A revised Form 7—better for patient rights?

Involuntary patients have the right to ask for a hearing with a review panel if they want to challenge their certification. To do so, they (or someone on their behalf) must fill out Form 7.

Earlier this year, the Ministry of the Attorney General, together with the Ministry of Health and the Mental Health Review Board, revised Form 7, partly in response to the Community Legal Assistance Society’s report Operating in Darkness, which was critical of many aspects of the Mental Health Act and how it was implemented in practice. In May, the Mental Health Review Board announced “that after several months of consultations, our new Form 7 ‘Application for Review Panel Hearing’ has received Cabinet approval by way of an Order in Council approved on May 15, 2018.”

I had fully intended to write a post comparing Form 7 before and after the revision, highlighting the changes that help involuntary patients exercise their rights—and expressing some optimism that the ministries overseeing mental health service delivery are taking patients’ rights seriously. The form has taken some small steps in the right direction, but my first reaction after looking closely at the revised Form 7 was profound disappointment at a lost opportunity to make the form not just patent friendly but also patient empowering, which can have important therapeutic effects.

I’m not sure who was involved in the “several months of consultations,” but, having overseen a patient-oriented research project, I can almost guarantee that patients and family care partners weren’t consulted about the Form 7 revision, because the new form has quite a few obvious usability problems. I also wonder if frontline staff were consulted about how the form would fit into their workflow.

The revisions may have been intended to support patients’ rights, but what it mainly seems to do is help the staff at the Mental Health Review Board process applications. This endeavour is worthy in itself and may have positive downstream effects for patients who want timely access to a review panel, but I can’t help feeling that if the Ministry of the Attorney General had also taken the time to speak to a handful of patients, family caregivers, and nurses responsible for sending the completed form to the review board, it could have produced a much more user-friendly form that serves all parties better.

What did the revision get right?

When it comes to patient rights, the revised Form 7 does improve upon the older version in a few key ways. Here is what Form 7 looked like before the revision:

Old version of Form 7. It says, 'FORM 7, MENTAL ACT [ Section 25, R.S.B.C. 1996, c. 288 ] APPLICATION FOR A REVIEW PANEL HEARING. The information on this form is collected pursuant to section 25 of the Mental Health Act. It will be used to document and initiate your application for a review panel hearing. Any questions you have about this form may be addressed to the director or staff of this facility. To the director of [name of designated facility], I, [first and last name of applicant (please print)], request a hearing by a review panel, in the case of [first and last name of patient (please print)], [ward/unit]. [Signature of applicant], [Date of signature], [Organization (if representing an organization when making the application)], [relationship to patient], [address of organization]."
Old Form 7, last revised in 2005.
Here is the revised Form 7 (two pages):

Page 1 of Form 7. Follow the link https://www2.gov.bc.ca/assets/gov/health/forms/3507fil.pdf to get a machine-readable version.
Page 1 of the revised Form 7.
Page 2 of Form 7. Follow the link https://www2.gov.bc.ca/assets/gov/health/forms/3507fil.pdf to get a machine-readable version.
Page 2 of the revised Form 7.

Contact information for the Mental Health Review Board

Applicants used to have to fax, mail, or hand-deliver Form 7 to the Mental Health Review Board office, but the old Form 7 didn’t include a fax number or address. Emailed applications were not accepted:

Apply for Review Panel Hearing Where an involuntary patient wishes to become a voluntary patient or be discharged from hospital and his/her request to the attending physician to change his/her status has been denied, a patient may apply for a review panel hearing by filling in a Form 7: Application for Review Panel Hearing (PDF, 36KB). The application form may be obtained from hospital staff or the community mental health team. An involuntary patient is entitled to a hearing to determine whether his/her detention should be continued. Generally, a patient is eligible to apply for a hearing after the initial admission on two certificates and after each renewal of his/her certificate. The application for a review panel hearing may be made by a patient or by someone else on the patient's behalf. The application must be made in writing and signed. In order to protect a patient's privacy and ensure confidentiality, the board does not accept applications for review by e-mail. Submit the Application The completed form (Form 7: Application for Review Panel Hearing [PDF, 36KB]) should be given to the hospital staff who will then give the form to the director or designated staff member for faxing to the Mental Health Review Board office. A rights advisor or other person may deliver the patient's application directly to the board office. Where the patient is on leave, arrangements for a review panel hearing may be made through the patient's community mental health team. The form may be sent to the board office by fax or mail or by hand delivery.

(from the Mental Health Review Board’s “Review Process” page, which as of this writing hasn’t been updated to reflect the new Form 7)

The new Form 7 has not only a fax number but also an email address:

INSTRUCTIONS: Please complete this form and submit to the Mental Health Review Board: by fax: 604-660-2403 or by email: MHRBscheduling@gov.bc.ca

The Mental Health Review Board’s mailing address appears at the bottom of the page:

Please direct any inquiries to: 604-660-2325 Mental Health Review Board, #302 - 960 Quayside Drive, New Westminster BC V3M 6G2 | www.mentalhealthreviewboard.gov.bc.ca

Fields for the patient’s contact information

When an involuntary patient in hospital asks for a review panel, the Mental Health Review Board knows where they are and can easily reach them to tell them when their hearing date has been scheduled. But if people on extended leave, who are still certified but are able to live in the community, apply, the review board has to know how to get in touch with them.

The old Form 7 didn’t ask for that information, but the new Form 7 does:

Form fields for "Patient personal health number," "patient phone number," and "patient email address"

Information about legal representation

The new Form 7 has a section explaining to patients how they can get legal representation at their hearing. Checking the last option prompts the Mental Health Review Board to forward the request directly to the Mental Health Law Program. Before this addition the onus was on the patient to contact the Mental Health Law Program by phone.

Patient’s Right to Legal Representation. As the patient you may choose to: • Attend the Review Panel Hearing without a representative; Ask a family member, friend or near relative to represent you; Hire a lawyer in private practice to represent you; or Request free legal representation from the Mental Health Law Program (MHLP). If you choose this option, the Mental Health Review Board will submit your request directly to the MHLP, who will contact you to discuss the availability of an advocate at your hearing. If the MHLP is able to represent you, you understand that you consent to the release of your health records to the MHLP. For further information, please contact MHLP at 604-685-3425 or toll free 1-888-685-6222.

Fields for certification and renewal dates to help with scheduling

The Mental Health Review Board has a statutory obligation to schedule a hearing within 14 days or 28 days after receiving an application. To facilitate scheduling, please provide the following information: Patient's date of birth, Admission date, Date first Form 4 signed, Date second Form 4 signed, Date most recent Form 6 signed, Date most recent Form 6 expires

Under the Mental Health Act, an involuntary patient who is in a one-month certification period and applies for a review panel hearing must get that hearing within 14 days from when they apply. If a patient is in a three- or six-month certification period, their hearing must be within 28 days from when they apply. Asking for certification and renewal dates helps the Mental Health Review Board meet their legal requirements to give involuntary patients timely access to the review panel.

Definitions and instructions on how to fill out the form

Page 2 of the form explains what the review panel does, what it means to be on leave, and how to fill out the form. For hospital or mental health team staff, the form also explains what a case presenter is.

More Instructions for Completing this Application At a review panel hearing, a review panel makes a decision about whether or not an involuntary patient should continue to be certified. An involuntary patient may apply for a review panel hearing by completing this form. A patient or someone acting on behalf of the patient completes Part A of the form, and the patient or person acting on behalf of the patient then signs it. A patient may select one of the four options under the heading “Patient’s Right to Legal Representation.” The patient’s facility/team then completes Part B of the form. An involuntary patient may be in a designated facility (e.g., hospital) or living in the community. An involuntary patient living in the community is referred to as being on leave and must comply with treatment in the community or risk being recalled to a designated facility. * A case presenter is a health professional (usually the patient’s treating psychiatrist) who is knowledgeable about the patient’s history and condition and can give evidence and answer questions at a review panel hearing. A case presenter may be the patient’s case manager, nurse, or social worker.

What are the problems with the new Form 7?

It still uses unnecessarily complex language

The form begins:

The information on this form is collected pursuant to section 25 of the Mental Health Act. It will be used to document and initiate your application for a review panel hearing. Any questions you have about this form may be addressed to the director or staff of this facility.

Because “[Section 25, R.S.B.C. 1996, c. 288]” already appears under the title of the form, I don’t think the first sentence is necessary. It’s likely uninteresting to the users of this form—namely the patient (or applicant on the patient’s behalf), hospital or mental health team staff, and Mental Health Review Board staff.

As for the other sentences, why not use simpler language, like:

Fill out and sign this form to apply for a review panel hearing. If you have questions, ask the hospital staff or your mental health team.

The instructions are fragmented and unclear

The “More instructions” section on page 2 is poorly organized. The purpose of the review panel is pretty fundamental and should probably at the beginning of the form, and the “who does what” content in the second paragraph should be more closely linked to the instructions on the first page:

INSTRUCTIONS: Please complete this form and submit to the Mental Health Review Board: by fax: 604-660-2403 or by email: MHRBscheduling@gov.bc.ca

A naive reader who’s never been through the process of applying for a review panel might be confused about who’s responsible for sending the fax or the email, especially if they’re on extended leave.

Finally, asking applicants to flip between pages 1 and 2 to understand how to fill out the form hinders usability. I understand the need to keep form fields to a single page for faxing, but reorganizing the first page could help save some space. I’m not sure if it’s legal requirement that the request for a review panel be made as a declaration “I, [applicant name], request a hearing…” but if it’s not, moving to a more straightforward list of form fields—patient name, applicant name, signature, date—would not only be more compact but also be less confusing than the current form’s Mad Libs format. It may also make data entry easier for Mental Health Review Board staff.

The form is unclear about what information is required and what is optional

A patient in hospital may wonder why they’re being asked for their email address and phone number. And whether to provide the hospital’s phone number or their home number in the community. Someone who doesn’t trust the mental health system may be reluctant to give more personal information than needed. But the form doesn’t make it clear whether the review board will still process an application if some fields are left blank.

The form is somewhat insensitive to power differences between patients and staff

Applying for a review panel hearing isn’t just a transaction—often it’s a patient exerting agency in one of the few ways they can. The  sense of control from exercising their rights can have therapeutic effects. The old Form 7, although bare bones, puts the power in the hands of the applicant. But splitting the form between patient and staff, the revised form forces the patient to cede some of that agency to their treatment team, which can deter applications in cases where the patient doesn’t trust their treatment team.

This problem may be less pronounced in hospital, where in either case patients have to trust a nurse to fax in the application, but people on extended leave or someone on their behalf used to be able to apply directly to the Mental Health Review Board for a review panel hearing. They may still be able to do so, but the new Form 7 strongly implies that the mental health team has to fill in Part B. It is unclear about whether the review board would still process applications if patients chose to bypass their mental health teams and left Part B blank.

If the form asks staff to get involved, it should also lighten the burden on patients

The treatment team is in a better position to know the name of the facility and the ward or unit. If staff now have to fill out certification and renewal dates, they should also fill out the facility and unit name.

PART A – To Be Completed By Patient/Family/Facility/Team: To the director of [name of designated facility], [ward/unit]

Information about the Mental Health Law Program is intimidating and could possibly lead a patient astray

The last option about representation at a review panel hearing reads as follows:

Request free legal representation from the Mental Health Law Program (MHLP). If you choose this option, the Mental Health Review Board will submit your request directly to the MHLP, who will contact you to discuss the availability of an advocate at your hearing. If the MHLP is able to represent you, you understand that you consent to the release of your health records to the MHLP. For further information, please contact MHLP at 604-685-3425 or toll free 1-888-685-6222.

The last sentence might imply to some readers that they can call the number for more information about whether the Mental Health Law Program is suitable for them before they submit their application. The Mental Health Law Program may not have the resources to advise callers if they don’t have a hearing already scheduled. Calling and being turned away at reception could further dissuade a patient from exercising their rights.

The paragraph can be reformatted to be easier to digest. As an example:

If you check this box:

1. the Mental Health Review Board will send your request to the MHLP,

2. the MHLP will contact you about whether an advocate is available for your hearing, and, if so,

3. you consent to release your health records to that advocate.

The form has a few other features that I don’t have the legal expertise to comment on—like whether asking for the patient’s personal health number is a privacy concern and why both date of admission and date of first Form 4 are needed—but if I knew the full context of how the Mental Health Review Board would use this information, I’d probably be able to suggest a few other changes that could improve usability.

For example, if the Mental Health Review Board simply wants to distinguish between one-month certification periods and three- or six-month certification periods for scheduling, checkboxes offering those options would suffice—and would save a lot of space. Similarly, checkboxes for “in-patient/extended leave” and “under 16/over 16”—if these are the relevant details that the review board’s trying to get at—would be much easier for everyone involved to use and interpret. And they would make the purpose of the fields transparent.

What kills me is that so many of these very basic usability issues could have been solved by talking to a handful of people. Asking

  • one patient in hospital,
  • one person on extended leave,
  • one family care partner,
  • one nurse in hospital, and
  • one mental health team member

would have uncovered points of confusion that, when corrected, would save a lot of administrative time and help the patient feel more empowered.

Form 7 (and Form 13, the focus of our rights materials) aren’t the only Mental Health Act forms that need to be updated. If the government decides to go through the effort of changing any of the other forms, I hope they’ll speak directly to the people who use them first.

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