Hospital managers protocol

1 Introduction

1.1 Hospital managers

In England, NHS Hospitals are managed by NHS Trusts and NHS Foundation Trusts such as Rotherham Doncaster and South Humber NHS Foundation Trust. For these hospitals the trusts themselves are defined as the “hospital managers” for the purposes of the Mental Health Act 1983 (MHA).

Hospital Managers have the authority to detain patients under the MHA and have the primary responsibility for seeing that the requirements of the MHA are followed. In particular, they must ensure that patients are detained only as the MHA allows, that their treatment and care accord fully with its provisions and that they are fully informed of, and supported in exercising, their statutory rights.

The hospital managers have equivalent responsibilities towards patients who are subject to community treatment orders (CTO).

In practice most of the responsibilities of the hospital managers, examples of which include admission and transfer of detained patients, provision of information and reference to the mental health tribunal, are actually taken by individuals (or groups of individuals) on their behalf, such as, MHA office staff and ward staff.

1.2 Trust associate hospital managers

Consideration for and decisions about discharge from detention and CTO’s are taken by panels of people specifically selected for the role (hospital managers panels). Hospital managers’ panels consist of 3 or more people and can include members, but not employees, of the trust, for example, chair and non-executive directors of the trust, as well as people appointed by the trust for this purpose. Those appointed for this purpose must not be employees of the trust and are often referred to as associate hospital managers.

Within the Rotherham Doncaster and South Humber NHS Foundation trust the role of hospital managers’ panels is undertaken by trust associate hospital managers and for the purposes of this protocol will be referred to as trust associate hospital managers. The chairs of the panels is referred to as a senior trust associate hospital manger.

2 Purpose

The protocol aims to:

ensure that patients have their right to have their detention or CTO reviewed by the trust associate hospital managers
ensure that the trust has sufficient trust associate hospital managers to meet the requirements of the MHA
provide guidance to trust associate hospital managers in performing their duties
ensure trust associate hospital managers and the board of directors have confidence in the procedures adopted by the trust in ensuring that the functions of the hospital managers are discharged effectively and lawfully

3 Scope

Although hospital managers have a range of authorities, duties and responsibilities this protocol applies only to the power to discharge under section 23 of the MHA.

4 Responsibilities, accountabilities and duties

4.1 The board of directors

As hospital managers, the trust is responsible for ensuring that the requirements of the MHA are fully met and that there are sufficient trust associate hospital managers to fulfil the requirements in terms of consideration for discharge. The board of directors have overall responsibility for the appointment of trust associate hospital managers.

4.2 Mental Health Act manager

The MHA manager will be responsible for the operational management of the MHA, including the functions of the trust associate hospital managers. They will:

oversee a performance review of each trust associate hospital manager at least once every 3 years
have overall responsibility for matters relating to the competence and conduct of trust associate hospital managers
report, as required, to the board of directors or any of its designated committees

4.3 Mental Health Act offices

The MHA offices of the trust will be responsible for the:

planning and co-ordinating hospital managers Hearings to consider discharge of patients subject to detention or CTOs
attending hospital managers hearings

4.4 Hospital managers (under section 23 MHA)

Hospital Managers have important responsibilities in relation to detained patients, in particular, their duty to review and consider discharge from detention or CTOs and this protocol refers only to those powers delegated under section 23 of the MHA (power of discharge).

When holding a review, trust associate hospital managers are required to act in conformity with the MHA 1983 and the Code of Practice issued as set out in section 118 of the MHA 1983. The most recent Code of Practice was issued in April 2015. The key chapters relating to hospital managers is chapter 38 (the hospital managers’ discharge power).

5 Procedure or implementation

5.1 Eligibility to act as a trust associate hospital manager

The chair of the trust and the non-executive directors of the trust board are all eligible but not required, to act as trust associate hospital managers for the trust. The trust also appoints a number of trust associate hospital managers who are also eligible to participate in hospital managers panels.

Trust associate hospital managers may not be employees of the trust.

5.2 Appointment of trust associate hospital managers

The trust will appoint a sufficient number of trust associate hospital managers, so that there is a sufficient pool of trained trust associate hospital managers for panels.

Applicants will need to be able to demonstrate some, or all of the following:

an interest and awareness of mental health issues
an understanding of health and social service organisations
an understanding of equality issues
a good understanding of confidentiality
the ability to analyse complex problems
the ability to read and comprehend detailed reports
the ability to actively listen and question
the confidence to question and challenge sensitively
the ability to work as a member of a team
the ability to bring objectivity and an impartial approach to tasks

When necessary, the trust will advertise for trust associate hospital managers.

5.2.1 Trust associate hospital manager recruitment

Application form completed.
Interview, MHA manager or HR representative or carer or service user representative.
Reference and CRB checks 2 references required.
3 year, appointment confirmed by trust board appointment letter issued.
Induction.
Observation of 3 panel hearings.

Applicants who are regarded as suitable and whose references are acceptable will then be subject to DBS clearance procedures. Following an acceptable outcome a recommendation will be made to the board of directors who will have responsibility for making the appointment.

Trust associate hospital managers are not employees of the trust, but appointment will be made subject to a formal agreement (appendix A).

The trust gives no undertaking of any minimum number of Hearings to be offered to each trust associate hospital manager, but it will take account of the need to ensure that all trust associate hospital managers have sufficient opportunity to sit in hearings. This is to both maintain their confidence and skills and to ensure that at least 12 hearings can be attended by each trust associate hospital manager, in a 12 month period.

Under the agreement
The trust associate hospital manager will	The trust will
Maintain confidentiality at all times	Provide training for the role of the trust associate hospital manager
Attend and participate in a minimum of 12 hospital managers hearings annually	Insure the trust associate hospital manager whilst on trust premises
Attend training and development sessions and at least 75% of formal trust associate hospital managers 4 annual meetings	Indemnify the trust associate hospital manager in respect of performance of the role
Adhere to relevant trust policies	Provide necessary administrative support
Adhere by the principles of data security	Provide necessary information resources
Participate in an annual review	Reimburse all agreed fees and expenses incurred in the discharge of the role
Participate in a 3 yearly performance review

The initial appointment will be for a period not longer than 3 years, subject to an annual review and 3 yearly performance review. At the end of this period, the trust associate hospital manager will have a review of their continuing suitability, the outcome of which will be discussed with the deputy director of nursing and allied health professionals executive medical director to decide whether to renew the appointment.

The trust may terminate the appointment with the trust associate hospital manager with one month’s notice and if there has been a substantial breech of the undertakings in the agreement, the agreement may be terminated without prior notice.

Any such decision will be taken by the MHA manager in consultation with the director of nursing and allied health professionals executive medical director.

The trust associate hospital manager may also terminate the appointment immediately by notice in writing to the MHA manager at any time.

5.3 Induction of trust associate hospital managers

The trust is committed to the provision of a high quality service to patients and recognises its responsibility to provide appropriate training and to monitor the effectiveness of the trust associate hospital managers.

The trust associate hospital managers will receive the following training and sign an agreement on maintaining confidentiality before they have access to any patient information. The training will include:

familiarisation with key elements of the MHA and relevant sections
familiarisation with key elements of the code of practice
attendance or e-Learning for the following mandatory training sessions:
- MCA or DoLS (leaflet)
- safeguarding, adults (leaflet) safeguarding, children (leaflet)
- domestic abuse (leaflet)
- prevent (leaflet)
- data security (e-learning or face to face)
- equality, diversity and human rights (face to face)
- infection and prevention control
- introduction to MHA (face to face)

Support for the induction process will be achieved through:

contact with the MHA manager for advice and support
observations at hospital managers hearings
the opportunity to discuss with the panel chair and panel members following observation at hospital managers hearings, no trust associate hospital manager will be allowed to sit as a member of a panel until completion of all the induction training

5.4 Training

As well as the initial training the trust will provide update training. The trust considers that training events will assist in determining and maintaining consistency in the delivery of standards. The expectation of the trust is that trust Associate Hospital Managers will endeavour to attend all training events provided. Training will include:

developments in mental health
developments in mental health law
skills development, (particularly in relation to chairing panels for those looking to assume this role)
equality, diversity and human rights training
data security training

Trust associate hospital managers will not be expected to chair hospital managers hearings until they have sufficient experience of participating in reviews and have received training in chairmanship. Those who are approved to chair will be known as senior trust associate hospital managers but otherwise the same obligations, duties and responsibilities for trust associate hospital managers will apply to them.

5.5 Annual review

The MHA manager will undertake an annual review with each trust associate hospital manager which will be a paper review (appendix B) and will include:

training undertaken
number of hearings available for
number of hearings attended
number of meetings chaired (where appropriate)
specific strengths
feedback from peers
learning and development needs

5.6 Three year review

The MHA manager will hold three yearly formal performance review meetings with each trust associate hospital manager (appendix C). Those meetings will review:

the on-going commitment to the role of trust associate hospital manager
attendance at training sessions
review of personal training and development needs
consideration of any problems encountered
feedback of trust performance over previous 3 years
any issues which an individual trust associate hospital manager wishes to bring to the attention of the trust

Nothing in the review process precludes the MHA manager convening an early discussion with a trust associate hospital manager in the event of any issues being raised which give rise to concerns about good practice.

The trust will reimburse expenses in respect of attendance at a review meeting.

5.6 Confidentiality

Although trust associate hospital managers are not RDaSH employees, they have the same duty as employees to maintain and protect the confidentiality of information relating to patients, colleagues and business information.

The Health and Social Care Information Centre (HSCIC) has established four confidentiality rules that must be followed:

confidential information about patients should be treated confidentially and respectfully
members of a care team should share confidential information when it is needed for the safe and effective care of an individual
information that is used for the benefit of the community should be anonymised
an individual’s right to object to the sharing of confidential information about them should be respected

Prying and gossiping are unethical. Trust associate hospital managers must not discuss personal confidential information about patients or colleagues.

If there is a potential conflict of interest, for example, a trust associate hospital manager has been asked to sit on a panel for someone they know, they must inform the MHA office immediately.

If a trust associate hospital manager needs to refer to another case they have been involved in, for example, if it is a difficult decision and they have been involved in a similar case, they must do so in a way that does not identify the patient concerned.

5.7 Complaints about trust associate hospital managers

If there are any concerns raised about the practice or conduct of a trust associate hospital manager, the nature of the issue will be investigated by the MHA manager in the first instance.

Dependent upon the seriousness of the issue, the outcome may be that a letter highlighting concern will be sent from the MHA manager to the trust associate hospital manager.

More serious issues will require further investigation and may necessitate a meeting between the trust associate hospital manager, deputy director of nursing and allied health professionals deputy medical director and the MHA manager. The findings from this meeting will be reported by the deputy director of nursing and allied health professionals deputy medical director to the director of nursing and allied health professionals executive medical director.

The director of nursing and allied health professionals executive medical director will then make a decision regarding any further action which could include further training, suspension of the trust associate hospital manager or even termination of the agreement as a trust associate hospital manager.

Any trust associate hospital manager who is unhappy with the decision of the director of nursing and allied health professionals executive medical director will have the opportunity to formally raise this with the chief executive.

Complaint and, or concern raised.
Initial investigation by the MHA manager.
MHA manager reports to deputy medical.
Director deputy medical director recommends any action required.
- letter from deputy medical director to trust associate hospital manager
Further investigation and, if necessary, meeting between trust Associate hospital manager, deputy medical director and MHA manager.
Report from deputy medical director to executive medical director.
Decision from executive medical director re action.
Opportunity to formally raise objection to outcome with chief executive.

5.8 Conduct of hospital managers

Hearings refer to the procedure for hospital managers hearings (appendix D).

5.9 Remuneration

The remuneration provided to each trust associate hospital manager is set by the trust and reviewed periodically. Sessions will attract remuneration plus travel expenses.

When a managers hearing has to be cancelled within 24 hours of the planned hearing the trust will endeavour to provide hospital managers with as much notice as possible. However when a managers hearing is cancelled within 1 working day of the original hearing the trust will offer remuneration for this. Such instances must be recorded on the trust associate hospital managers claim form.

6 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

7 Links to any other associated documents

Procedure for hospital managers’ hearings

8 References

MHA 1983 Code of Practice, Published 2015.

9 Appendices

Document control

Version: 3.
Unique reference number: 83.
Approved by: Mental health legislation operational group.
Date approved: 14 July 2022.
Name of originator or author: Mental Health Act manager.
Name of responsible individual: Mental health legislation operational group.
Date issued: 28 July 2022.
Review date: May 2025.
Target audience: Hospital managers or all trust staff.

Page last reviewed: April 30, 2024
Next review due: April 30, 2025

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