Recruitment information for

Second Opinion Appointed Doctors(SOADs)

Contents

  1. The Care Quality Commission
  2. The second opinion service
  3. SOAD job description
  4. Conflict of interest
  5. Fees and expenses
  6. Equality and human rights
  7. Guidance on completing the application form

Form 1Application form

Form 2Equal opportunities monitoring information

You can find further guidance for SOADs on our website and in the Code of Practice.

This recruitment information is produced by the Care Quality Commission

1.The Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of all health and adult social care in England.

Our aim is to make sure better care is provided for everyone, whether that’s in hospital, in care homes, in people’s own homes, or elsewhere.

Our vision is of high quality health and social care that:

  • Supports people to live healthy and independent lives
  • Helps people and their carers make informed choices about care; and
  • Responds to individual needs.

By high quality care, we mean care that:

  • Is safe.
  • Has the right outcomes, including clinical outcomes (for example do people get the right treatment and are they well cared for?).
  • Is a good experience for the people who use it, their carers and their families.
  • Helps to prevent illness, and promotes healthy, independent living.
  • Is available to those who need it when they need it; and
  • Provides good value for money.

Our values are to:

  • Put the people who use services first, be informed by what they tell us and stand up for their rights and dignity.
  • Be independent.
  • Be expert and authoritative, basing our actions on high quality evidence.
  • Be a champion for joined up care across services.
  • Work with service providers and the professions to agree definitions of quality.
  • Be visible, open, transparent and accountable.

We regulate health and adult social care services in England, whether they're provided by the NHS, local authorities, private companies or voluntary organisations and we protect the rights of people whose rights are restricted under the Mental Health Act.

We make sure that essential standards of quality and safety are being met where care is provided, and we work towards the improvement of care services. We promote the rights and interests of people who use services and we have a wide range of enforcement powers to take action on their behalf if services are unacceptably poor.

Our work brings together independent regulation of health, mental health and adult social care. Before 1 April 2009, this work was carried out by the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection. These organisations no longer exist.

Our main activities are:

Registering providers of health care and social care – to ensure they are meeting the essential standards of quality and safety.

Monitoring how providers comply with the standards – gathering information and visiting them when we think it is needed.

Using our enforcement powers – such as fines and public warnings if services drop below the essential standards. If we think that people’s rights or safety are at risk, we will act quickly – including closing a service down if necessary.

Acting to protect patients whose rights are restricted – acting to protect patients whose rights are restricted under the Mental Health Act.

Promoting improvement in services – by conducting regular reviews of how well those who arrange and provide services locally are performing.

Carrying out special reviews – of particular types of services and pathways of care, or undertaking investigations on areas where we have concerns about quality.

Seeking the views of people who use services – involving them in our work and publishing a statement on how we do this.

Telling people about the quality of their local care services – this will help providers and commissioners of services to learn from each other about what works best and where improvement is needed, and help to shape national policy.

2.The second opinion service

The Mental Health Act 1983 introduced the Second Opinion Appointed Doctor Service as a safeguard of the rights of patients detained under the Act who either refuse the treatment prescribed by the Approved Clinician or are deemed incapable of consenting. From November 2008, the amended Mental Health Act introduced additional safeguards relating to Supervised Community Treatment and ECT.

The role of the SOAD is not to give a second clinical opinion in the conventionally understood medical form of the expression, but to decide whether the treatment recommended is clinically defensible and whether due consideration has been given to the views and rights of the patient.

The SOAD is an independent Consultant Psychiatrist appointed by the Care Quality Commission to undertake this statutory function, and only ‘becomes’ a SOAD when appointed to an individual second opinion. The Care Quality Commission is responsible for the appointment of SOADs and manages the SOAD service.

CQC receives around 12,000 requests for second opinions each year. The SOAD Service is supported by CQC's dedicated team of staff who receive the requests for second opinions from providers and work with SOADs to allocate requests promptly.

Section 58 and the Second Opinion Process – people detained in hospital being treated with medication

Section 58 of the revised Mental Health Act 1983 directs that certain treatments (medication) cannot be given except in an emergency without either the capable consent of the patient or, in the absence of such consent, the authorisation of a Second Opinion Appointed Doctor (SOAD).

Where a patient either refuses or is incapable of giving consent to treatment falling within Section 58, the approved clinician must arrange for CQC to be contacted to request a Second Opinion so that a SOAD can be appointed.

Once appointed, the SOAD visits the hospital where the patient is detained and reviews any relevant notes to obtain background information on the patient and the proposed treatment. They talk with the patient about their treatment and their views and they also talk with the approved clinician and two “statutory consultees” (a nurse and another person who is neither a nurse nor a doctor but who has been professionally concerned with the patient’s treatment).

Following this process of interviews and consultations, the SOAD must make two decisions:

  1. Consent of the patient: Is the patient refusing to give their consent to the treatment or is the patient not capable of understanding the nature, purpose and likely effects of the proposed treatment, or is the patient actually consenting?
  1. Is the treatment appropriate?

In order to make a decision, the SOAD must be clear that their role is to provide an additional safeguard to protect the patient’s rights.

The Code of Practice explains that: (para 24.56-58) “…SOADs act as independent professionals and must reach their own judgement about whether the proposed treatment is appropriate. SOADs should, in particular:

  • consider the appropriateness of alternative forms of treatment, not just that proposed;
  • balance the potential therapeutic efficacy of the proposed treatment against the side effects and any other potential disadvantages to the patient;
  • seek to understand the patient’s views on the proposed treatment, and the reasons for them;
  • give due weight to the patient’s views, including any objection to the proposed treatment and any preference for an alternative;
  • take into account any previous experience of comparable treatment for a similar episode of disorder; and
  • give due weight to the opinions, knowledge, experience and skills of those consulted".

If the SOAD decides that specified treatment should be given to the patient without their consent, this is authorised by completing a Form T3. In some cases the SOAD may instead complete a Form T2 to indicate that the patient has consented to the treatment plan. The SOAD may decide not to authorise all or part of the treatment plan.

The treatment authorised on Form T3 may not be in accord with the SOAD’s own personal practice, but must be reasonable in their opinion.

At the conclusion of the process, SOADs are required to record the reasons for their decision, which is given to the Responsible Clinician (RC) who may provide this to the patient if it is appropriate to do so. See CQC's Guidance Notes on the Wooder case for further details.

Section 58a and Second Opinions - ECT

The revised Act sets out new parameters for the treatment of patients with ECT in the newsection 58A. The law distinguishes between patients under 18 years of age and patients over18 years of age. These are dealt with separately below.

ECT and patients over 18 years of age

For any patient over 18 years of age who is detained under or subject to a section of the MHAto which Part 4 applies, ECT may be given:

  • in an emergency (i.e. if it is immediately necessary to save life or prevent a seriousdeterioration of the patient’s condition) under section 62; otherwise
  • under the authority of Form T4 (certificate of consent to treatment) if either the approvedclinician in charge of the treatment or a SOAD has certified that the patient is capable ofunderstanding the nature, purpose and likely effects of the treatment and consents to it; or
  • under the authority of Form T6 (certificate of second opinion) where a SOAD hascertified that the patient is not capable of understanding the nature, purpose and likelyeffects of the treatment, but that it is appropriate for the treatment to be given.

The SOAD must also certify that giving ECT would not conflict with any advance decision, or any decision of an attorney, deputy or the Court of Protection.

This means that, except in an emergency when section 62 powers can be invoked, anycapacitated patient’s refusal of consent to treatment with ECT must be respected.

ECT and patients under 18 years of age

ECT treatment is rarely given to patients under 18 years of age, but all SOADs should be awareof the legal rules established under the revised Act.For any patient under 18 years of age, whether that person is detained under the MHA or is aninformal patient7, ECT may be given:

  • in an emergency (i.e. if it is immediately necessary to save life or prevent a seriousdeterioration of the patient’s condition), and where the patient is detained under or subject toa section of the MHA to which Part 4 applies, under section 62; otherwise
  • under the authority of Form T5 (certificate of consent to treatment and second opinion) ifa SOAD has certified that the patient is capable of understanding the nature, purposeand likely effects of the treatment and consents to it, and that it is appropriate for suchtreatment to be given; or
  • under the authority of Form T6 (certificate of second opinion) where a SOAD hascertified that the patient is not capable of understanding the nature, purpose and likelyeffects of the treatment, but that it is appropriate for the treatment to be given. TheSOAD must also certify that giving ECT would not conflict with any advance decision, orany decision of an attorney, deputy or the Court of Protection.

Therefore, for informal patients under 18 years of age, section 62 is not available, but for detainedpatients under 18 years of age it is available and emergency powers may have been used priorto the SOAD visit. With this exception, SOAD procedure is the same irrespective of whether thepatient in question is detained or informal. A SOAD visit will be necessary to consider ECT.

Part 4a and Second Opinions – Supervised Community Treatment

SOADs have a specific role in relation to patients who are subject to Supervised CommunityTreatment (SCT). This is set out at Part 4A of the revised Act.

Force may not be used to treat SCT patients while they are in the community if they object totreatment. Force may be used where a patient is incapacitated, provided that the person givingthe treatment decides that the patient does not object to the treatment (see Code of Practice23.24 – 23.25).

A patient who is capable of giving consent and refuses to do so therefore cannot be compelledto accept treatment. Neither can treatment be imposed upon an incapable patient if it conflictswith a valid advance refusal of treatment or a Court of Protection ruling, or with a refusal ofconsent by a deputy or attorney as defined in the Mental Capacity Act: in such cases the patientmust be considered to have equivalent status as if they were contemporaneously refusingconsent.

For the first month of an SCT, treatment can be given to an SCT patient (provided that the patient isnot refusing consent to it) without SOAD authorisation. After the first month SOAD certificationis needed (irrespective of whether the patient is consenting or incapable but compliant), unlessthe three-month period that was applicable to treatment with medication as an inpatient is still toexpire at this time, in which case that three-month period must run its course before certificationis needed.

Assuming they support the treatment, SOADs are required to certify the appropriateness ofmedication for mental disorder (i.e. irrespective of whether the patient is consenting to it or lackscapacity to consent) given after the first month of a patient being in the community on SCT.

In the less likely circumstance that treatment with ECT is proposed for an SCT patient, there isno ‘one month’ initial period when SOAD certification of its appropriateness is unnecessary. Aswith medication, SOADs are required to certify the appropriateness of ECT irrespective ofwhether the patient is consenting to it or lacks capacity to consent.

SOAD visits to SCT patients will take place in hospitals, outpatient clinics or somewheresimilar that has been agreed between the “Approved Clinician in charge of the treatment inquestion” and the SOAD. SOADs are not expected to visit patients at home.

Theprocedure for the SOAD visit is similar to that for detained patients, except that the statutoryconsultee rules stipulate only that at least one statutory consultee shall not be a doctor, and thatneither can be the Responsible Clinician or “Approved Clinician in charge of the treatment inquestion”.

There is only one statutory form (Form CT011) for the SOAD to use for certifying theappropriateness of ECT or medication to any SCT patient.The form does not require SOADs to certify whether the patient is consenting or incapable of doing so, nor whether a patient with capacity is consenting or refusing. However, it may be appropriate to address these questions when giving reasons for the decision toauthorise any treatment using this form.

A statement of reasons is required by the statutory formirrespective of the whether the patient has capacity, and irrespective of, if so, he or sheconsents to the treatment in question.

In what ways do I benefit from being a SOAD?

Those who have become SOADs understand the importance of their role as a safeguard for detained patients and the difference they can make to patients and other services through their contact with patients and hospital staff.

Second Opinion visits involve visiting different hospitals and consulting with a wide range of professionals. On a personal level, the nature of the work can provide an invaluable development opportunity for consultants to broaden their experience by seeing first-hand different approaches to psychiatric treatment and to view different hospital environments. It is different from routine clinical work, and provides a refreshing change.

As a SOAD, you are provided with full training on the requirements/expectations of the role. This includes training on the Mental Health Act, Mental Capacity Act and other relevant case law and clinical aspects of the role– all of which will be relevant for all consultants.

The Care Quality Commission will provide full support for doctors undertaking this role. Our team of dedicated SOAD coordinators provide administrative support, and make the arrangements so that you are able to concentrate solely on your role as an independent doctor.

Lead SOADs provide peer support with ongoing opportunities to discuss any issues that arise. By creating local teams and through training events, there will also be opportunities to meet colleagues and share experiences.

This is a flexible role, and recent changes to how second opinions are organised now offersyoua choice as to how and when you can fit this work around your current working commitments. There will be opportunities to plan guaranteed full or half days work in advance or to take on ad-hoc requests.

3.SOAD job description

Role responsibilities for SOADs

SOADs are expected to undertake all aspects of the role relating to Section 58, Section 58a and Supervised Community Treatment and must:

  • Interviewthe patient in private wherever possible.
  • Read the patient’s notes.
  • Read the RC’s treatment plan.
  • Talk to the RC and nursing staff.
  • Talk to a secondprofessional.

A SOAD is required to make decisions, based on their own independent judgement, taking into consideration clinical rationale, the interests of the patient, and the implementation of the Act and the Code of Practice.

Having made these decisions, the SOAD must then record their decision and the reasons for it. S/he must also report to the Care Quality Commission any issues of concern which may require a Mental Health Act Commissioner visit to the facility or other action.

Person specification – SOAD

Successful candidates will have held permanent substantive posts as consultant psychiatrists, almost certainly for at least five years. We are looking for consultants with demonstrable commitment to a rights-based approach, in-depth knowledge and experience of psychiatry in a variety of clinical settings, and considerable experience of working with detained patients. Candidates should have current or recent hands-on practice in a clinical environment, and should be up to date with current practice, both clinical and non-clinical, including measures to promote equality of service provision for all patients.

The role of SOAD is a challenging one which demands professional credibility, the ability to question decisions in a non-adversarial but firm style, and excellent negotiating and inter-personal skills. It is important to counter in practice any perception that the role is a rubber-stamping one. It will be necessary for you to be able to place decisions about medication within the wider context of treatment, and you must be able to balance the interests of the patient against the need for treatment. The ability to employ independent judgement and to justify decisions in the face of potential external pressures is essential. We are particularly interested in candidates who can demonstrate an interest in and commitment to improving the lives of detained patients. We would like to recruit more women and more candidates from BME groups as our SOAD body does not currently adequately reflect the patient population.