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CHAPTER 5: BARRIERS AND FACILITATORS
PLANNING FOR THE IMPLEMENTATION OF THE MHCT ACT
5.1 The preparatory work for the implementation of the MHCT Act undertaken by the Joint Local Implementation Groups and their co-ordinators is outlined in Chapter 1 of this report and is therefore not repeated here. Although many respondents in this study knew of the work of the JLIP co-ordinators, they commented that much of the strategic work had not filtered down to the local level prior to implementation.
5.2 A significant issue mentioned by MHOs in relation to planning was that they were still becoming familiar with the intricacies of the Adults with Incapacity (Scotland) Act 2000 ( AWI Act) whilst considering the impact of the MHCT Act. For a number of those interviewed this meant that they had not had the resources or capacity to focus significantly well on the workload impact of the MHCT Act. As one MHO put it: 'y ou need to remember that the impact of AWIA had already taken its toll on the MHO workforce' ( MHO, North Lanarkshire).
5.3 Responses to planning for the implementation of the MHCT Act (firstly for April 2005 and subsequently for the delayed date of October 2005) fell mainly into two categories, workforce redesign and the provision of appropriate training. Workforce redesign appears to have taken place primarily within MHO services. There was no evidence to suggest service redesign within GP services in response to the implementation of the MHCT Act.
5.4 There was limited evidence to indicate service redesign had been considered to meet the requirements of the MHCT Act within psychiatrist services. One specific example, however, was identified within NHS Lothian. Each consultant psychiatrist provided dedicated time to undertake MHCT Act work on a rotational basis, by clearing clinics and other appointments on the specified day. In addition an acute support team to prevent admission and support early discharge was also established. Whilst enabling staff to meet their statutory requirements, it was felt that this development had had a knock-on effect for both waiting times and more generally on out-patient services.
'It has certainly taken resources away from out-patients, which I think has been reduced by 20% although psychiatric sessions have increased they have focused on MHA work. Reduced capacity for other work therefore means that out-patient work has been affected and waiting times have increased' (Consultant psychiatrist, Lothian).
5.5 Work had also been done at that time to ascertain the impact on psychiatric services or staff by a number of health board areas and significant discussions amongst the teams most likely to be affected by the implementation of the MHCT Act appeared to have taken place. What is not clear is to what extent the monitoring of impact and local discussions led to any significant change in work plans. In addition there was no indication from the sample of the extensive provision of additional psychiatric sessions to meet the needs associated with the implementation of the MHCT Act.
5.6 In general it was acknowledged that prior to implementation discussions amongst staff both within and across disciplines had created anxiety and concern about what the impact of implementation would mean for those working in this field.
TRAINING/INFORMATION PROVISION
5.7 Relevant professional groups were all required to go through statutory training programmes on the MHCT Act before its implementation (information on training programmes can be found at: www.scotland.gov.uk/Topics/Health/health/mental-health/mhlaw/training). For all those interviewed in this study, training had been provided (often on a local as well as national basis). A number of staff interviewed had also been involved in developing and contributing to local training. Where joint training had been successfully undertaken this was seen to be valuable in recognizing the impact of the Act across the multi-disciplinary group (for example, the impact of nursing staff having to leave the ward and escort patients to tribunals on a more regular basis than under the 1984 Act was acknowledged). One respondent noted: 'it was gratifying to see we all had the same fear in our eyes and the same thought, how will we cope with this extra work?' (Consultant psychiatrist, Lothian).
5.8 There were also a number of examples of one discipline contributing to training for another (for example MHOs contributing to GP training was viewed as valuable).
5.9 Training provided nationally to MHOs was acknowledged as being relevant and of good quality as well as being valuable in facing the unknown quantity that was the MHCT Act. However responses from psychiatrists interviewed indicated a mixed experience with regard to training. Some believed that it was not extensive enough and that they had not found it useful as the Code of Practice had not been available while it was being undertaken. One psychiatrist noted that in their area training has amounted to ' occasional presentations by MHO colleagues and e-mail updates' (Consultant psychiatrist, Tayside). Only a small number were positive about the training. Where psychiatric staff had been involved in locally organized training they had found this to be valuable when it involved other medical and social work colleagues.
5.10 Individuals who had been involved in the provision of information and advice to colleagues over the first 12 months of implementation said that this role had taken up varying amounts of time. It appeared that those in dedicated MHO posts and psychiatrists with significant experience of the MHCT Act performed this function on a regular basis across geographical areas and disciplines. Perhaps not surprisingly colleagues called upon those professionals with early experience of working with the MHCT Act in the initial stages of implementation. However those who had a significant role in giving information or advice felt that this had dissipated over time as colleagues had become more experienced in their use of the legislation.
5.11 The majority of respondents felt that despite training provided prior to implementation it was only when work with the MHCT Act began that the actual impact on workloads became clear.
5.12 Respondents indicated while their needs had been met via the planning for implementation in the period prior to October 2005, since they had begun to work with the MHCT Act these views had changed significantly.
5.13 The majority of MHOs and psychiatrists interviewed as well as one GP felt that the impact of the additional workload associated with the MHCT Act had not been well enough considered. It was argued that further resources should have been deployed to meet this need. Suggestions over what resources were required varied from additional psychiatric sessions, additional MHO posts to more administrative support.
5.14 There were a small number of professionals who felt that, for them, no additional resources were required as their workload had not significantly altered. Three of these respondents worked in out-of-hours teams where only work for emergency orders and short-term orders was carried out and designated MHO roles were not held. None of these respondents had direct experience of applying to and working within the Tribunal system, and did not feel able to comment on what, if any, additional resources might have been helpful during the initial 12 months of implementation.
IMPACTS ON TIME
5.15 Respondents were asked to identify what, in their view, made the process of evoking the compulsory powers more time consuming than under the 1984 Act. These are discussed below.
Forms
5.16 Forms for applying for CTOs in particular were highlighted as being significantly longer than previously was the case. These forms were seen as being more complex in terms of the process of completion as well as being very repetitive (an update on the situation relating to application forms can be found in chapter 7, paragraph 7.41).
5.17 Clinicians were also very concerned about the time taken to complete suspension forms. The nature of the forms meant that in many instances forms would have to be filled out every day for some patients.
'Suspension forms are the real problem, they are a total nonsense. Admission to an open ward has within it an acknowledgement that patients will have trips out of the ward including overnight stays dependent upon their clinical condition. Having to complete a new form every time one of these events take place is just a total waste of time. We all understand what it means to be in an open ward so I don't understand why they are necessary. They are okay for a locked environment but not an open ward' (Consultant psychiatrist, Lothian).
'Suspension forms are a particular nuisance' (Consultant psychiatrist, Tayside).
'Suspension forms are a disruptive and unnecessary administrative burden. Being a psychiatric in-patient on an open ward has always involved passes out as determined by mental state. It should not be necessary to fill out forms for this' (Consultant psychiatrist, Lothian).
A variety of methods were being deployed to combat the amount of time this was taking. It was recognized that many of these methods were circumventing the MHCT Act rather than implementing it, however respondents felt this was the only viable option. In some cases a form was required for a short visit by a patient ( e.g. to the shops or bank) and it seemed ' easier' to get someone else ( e.g. a nurse) to go instead. It was felt that this may lead to a more restrictive environment, which is clearly not in-line with the principle of least restrictive alternative.
5.18 There were a number of examples of difficulties downloading forms either because of software or hardware problems. Staff had to access paper copies, handwrite them and then have them typed by administrative staff (where possible). This invariably added more time to the application process. Of the respondents who indicated an IT difficulty with the forms some had resolved the issue by purchasing new software or hardware but many were still having difficulties.
5.19 MHOs in particular commented on the additional time required to access administrative support to complete forms as administration staff were already overstretched. Waiting sometimes a day to get a form typed lengthened the process even more. The overall number of forms was also commented upon: ' there are more forms for everything, especially getting out of the hospital' (Consultant psychiatrist, Highland).
5.20 For medical records/administrative staff instances of computers crashing, computers not being compatible with new software, the inability to save completed online forms and in some instances a lack of an IT system being in place to accommodate the MHCT Act paperwork were cited. While acknowledging that new equipment was being brought in to replace older computers there were still a number of issues around reporting/recording mechanisms.
'We have worked with our IT supplier to change the Mental Health Act module. It is now in place but further work is necessary on reporting mechanisms. We also need to work on saving up-to-date information on patients current mental health Act status with wards who say they are swamped by copies of forms involved' (Medical Records staff member, Glasgow).
5.21 For only a small group within the sample the completion of the forms were carried out on-line. Psychiatric staff noted in particular that the forms were not often available on the ward and that going in search of them took time. It was noted that it was unlikely they would be able to access them via computer on the ward.
Prescribed consultation (additional meetings)
5.22 The consultation and co-ordination required in making an application was acknowledged as very prescribed, particularly by MHOs. Talking in detail to patients about named persons, advance statements and advocacy was noted as taking significant amounts of time.
5.23 Interviewing patients was also viewed as taking longer than would have been the case under the MHCT Act (partly due having to discuss the named person or advance statements or advocacy) but also because of a need to know the patient much better than they might have done before. This was because it was expected that they would have a longer-term relationship with patients through the designated MHO role. Direct discussion with those providing the medical reports was also viewed as an additional task.
5.24 It was acknowledged that this prescribed contact was in direct line with the principles of the MHCT Act and promoted good practice. Indeed a small number of respondents noted that if good practice was being followed under the 1984 Act, the consultation element should take approximately the same amount of time as under the MHCT Act.
Tribunal Hearings
5.25 Time spent at tribunal hearings varied considerably but was generally significantly longer than would have been the case at the Sheriff court (see Table A4.12 for time differences for psychiatrists and MHOs).
5.26 Time spent at hearings meant planning other tasks around them was problematic, as it was never known how long each hearing would last. Examples were given of tribunal hearings that had lasted for 4+ hours. Professionals were concerned that this was difficult for patients, as well as taking them out of their work environment, sometimes for a whole day (including travel time).
'We have to deliver the forms to the Tribunal service in person as we don't have a courier service. This takes time and then you don't get a date right away but have to wait, although you know it will be within five days, you have to keep yourself fairly free until it is confirmed. Then you go to the hearing and this can take on average 3-4 hours, so with this and travel you can write off the best part of the day, especially as they are never local. You might need a curator, which takes longer again and will result in an interim till things get sorted out. In fact I have never been to a first time CTO hearing where the outcome was not an interim order. The whole process is very stressful and time constrained for both the worker and the patient' ( MHO, Argyll and Bute).
5.27 Different experiences were reported in relation to what role they played at a hearing. MHOs were sometimes asked to lead the evidence and on other occasions were not, leading to unpredictability over the amount of time required. It was acknowledged that while the Convener determined the way the hearing was conducted this was seen as confusing when the role was not consistent at every hearing.
5.28 A number of psychiatrists had not expected to have to attend every hearing, which meant that time spent at hearings had not been adequately calculated for regarding workload.
'We never anticipated that we would have to attend every single hearing but it has become clear that the expectation is that we would attend every one. If this had been made clearer to us at the beginning we would have planned better' (Consultant psychiatrist, Highland).
5.29 It should be noted that it was acknowledged that as a radical change in the way detention is organized coupled with the introduction of the MHTS system and the processes associated with it, it was to be expected that the first 12 months of operation would be extremely challenging.
Designated MHO role
5.30 As this was a new requirement for MHOs it was not clear how much longer this task would take (as there was no real comparable role under the 1984 Act). Respondents indicated that in general it meant cases were held much longer on caseloads and involved the worker in additional tasks, particularly in following through various aspects of the care plan and care managing this element.
5.31 In addition it should be noted that out of hours service ( OOHS) staff, in general, did not carry this role and therefore, in those instances where patients come into the system via the OOHS, they were subsequently passed to the relevant area team the following day (and picked up by the designated MHO role where required). This process would have been the same for a Section 18 under the 1984 Act but the expectation of continuation of involvement of a specified MHO would not have been prescribed.
Working with Mentally Disordered Offenders ( MDOs)
5.32 Working with MDOs was a significantly new role for a much broader range of MHOs than was previously the case, through undertaking the designated MHO role. The expectation of a number of people in institutions such as the State Hospital appealing against levels of excessive security being moved to other settings with designated MHOs throughout the country, meant this type of work would become more common. This was an area of concern with regard to future workloads. Additional work was anticipated in getting to know patients or travelling to and from, for example, the State Hospital, although difficult to accurately quantify. To the end of February 2007 there had been 43 Appeals hearings held, and a further 14 were planned for 2007. In addition, 15 hearings had been cancelled or withdrawn and a further 8 had not been processed because of incomplete applications or there was no hearing date set (data from the Scottish Executive). There would undoubtedly be an impact on workload from this level of activity, particularly for MHOs acting in this new role.
5.33 MHOs preparing to undertake the role were concerned about their level of expertise in the area. The support required to undertake the new role appeared patchy.
Travelling to/from tribunal hearings
5.34 Travelling to and from tribunal hearings was brought up as an issue by some respondents, particularly those for whom local venues for hearings were not widely used. In rural areas respondents reported spending considerable time travelling to and from hearings ( e.g. a four hour return journey for a hearing in Inverness). There was concern that more local venues were not being considered for use by the Tribunal Service to reduce travel times for patients and staff. A small number of psychiatrists noted that they had arranged to provide evidence to the hearing by telephone. It is not clear whether or not, as the applicant, the MHO would have the same opportunity to use this time-saving mechanism. Some respondents also mentioned how traveling to hearings also impacted on nursing staff who were accompanying patients. This was particularly time consuming where there was more than one hearing for a particular case.
'There have been issues for nursing staff in terms of their time. They used to have to accompany patients to court once, but they now have to attend tribunals with patients much more frequently due to the number of interims and the venue for the hearing is further away than before. This means time away from the ward that staff did not have to cope with before' (Consultant psychiatrist, NHS Lothian).
5.35 Clearly this was a more prevalent issue for those working in rural areas or in areas where MHTS hearings are centrally rather than locally focused. It was recognized though that the availability of more suitable local accommodation may make additional venues challenging to organize.
Deadlines
5.36 The necessity of beginning the paperwork for a full CTO only 14 days into a STDC was an area of concern for all professionals interviewed. Psychiatrists argued that this timeframe meant they were being asked to comment on whether or not grounds for the CTO were being met too early in the process. For many this way of working did not feel like good practice.
'I am being asked too early about whether or not a patient might need a full CTO, clinically I am often not sure at that stage, but we feel forced into it because of the strict timescales. This can mean work undertaken which in the end is not required - I cannot believe this is a good use of anyone's time, we need to review this process at an early stage' (Consultant Psychiatrist, Forth Valley).
Notification of tribunal hearing dates
5.37 The short turnaround for notification of dates for tribunal hearings have had a number of impacts on time and time management. Often professionals would have to leave colleagues to pick up work for them or cancel appointments with patients in order to ensure their attendance at a hearing.
'I have never yet received notification and papers for a hearing prior to it going ahead. I hear through the grapevine or from the MHO and sometimes in a telephone call. It has not been unusual for me to receive the papers for a hearing two weeks after it has been held' (Consultant psychiatrist, Lothian).
5.38 There was also general concern that despite the MHTS being informed when individuals were on leave, hearings, which could only result in interim orders, were still being scheduled. This was felt to be a considerable waste of everyone's time and unnecessarily anxiety provoking for the patient. It should be acknowledged, however, that in order to protect the rights of the patient and to fulfill their legal obligations under the MHTS Act the Tribunal must convene a hearing within five days of the application being made.
'I had one example where both the MHO and I were on annual leave, the patient had sacked their lawyer and had no replacement representation and the second opinion psychiatrist was just returning from leave the day of the proposed hearing and had no space in their diary. The hearing went ahead, the second opinion psychiatrist was then forced into cancelling a whole days work to attend and of course it ended in an interim order because hardly any of the key players were there and the patient had no legal representative (Consultant psychiatrist, Lothian).
Interim orders
5.39 The number of interim orders being made meant attendance at more than one tribunal hearing per order was commonplace. A number of respondents indicated that it was common for them to have to attend sometimes up to three hearing before a full order was granted. In addition respondents indicated that they often had to present to different tribunal members at each hearing, requiring repetition of information (which was seen as adding to patient distress). This again required staff to spend significantly more time on an application than previously. This would seem, however, to be a problem relating to the numbers of tribunal members and the logistics of trying to ensure consistency between hearings. Continuity of tribunal members (where possible), which would lead to shorter subsequent hearings, may be important in resolving this issue. However, as noted earlier (see chapter 1, paragraph 1.17) while there were initial problems in recruiting medical members, this is no longer the case and was not the case for other types of tribunal members (for further discussion on interim orders see chapter 7, paragraphs 7.23 - 7.28).
Curator ad litem
5.40 The issue of the appointment of a curator ad litem to protect the rights of those patients who lack capacity to instruct a solicitor was also cited by a large minority (40%) of respondents as an area which caused time delays and which requires urgent clarification.
5.41 At the time of interviewing the need for a curator is often not identified in advance of a hearing, which meant that a minimum of one interim order (although data gathered indicates that this will more than likely be two, particularly where an independent medical report is required) will be required to facilitate the appointment of a curator and to allow them to carry out their work. Clearly this involves a range of professionals (nursing staff, GPs, MHOs and psychiatrists) in attendance at, and preparation for, a number of hearings with the consequent implications for their workloads (for an update on the situation relating to curators see chapter 7, paragraph 7.31) .
Short-Term certificates
5.42 Psychiatrists noted that as an STDC is the expected route into the new legislation, they are involved at an earlier stage in the process of detention than would have been the case under the 1984 Act (and consequently for longer). This longer involvement with cases was potentially going to have further impacts on workloads in the future.
The named person
5.43 It is a responsibility under the Act (section 45(1)(b)) for the MHO to ascertain the name and address of the patient's named person. It appeared that very few patients currently had a named person ahead of a detention order process being started and the process of nominating a named person did not seem widespread at this early stage in implementation. The Mental Welfare Commission has recorded that in only 60% of short-term detention cases was the named person recorded, and were consulted in 43% of cases (Lyons 2006). The Commission argued that this should increase as there was perhaps a lack of understanding of the named person provisions in some quarters in the early stages of the MHCT Act. More updated information on this will be available in the annual report from the Mental Welfare Commission (to be published in November 2007).
5.44 While some MHO staff were ensuring that a patient knew about their rights in relation to the named person some patients seemed reluctant to nominate someone (which meant that the nearest relative was being nominated by default). This was seen to be a potential problem for some patients who did not want their nearest relative informed. It was also unclear to some (and is not stated in the MHCT Act) whether a patient who is deemed competent could forego having a named person at all if they chose.
5.45 Out of hours staff reported great difficulty in asking individuals during a crisis or whilst they were being detained about nominating a named person. This tended to be left to the relevant area team staff during follow-up work.
5.46 There was also no consistent method of recording the details of the named person. Access to the named person's details was not standardised and it could be difficult for staff to know where to find them (particularly out of hours staff and other disciplines). Additional time was being spent trying to find this information. A small number of areas advised that they had developed named person registers or databases, which could be accessed out of hours, although not necessarily across disciplines. In two other areas ward staff were being encouraged to keep details of named persons in ward notes for ease of access out of hours.
Advance statements
5.47 Although not formally part of the interview process, a number of respondents mentioned the use of advance statements as a positive development for patients that had not yet been realized to any great extent. It was reported that these were not well utilised to date and that there appeared to be a number of reasons for this which included:
- A lack of clarity over who is responsible for raising the making of the advance statement with the patient and therefore practice varies across the Scotland
- Making an advance statement did not seem to be a priority for many staff. This may therefore mean the opportunity is being lost
- If patients cannot get what they want via an advance statement, ( e.g. the relevant resources are not available or it will not prevent detention) then they do not see any reason to make a statement
- When patients understand that the clinician can overrule what they want, even if they have to justify this decision, then they are not motivated to make a statement
- The timing of when to discuss advance statements with individuals was thought to be crucial.
5.48 Eight of the 14 respondents who mentioned advance statements indicated that given their workload under the MHCT Act they would not have time to work with patients to develop advance statements, particularly where it is not their legal responsibility to do so.
OUTCOMES
5.49 The focus of this study was not on the effectiveness of the MHCT Act or outcomes for individuals under its provisions. Nevertheless, some respondents reported their own experience, their observations of patients' experiences and their discussions with patients during the process of detention.
5.50 There was a varied response to the question of whether or not the process and outcomes for individuals was better/worse/different or the same as under the 1984 Act. Responses were fairly evenly split between the positive and negative. Positive views focused on the participatory nature of the process for individuals and the fact that they could contribute to their own outcome transparently. Negative views were about the pressure and stress for patients being so included and exposed in the process. Two respondents felt their experience had been mixed, depending upon the actual hearing itself and just how unwell the patient was at the time. Three respondents thought it too early to comment.
5.51 One major area commented on was the shift from court setting to hearing setting (the tribunal). This move was seen as paramount in removing stigma from those with mental health problems and the perception of them being criminalized via the court system in place under the 1984 Act.
'Outcomes are better for patients on a number of levels. CTOs are more flexible and reflect modern psychiatric practice. STDC decision-making by the patient's own consultant is better than a GP making an order for three days which gets you nothing. Twenty-eight days is much more helpful and often the full time is not required. In terms of process it is clearly better for patients to be at tribunal hearings rather than being hauled off to court, which felt punitive and like they were criminals. Also, often Sheriffs were too deferential to professional staff, tribunal members are much more likely to question and make you justify your own decisions' (Consultant psychiatrist, NHS Lothian).
5.52 For those respondents who felt that the process was negative for patients, the issue was one of pressure and stress on patients who were often extremely ill 'being forced to perform' in front of the tribunal. The length of time tribunals were taking as well as the number of interim orders granted requiring attendance at multiple tribunals was viewed as putting extreme pressure on very unwell individuals. One respondent noted that they had had a very elderly patient with dementia who had been at a tribunal lasting 5+ hours and argued: ' this cannot be in anyone's best interests' ( MHO, Argyll and Bute).
'Being forced to attend a hearing when you don't want to or are feeling overwhelmed generally by the process cannot be a good thing. Neither is being bombarded by information that you can't or don't want to take in. Finally for some patients, their illness impacts on their ability to participate in the process and I do not think this is recognised' ( MHO, Edinburgh City).
5.53 A number of respondents noted their concern over the ever increasing involvement of solicitors in the process. The prominent role of solicitors was seen to further legalise a process which had been intended to remove patients from such a setting.
'The involvement of solicitors is not helpful as they often do not understand the nuances of mental health. I feel they pay scant regard to the patients best interests, only to winning the case' ( MHO, Lanarkshire).
Where solicitors were mentioned they were discussed negatively in terms of their general impact on the process, particularly in relation to lengthening or holding up tribunal hearings.
5.54 It has to be acknowledged, however, that despite removal to an informal setting, the process of detaining an individual remains a legal one.
IMPACT ON WORKFORCE
5.55 Respondents indicated that there had been an overall impact on their individual workforces. The key words used to describe the impact were, ' stressed', ' burnt-out' and ' demoralised'. A further concern was that the level of work involved in the evocation of compulsory powers meant that many professionals were working in a hands-off fashion, 'more process than productive' was how one GP described the experience.
5.56 Concerns were also expressed about how the impact on the overall workforce might affect recruitment and retention of staff in the future (for further discussion see chapter 7, paragraphs 7.34 - 7.39). For MHOs there was a significant issue with regard to status, pay and conditions which appeared to vary across respondents. A number of those MHOs interviewed indicated that they worked in local authorities, which paid enhanced rates to MHOs in recognition of the change of role. In addition they had, in the main, been granted senior practitioner status. The balance of MHOs interviewed worked in areas where negotiations were still ongoing with regard to enhanced payments (or where any enhanced payments were dependent upon a number of factors). There did not appear to be similar salary issues for consultant psychiatrists, nor for GPs.
CHANGES IN PRIORITIES
5.57 Changing priorities in terms of workload appeared to affect all those interviewed (except those in dedicated MHO posts). For MHOs working in a mixed role, a shift had taken place making their MHO function take precedence over other work. For consultant psychiatrists the majority felt that their priorities had shifted to work with the detained population, with the non-detained, informal or out-patient population losing out as a result.
PRINCIPLES
5.58 It was reported that the principles underlying the MHCT Act were at the forefront of everyone's mind, particularly the least restrictive alternative. Most respondents stated that they felt the system set-up to evoke compulsory powers made them think through the principles at all points in the process.
5.59 Respondents, however, reported feeling compromised to go for outcomes which they felt the tribunal would agree to, rather than what was clinically best for the patient. One commented that they were:
'always looking for the least restrictive option or at least one which will pass muster with the tribunal. We felt with one case recently we had to go for a community-based CTO as the least restrictive option. The outcome was that this provided the patient with the opportunity for a second overdose, almost immediately following this they were detained in hospital' (Consultant psychiatrist, Grampian).
5.60 A small number of respondents expressed concern about the ability to consider the principles in an environment where resources felt so stretched. A few felt they were unable to comment on the impact of the principles on day-to-day work practice because of limited involvement in use of the MHCT Act.
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