Nigel Turner's HyperGUIDE to the Mental Health Act

Supervised Discharge

Introduction to Supervised Discharge

Supervised Discharge is an arrangement created by the Mental Health (Patients in the Community) Act 1995. While Section 117 of the Mental Health Act requires health and social services authorities to make aftercare arrangements for certain people who have been detained under the longer Sections, it does not require the person concerned to comply with any of those arrangements. Supervised discharge, or "aftercare under supervision", allows certain Requirments to be imposed on the person who is discharged (who in the Act is called "the patient"). Under these arrangements there is a named "Supervisor" who is the lead person in overseeing the Requirements. The overall purpose of an Application for Supervised Discharge is that it is made "with a view to securing that [the patient] receives the aftercare services provided ... under Section 117".

Who can be made subject to Supervised Discharge?

Potentially anyone who is liable to be detained for treatment in hospital under the Mental Health Act - generally those to whom Section 117 applies - even if they are on authorised leave under Section 17.

Conditions which must Apply to the Patient

The grounds for the Supervision Application are that:

• the patient has a least one of the four forms of mental disorder and
• there would be a substantial risk of serious harm to the health or safety of the patient, or the safety of other persons, or of the patient being seriously exploited, if she/he were not to receive the aftercare services provided and
• being subject to supervised discharge is likely to help to secure that the patient does actually receive the aftercare services.

Requirements which can be Imposed on the Patient

• that the patient lives at a specified place
• that the patient attends at specified places and times for the purpose of:
  
  • medical treatment
  • occupation
  • education
  • training.
• that the following people may be given access to the patient at the place where he/she lives:
  
  • the supervisor who is named in the application
  • any doctor
  • any Approved Social Worker
  • any other person authorised by the supervisor.

Although the person can be required to "attend for treatment", medical or other treatment cannot be imposed. This is similar to the effect of Guardianship, as are the requirements generally which can be imposed.

Applications for Supervised Discharge

Applications for Supervised Discharge can only be made by the Responsible Medical Officer, which is different from Applications for admission or Guardianship, which are made by an Approved Social Worker or the Nearest Relative. The Application is submitted to the Health Authority which has (with others) the responsibility for providing aftercare under Section 117. The Application must be based on 2 Recommendations.

Recommendations for Supervised Discharge

The two Recommendations required must be from:

• the doctor who will be professionally concerned with the patient's medical treatment after the patient leaves hospital, who is termed the Community Responsible Medical Officer [CRMO]. If the RMO in hospital will also be the CRMO on discharge, then the Recommendation has to be made by any other doctor.
• an Approved Social Worker.

Information to Accompany the Application

The following information must be supplied with the Application:

• a statement by the CRMO that he/she will be in charge of the patient's medical treatment as part of the aftercare services
• a statement by the Supervisor that she/he "is to supervise the patient with a view to securing that" the patient receives the aftercare services
• details of the aftercare services
• details of any Requirements being imposed.

Appeals Against Supervised Discharge

Appeals can be made to the Mental Health Review Tribunal. The Mental Health Act Managers have no specific role in Supervised Discharge and no power to end it. Therefore, there is no appeal mechanism involving the MHAM.

When Does the Supervision Order Start and End?

It starts when the person previously detained under the Act in hospital for treatment, and for whom a Supervision Application has been accepted, leaves hospital. If the person is on authorised leave and is not required to return to hospital, then the Supervision Order starts when the leave ends.

It runs for six months initially, the six months starting with the date the Application was accepted by the Health Authority. It can be renewed for a further 6 months and then for a year at a time.

The renewal process is similar to that for people detained for treatment, and for people subject to Guardianship, under Section 20. In this case, the Community Responsible Medical Officer provides the renewal report to the "responsible aftercare bodies" (the Health Authority and the local social services authority), stating that the original conditions are still met. The renewal takes effect by the renewal report being provided to these bodies. The new period of Supervised Discharge starts when the previous period ends.

The Supervision Order can be ended by the CRMO, after consultation. The Order automatically comes to an end if the patient:

• is admitted, under the Mental Health Act, to hospital for treatment, e.g. under Section 3
• is made subject to Guardianship.

Consultation and Information

The 1995 Act contains considerable duties of consultation, and of the provision of information about Supervision Applications. While much of this is consistent with good practice and common sense, the fact that it is set out so formally in the Act itself does make the processes appear cumbersome.

1. Before making a Supervision Application the Responsible Medical Officer must ensure the following people have been consulted and must take into account the views of:
   • the patient
   • at least one worker who has been "professionally concerned with the patient's medical treatment in hospital"
   • at least one worker who will be "professionally concerned with the aftercare services to be provided for the patient under Section 117"
   • an informal carer (if one exists) - someone who will play a substantial part in the care of the patient, but who will not be professionally involved with the aftercare services
   • the Nearest Relative (if practicable, and subject to a proviso).
2. Upon actually making the Supervision Application the RMO will inform:
   • the patient, orally and in writing
   • any informal carer who was consulted
   • the Nearest Relative if consulted earlier about the possibility of the Application being made
   ...and the information given shall include the fact that an Application is being made, details of the aftercare services, details of any requirements to be imposed, and the names of the proposed Community Responsible Medical Officer and Supervisor.
3. Before accepting a Supervision Application the Health Authority must consult:
   • the local social services authority which shares the Section 117 responsibilities.
4. When a Supervision Application is accepted the Health Authority must inform the following people that the Supervision Application has been accepted:
   • the patient, orally and in writing. This information must include details of what aftercare under supervision will mean in practice, and of the patient's right to appeal to the Mental Health Review Tribunal
   • any informal carer who was consulted about the possibility of the Application being made
   • the Nearest Relative if consulted earlier
5. If the responsible aftercare bodies are considering a change to the aftercare services or to the requirements imposed on the patient, those bodies (the Health Authority and the local social services authority) must ensure that the following people have been consulted about the proposed modification, and must take their views into account:
   • the patient
   • any informal carer
   • the Nearest Relative (if practicable and subject to a proviso)
   ... and the same people who are consulted must be informed of any actual modification made.
6. If there is to be a change in who acts as the Community Responsible Medical Officer or as the Supervisor (including changes which take place between the Application being made/accepted and the actual Supervision Order starting), the responsible aftercare bodies must inform:
   • the patient, orally and in writing
   • any informal carer
   • the Nearest Relative (if practicable and unless the patient requests otherwise).
7. When the Community Responsible Medical Officer intends to renew a Supervision Order the CRMO must ensure that the following people have been consulted and must take into account the views of:
   • the patient
   • the Supervisor
   • at least one worker who is professionally concerned with the patient's medical treatment, unless the only such person is the CRMO her/himself
   • at least one worker who is professionally concerned with the aftercare services (other than medical treatment)
   • any informal carer
   • the Nearest Relative (if practicable, and subject to a proviso)
8. When the Supervision Order is renewed the responsible aftercare bodies (Health Authority and local social services authority) must inform:
   • the patient, both orally and in writing, of the renewal, and of what this means in practice. The information must include details of what rights exist to appeal to a Mental Health Review Tribunal
   • any informal carer consulted about the renewal
   • the Nearest Relative if consulted about the renewal
9. When the Community Responsible Medical Officer is planning to end the Supervision Order, the CRMO must ensure that the following people have been consulted, and must take their views into account:
   • the patient
   • the Supervisor
   • at least one worker who has is professionally concerned with the patient's medical treatment, unless the only such person is the CRMO her/himself
   • at least one worker who is professionally concerned with the aftercare services (other than medical treatment)
   • any informal carer
   • the Nearest Relative (if practicable, and subject to a proviso).
10. When a patient ceases to be subject to a Supervision Order - for whatever reason, the responsible aftercare bodies (Health Authority and local social services authority) must inform:
    • the patient both orally and in writing
    • any informal carer
    • the Nearest Relative (if practicable, and if the patient does not want the Nearest Relative to be informed, then only if the proviso conditions over-rode the patient's similar wish when consultation took place earlier about the possibility of the Supervision Order being ended).

Proviso Regarding Consultation with the Nearest Relative

If the patient objects to contact being made with the Nearest Relative, then the Nearest Relative will not be consulted unless:

• the patient has "a propensity to violent or dangerous behaviour towards others", and
• the RMO or the CRMO (as the case may be) thinks consultation is appropriate.

Further Guidance

The Department of Health has issued a Supplement to the Mental Health Act Code of Practice to give further guidance on supervised discharge.