is particularly difficult when senior colleagues have been practising in a certain way for many years, but wordings have changed or case law has altered the way things are now done. When it comes to teaching about Deprivation of Liberty Safeguards (DoLS), things become even more confused as the law is not at all clear in this area.
It is interesting to note that the Royal College of Psychiatrists’ exams seem to improve knowledge. This is all the more surprising as the College exams cover a number of different countries each with their own specific mental health legislation. Consequently, the questions in the exam cannot relate specifically to any one piece of legislation as the basis of the legislation can be significantly different. Time in training seems to correlate positively with improved knowledge. It may be that the combination of time in training and the focused study that exams bring about help doctors to learn legislation better.
Mental health legislation is tested for by competencies in regards to applying the law, contrary to what is stated in the paper. The curriculum for core training states that a trainee should be able to ‘Apply the legislation appropriately at all times, with reference to published codes of practice’ 5 and there are a variety of work-place based assessments that can be used to assess this competency. What may be missing is the application of that competency to the trainee.
Why is the lack of knowledge important?
Although not proven in this paper, or any other that I am aware of, there is a concern that a lack of knowledge with respects to the law will lead to inappropriate use of mental health legislation on patients. Clearly the most concerning aspect of this is inappropriate detention of people who should not be detained, consequently both depriving someone of their liberty and detrimentally affecting their therapeutic care. There is also the concern that someone is allowed to leave who should be detained and then that individual undertakes risky behaviour to themselves or others.
A secondary problem is compensation. I am aware of some audits that have not yet been published showing that a significant number of detentions are illegal because of forms not having been filled out correctly. Once again these audits cannot prove that lack of knowledge leads directly to these events, but it surely is not too far a leap of logic to suggest that at least there might be a link between them. Each day of illegal detention now has a cost associated with it as does each intramuscular injection given during an illegal detention.
Why might there be this lack of knowledge and what can be done to rectify it?
As doctors across various specialties have over the years been shown to lack knowledge in mental health legislation it cannot be just down to psychiatric training alone. Reference Buller, Storer and Bennett2–Reference Schofield4 Medical schools vary tremendously in their depth and breadth of training in the law related to medicine. Some having dedicated time and modules for it, including some having professors of law and ethics applied to medicine, whereas others have little teaching about this area.
Within psychiatry there is another phenomenon with respect to training especially when applied to mental health legislation that requires thoughtful consideration. In discussions with many trainees, very few have had direct supervision of applying a Section 5(2) or doing a Mental Health Act assessment with a senior colleague or see one done before doing one themselves. This direct observation may be difficult to achieve, but with some thought and effort it should not be insurmountable. There is some suggestion that Section 5(2) orders are converted more frequently to a Section 2 or 3 order when discussed with a senior colleague than when not, Reference Buller, Storer and Bennett2,Reference Mason and Turner3 again suggesting that clinical supervision would better improve care for our patients. Perhaps a minimum number of Assessed Clinical Encounters (ACEs) or mini-ACEs on applying legislation to patients at a certain point of training would focus the minds of trainees and trainers alike.
Improved training in relation to the Mental Health Act 1983 for junior doctors was one of the main recommendations of a well-constructed systematic review done by the Department of Health Reference Churchill, Wall, Hotopf and Wessley6 conducted more than 11 years ago. Alongside this, teaching has been shown to have positive effects on outcomes of the Mental Health Act. Reference Schofield and Zigmond7
Surely it is time to consider the importance of this area of training in relation to doctors? With this in mind, practical courses would be very valuable in assisting overall knowledge in this area. One should be aware though that the courses need to be led by trainers with sufficient knowledge, experience and access to up-to-date legal material, otherwise misunderstandings will just be passed on. To that end the courses covering the Mental Health Act, Mental Capacity Act and DoLS run by the Royal College of Psychiatrists (College Education and Training Centre) are put together and overseen by a group of psychiatrists with ongoing input from leading national figures in both psychiatry and law on the content of the courses. This hopefully improves the accuracy of the material and helps keep it relevant and up to date.
Although medical legislation can be found in various competencies including foundation year 1 (F1) competencies, 8 it is not seen as one of the mandatory competencies and therefore receives less time and recognition. Perhaps practising legally and not detaining or allowing people to leave hospital inappropriately should be a mandatory part of training for every doctor no matter what the specialty.
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