Knowledge and confidence of the mental health act in Scotland: a survey of general practitioners

Introduction

The Mental Health (Care & Treatment) (Scotland) Act 2003 came into force in October 2005. It affects the work of all health and social care professionals in Scotland. The impetus for the new act came largely from a change in psychiatric practice with the move towards care in the community. ¹

General practitioners (GPs) are front-line clinicians and the cornerstone of community psychiatry. They are expected to use the mental health act in emergency psychiatric situations to protect the safety of some of the most vulnerable patients they serve. Although infrequent, this process can be complicated and time consuming and it is therefore vital they are knowledgeable and confident in using this legislation.^2,3

Training and education of health care professionals is necessary to achieve sustainable improvements in patient care and safety. Theoretically, training should improve mental health literacy and improve confidence in using the mental health act. This improved confidence would hopefully lead to more front-line clinicians becoming involved in emergency psychiatric situations and feeling they have the skills to do so.^4,5

Previous studies in the UK and Australia have looked at attitudes of GPs towards dealing with mental health problems in primary care. These have suggested there has been limited training and knowledge of referral pathways and local resources. A need for further training in various aspects of mental health work was identified.^6,7 In the UK, GPs have suggested that this lack of training and knowledge may contribute to lack of confidence in the management of patients with mental health problems in a primary care setting. ⁷ In relation to mental health act work, training in its practical use has been identified as a requirement for GPs. ⁸ Training sessions have been identified as one factor which may increase uptake and confidence in using mental health resources among primary care physicians, but the research in this area is limited. ⁹

Most studies in this area have looked at training and knowledge in the mental health act in England and Ireland. Many of these have also focussed on psychiatrists rather than GPs. No previous studies have been conducted in Scotland in this important area to establish the knowledge, confidence and training requirements in the mental health act amongst GPs.

Aim

The aim of this study was to examine GPs’ knowledge and confidence in the use of the Mental Health Act (2003) and of local policy. It was our aim to establish the relationship between previous training in this area and current knowledge and confidence. We also looked to identify the relationship between previous practical experience in using the act and current knowledge and confidence. Finally, we looked to explore GPs’ views on the need for further training and the aspects of training they would find beneficial.

Method

An anonymous ten-question online survey was devised. The survey asked GPs to self rate knowledge, training and confidence in using the Mental Health Act. It also asked about knowledge of local protocols and procedures relating to the use of the mental health act in the Forth Valley area. Finally, it asked if GPs would be interested in accessing an online learning module in this area. There was space at the end of the survey for free text comments.

The survey was distributed by nhs.net email to all GPs in Forth Valley Health board. A contact mailing list was kindly provided by primary care which identified 252 contacts. The survey was initially distributed in January 2013 and a reminder email sent in February 2013. The online survey was open for a period of 2 weeks.

Data were analysed using Microsoft Excel spreadsheets and statistical analysis done via Graph Pad software using Fischer’s exact test. Statistical analysis was used to explore the correlation between training and knowledge, training and confidence, previous use and knowledge and finally previous use and confidence. In order to perform Fischer’s exact test, GPs’ responses on knowledge and confidence were dichotomised into two groups (fair / better and poor / worse). As this was a survey of NHS staff, the local ethics committee did not consider ethical approval to be necessary.

Results

A total of 80 responses were received from a total of 252 GPs contacted, giving a response rate of 32%. The results are shown in Table 1.

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Table 1.

Survey results.

% (n)
1. How would you rate your current knowledge of the Mental Health Act?
Excellent	1.3 (1)
Good	11.3 (9)
Fair	50 (40)
Poor	33.8 (27)
Very Poor	3.8 (3)
2. During your time as a GP, have you ever received any teaching or training in the Mental Health Act?
Yes	45 (36)
No	55 (44)
3. How often do you use the Mental Health Act in your day to day work?
Frequently	1.3 (1)
Occasionally	6.3 (5)
Rarely	80 (64)
Never	12.5 (10)
4. How often do you use the Mental Health Act in your out of hours work?
Frequently	0 (0)
Occasionally	11.3 (9)
Rarely	17.5 (14)
Never	2.5 (2)
Don’t do OOH	68.8 (55)
5. In your time as a GP, have you ever detained a patient under the Mental Health Act?
Yes	75 (60)
No	25 (20)
6. How would you rate your confidence in utilising the Mental Health Act when required?
Excellent	1.3 (1)
Good	12.5 (10)
Fair	30 (24)
Poor	43.8 (35)
Very Poor	12.5 (10)
7. How would you rate your knowledge of the local Psychiatric Emergency Plan
Excellent	1.3 (1)
Good	8.8 (7)
Fair	23.8 (39)
Poor	48.8 (9)
Very Poor	17.5 (14)
8. Are you aware of procedure and policy relating to transfer of patient to hospital following detention in community?
Yes	26.3 (21)
No	72.7 (59)
9. Would you be interested in using an online learning module relating to the Mental Health Act should this become available?
Yes	98.7 (79)
No	1.3 (1)

There was no statistically significant association found between previous teaching and training in the act and current self-rated knowledge (p = 0.1734). Similarly, no statistically significant association was found between previous teaching and training in the act and current confidence (p = 0.3792). Previous use of the act was associated with better current knowledge (p = 0.0074). Previous use of the act was also associated with higher current confidence in using the act (p = 0.0005).

Nine respondents (11%) made free text comments. A number of respondents commented on difficulties in communication between primary and secondary care when using the mental health act and felt this was an area which could be improved. Some commented on the procedures that required to be followed when using the mental health act and felt they could be simplified and made easier to use. One respondent felt it essential that the process for using the Mental Health Act and transporting the patient to hospital is as straightforward as possible. Two respondents suggested an interactive meeting between primary care and mental health services may be a positive step to improving learning in this area.

Discussion

This was the first study in Scotland looking at GPs training, knowledge and confidence in the use of the mental health act. Less than half of the GPs surveyed had experienced any previous training in the use of this important piece of legislation. This is in keeping with previous studies in Ireland, which identified only one in two GPs as having had training in the use of the Irish mental health act. ⁸ Despite the lack of training, three quarters of our respondents had previously used this legislation. The overwhelming majority were keen to explore further teaching and training in this area and this is something that is in keeping with the limited previous research in this area.^6,7,10

The majority of respondents felt their knowledge of the mental health act was fair or better, with a third of respondents identifying their knowledge of this legislation as poor. Some previous studies have found a lack of knowledge amongst psychiatrists and general hospital doctors with regard to the assessment of mental capacity, however there is limited literature on knowledge of GPs, particularly in Scotland.^10,11

More than half of respondents rated their confidence in using the act is poor or worse. NICE guidelines on service user experience set out that those performing assessments under the mental health act should do so “in a calm and considered way” and this is something that would likely be affected by the confidence of the medical practitioner involved. ¹²

Our study would suggest that previous teaching and training does not significantly impact the current levels of knowledge or confidence in using the act. A previous study found that training in the use of the mental health act increased user-friendliness, with no distinction between formal or informal training. This study did not analyse the relationship between training and knowledge or confidence. ⁸

Our findings suggest previous practical experience in using the act does appear to significantly improve current knowledge and confidence levels. These findings would be in keeping with both recent and historic literature, which stresses the importance of practical and situational knowledge along with professional experience and judgement in improving workplace confidence and competence. These studies have not however focussed on our target population or the mental health act.^13–16

There is no current literature that looks at levels of knowledge and confidence and how this effects mental health act practice or service user experience. This is clearly an area that requires further research.

There are some of limitations to this study. Firstly we recognise the low response rate of 32%. This is clearly a lower response rate than would be desirable but appears to be in keeping with response rates to other online surveys of medical staff which have been published in the literature. Secondly, the results of this survey are limited to one health board and therefore cannot be generalised to the full of Scotland or indeed the United Kingdom.

There are a number of strengths of this study. This is clearly an area which has been poorly researched previously and we are the first to shed some light into this important issue in Scotland. Our study has also highlighted areas for further important research. Our findings could potentially provide a basis for the design of interventions to improve Mental Health Act training. Following interventions there would hopefully be an improvement in mental health act practice, service user experience and patient safety.

Clinical implications

The academy of medical royal colleges has set out recommendations that all health practitioners should have training in mental health and that competencies need to be checked. They have also highlighted that training in primary care requires improvement. They suggest a role for secondary care mental health specialists in training, supervising and supporting primary care staff to acquire and maintain skills in mental health. ¹⁷ With other research in this field highlighting informal training as beneficial and our free text comments suggesting interactive learning sessions between primary and secondary care, perhaps this would be a way forward in establishing improvements in this area.

With our study highlighting the importance of past practical experience, this brings into light the issue of psychiatric rotations as part of GP training schemes. This is something that has been widely debated previously with some suggesting that these rotations should be mandatory. This is an issue of course not only related to mental health act practice but to the management of mental health problems as a whole. ¹⁸ The Royal College of Psychiatrists and the Royal College of General Practitioners recently recommended that GPs in training would benefit from spending an attachment in Liaison Psychiatry, but there remains no fixed guidance on this that must be followed. ¹⁹

With the introduction of the new broad-based training programme in England this year, we are perhaps looking at a changing time in medical training which may address some of these issues. The new broad-based training programme aims to train doctors in a way that is flexible in order that they are able to transfer their learning and experience between specialties. It also gives trainees the opportunity to gain broader experience of delivering patient care across the various health care sectors. With trainees spending a minimum of 6 months in both psychiatry and general practice during this programme before deciding on which specialty to pursue, this could be an ideal time to gain valuable skills in managing psychiatric emergencies in the community and using the mental health act. ²⁰

Our study found that most GPs in Scotland are not trained in the mental health act. They are however receptive to the concept of having more training. Practical use of the mental health act, however, seems to improve self-rated knowledge and confidence more than actual training itself. For training to meet the needs to GPs, it therefore needs to be experiential.