opinion & debate Psychiatric Bulletin (2003), 27,364^366 PETER WEBSTER, ULRIKE SCHMIDT AND JANET TREASURE ‘Reforming the Mental Health Act’: implications of the Government’s white paper for the management of patients with eating disorders Patients with severe anorexia nervosa have a high mortality and relapse rate, yet specialist services and practitioners are few. A signifi- cant minority need detention with involuntary treatment. Furthermore, the mean age at presentation is 16 years, where detention under the Mental Health Act 1983 or parental consent is unclear and variable. This article addresses the implications of the proposed new Mental Health Act for people with eating disorders. The main issues are those of incapacity, assessment procedures, community detention, detention in 16 -18-year- olds, implications for carers and resource implications.We hope to show that eating disorders, just like other illness categories, have special needs that cannot be blanketed under one process and that the Act has positive features, but also presents significant concerns. The Mental Health Act 1983 and eating disorders Anorexia nervosa has the highest mortality of any psychiatric disorder, being in the order of 15% over 20 years (Sullivan, 1995). Despite this, clarification that feeding someone against their will is lawful under the Mental Health Act 1983 only occurred in 1997 (Mental Health Act Commission, 1997). More recently, this policy has been deemed consistent with the Human Rights Act 1998 (Radcliffes solicitors, 2000). Children aged under 16 years have usually been treated under parental consent, but controversy exists over the 16- 18-year-old group. New aspects of the white paper It is the first part of the white paper ‘The New Legal Framework’ that is most relevant to eating disorders. The key changes in the Act can be summarised as there being a broadening of definitional criteria for detention, a common assessment pathway for detention for all disor- ders including a 28-day tribunal, the introduction of powers of community detention, altering detention and representation rights of children and increasing access to independent representation for all patients under detention (Department of Health, 2000a). The Royal College of Psychiatrists has reacted strongly regarding a number of areas including the broadness of definitional criteria, the reduction of medical supervision and resource implications (Royal College of Psychiatrists, 2001). We will examine how these issues are relevant to eating disorders in the context of how the new Act is structured. The common criteria for mental illness and phases of assessment The white paper proposes a broader definition of mental disorder matched by clearly-set limits on the circum- stances appropriate for detention. In contrast to other patient populations (Royal College of Psychiatrists, 2001), diagnostics are reasonably straightforward in eating disorders and the new broadened definition of mental disorder does not cause undue concerns in the field of eating disorders. Re-feeding is always the main treatment with severe cases of anorexia nervosa. Criteria for admission/detention are not formalised, but focus on severe medical or psychiatric risk or failure of community treatment (Szmukler et al , 1995). Thus, the first step of the assessment process is relatively uncontroversial, with one exception that centres on the issue of capacity. Assessment of capacity is recommended but not formalised in the new Act. The Law Commission identified incapacity being present if a person is suffering from disorder of the mind and brain resulting in impaired ability to retain and/or understand a decision and to reason rationally so as to make a balanced decision based on that information (Mental Incapacity Act: Law Commission 1995). Treatment may be provided under common law if it is in the patient’s best interest and/or in order to save life or ensure improvement/prevent deterioration in health, while being in line with current opinion. In severe anorexia nervosa, capacity can be compromised in all areas due to Webster et al Management of patients with eating disorders 364