Portfolio careers

Approval under S12 (2) of the MHA or becoming an AMP under section 22 of the Mental Health (Care and Treatment) (Scotland) Act 2003, is usually a rite of passage for a resident having gained their MRCPsych.

There is a simple process of application, with mandated attendance at a validated S12 induction course. Psychiatrists need to be registered medical practitioners with a licence to practice. Approval is not automatic or immediate but is usually complete in a couple of months.

There is a different more in depth process for those who do not have MRCPsych. For those who are psychiatrists, a minimum of four years full time equivalent experience in psychiatry, preferably in a range of subspecialties, ideally following the structure of training that usually leads to MRCPsych, is required.

Associate Medical Practitioners (Scotland) are approved under section 22 of the Mental Health (Care and Treatment) (Scotland) Act 2003 and perform statutory functions under that Act, including granting Short-Term Detention Certificates and providing reports in relation to Compulsory Treatment Orders.

AMP approval brings specific statutory responsibilities, training requirements and medico-legal work that need to be recognised in the workload of psychiatrists. AMP status is subject to 5 yearly update training with specialist components for forensic psychiatry and CAMHS.

The role of a SOAD, like that of a S12 approved doctor, is absolutely essential for the care of patients detained under the MHA. Given the statutory requirements for when an approved clinician (AC) must request a SOAD, there is no shortage of work!

The role of the SOAD is to consider whether the treatment recommended is clinically defensible and medically necessary, and importantly, whether the views of the patients have been considered. A key issue is patient safety. SOADs are central to safeguarding the rights of patients detained under the MHA.

SOADs in England are recruited by the Care Quality Commission (CQC) who run an open recruitment system, with links to recruitment information on their website (2).

Consultant psychiatrists with at least five years experience can apply. They need to be registered medical practitioners with a licence to practice and be members of RCPsych. They must be S12 approved or have been approved within the preceding 12 months if recently retired though this status does not need to be maintained while working as a SOAD.

There are equivalent application processes for Wales through the Health Inspectorate Wales. There is an interview and the application process should be complete within 2-3 months.

Designated Medical Practitioners provide an independent statutory second-opinion safeguard in Scotland. The role is broadly equivalent to the SOAD role in England and Wales and Northern Ireland.

DMPs are appointed by the Mental Welfare Commission for Scotland to assess and, where appropriate, authorise certain treatments for people subject to compulsory treatment who do not or cannot consent. DMP work requires senior clinical judgement, independence, and detailed knowledge of consent to treatment provisions under Scottish mental health and incapacity legislation.

These are the third in what could be considered a triumvirate of independent doctor roles linked with the MHA, all involved at different stages, but each with a crucial role to play. Unlike S12 approved and SOAD roles, being a medical member of the First Tier Tribunal (Mental Health) involves explicit team working. Tribunal doctors sit with two other panel members (one legal and one lay specialist) and together they review the cases of detained patients and direct their discharge where the statutory criteria for discharge have been met.

It is important to recognise that psychiatrists have powers above and beyond other doctors to compel patients to be in hospital and to comply with treatment against their will. Tribunals are one of the main safeguards that allow patients and the wider public to continue to allow psychiatrists this power and have trust in the system. Tribunals take very seriously the deprivation of liberty resulting from detention and consider very carefully the legality of ongoing detention.

The role of the medical member is to review the relevant reports and clinical information and, in approximately 60% of cases, the patient, in advance of the hearing and then use this information to help the panel opine regarding the statutory criteria. Medical members can also assist the panel when considering the capacity of the patient, communication and engagement issues, and how to address the patient with sensitivity based on their current mental state and any particular vulnerabilities. Given broader medical knowledge, the medical member will also be aware of wider health implications and risks of any treatment decisions made.

The Mental Health Tribunal for Scotland determines applications and reviews relating to compulsory measures under the 2003 Act. Tribunal panels include legal, medical and general members.

Medical members contribute clinical expertise to the Tribunal’s decision-making, including consideration of the presence and nature of mental disorder, risk, treatment, care planning and statutory criteria. Medical members may meet or examine the patient before the hearing, depending on the circumstances and Tribunal procedure.

As expert witnesses, psychiatrists can be asked to draw on their knowledge and expertise to provide their opinion to help courts resolve specific matters. They are instructed by lawyers, usually for one party, but their overriding duty is to assist the court and their opinion needs to be impartial.

This duty supersedes any duty the psychiatrist has to the instructing party, or indeed the party that is paying their fee. In some civil and family cases, there is provision to be jointly instructed by the different parties.

There is no ‘minimum standard’ legal requirement to becoming an expert witness. But it is necessary to be able to demonstrate and explain why a psychiatrist believes they have the necessary knowledge and experience to be able to offer an opinion in any given case.

There are several options if embarking on private clinical work. A psychiatrist can work on their own, running their own business, or can join something that is already established. Joining an established organisation means governance, administration, secretarial support, marketing and so on is managed by someone else.

In the most straightforward of situations, such as working for online providers of psychiatric assessments (but also many organisations providing face to face consultations), agreement can be reached to do a certain number of consultations when the psychiatrist is most available.

Where only assessments are undertaken, this is discrete and contained, with no requirement for ongoing clinical responsibility. While this can be advantageous for many, the disadvantages are that there is no opportunity to develop a service, or a relationship with a patient over time.