Medico-legal - Independent mental capacity advocates

How an independent mental capacity advocate can help with continuity of care between GP and hospital. By Nicky Davies

The Mental Capacity Act 2005 recognised that patients with mental health conditions, dementia, learning disabilities and brain injuries were potentially missing out on support in making serious decisions about their health, their accommodation and/or adult protection.

It was also recognised that a large number of patients had nobody appropriate, be it family or friends, to act in their best interests in an unpaid role. The independent mental capacity advocate (IMCA) role was established in 2007 to address this concern.

Using the IMCA service

Some common questions include:

  • What is an IMCA?
  • How can they help me in my role as a GP?
  • Why and when would I need to involve an IMCA?
  • Isn't it just more work for us?

Under the 2005 Act, all local authorities must provide this statutory service for patients who meet the following criteria:

  • A mental capacity assessment establishes that the patient lacks capacity concerning a specific life-changing decision, for example, undergoing serious medical treatment or making a long-term change to their accommodation.
  • It can also apply to care reviews or when a safeguarding matter has arisen.
  • The patient must also have nobody appropriate or willing to act in their best interests in an unpaid role.

It is worth knowing all of the criteria for IMCA involvement, even though most patients come to the GP surgery with a medical reason. A patient may disclose abuse in the home, or the GP may be first to realise that a degenerative condition is making their accommodation unsafe.

Serious medical treatment involves referring a patient for hospital interventions; it can then be helpful to refer them for an IMCA. A social worker will appoint one if necessary.

GPs can refer directly, or flag up the need for an IMCA in the referral. Once the decision has been made to proceed with treatment, an IMCA can ask questions on the patient's behalf. It may also be necessary for the hospital to apply for a deprivation of liberty authorisation.

Discussion

In this case study (see box), if an IMCA had been instructed when the GP decided that JB needed to see a consultant, with the possibility of serious medical interventions being carried out, the IMCA could have been present at all of the hospital consultations.

The IMCA would ask whether the proposed treatments were necessary, if less invasive procedures could be considered, and if the investigations revealed serious illness, how treatment would be offered, considering JB's age and comorbidities.

The IMCA would also discuss the risks and whether these outweighed the benefits. An IMCA can request a second opinion and, if necessary, apply to the Court of Protection if a best interests decision cannot be agreed upon.

Case study

Patient JB was accompanied by carers from his residential home to have a routine blood test. The GP was concerned about the results and an urgent referral was made for JB to see a consultant, which could lead to him undergoing medical interventions.

It is established that JB has no friends or family to act on his behalf and lacks capacity in relation to these decisions.

JB attends a hospital consultation, where it is decided that he needs invasive surgery under general anaesthetic. A week before the procedure is due, a referral for an IMCA is made by the hospital.

The IMCA arranges for the professionals involved in JB's care to attend a best interests meeting, but the consultant is unavailable before the procedure date. With only limited information, a best interests decision cannot be made, so the procedure is cancelled.

Continuation of care

The IMCA can facilitate care that is already being given by the GP continuing into the hospital environment, or support the patient through a move made because of safeguarding or general care needs.

Most importantly, the IMCA gathers information which can help the GP with the future care of their patient. An instruction from the GP could allow IMCA involvement to continue while the patient is living in the community or is in hospital.

IMCAs work alongside social workers, health facilitation nurses, community mental health teams, and managers and carers of nursing, residential and care homes. They also occasionally work with families if safeguarding is a concern.

  • Ms Davies is an independent mental capacity advocate with Choice Advocacy in Bradford

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