This report explores the context in which the decision of whether to use the MHA or the MCA to authorise a deprivation of liberty is made and the different factors that practitioners use to assess and weigh up which Act is most appropriate and ‘least restrictive’ for the individual concerned. The research used a mixed-methods approach with an online survey to capture the diversity of factors that influence decision-making across clinical groups, and qualitative interviews with clinicians and professionals to explore in depth their understanding of the interface and experiences of making this decision in practice. A large proportion of participants in this research report encountering people to whom this decision applies at least once a month, if not weekly. This decision most commonly applies to people who have dementia, but also to people with a wide range of mental disorders, including those with functional mental illnesses, neurodevelopment and neurological conditions. Participants report most commonly applying this decision to people in community settings, but application also occurs in mental health and acute hospitals including in the emergency department. There is a lack of common understanding around fundamental issues on which this decision is based including core concepts of capacity and objection. Blanket rules exist within professional groups and across different settings that restrict decision-making. The rights afforded to people admitted and treated in some settings and areas of England may not be afforded to those in others. The majority of participants report that their training covered decision-making at the interface of the Acts. However, codes of practice and case law are described as difficult to understand and keep up to date with. Understanding clinical decision-making at the in. Practitioners highlight a number of different ways in which patients are unlawfully deprived of their liberty as a result of the factors outlined above.

This paper presents a review, in two parts, of the first ten years of the Court of Protection, a specialist mental capacity court in England and Wales which applies a functional model of mental capacity. The first part outlines the history of the functional model in England and Wales, and the development of this specialist mental capacity court (Court of Protection), created by the Mental Capacity Act 2005. The second part presents an empirical and case-based study of 40 published cases of capacity disputes presented to the Court of Protection, or to the Court of Appeal on appeal from the Court of Protection, during the first ten years of its existence. The authors found that in 70% of cases the subject of proceedings (or P) had either a learning disability or dementia, and the court ruled on P’s capacity for a wide range of issues, most commonly residence, care and contact. The judge considered the support principle, or whether practical steps were taken to maximise P’s capacity, in 23 of 40 (57.5%) cases. The subject P was determined to have capacity in 13 cases, to lack capacity in 22 cases, and in 5 cases P was found to have and lack capacity for different issues before the court. The functional inability to use or weigh relevant information was most commonly cited by the judge, being cited in all but 2 cases in which P was determined to lack capacity and inabilities were cited. The propensity for the system to learn was shown by an increase in the proportion of cases which considered the ‘causative nexus’ from 2013, when a Court of Appeal case emphasised that impairment must not merely be present alongside functional inability but must be the causal basis of inability. The authors conclude that whilst the Court of Protection is still on a learning curve, its work provides a powerful illustration of what taking capacity seriously looks like, both inside and outside the courtroom.

Findings of an audit on the use of the MCA and Safeguarding Adults procedures across the nine prison and young offender institution healthcare teams in London. The audit reveals that: safeguarding is afforded a high priority by offender healthcare services; the organisational infrastructures for safeguarding (policies, procedures, training, etc) were rated higher than the infrastructures for the Mental Capacity Act (MCA); there are good working relationships between prison authorities and healthcare services around safeguarding, but the role of healthcare staff in safeguarding is limited by the prison context; mental capacity tends to be treated within offender healthcare services as an aspect of safeguarding; knowledge of and practice around the MCA is patchy – senior clinicians tend to have a good grasp of their obligations under the Act and how to apply them, while frontline nursing and other staff generally do not; there is a very weak infrastructure to support practice in relation to the MCA (policies and procedures, training, information, guidance, supervision, records); it is recommended that priority be given to strengthening the infrastructure to ensure that frontline practice in offender healthcare services is compliant with the MCA and the Care Act.

Findings of a research project to better understand the knowledge and experience GPs have of advance decisions. Five themes emerged from this study and include: GPs had significant gaps in knowledge about advance decisions and how they can benefit people; GPs imposed a financial barrier by charging for appointments to discuss advance decisions; GPs felt that conversations about death, dying and planning for the end of life would be too upsetting or difficult; GPs had negative preconceptions about refusing treatment; and GPs had practical concerns about the ease and process of supporting a person to make an advance decision.

Findings of a survey of care home managers to look into how successfully the Mental Capacity Act (MCA) was being implemented on the front line of residential care. Respondents answered questions on the five principles of the MCA, and the questions asked how well they lead and supported their staff teams to understand and enact these principles. This research shows how some managers take a range of approaches to MCA implementation. Mentorship, coaching and active, floor-based management seemed to recur in the answers from managers who really wrote confidently about their staff team’s understanding of the MCA. One of the greatest apparent barriers to MCA implementation was information and knowledge not filtering down in homes where managers considered that the MCA, capacity assessments, Best Interests Decisions and DoLS were the concern of managers only, when this should not be the case and all staff should be engaged with, and inform these processes.

The focus of this report is on the MHA and its interface with the MCA, Deprivation of Liberty and the implications of the Supreme Court judgment (P v Cheshire West and Chester Council and P and Q v Surrey County Council [2014] UKSC 19). The latter has made it clearer and easier for providers and decision makers to identify where a person is being deprived of their liberty but has also led to a considerable increase in the numbers of people in England and Wales who are considered to be deprived of their liberty for the purposes of receiving care and treatment. The paper summarises the findings from a survey on the court judgment impacted on AMHP practice and service delivery. They show that there has been significant impact on AMHPs and service providers, but the situation appears to be more challenging for certain local authorities where a large proportion of their Best Interests Assessors for DoLS are drawn from the AMHP service. Landmark changes impacting AMHP practice and the local authorities on behalf of which the professionals act have been made as result of the Cheshire West judgement but there remain barriers and challenges in fully implementing these changes arising from the complex and bureaucratic DoLS framework. The Law Commission has been tasked to look for a framework that is simpler, while still protecting the rights of vulnerable people with mental health problems and those who lack capacity, with final report and draft legislation due to be published in summer 2017.