I know SOADs are allowed to assess remotely but can they assess by telephone? Is there anything to prevent them doing this?
Hi Karen
Yes, SOADs can assess by phone, though they encouraged to use video link, particularly if assessing patients with dementia, intellectual disabilities and autism. Some community patients prefer phone discussions to attending an appointment. Clearly remote assessments came in as a result of the pandemic and stuck, though the new MHA may reverse this process, except for the tiny number of capacitated and refusing patients who require urgent ECT.
I know SOADs are allowed to assess remotely but can they assess by telephone? Is there anything to prevent them doing this?
Yes. But whether the ‘anything’ will actually prevent them is another matter. It’s a matter waiting to come before the courts.
I had a telephone conversation with a SOAD a few days ago after I called up the CQC - because I was not willing to wait between 23 days and 204 days (according to data released under FOIA at the CQC for 2023). And I was not willing to fudge the law under S62(1) to enable regular medications and PRNs - as has been happening for the last 30 years. The response was quite favourable. The SOAD lead agreed without persuasion that a visit was best undertaken in person with an attempt to meet the patient FTF.
The General Medical Council and RCPsych have provided very clear statements on the nature of remote consultations. It is not uncommon for prescribing to be unlicensed in psychiatry. The GMC standards on prescribing along with MHRA and NICE have been very clear about the rules. But nobody has been looking into the rules. Hence - a matter waiting to come before the courts, and whatever the outcome at that stage - everybody will then become OCD about the matter including SOADs.
I’m not going to present a dissertation here as to why remote assessments by SOADs are fundamentally flawed - because I would have to pick apart and present all the relevant standards on prescribing. SOADs are involved in authorisation of prescribing which I assert engages GMC rules.
But the long history of UK culture, is to wait until a disaster - then to react. Quite a percentage of SOAD requests will be for patient ‘under S62(1)’. There are other issues of course requiring SOADs.
For a deep insight see that Yadav & Zigmond 2013 concluded:
Our study suggests that the urgent treatment provisions of the Mental Health Act 1983 are increasingly being used for a full treatment plan while awaiting SOAD examination. This is perhaps unlawful use of the urgent treatment provisions and is certainly outside the guidance of the Code of Practice.
[Yadav R, Zigmond AS. Mental Health Act 1983: use of urgent treatment in clinical practice. The Psychiatrist. 2013;37(5):156-159. doi:10.1192/pb.bp.112.038414]
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Thank you both for those interesting,competing views. I was concerned about a telephone appointment as my client has unpleasant side effects which would not come to light over the telephone.
Hi again Karen
Not sure that Russell and my comments conflicted or competed. I, as one of the 4 Regional Lead SOADs, stated the current legal position in relation to assessments. Russell noted that there are currently significant delays in SOAD assessments taking place, resulting in unfortunate use of s62 powers and some of the weaknesses of remote assessment. I absolutely agree that in patients who may have serious adverse effects remote assessment even with video link is likely to be inferior, though if the SOAD has concerns in this area then they can arrange to see the patient face to face or can hand back the assessment for another SOAD to do a f2f. Remote assessment on the other hand might result in a more rapid assessment, which might be beneficial for some patients and, as I previously noted, some CTO patients refuse to attend appointments.
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Yes-noted. I had never seen a telephone SOAD appointment before and I was surprised.
This about the worst sort of cases to assess remotely. ‘Encourged’ is in the passive voice. Who’s encouraging them? In all of the following, I have asked questions and raised matters for consideration. I have not made any assertion against any particular SOAD or group of SOADs. I have shared my experience-based observations - which cannot be representative of any situation locally or nationally.
Every registered medical doctor with a licence to practice medicine in the UK is required to ensure they are acting safely and appropriately - says the GMC. SOADs are engaged in authorisation of medications - which is prescribing, even if they are not the initiators of the prescribing. On the other had but for their authorisation, prescribing cannot be initiated under a T3 [via exception to S58(3)]. It is a moot point to argue that they are not engaged in prescribing activity. I strongly suggest that all SOADs consult with their defence bodies for more authoritative opinion.
Whist all of the following (under Safe and Appropriate below) will not apply directly to SOADs, they are relevant when assessing treatment plans. SOADs will assess a fair amount of prescribing initiated via S62(1) which will have declared “not irreversible” and “not hazardous”. Quite often said medications are approved. This means that the medications ought to be specifically checked to ensure ‘reversibility’ and potential for ‘hazard’. [There is a widespread assumption that most medications have reversible effecs or side-effects. That may be true. However materiality (Montgomery 2015 UKSC) is not simply ousted when authorising or prescribing medications for non-consenting patients.
In addition, in complex situations (especially if unlicenced medications are to be authorised) registered doctors are normally advised by para 97 of GMC standards on prescribing to consult with a pharmacist in certain situations. I am currently unaware that SOADs do that. In addition, SOADs will not have ready access to medication histories. I hardly ever find them in electronic or paper records.
Do SOADs evaluate whether diagnoses have been properly made? I have doubts because of the number of so-called EUPD patients around the country who have been drugged up via T3s (seemingly oblivious to CG78 of NICE). In addition polypharmacy via T3s seemed to have become a norm in the last 5 years.
Safe and appropriate
The following are standards expected of all doctors involved in prescribing. This is not an allegation against SOADs, even if so construed.
Safe means:
- Having sufficient information about the patient’s current medical conditions, other medications, potential drug interactions/contraindications to assess risks.
- Ensuring the medication is still clinically indicated and the intended benefits outweigh potential adverse effects.
- Determining if the dosage/formulation remains suitable based on the patient’s latest health status.
- Establishing a plan for monitoring the patient’s response and any potential side effects.
What is safe is captured in aggregate by the following paragraphs. Assumptions are easily made.
- Paragraph 1 (Good medical practice): Doctors must work within the limits of their competence and follow professional standards.
- Paragraphs 21-26: Considering the suitability of the mode of consultation (e.g., face-to-face vs. remote) for safe prescribing.
- Paragraphs 27-33: Ensuring sufficient information is available to prescribe safely, especially when not the patient’s regular prescriber.
- Paragraphs 59-66: Exercising caution when prescribing controlled drugs, drugs that are liable to misuse, or those requiring additional safeguards.
- Paragraphs 93-97: Monitoring, follow-up, and review arrangements to ensure ongoing safety of prescribed medicines.
- Paragraphs 99-102: Ensuring secure procedures for repeat prescriptions to maintain patient safety.
Appropriate means (not a full list):
- The repeat prescription aligns with the intended therapeutic goal and standard of care for the patient’s condition.
- Non-pharmacological alternatives have been considered where relevant.
- The duration of the repeat prescription is reasonable based on the clinical situation.
- The patient has been properly counselled on the medication’s use, precautions, etc.
- Prescribing the repeat remotely does not compromise the a doctor’s ability to properly evaluate the ongoing need/suitability.
What is appropriate is captured in aggregate by the following paragraphs (not a full list):
- Paragraphs 20 and 35-40: Assessing the patient’s needs, establishing a dialogue, and obtaining consent before prescribing.
- Paragraphs 41-44: Assessing the patient’s capacity to make decisions about treatment.
- Paragraphs 45-52: Providing sufficient information to patients about their medicines and considering their preferences.
- Paragraphs 76-79: Ensuring prescriptions are appropriate when based on recommendations from other healthcare professionals.
- Paragraphs 103-109: Prescribing unlicensed medicines only when necessary to meet the patient’s specific needs.
Conclusion
Essentially, “safe and appropriate” as conceptualised by the General Medical Council imposes on doctors authorising repeat prescriptions, even remotely, to ensure medications are still clinically justified, carry an acceptable risk-benefit profile specific to individua patients, and follow best practice guidelines as much as possible.
It would be illogical to infer that SOADs are not involved in authorising and initiating of prescribing or that they are not bound by the above. Any person or organisation encouraging medical doctors to do other than what is their duty, ought to be held to account.
I have been assessed over the phone, so l know it happens