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26th September 2015

Making the Difficult Decisions

I've been using a case study to deliver some teachings about how we make decisions under the Mental Health Act. This case study was used in a research project which produced some interesting findings as to how practitioners make assessments under the Mental Health Act. I found this decision making process useful as to how health and social care staff work together to carry out the best interventions for people.

How this case study worked is that doctors and social workers were given some background information, and then viewed a video of a home visit to someone with a diagnosis of mental disorder where there were concerns expressed from the person’s neighbours about the man’s behaviour. The doctors and social workers who were part of the research project were asked to discuss what they would do next. The research study was part of a book called Decisions and Dilemmas, Working with Mental Health (Jill Peay Hart Publishing 2003).

So here’s what I learnt from this study.

Practitioners must follow the law

Health and care staff cannot be expected to be experts in all areas of the law, but they cannot ignore the law. The law may restrict their choices, and might go against what they think is best for the person, but at end of the day we all must operate under what the law allows. Sometimes this makes practitioners feel uneasy, that they may be leaving someone in a vulnerable position, and others involved in the care of someone may be left wondering why the person can’t be admitted to hospital. However, I think it is important to say that just because someone does not meet the criteria to be admitted under the Mental Health Act, this does not mean professionals should just walk away and do nothing. The discussion of the case study amongst doctors and social workers was that they would keep the situation under review, and offer alternative ways of managing the care of the person.

Group dynamics do come into play

Where two members of staff, say a doctor and a social worker, are working out what to do, their styles and personalities interact and we should recognise that. Perhaps the doctor is very fixed in their views, and state their position before gauging what the other worker thinks. Other doctors want to hear what the other worker thinks before coming to a judgement. Ideally a better decision is made because of the discussion that is placed between the professionals.

Capacity is an important consideration

If the decision is that it is in the person’s best interests to be admitted to hospital, and they are willing to go, then it is their right to be admitted on a voluntary or informal basis. However that can only happen if the person is capable of making an informed decision. Therefore the workers involved must assess the person’s capacity to make that decision. If the person does not have capacity then the workers may have to use the law anyway to admit the person to hospital.

Practitioners should look for evidence before working out what’s best

Are there any risk factors and what is the level of that risk? What is our evidence, is it something someone else has told us, and how reliable is that? There are different aspects of risk that need to be considered when we are thinking about using the law to admit someone to hospital, the risks to the person, and risks to others. Gathering evidence may be difficult. Particularly strong in the case study discussions was the weight of medical evidence, such as the history of the person’s illness. However, evidence about social factors was equally important in making decisions, but is sometimes difficult to weigh up. In the case study scenario, it may be difficult to assess whether the patient is paranoid about his neighbours, or the neighbours are harassing the patient.

Different people have different perspectives on risk

What is your perspective on risk? Some workers may be particularly risk averse, and their first choice will usually be that the person should be protected by being cared for in hospital. Other workers may feel uncomfortable with this and wish to promote a less restrictive option that may mean the person remains at home. Workers should be able to share their perspective on risk and examine what the real concerns are. We may have historical information about risks, and we should not take at face value something we read in case notes. In the case study scenario the patient had a criminal record for possession of an offensive weapon. Another worker described this later in the discussion as a small pocket knife. Sometimes we need to examine the detail of the evidence about risk factors that we are basing our decisions on.

Postponing a decision should not mean avoiding one

Can we put off doing anything because we need more information? There’s nothing wrong with seeking more information, particularly if we are thinking about something as important as compulsory hospital admission. However, that does not mean walking away and doing nothing. Is there something we can put in place to ensure the person is safe, and then review the situation on another day?

One of the conclusions in the book is the different approaches to decision making about whether someone should be admitted to hospital. The law, though often complex and open to interpretation, looks to deliver a clear course of action. The field of mental health is never that clear, and lots of factors such as the values of the workers involved can change the decision to be made.

How does any of this help health and social care staff? Well it might help explain what’s going on when doctors and approved mental health professionals are undertaking a Mental Health Act assessment on someone you work with. It also shows the usefulness of a case study in improving our decision making skills. It might be good practice to rehearse our skills on a case study before making decisions about using the law with a real person!

David Beckingham - QCS Expert Mental Health Contributor

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