Scottish Government

Main Findings

• There was considerable variation across the 4 case study areas in how Local Authorities and Health Boards had approached training on the Act in general and on Part 5 in particular. As it was known that Part 5 and the Code of Practice were under review, an element of postponing training until after the review was detected
• Health sector respondents had received fewer hours of training in the Act generally, but with greater focus on Part 5, than local authority sector respondents. The majority of those who had attended training were broadly satisfied with the training they had received, but there seems to have been a poor attendance of independent sector professionals, as no specific mechanism exists for training them
• Some responses from the professional groups that had received training expressed concern that GPs had not received sufficient training on the Act, especially on Part 5. The GPs as a group were perceived by other respondents as not fully engaged with the Act
• Some medical practitioners were reluctant to provide certificates for any treatment apart from that for which they are directly responsible, some were anxious about their ability to assess capacity and, in some circumstances, there was felt to be a lack of adequate time or information to carry out an assessment
• There was a fair degree of confusion across respondent groups about what would be appropriate to include in the definition of "treatment"
• Some confusion was expressed about what should be done with certificates of incapacity, both in terms of central storage and dissemination of awareness that they exist in respect of particular patients

Background

Part 5 of the Adults with Incapacity (Scotland) Act 2000 is concerned with provisions to safeguard the interests of adults with incapacity in relation to medical treatment and research. Part 5 came into effect on 1 July 2002. A code of Practice, giving guidance on the operation of Part 5, came into effect in conjunction with Part 5, following wide consultation by the Executive. Section 47 of the Act confers a general authority on the medical practitioner primarily responsible for the treatment of the adult with incapacity to do what is reasonable in the circumstances to promote or safeguard the person's health, provided that a certificate of incapacity has been completed. After Part 5 and the Code of Practice came into effect, concerns were expressed about the procedures for the operation of Part 5; doctors in particular were concerned about the processes connected with the completion of certificates under section 47, and additional workload implications. As part of a review of the Code of Practice, and Part 5 in general, the Scottish Executive commissioned a qualitative research study to:

• examine experiences of the operational impact of Part 5 of the Act (within 4 case study areas) for adults who fall within the scope of Part 5, carers and those who represent such individuals: and for health and social care professionals with a responsibility for operating the Act and those with a direct duty under the Act
• explore levels of awareness about the provisions of Part 5 among health and social care providers and other key stakeholders
• explore the views of key stakeholders on factors that might facilitate or inhibit the implementation and operation of Part 5, drawing on their own experiences, in particular on the issues of training and information and on assessment and certification procedures

Profile of Respondents

Questionnaires were used to solicit the views of health and social care professionals and to recruit them for interview. A range of professionals from both sectors were interviewed. These interviewees also acted as "gatekeepers". They introduced the project to carers of people who had come within the scope of Part 5 of the Act, so that researchers might conduct interviews with them. Concurrently, interviews were held with those who had provided training in the Act. Representatives of organisations with a stated interest in the implementation and operation of the Act were also interviewed. These were both voluntary groups and organisations representing interested professionals.

Table 1: Number of responses by respondent and type of response

Detailed Findings

The majority of professionals from all 4 areas thought they would need to make use of the Act. There was a considerable variation across sectors in the proportions of those who said they would make use of Part 5, with the health sector much more likely (68%) than the local authority sector (40%). Health sector respondents reported a longer period of training specifically focused on Part 5 than those in the local authority sector. A large majority (72%) of professionals were very or reasonably satisfied with the training they had received. Seventy three percent said they knew of someone they could contact for advice about the operation of the Act. A variety of approaches to training on the Act had been taken across the 4 case study areas and the training offered to GPs, in particular, was felt to be inadequate. Postgraduate training was reported as a current but patchy mechanism to ensure GPs attend training. Experiences across professional groups indicated that GPs were not fully engaged with the Act. GP respondents also revealed a lack of understanding about Part 5, although they were approving of the principles within the Act and were keen to increase their understanding.

Concerns were expressed about the wording of the section 47 certificate, who should be involved in completing the certificate, and medical staff refusing to participate or lacking awareness.

Forty percent of respondents thought that the introduction of Part 5 had improved areas of their professional practice Reported improvements included better advocacy for the adult; greater awareness of accountability to relatives and carers; consideration to the minimum intervention required; awareness of consent issues, and protection for the professional. However, a small minority of respondents across professional groups thought their practice had been harmed: they cited an increase in workload responsibilities, lack of knowledge by other health professionals about the law, and time delays in treatment.

In response to the confusion reported about the storage and dissemination of awareness regarding certificates of incapacity, respondents identified benefits which might arise out of central storage system, including the ability to monitor the use of Part 5. Confusion was also expressed over the most appropriate medical practitioner to assess and certify adults.

Four carers of adults who had come within the scope of Part 5 of the Act were also interviewed. They did not appear to have appreciated the significance of the certification procedure, but all reported being consulted about the treatment and care of their relatives, which was important to them.

Conclusions

The overall emerging picture was that the respondents were building up their experience of operating Part 5 of the Act, with relative ease. There appears to be some disparity in knowledge of Part 5 of the Act which compromised respondents ability to implement Part 5 if colleagues had not received appropriate training. Confusion was expressed about storage of section 47 certificates, and about which medical staff were empowered to issue the section 47 certificate. There was also confusion over the role of the adult's next-of-kin in consenting to treatment.

Factors facilitating the implementation of Part 5 relate to goodwill, willingness to exhibit good practice and act in the best interest of patients. Barriers to implementation relate to the lack of an existing monitoring system, the perceived value of the Act, confusion over the term "treatment", the inability or reluctance of some medical practitioners to assess a person's capacity, and GPs exhibiting little familiarity with Part 5. Carers of adults subject to the provisions of Part 5 appeared to have little awareness of what Part 5 entailed.

Information about the Main Report

The main report provides further detail about the background to the study, the profile of respondents, the research stages, ethical processes, and data collection tools. It provides a quantitative analysis of the postal questionnaire returned by practitioners who had received training about the Act and Part 5 of the Act. It offers a qualitative analysis of the experiences of practitioners, carers and other stakeholders of the implementation of Part 5 of the Act. Conclusions and recommendations are drawn from the findings.