Mental Health Care Bill: briefing

Involuntary commitment was felt to be the ‘meat’ of the Bill, according to Prof. Freeman. The process is similar to that for an assisted care service user, but a new provision is added. This is that there will be a 72-hour waiting period, during which the service user will receive treatment without going through the certification process. It was felt that many people recover after 72 hours, and there were significant benefits to not certifying them. One indication was that this could lead to as much as a third reduction in the number of certifications. If after 72 hours, the person has not recovered, they will then be certified. It was felt that this would be a useful innovation, when viewing the problem of depriving someone of their fundamental freedoms, although due regard was needed for the service user, their family and the community.

Chapter 6
Chapter 6 deals with State Patients. The contentious issue in this regard was the fact that many people, particularly legal people, felt that the individual should still serve their sentence after they improve. However, Prof. Freeman expressed the view that if they were stable, it was not acceptable to continue to keep them in an institution if their crime was committed while psychiatrically ill. He said that this was an argument between community attitudes and the potential abuse of rights by keeping a ‘well’ person in an institution.

Chapter 7
This deals with mentally ill prisoners. The view was that these patients should be treated in prison, wherever possible, and if they were transferred to an institution this should be for as short a period as possible. Prof. Freeman indicated that if the person was still not stable when their sentence was completed, at that point they could be certified as involuntary patients. He also said that there was a difference between the Bill and the current act, in that under the current act, the person’s sentence pauses when they enter the institution and continues after they are released, where now time spent in an institution runs concurrent to their sentence.

Chapter 8
The notable issue here was who could be appointed as an administrator, in the case of incapacity. In most cases this would be the Clerk of the Court, but in some circumstances, particularly with larger estates, it was felt that an independent administrator should be appointed.

Chapter 9
One issue which Prof. Freeman drew attention to in connection with regulations was that of surgical procedures and medical treatment. Chapter 3, in discussing rights, stipulates that the least intrusive medical interventions be sought, which Prof. Freeman explained by saying that foe example, medication should be tried before shock treatment. He also said that such regulations would need to allow for developments in medical technology. For example, there are currently no treatments which require surgery, although there are some in the testing phase. If these were to be found useful, allowances would have to be made.

Major Changes from the Current Act
Prof. Freeman drew attention to the addition of the word ‘care’ in the title, to indicate that the Bill does not deal with prevention and promotion. He commented that some of the items included in the Bill, such as the chapter on rights, could be argued to be beyond the scope of ‘care’. However, he said that it was felt that this was appropriate. He also said that he had attended two international conferences hosted by the International Academy on Law and Mental Health, and when presenting the Bill, it was indicated that South Africa was a world leader in the area of patient’s rights.

The Bill introduces the words ‘mental health care practitioner’, and the definition of this person is left somewhat vague. The current act limits who can make assessments, which has implications for resource-poor rural areas, for example. The Bill consequently expands the list of people who can make recommendations, including psychiatric nurses who Prof. Freeman suggested were making an important contribution and should be included. The inclusions had been discussed with various bodies, such as the Medical Association and the Society of Psychiatrists, all of whom felt that the expansion was a good idea.

With regard to the doctors, Prof. Freeman said that all doctors were included in the draft regulations, but this was somewhat problematic owing to the quality of psychiatric training doctors who had been trained quite a long time ago had received. He suggested that over time, it was likely that this would be limited, to ensure that doctors making assessments were appropriately trained. With regard to nurses, he indicated that all nurses currently receive psychiatric training and there had been discussions about their inclusion, but no conclusions. It was felt that research was necessary, but no one had submitted a tender for this research.

The Mental Health Review Board was the next item discussed. Prof. Freeman indicated that currently, a magistrate was required to certify someone, and this occurred after two doctors examined the patient. However, he suggested that this process was little more than a rubber stamp, and the creation of the Review Board was an indication of the desire to take certification more seriously and prevent abuses of the system. The Review Board (to consist of at least one community member, one medical practitioner and one legal representative) did have some financial implications, particularly initially. However, it was expected to more than justify this initial cost due to the shorter stays and smaller number of certifications which are the expected result. The initial cost will need to come from the provinces, and Prof. Freeman said that the figure is likely to be around R1, 5 million. However, in the long-term, savings to institutions are likely. However, he stressed that there was uncertainty over exactly how the process would be handled, and the precise requirements and implications.

Prof. Freeman again mentioned that the 72 hour waiting period for assessment was new, and there had also been a reduction in the length of time between reviews, from reviews at one year, five years and every three years thereafter, to a review at 6 months, one year and every year after that.

Another new provision was the introduction of a category of patient described as under involuntary but living in the community. Prof. Freeman indicated that this was not altogether new, since there were similar sorts of things in operation, but that it was likely to be quite significantly expanded. Effectively, the idea is that certain patients will be allowed to live in the community, but obliged to report for medications, will have to live in certain areas, and will have certain activities, such as drinking, forbidden. Failure to do so will lead to a return to detention in the institution. He said countries like Canada had implemented the idea over time and with some success. He also emphasised that it would need to be slowly phased in.

Prof. Freeman pointed out that section 66 of the old Act had been dropped. This section prevented anyone from reporting what happened in institutions. The removal of this provision was aimed at ensuring that institution staff were accountable and this will protect patients. A provision dealing with hospital boards had been left out of the new Bill, because it was felt that the issue would be dealt with in the Health Bill.

Example of administrative procedure – Involuntary admission/treatment

Prof. Freeman then examined the procedure of involuntary commitment, to identify the checks and balances which the Bill sought to build into the system, to protect the rights of patients. The involuntary admission procedure is an example of one of the administrative procedures which the Bill is concerned with. The referral of the patient comes from the family in most cases, although there may be exceptional cases in which a patient is referred by a health care provider. Then he/she was examined by two mental health care practitioners, and a decision made as to whether the patient is incapable of or unwilling to consent to treatment as well as whether or not the patient poses a potential harm in terms of the provisions in the Bill. At this point treatment is started, and the 72-hour observation period begins. After 72 hours, if it is felt that further care is needed, the patient must be moved to an appropriate institution. A decision must be made as to whether the patient will be an inpatient or outpatient i.e. live in the institution or the community, and the Review Board must be notified within seven days. The determination as to inpatient status can be changed at a later stage. Prof. Freeman felt that this process should still require the involvement of the courts, as there were legal implications in removing a person’s rights, although it would be acceptable if this was merely an instance of ‘rubber-stamping’, since the process was fairly comprehensive. There was also an appeal process, which the family and the patient had recourse to, which was obliged to take account of all interested parties, for example if the family members had opposing views to each other. The patient also has recourse to the review process after six months, and one year etc.

Discussion
Dr Nkomo thanked Prof. Freeman and asked the Director General for comments.

The DG said that the Department had conducted an assessment, with the provinces to investigate the possible costs in restructuring and had found that the costs involved were not prohibitive and could be accommodated within the existing budget. He also said that it was felt that after two years, a shift towards shorter stays would be seen, with cost savings resulting. With regard to hospital boards, he said that the National Health Bill would include details, and he indicated that there was a consensus between the provinces and nationally that instead of creating different procedures, specific provisions concerning mental health be included to accommodate psychiatric hospital boards and allow transparency. He drew attention to the review of institutions, which had indicated some causes for concern, and it was felt that certain structural problems had thus far inhibited change. However, he expressed his wish that these institutions should be more open to change.

Dr. Jassat (ANC) asked how the integration into primary and tertiary care was envisaged. He also raised a point concerning the administration of property, asking whether this was not a welfare issue. With regard to chapter 3, he asked whether in terms of controlling adult relations, sterilisation for genetic reasons had been considered, although not in a eugenic light. He also asked whether the Review Boards rewarded good behaviour, or normal behaviour. And his final question concerned whether various groups such as the Scientologists had expressed views on the Bill.

Ms Dudley (ACDP) drew attention to the fact that the Aged Care Network had made a representation to the Committee concerning fears of older people with regard to coping with mentally ill adult children. She asked how easy it would be for an older person to have someone re-committed. With regard to the leave of absence and the discharge into the community (i.e. the issue of outpatient care), she asked if any community input was envisaged. In particular, she asked how communities could be forewarned.

Dr Baloyi (IFP) asked what the envisioned role of the general hospital as opposed to the psychiatric hospital was to be. He also asked whether the Review Boards were to be linked to hospitals or to regions. He also raised a general question as to how the Bill empowered general hospitals, in line with a primary healthcare approach.

Dr Luthuli (ANC) asked whether the 72 hour observation period did not foster the situation in which people would be discharged and then proceed to do the same thing again (in the case of toxic psychosis i.e. abuse drugs/alcohol) and then relapse.

Dr. Rabinowitz (IFP) asked whether the overall accountability would lie for example with the Health Professions Council, and whether or not a mental health ombudsman was envisaged, to ensure the requirements were being met. She also asked how the envisaged infrastructure for involuntary community care would be financed, since South Africa was not as wealthy as Prof. Freeman’s example of Canada. She also asked for elaboration on the distinction between hospital and review board, as well as who would pay for the hospital board and review board.

The Director-General volunteered an answer to the final question, saying that the Review Board had nothing to do with the running of the hospital, and in terms of the existing Act, all hospitals were run by a board. He said that, in the case of a mental hospital, certain specific provisions were necessary, but this would not fundamentally alter the hospital boards functions.

Prof. Freeman sought to address several questions at once, by outlining the different levels of care. He said that in terms of the existing policy, wherever there was health care, there should be mental healthcare. The responsibilities of each level of healthcare were decided on by the department, although staff considerations played a major role in these decisions. For instance, in terms of voluntary care, if it could be dealt with at primary level, this should be done. He said that, if it was felt that general hospitals could deal with some of the functions, resources should be shifted to these facilities. Units could be created within the general hospital with staff and a locked door, to deal with 72-hour assessments. He acknowledged that the 72-hour assessment might encourage a "revolving door" situation, but in such cases, referrals should be made to institutions for more comprehensive rehabilitation, or involuntary care in the community.

Prof. Freeman reinforced the view that what was needed was a shift in resources, rather than new resources. It currently costs R250 per patient per day in a hospital, and this money would be shifted to the community. He said that currently, pilot programs were underway, to assess the situation. He said that there was a need to work with the provinces and to be flexible and creative to make the best uses of the available resources. He said that this was unlikely to be an easy process, but felt that it was a logical one, which would be facilitated by the legislation under discussion.

In terms of sterilisation, Prof. Freeman indicated that the Sterilisation Act had been passed three years ago, and it dealt with some of the issues. In cases where people are stabilised, it was felt that it was preferable to opt for voluntary sterilisation.

In response to Dr Jassat’s question, he agreed that in some senses, the Review Boards could be seen as Parole Boards, aiming at providing the best care to people.

In terms of the Scientologists, he said that they had formed the Citizens Commission for Human Rights, and this group was likely to be represented when public submissions were heard. In a sense, he said that their views could be seen as a modified version of the anti-psychiatry movement. They had developed a ‘model mental health act’, which the department had examined and taken note of, incorporating some of the better ideas. However, Prof. Freeman said that he felt the view of human rights proposed by this group was too extremely individualistic, and did not reflect an adequate understanding of the issues around mental health.

With regard to the policing of conditions in the community, the issue raised by Ms Dudley, Prof. Freeman said that the department had some experience, in the form of the conditional discharge granted to state patients, although he acknowledged that there was likely to be a need for additional people to monitor the situation. However, he suggested that the long-terms savings would cover these costs. He also indicated that at the moment, there were efforts to track defaulters, but that this was difficult without adequate resources.

In terms of community consultation, he indicated that no provision had been made for this because it was not clear how to build this in. In a context where the family did not want to take responsibility for the patient but the patient was stable, the government could not act as a holding house. In terms of notifying the community, Prof. Freeman pointed out that there was a difficulty in deciding who should be notified i.e. who constituted ‘the community’, but agreed that this might be looked at.

Addressing Dr Baloyi’s question, Prof. Freeman said that the Review Boards could cover individual hospitals or regional groupings, depending on the provinces recommendations.

In terms of a mental health ombudsman, Prof. freeman indicated that two pilot studies had been set up, to assess whether this was necessary, or whether the functions could be handled by a larger monitoring body, ensuring mental health representation.

Dr Rabinowitz asked if that meant that the Health Professions Council had the ultimate authority.

Prof. Freeman replied that he felt there was a need for an independent body to monitor the professional council, since there was a tendency for professionals to protect each other.

The Director-General stepped in to say that the department was finalising the complaints procedure, and were watching the pilot studies. He also said that depending on the nature of the complaints, for example in cases where ethic were concerned, reports would go to the professional body.

Dr Cwele asked for clarification on involuntary community care, particularly the issue of monitoring. He also said that, in terms of the requirement for closer co-operation between primary healthcare and hospitals, it seemed critical whether or not hospitals had the appropriate facilities. He asked whether tan audit had been done to assess the capabilities of the general hospitals. He asked for clarification on who constituted a mental healthcare practitioner, with particular reference to any levels of key competency or guidelines which had been developed. He also raised a question about who was responsible for financing the legal representation provided for in the Bill, whether Justice had been consulted about this matter. Related to this, he asked what the costs were of shifting from magistrates to High Courts and whether this shift did not have adverse effects for accessibility.

A question was raised concerning whether current medical training provided practitioners with the skills to make an adequate assessment.

Dr Baloyi asked whether the role of NGOs was to be defined in the act or the regulations.

Ms Malumisa (ANC) asked if there were procedures for the discharge of patients, for example was the family notified, and prepared.

Dr Gous (NNP) asked whether involuntary and voluntary care was possible under private institutions or was it solely the domain of the State.

Prof. Freeman said that not all general hospitals had the capacity to fulfil the envisaged functions right away, but that a shift in resources would address this issue over time. He emphasised that it had been a slow process over a number of years. He also said that where there was insufficient capacity, the hospital would have to refer people. However, at the moment there was the situation where people were being transported long distances unnecessarily.

In terms of financing legal aid, he said that he had hoped for the Committee’s input, since Parliament would have to make the decision. Justice had said no, but if this was denied, then it might be unconstitutional. If the provision was taken out of the Bill, it was felt that it would be severely watered down.

With regard to the High Court, Prof. Freeman said that there was no problem with getting a rubber stamp from the High Court, and consequently there was no additional responsibility, since magistrates were still required to do this.

The Society of Psychiatrists had made the recommendation on medical practitioners making assessments, and therefore they held the view that the medical curriculum adequately dealt with the issues. Prof. Freeman indicated that he felt the training had improved, but expressed reservations over the training that had been received at an earlier stage.

The Director-General indicated that it would be necessary to consider the issue carefully, with the Health Professionals Council, and they could oblige through recommendations for the CPD program, to make it part of the community care modules. He also said that a time-frame for the completion of adequate training could be included in the act, to ensure that after such time, doctors were competent in this regard.

Prof. Freeman addressed the issue of NGOs by saying that it would be dealt with in the regulations. He expected these to be facilitatory, rather than stipulated exactly what NGOs would be required to do. Provision would also be made for the transfer of funds.

At this point, the meeting moved to another venue, as the next meeting was due to start at that venue. Several of the members excused themselves.

Prof. Freeman said that, in terms of preparing the community and the family, the issue had been considered, but there was uncertainty over whether to address it in codes of practice, the regulations or the legislation. It was accepted that there were provisions in the codes, but that this was seldom followed in practice. However, if it were legislated, resources would be needed. If this was not provided, what were the implications, particularly in the context of vary few social workers especially in rural areas.

He responded to Dr Gous’ question by saying that with voluntary care, mental health should be the same as any other type of healthcare - those that could afford to and who chose to could receive treatment from private institutions. However, the issue of involuntary care is more complex, because there was a perverse incentive to commit someone if you were then going to get paid for looking after them. However, many people had a great reluctance to attending State institutions, if they could afford alternatives. Prof. Freeman indicated that the general feeling was that this issue would be dealt with in the regulations, rather than in the legislation. However, he suggested that guidance from the Committee would be appreciated. He said that what often happened was that people initially sought private care, and then went to the State when the situation became chronic. The problem with this was that the private treatments were often expensive, and the State could not provide the same medication. As a result of changes to medication, patients often relapsed.

An ANC committee member indicated that there were similar situations in the medical sphere, and asked what recourse the State had in the psychiatric context.

Dr Nkomo asked the Director General if there were guidelines for this.

Dr Ntsaluba replied that the situation now was that the State remained the place of last resort for most people, and this issue was part of the reason for the limits to the minimum benefits package. He said that ultimately, nobody could be turned away by the State. He continued by saying that there was an attempt underway to incorporate mental health care into the minimum package, and that if a person was on the minimum package, it was hoped that resources would be transferred. However, he recognised that in the case of chronic illness, this was difficult.

Prof. Freeman added to this last point by saying that, fundamentally, the rights of someone with a chronic mental illness were the same as those of someone with a chronic physical condition, such as diabetes.

Dr Maloyi (ANC) said that despite the fact that the law and the Constitution were good, people were being turned away from institutions, and had no recourse to defend themselves because they were illiterate and unaware of their rights.

Dr Ntsaluba reiterated the fact that nobody should be turned away, agreeing that this issue involved communication and education, of both the public and staff.

Ms Baloyi (ANC) agreed that there was a need to educate patients about their rights.

Dr Nkomo said that an evaluation of the Patient’s Rights Charter had been planned but that there was not enough time.

Dr Rabinowitz asked whether there was a fast-track procedure to deal with patients after hours. She also asked if there couldn’t be a government minimum benefit offer, irrespective of whether treatment was from State or private facilities, to ensure protection of the right to access.

Dr Nkomo suggested that that issue was more appropriate to a discussion on the National Health Bill.
In response to the first part of Dr Rabinowitz’s question, Prof. Freeman quoted the relevant sections of the Bill (Chapter 5)

Dr Nkomo ended the meeting by saying that the Committee would keep in contact with the Department, so that the soonest passage of the legislation could be facilitated.

Appendix:
MAIN AIMS OF THE MENTAL HEALTH CARE BILL

~ Promote human rights of people with mental disabilities through

Legislation rights

Procedural functions

~ Improve mental health services through a primary health care approach an emphasis

on community care.

~ Protect the health and safety of the public in circumstances where a person with mental

disabilities may be a danger to him/herself or others.

~ Set out the framework and statutory roles with respect to:-

• voluntary users
• assisted users
• involuntary users
• state patients
• mentally ill prisoners

1. Chapter 1 provides for the definitions.
2. Chapter 11 deals with fundamental provisions.

This Chapter outlines the role of the State in providing mental health services.

It provides for much greater accessibility and integration of mental health services at the various levels of health care provision than is presently the case.

3. Chapter 111 covers rights and duties relating to mental health.

The specific rights dealt with include-

1. respect, human dignity and privacy;
2. consent to care, treatment and rehabilitation and admission to health establishments;
3. unfair discrimination;
4. exploitation and abuse;
5. determinations concerning mental health status;
6. confidentiality;
7. limitations on intimate adult relationships;
8. right to be represented;
9. right to discharge report; and
10. full knowledge of rights.

1. Chapter IV provides for setting up Mental Health Review Boards.

This Bill makes provision for the establishment of Mental Health Review Boards with provinces specifically to ensure the protection of the rights of persons who are committed into care, treatment and rehabilitation without their consent.

(5) Chapter V deals with voluntary, assisted and involuntary mental health care.

1. This Chapter regulates the procedure authorising the provision of care treatment and rehabilitation.
2. In this Bill, voluntary patients are viewed and treated in the same manner as persons with other health problems.
3. Processes are set up for the admission and treatment of persons who are unable to give informed consent due to mental illness or intellectual disability (assisted) users. This includes making applications, examination of the person by mental health care practitioners and a review and confirmation by a Review Board. Appeal processes and periodic reporting are put in place.
4. With regard to involuntary care and treatment, similar processes to those applicable to "assisted" patients are set out. In addition, provisions are made for a 72 hour assessment period which may enable a user to recover from an illness before being committed to a psychiatric hospital. The decision of the Review Board is sent to a Judge for further consideration.
5. The Chapter also deals with maximum security facilities which are at times required for mentally ill people.

6. Chapter VI deals with state patients.

This chapter deals with people declared by the courts to be unfit to stand trial.

Processes are set up for the transfer of the patient from detention centre, leave of absence, periodic reports through to discharge procedures.

7. Chapter VII deals with prisoners who are mentally ill.

If a prisoner becomes mentally ill to such an extent that they must be transferred to a psychiatric hospital, this can be done after various procedures have been followed. Tranfer back to the prison or discharge after the expiry of sentence are covered.

8. Chapter VIII provides for the care and administration of property of the mentally ill

and intellectual disabled.

Provision is made for an administrator to be appointed to administer and manage the

property of a mentally ill person when the need for this arises.

9. Chapter IX deals with regulations.

The Minister, after consultation with the relevant MECs, may issue regulations regarding a number of issues, including-

1. surgical procedures or medical or therapeutic treatment;
2. norms and standards;
3. maximum security facilities;
4. funding of non-government organisation; and
5. licensing of facilities.

6. Chapter X deals with general provisions.

This Chapter deals with offences and penalties; establishment of technical committees; assignment and delegation of powers, limitation and restrictions of liability; repeal laws and transitional arrangements.

(B) CHANGES FROM CURRENT ACT

Some of the major changes from the current act include-

1. Changes in title of the statute.
2. Inclusion of a Chapter dealing with patient rights. This chapter is critically important as people with the mental disabilities are still discriminated against and not protected sufficiently by law.
3. Introduction of a "mental health care practitioner" category. This will allow for much greater accessibility to various mental health services. It will also ensure that mental health functions are carried out by people able and qualified to do so.
4. Addition of "Mental Health Review Boards:. This will protect patients from arbitrary or unnecessary committal and retention. This involves a shift from certification by a magistrate (which in practice has merely become a magisterial ratification) to a Board which includes a legal person (who may be a magistrate), a mental health care practitioner and a community member.
5. Introduction of 72 hour assessment period prior to involuntary admission at a psychiatric hospital. This is added as many people recover in this period and the system can avoid many problems and save on administration associated with certification. This is also advantageous to the service user.
6. Shortening of the period of review for involuntary, assisted, state patients and prisoners who are mentally ill.
7. Various sections of the current Act have been omitted. For example, the section prohibiting the reporting of conditions in psychiatric institutions and how to deal with patients from other states. Hospital Boards have been taken out to avoid duplication with the proposals of the Health Bill. (Transitional arrangements have been made until such time as the new Health Bill is passed).

~ Application make by person close to potential user. (In exceptional cases can be made by

health care provider).

~ Head of the Health Establishment causes person to be examined by two mental health care practitioners. Must decide whether the person

• is incapable of making informed decision and is unwilling to receive care, treatment and rehabilitated
• 15 mentally ill to the extend that he/she is likely to inflict serious harm on him/herself or others or care, treatment and rehabilitation is needed for the protection of the financial interests or reputation of the user.
• Must receive involuntary care.

~ a third mental health care practitioner decides if there is discrepancy

~ within 48 hours the person must be admitted to a health establishment. (This can be referral

from the establishment where the initial assessment is done).

~ Treatment is started and the user is given a 72 hour period to be assessed as to whether

further involuntary care is required.

If affirmative a decision must be made as to whether the involuntary care is to be provided the Head of the Health Establishment must notify the Review Board with within 7 days.

~ If the person is to be admitted as an inpatient he/she must be transferred to a psychiatric hospital (if not already at such a facility)

~ The user may be transferred to being an out patient user as appropriate.

~ If involuntary care, treatment thab is granted documents must be referred to a High Court.

~ A user (or associate) may appeal to the Review Board against the decision on involuntary care. If the Review Board does not uphold the appeal it must sent the documents to a High Court for review.

~ The Review board must fully consider the request for further involuntary care and call for such information as may be necessary to make their decision.

~ Six months after commencement of care and every twelve months thereafter a review of the user must be completed and reasons why the user must continue with involuntary services must be motivated. The Review Board must consider each review.

Some of the major changes from the current act include-

(a) Changes in title of the statute.

Inclusion of a Chapter dealing with patient rights. This chapter is critically important as people with the mental disabilities are still discriminated against and not protected sufficiently by law.

1. Introduction of a "mental health care practitioner" category. This will allow for much greater accessibility to various mental health services. It will also ensure that mental health functions are carried out by people able and qualified to do so.
2. Addition of "Mental Health Review Boards:. This will protect patients from arbitrary or unnecessary committal and retention. This involves a shift from certification by a magistrate (which in practice has merely become a magisterial ratification) to a Board which includes a legal person (who may be a magistrate), a mental health care practitioner and a community member.
3. Introduction of 72 hour assessment period prior to involuntary admission at a psychiatric hospital. This is added as many people recover in this period and the system can avoid many problems and save on administration associated with certification. This is also advantageous to the service user.
4. Shortening of the period of review for involuntary, assisted, state patients and prisoners who are mentally ill.
5. Various sections of the current Act have been omitted. For example, the section prohibiting the reporting of conditions in psychiatric institutions and how to deal with patients from other states. Hospital Boards have been taken out to avoid duplication with the proposals of the Health Bill. (Transitional arrangements have been made until such time as the new Health Bill is passed).
6. Introduction of involuntary community commitment. This allows for users who require involuntary treatment, but who do not need to be admitted, to receive care in the community.