Chapter 9: Appointment of RMO and Designation of MHO (sections 230 and 229)
This chapter examines the appointment and designation of two key members of the patient's multi-disciplinary team: that is, the appointment of the patient's responsible medical officer ( RMO) under section 229 of the Act and the designation of the patient's mental health officer ( MHO) under section 230. An RMO and an MHO must be appointed/designated subsequent to the use of certain compulsory powers under the Act.
Appointment of RMO
01 Section 230 of the Act states that the relevant hospital managers must appoint an approved medical practitioner (that is, a medical practitioner approved under section 22 of the Act) to act as a patient's RMO. This appointment must be made "as soon as is reasonably practicable" after the occurrence of what sections 230 and 232 term an "appropriate act". These are:
the granting of an emergency detention certificate;
the granting of a short-term detention certificate;
the making of an interim compulsory treatment order or a compulsory treatment order;
the making of a temporary compulsion order;
the making of an interim compulsion order or a compulsion order;
the variation of a compulsory treatment order or a compulsion order;
the making of an assessment order;
the making of a treatment order;
the making of a hospital direction;
the making of a transfer for treatment direction;
the transfer of the patient to another hospital under sections 124(2), 125(4)(b), 126(4), 218(2), 219(4)(b) or 220(4)(b) of the Act; and
the return of the patient to a hospital under sections 125(5), 126(5), 219(5) or 220(5) of the Act.
02 The RMO must be appointed by the relevant hospital managers. This means:
the managers of the hospital in which the patient is currently detained or which is specified in the order;
where a CTO or CO has been varied, the managers of the hospital which is specified in the order following modification under section 102, 103, 104, 106, 166, 167, 169, 171 or, as the case may be, 193(6) of the Act;
in the case where a patient has been transferred under the provisions of sections 124(2), 125(4)(b), 126(4), 218(2), 219(4)(b) or 220(4)(b) of the Act, the managers of the hospital to which the patient is transferred;
after receiving notice from the managers of the sending hospital that the transfer is to proceed and the patient is received in Scotland, the managers of the receiving hospital to which a patient has been transferred under the cross border provisions, prescribed by The Mental Health (Cross-border transfer: patients subject to detention requirement or otherwise in hospital) (Scotland) Regulations 2005; or
the managers of the hospital to which a patient has been returned after an appeal against a transfer under the provisions of sections 125(5), 126(5), 219(5) or 220(5) of the Act.
03 The RMO must be appointed "as soon as is reasonably practicable" after the occurrence of "an appropriate act" in relation to the patient. It may be the case that it is possible for the RMO to be appointed the same day. However, in a situation where the RMO may have to come from a different hospital or service, "as soon as is reasonably practicable" could be interpreted as meaning within the next working day.
04 If a patient is made subject to compulsory powers and already has an RMO who is an approved medical practitioner in the terms of the Act, best practice would be for that RMO to continue to act as the patient's RMO. Wherever a patient is made subject to compulsory powers but does not already have an RMO who is an approved medical practitioner in the terms of the Act, it will be necessary to appoint an RMO who is an approved medical practitioner. Arrangements must be such as to establish without delay or dubiety the RMO in respect of every patient after the occurrence of an "appropriate act".
05 Managers of an acute medical/surgical hospital will need to ensure that arrangements are agreed and in place with acute psychiatric hospitals/ services to provide available approved medical practitioners unless approved medical practitioners are already on the staff of the acute medical/surgical hospital.
06 There will therefore be occasions where, in effect, a patient has two RMOs: that is, an approved medical practitioner who is acting as the patient's RMO in terms of the Act and a medical/surgical consultant acting as an RMO, albeit not under the Act. In this situation, medical or surgical care should continue to be the responsibility of the medical/ surgical consultant while decisions about the treatment of mental disorder and the review of any detention procedures should be the responsibility of the approved medical practitioner who is acting as the patient's RMO appointed under the Act.
07 Where it is considered appropriate to discharge a patient from hospital, it should be noted that the RMO appointed under the Act will need to revoke the authority to detain the patient prior to a medical/surgical consultant discharging the patient from hospital. Where it is considered that the patient does not require to be detained in hospital but continues to satisfy the conditions for formal treatment under the Act, then the RMO should consider whether a suspension of detention or a CTO in the community would be more appropriate.
08 Hospital managers will need to ensure that arrangements are in place to cover the absence of an RMO: for example, through holiday or illness. Section 230(3) of the Act permits them to authorise any approved medical practitioner to act in place of the patient's RMO for a particular purpose or in particular circumstances.
09 The importance of ensuring that another approved medical practitioner is appointed swiftly to act as the patient's RMO in any circumstance where the patient's "usual" RMO is absent cannot be overemphasised. Hospital managers should have procedures in place to ensure that the patient, his/her relatives and carers, as well as the members of the patient's multi-disciplinary team, are always able to find out quickly who is acting as the patient's RMO.
Designation of MHO Responsible for Patient's Case
10 A local authority must ensure that an MHO is designated as responsible for the case of any person in respect of whom a "relevant event" has taken place. The local authority must designate an MHO "as soon as is reasonably practicable" after a "relevant event" takes place. These "relevant events" are listed at section 232 of the Act. They are:
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; and
the making of a transfer for treatment direction.
11 The local authority must also designate an MHO where it receives notice of a proposed removal from Scotland under The Mental Health (Cross-border transfer: patients subject to detention requirement or otherwise in hospital) (Scotland) Regulations 2005 of a patient who is receiving treatment otherwise than by virtue of the Act or the 1995 Act.
12 It should be noted that an MHO does not have to be designated subsequent to the granting of an emergency detention certificate. However, best practice would nonetheless dictate that where an MHO consented to the granting of an emergency certificate, he/she (or another MHO, if necessary) would remain involved with the case for the duration of the detention. Where an MHO had not been involved in the granting of the emergency detention certificate, best practice would be for the local authority to allocate an MHO to the case as soon as practicable so that they are able to consult with the patient's RMO.
13 It should be noted that where a patient has been admitted to hospital on an emergency detention certificate granted without an MHO's consent, the managers of the hospital to which the patient has been admitted must give notice of the matters notified to them under section 37 of the Act by the medical practitioner who granted the emergency detention certificate to the local authority for the area in which the patient lives, or the local authority for the area in which the hospital is situated if the hospital managers do not know where the patient lives. Hospital managers must inform the relevant local authority within 7 days beginning with the day on which they receive notice under section 37 of the Act. This means that the hospital must be able to refer a case to the local MHO service as soon after admission as possible, even when admission occurs out of hours. (For further information on the involvement of an MHO subsequent to the granting of an emergency detention certificate, see Part 5 of the Act or Chapter 7 of Volume 2 of the Code of Practice.)
14 A local authority is required to ensure that the patient has a designated MHO for as long as that patient is subject to the terms of any relevant event. It would therefore be best practice for each local authority to maintain an up-to-date list showing which MHO is designated to the care of each patient to ensure that the designated MHO may always be speedily identified.
15 Local authorities will need to ensure that the arrangements also cover the absence of any MHO, for example, through holiday or illness. Section 229(2) of the Act permits them to designate an MHO to act as the designated MHO in place of the previously designated MHO either for all purposes or for a particular purpose or for particular circumstances.
16 Local authorities will also need to ensure the availability of a service out of hours, usually via an out of hours/emergency duty team service. The patient's designated MHO will, for the most part, be based in the day-time service and will therefore need to be able to pass on relevant and updated information to the out of hours MHO service. In effect, all local authorities will have to designate MHOs who staff their out of hours services to enable them to undertake designated MHO duties when required.
Can the role of designated MHO be transferred, once appointed, to another MHO?
17 Yes, under section 229(2)(a) of the Act but best practice would be for local authorities to limit the number of changes to the patient's designated MHO during continuous periods of compulsory powers to ensure consistency and to lessen confusion for the patient, his carer/relatives and members of the patient's multi-disciplinary team.
Which local authority is responsible for designating the MHO?
18 Section 229(3) defines the "relevant local authority" in relation to designating an MHO. Where the patient is subject to hospital-based compulsion, then the relevant local authority is the local authority in which the patient was resident immediately before the relevant event occurred. Where a patient is subject to any form of compulsion in the community, the relevant local authority will be the authority in which the patient resides. Where a patient subject to detention in hospital was not resident in Scotland immediately before the relevant event occurred, the relevant local authority is the local authority for the area in which the hospital is situated. Although the Act does not require a new MHO to be designated after a patient has been transferred between hospitals within Scotland, it would be best practice for local authorities to liaise with each other to ensure that the patient continues to have a designated MHO.
19 Best practice would be for local health services to have procedures in place to ensure that local authorities are notified quickly of a relevant event. Similarly, best practice would suggest that local authorities will need to have processes in place to designate an MHO to the case of a particular patient and to communicate that designation and the MHO's contact details swiftly, to relevant parties.
20 Local authorities are expected to have agreements with all relevant and/or adjoining local authorities in respect of the designation of MHOs on their behalf in certain circumstances. This would cover the needs of patients in the State Hospital, in medium secure units or those admitted outwith their area, for example, patients who may be at some distance from their place of domicile. This will be particularly important where a patient who is subject to a community-based compulsory treatment order was immediately beforehand subject to a hospital-based order but now resides in a local authority which is different from that in which the hospital is situated.
What is the role of an MHO who is designated as responsible for a person's case?
21 The designated MHO must carry out specific functions and duties depending on which section of the Act the patient falls within. All relevant events for instance, require the MHO to complete a social circumstances report on the patient in terms of section 231 of the Act unless the MHO records why this would serve little or no practical purpose. (For further information on SCRs, see section 231 of the Act or Chapter 11 of this Volume of the Code of Practice.) In addition, there are other specific and general duties which the designated MHO should carry out. Examples of such duties include:
assisting the patient in the process of nominating a named person; (for further information, see Chapter 6 of this Volume of the Code of Practice)
assisting the patient to access advocacy services, and perhaps legal representation, if required; (for further information, see Chapter 6 of this Volume of the Code of Practice)
consulting on the existence or drawing up of advanced statements; (for further information, see Chapter 6 of this Volume of the Code of Practice)
referring to the local authority for a comprehensive community care assessment when required and when the MHO themselves is not completing one. (For further information, see Chapter 7 of this Volume of the Code of Practice.)
22 Best practice would be for the designated MHO to play a key role in the ongoing assessment and care planning for the patient. The MHO should participate as a core member of the patient's multi-disciplinary team. Their role in this team is to be responsible for ensuring that the patient's social circumstances are fully considered by that team when the patient's care and treatment is being planned and delivered. To carry out this role effectively, the MHO should liaise closely with local authority colleagues to put in place the social care components of the patient's care plan as well as liaising closely with the patient's named person, carers, relatives and independent advocate as a matter of course. The MHO should remain easily contactable by them and the other members of the patient's multi-disciplinary team.