Knowledge of emergency compulsory detention procedures among general practitioners in Edinburgh: sample survey

BMJ 1996;312:1462-1463 (8 June)

General practice

Knowledge of emergency compulsory detention procedures among general practitioners in Edinburgh: sample survey

Martin Humphreys, lecturer in forensic psychiatry,^a Ann Ryman, registrar ^b

^a Department of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Edinburgh EH10 5HF, ^b Royal Edinburgh Hospital Morningside Park Edinburgh

Correspondence to: Dr Humphreys.

There is increasing concern about doctors' knowledge of statutoryprovision for care of the mentally disordered, particularlyin relation to compulsory measures.¹ In Scotland any fully registeredmedical practitioner may detain a patient in hospital for 72hours given certain specific urgent circumstances, and withconsent only where practicable. More than 3000 such admissionsare recorded annually, not uncommonly initiated by a familydoctor. We interviewed a sample of general practitioners workingin Edinburgh to determine their understanding of this provision.

Subjects, methods, and results

A 1 in 4 random sample of Edinburgh general practitioners (n= 70) was selected. Eight declined to take part and we couldnot contact 12 others. The 50 who were interviewed representeda wide range of age and seniority. Nineteen had had some experiencein psychiatry. Questions were asked only about matters consideredessential to lawful emergency detention.

Table 1 gives the results. Forty two believed that the emergencyorder was intended to be the mainstay of compulsory care. Althoughmost were aware that standard documentation was not necessary,none was able to describe all the statutory requirements foremergency detention. Asked if any conditions were specificallyprecluded from being sole grounds for detention 10 said intellectualimpairment, eight psychopathic or antisocial personality, and13 intoxication with drugs or alcohol.

Table 1--Numbers of general practitioners giving correct
answers to questions about legal provision for compulsory
detention of mentally ill people
-----------------------------------------------------------
                                         No giving correct
Question                                  answer (n = 50)
-----------------------------------------------------------
What is the title and year of the current act ?  2
Which section should be mainstay of formal
 detention ?                                     8
May a patient be detained without the
 approved form A ?                              32
Conditions for emergency detention ?
Mental disorder                                  3
Urgently necessary                               5
Health or safety (of patient) or protection of
 other persons                                   0
No alternative to hospital                       0
Where practicable, with the consent of a
 relative or mental health officer              26
How is mental disorder defined in the act ?      1
Are any conditions specifically precluded
 from being sole grounds for detention ?        26
What period of detention does the
 emergency order allow ?                        30
Does emergency detention include the
 power to enforce treatment ?                   30
May one emergency order follow straight on
 from another ?                                  7

Comment

We interviewed 18.3% of general practitioners in the area, frompractices responsible for more than 300 000 patients. Thosewith a particular interest in mental illness were equally likelyto have been included in the sample, and it is unlikely thatthe non-participants represented a group with particular knowledgeof the law; indeed our initial approach may have discouragedthose with more limited understanding from taking part. Of concernis the possibility that others might have been sufficientlyindifferent to decline interview.²

We asked about the law, rather than actual procedure in an emergency.Some doctors did state that before using compulsory powers theywould always seek specialist advice, but in practice, givenurgent circumstances, there may be less time for thought thanduring our interviews.

The results were disquieting. Our interviewees were uncertainabout terminology and generally unable to define basic statutoryrequirements. Many doctors believed incorrectly that the presenceof certain disorders precluded detention and that treatmentcould be enforced under the emergency provision.

These are not isolated findings, though previous studies haveconcerned the knowledge of psychiatrists.³ Medical practitionersbase decisions about compulsory hospitalisation on a "needs"rather than a "rights" orientated approach, acting in the patients'best interest and often within the confines of the law.⁴ Nevertheless,lack of knowledge about statutory provision may lead to lossof the right to treatment for some or infringement of civilliberties for others in an area of the law where these are leastwell protected.

Most of the doctors interviewed estimated that they used theemergency powers of detention about once a year and then onlyafter exhaustive attempts to do otherwise. Nevertheless, a fifthhad detained three or more patients in the previous 12 months,and general practitioners initiated 86 urgent compulsory admissionsto hospital in Edinburgh during the 10 month study period.

It is difficult to identify how this sample might differ fromdoctors working in other parts of Scotland or further afield.Some priority should be given to the issue of mental healthlaw in continuing professional development for all those whomight use compulsory measures, particularly in a jurisdictionwhere the initial decision to deprive an individual of his orher liberty may be in the hands of a single practitioner. Otherfindings suggest that there are no grounds for complacency elsewhere.⁵

We thank all those general practitioners who so generously gaveus their time to be interviewed for this study.

Funding: None.

Conflict of interest: None.