General hospital doctors are often faced with the challenge of managing incapacitated or mentally disordered patients on general wards. All doctors should be proficient in assessing capacity and managing incapacitated patients. ¹ However, research suggests that there are gaps in knowledge of this area among doctors across the specialties. ^{Reference Hill, Mather and James2,Reference Jackson and Warner3} Until the recent introduction of the Mental Capacity Act 2005, common law permitted the treatment and care of incapacitated patients. Practice under common law has now been incorporated into the legislation laid out in the Mental Capacity Act. ⁴

A survey conducted by the Mental Health Act Commission found that general hospitals make use of the Mental Health Act 1983 for a relatively small but not insignificant number of patients. ⁵ Section 5(2) is perhaps the most commonly used order in general hospitals, particularly in acute situations or out of hours. The patient's medical or surgical team have a central role in implementing the Act, with the responsible medical officer (RMO) usually being the consultant in charge of the patient's physical care. In practice, the application is often carried out by a nominated deputy of the RMO, usually a junior hospital doctor. Documentation of the decision-making process and mental state of patients detained under section 5(2) on general wards can be poor, with no evidence that decisions have been discussed with the RMO. ^{Reference Hardern and Protheroe6}

Evidence from England, Scotland and Ireland suggests that there are significant gaps in knowledge of mental health legislation among psychiatric doctors. ^{Reference Bhatti, Kenney-Herbert, Cope and Humphreys7-Reference Swift, Nasir, Sheehan and Casey10} However, remarkably few studies have addressed levels of knowledge of the Mental Health Act or of capacity and consent in our general hospital colleagues. ^{Reference Lynch, Simpson, Higson and Grout11} The Mental Health Act Commission has highlighted the importance of training in its guidance notes on this matter and has suggested that this might well be provided in conjunction with a local mental health unit. ⁵

This study aimed to find out the level of knowledge and confidence of a cross-section of general hospital doctors regarding section 5(2), assessment of capacity and treatment of incapacitated patients under common law (as the investigation took place prior to the introduction of the Mental Capacity Act). The study also aimed to ascertain whether a simple training intervention, devised and delivered by the authors, could significantly improve knowledge and confidence.

Method

Results

Knowledge of treatment under common law and section 5(2)

The baseline performance on the nine knowledge-based questions showed gaps in knowledge, with fewer than half of the participants answering correctly on five of the nine items (Table 1). There were net improvements in answers to all of the nine knowledge-based questions after the training, with statistical significance being achieved for four of the items.

Table 1. Participants’ knowledge before and after the training session

Question	Correct answer	Number correct pre-training n (%)	Number correct pre-training n (%)	Net improvement n (%)	P a,b
1. Can a doctor treat a patient against their will under common law?	Yes	11 (61)	16 (89)	5 (28)	0.180
2. Can a doctor hold a patient in hospital against their will under common law?	Yes	10 (56)	12 (67)	2 (11)	0.625
3. Who can implement section 5(2)?	Any grade apart from PRHO/FY1	3 (17)	7 (39)	4 (22)	0.125
4. Where can section 5(2) be used?	Any general or psychiatric wards but not A&E	2 (11)	12 (67)	10 (56)	0.000c
5. What does section 5(2) allow you to do?	Hold an in-patient in hospital against their will	4 (22)	13 (72)	9 (50)	0.004c
6. Do you know where the paperwork for section 5(2) is kept?	Yes	1 (6)	6 (33)	5 (28)	0.063
7. At which point does section 5(2) come into effect?	On receipt of the papers by the hospital managers	7 (39)	16 (89)	9 (50)	0.004c
8. How long does section 5(2) last for?	Up to 72 h	9 (50)	18 (100)	9 (50)	0.004c
9. Once section 5(2) is in place, what should happen next?	Assessment for section 2 or 3	14 (78)	16 (89)	2 (11)	0.625

Discussion

Our study revealed a marked baseline lack of knowledge and confidence regarding the use of section 5(2), common law and capacity in this group of general hospital doctors. Interestingly, only a third of the participants felt that they had any experience of treating patients under common law. This may have been a perceived (as opposed to actual) lack of experience, perhaps indicating that some participants had been treating patients under common law while being unaware that they were doing so. There were also remarkably few participants (less than half) who felt confident about assessing capacity. These findings may reflect a fundamental lack of understanding regarding treatment under common law and capacity among some participants. The apparent lack of basic knowledge and confidence in these areas is concerning, since the introduction of the Mental Capacity Act 2005 requires doctors to demonstrate clearly that they have assessed capacity fully, made efforts to improve capacity and are acting in the patient's best interest. ⁴

There was an overall improvement in knowledge and confidence following the training intervention. Items for which statistically significant improvements were achieved included aspects of the powers and application of section 5(2). The lack of statistically significant improvements in other items might have been due to relatively good baseline knowledge in certain areas or smaller levels of improvement, as well as small sample size. After the training intervention there were still some gaps in knowledge in spite of all the necessary information being provided. The reasons for this were unclear but might have been due to a lack of interest in the material or the complexity of the issues covered in the training. Overall, the training intervention was well received and the participants felt they would benefit from further training. The use of clinical scenarios as a training aid generated the most interest, and participants requested more of these. The informal feedback was particularly positive from junior doctors, but it was noted some of the more senior participants were reluctant to participate in the session.

Declaration of interest

None.