IT IS about 5 years since my last fulminations on the topic of the Mental Treatment Act 1945 and its overdue replacement.

Well, Act No. 25 of the Oireachtas 2001 has arrived. Last June it was signed into law. And there it will remain unused until ministerial order provides regulations. So we are, at the moment, left with the 1945 MTAand a couple of later amendments to it.

My viewpoint is that of the GP. It is not totally selfish as I believe what is good for General Practice is good for patients.

My pamphlet of 1998 pointed out pitfalls in the implementation of the 1945 Act. Most often we GPs would examine the patient, sign the pink form and retire with a minimum of trouble (without monetary recompense, however). But how often was a Garda escort necessary and a white form demanded to cover the legal requirements of the escort? The Garda had strict orders to follow the 1945 Act, to the letter of the law. They were permitted to escort only a ‘person of sound mind’ (PUM) who by definition required at least 6 months detention.

In recent times, most patients needed less than 6 months. But many required Garda escort. The Garda needed a white form.

Commonly, the advice from the mental hospital at this point was to sign the pink and white forms; they would tear up the white form when the patient was admitted using the pink form. This method of problem-solving is not recommended. It is illegal.

It is worth quoting briefly from the following Abstract from a memorandum from the Mid-Western Health Board, dated 24/7/’98:

Judgement of the Supreme Court.

"I wish to advise of recent judgement of the Supreme Court relating to the detention of a patient – (which) – constitutes a serious interference with the rights of the individual. The only way in which such interference can be countenanced is strict adherence to the terms of the Act and, therefore, any defects in form filling, either on the GPs part or the receiving hospital’s part will constitute, on the face of it, a right of action on the part of the detainee".

The GP is not allowed, any more than anyone else, to solve problems by illegal expediency regardless of the pleadings of distraught relatives. Gardai have the duty and legal right to protect people from injury and self-harm. Let’s leave it to them until the law empowers us and protects us too.

We need to look at the Mental Treatment Act from the GP’s point of view. Though the new Act gives more protection to the patient, I’m sure more is desirable…and possible. However, let us look after ourselves as GPs. (In this regard, I hope the Minister has set aside €1,143,000to cover the GP fee of €381per committal!)

In my reading of the Act (2001), several important points arise. Doctors – and not only those in ‘approved centres’ - will have to know, in detail, the provisions of the Act that apply to them. I shall raise questions rather than give advice; because it would be unfortunate if the new Act were to be implemented with the confusion for which there is potential.

It is difficult to imagine that advice from General Practice was listened to in the framing of the Act. Though we pressed hard, there is nothing to ensure that the GP has Garda protection at the time of examination, or that he/she has access to consultant psychiatrist advice at the relevant time; or legal advice’; or that the GPs life/accident insurance is not rendered void by voluntarily entering a potentially dangerous situation; or that he or his family will be compensated in the event of injury or death (as would hospital staff and Gardai). On top of this, no circumstances are outlined in which medication may be given to an unwilling patient. This latter point is in contrast to the Garda who, explicitly in the Act, is allowed to restrain a subject if the Garda’s opinion so regards it necessary.

I would prefer to be crossed off the register than be killed or crippled without the large compensatory sum and pension for life that employees (Gardai and hospital staff) obtain when injured in the course of their duties. The same applies to road traffic accidents where we GPs act as good Samaritans. My refusal to attend RTAs was made known to the Medical Council 12 years ago in writing. The labourer is worthy of his hire with safety and facilities.

• Will it be legal to sedate an unwilling patient?;
• Will the GP, as heretofore, supply the ‘pink’ form?;
• And, despite the sniff of collusion, fill it in?
• Surely the Applicant should come to the doctor with a completed application?;

Does the doctor have a duty to advise the applicant of the legal duties the Act imposes on the Applicant, e.g. the Applicant must have ‘observed’ the patient not more than 48 hours before the day of the application. I don’t see it in the act (or in common sense) to offer quasi-legal advice.

Does Section 10(2) mean that once an application is made to a doctor that he/she has no choice but to examine the patient whether or not the doctor has any knowledge of the patient, or indeed of psychiatry? My layman’s reading of the Act suggests this may indeed be so.

Why is the onus on the doctor to send the completed application/recommendation to the ‘clinical director of the approved centre concerned’? Section 10(4). Are couriers to be made available at all times?

Section 13 states that the applicant shall arrange removal of the patient. In the light of all experience, can you believe this? Of course the GP will be asked to do it, as usual and the Act is deficient in not recognising this.

Section 13(3) states that if the clinical director and the GP (‘recommending doctor’) believe Garda escort is necessary due to "immediate and serious" risk of harm, the clinical director may request the Garda to assist.

Can you picture the scene at 3am in a fraught home? The doctor trying to contact the psychiatrist in charge; than a psychiatric opinion based on the doctor’s advice; the clinical director may request the Garda; sit and wait for the Garda while explaining it is illegal to sedate an unwilling, even violent patient.

When the enabling regulations are in place, will GPs be able to safely co-operate in the implementation of the Mental Treatment Act 2001? It is my humble opinion that what has brought General Practice to the point where an act of the Oireachtas can treat GPs with contemptible disdain is our lack of assertiveness. Our operation of the 1945 Act shows how pliant we have become. It is a pointer to why General Practice has become less attractive to new entrants.

We should say NO to the 2001 Act and the 1945 Act until our concerns are taken seriously. Indeed, we should say NO to a lot more until our specialty is recognised and funded with access to facilities for investigation and treatment.