Tuesday, 29 April 2014

Ask the AMHP – a new occasional column

Ask The Masked AMHP for the answers to your thorny MHA related problems. He might know the answer. Or not.

Here’s a question I recently received from a rather stressed and anxious AMHP (but then they all are, aren’t they?)

I’ve got 2 medical recommendations for Sec.3 on a patient who is in the medical assessment unit of our local hospital, but lives outside our area. The other area is currently trying to find a bed. Can I complete this application?

The Masked AMHP replies:

No, I’m afraid you can’t. You have to have the name and address of a hospital prepared to take the patient on your application form before you can sign it and therefore complete the application. But it’s even worse – your two doctors can’t make a recommendation for Sec.3 unless they can state the name of a hospital where appropriate treatment can be provided. And if they start giving a very long list of possible hospitals, in the hope that one of them might become available for the patient, that sort of defeats the object of suitable treatment being available.

The only thing I can suggest is that your two doctors make a recommendation for Sec.2. then they won’t have to name a hospital, and they can then leave. Since your patient is actually currently an inpatient on a general ward, you could see if you can detain the patient on that ward under Sec.2. You can then complete your application and the patient will be formally detained. The patient can then be transferred under the usual transfer arrangements once the other area has found a bed.

Here’s a question I had emailed to me by a student AMHP.

I am a student AMHP and a recent dilemma in the office has prompted me to write to you. If a person is on a CTO and the conditions of this are that they receive treatment in supported living should the living cost ie rent be paid through S117, local policy says not but I wanted to check.

Also, the local policy says that the person does not legally have to accept the S117 aftercare, however how does this fit in with aftercare that is a requirement of the CTO?

The Masked AMHP replies:

There is quite a bit of case law about S117 and housing costs, which I have covered on my blog. Normal living expenses, eg food, electricity, housing, are universal needs and are not arising from a mental health need. Therefore they are not covered by S117.

If the S117 aftercare is explicitly covered by the conditions of the CTO, eg that the patient resides in a certain place, then a failure to do so breaches his CTO. In such a situation, the patient would have to accept S117 aftercare.

Here’s a question from the blog:

Have you ever known a situation where one doctor disagrees and will not furnish a recommendation so a third doctor is sought in order to detain?

The Masked AMHP replies:

I have certainly had situations where one doctor has furnished a recommendation, but a second Sec.12 doctor has disagreed and refused. This is not uncommon for someone who is an inpatient, and the hospital Responsible Clinician has left a medical recommendation on the ward. I have to say that in these situations, I have been satisfied to go along with this and not therefore proceed with an application. However, theoretically, if as an AMHP you feel the dissenting doctor is acting perversely, and you are very concerned about risks to the patient if they are not detained, I do not regard it an unethical of obtain a further medical opinion. However, there’d have to be a limit to the number of doctors you could consult.

And here’s a final question from another stressed and anxious AMHP:

I’ve got a 16 year old girl on a Sec.2 in a private hospital. We do not feel she needs to be in hospital, and we have arranged for an alternative placement. The Community Responsible Clinician backs this plan. However, the hospital Responsible Clinician refuses to discharge her from hospital, and will not discharge the Sec.2. What can we do?

The Masked AMHP replies:

Crumbs! What a peculiar situation. The hospital RC has the final say in this, regardless of what the community RC thinks, and even if the community RC provided one of the recommendations. The patient can appeal against the decision, and as it’s a Sec.2 the Tribunal would generally be within 3 working days. In the meantime, you as the AMHP could make it clear that you would be recommending discharge, which might concentrate the mind of the hospital RC.

Keep your questions coming in! The Masked AMHP is always happy to try to assist.

Sunday, 6 April 2014

The Masked AMHP is Retiring…Sort Of

It’s true. After nearly 40 years as a social worker, and 33 years as a Mental Welfare Officer, approved Social worker, and approved Mental Health Professional, I am officially retiring.

I’ve seen a lot of changes in social work, and mental health service provision, over that time. In 1974, only two years before I started work as an unqualified social worker in 1976 (it was unusual then for social workers to be qualified), there had been a huge national reorganisation of social care provision, precipitated by the Local Authority Social Services Act 1970. This in turn had been inspired by the Seebohm Report, published in July 1968, which had proposed the integration of disparate social care services into single, generic departments overseen by local authority social services departments.

Until then, social care had been administered in a range of guises. For example, mental health had Mental Welfare Officers, defined by the Mental Health Act 1959. Services for children and families had Children’s Officers. Hospital social work was done by Hospital Almoners. In 1974, all these people were moved into these generic departments, and all became known as “social workers”.

The idea was that all social workers would have generic caseloads. This was an admirable aim.

Imagine a hypothetical family. Sid and Nancy are in their 30’s. They both met while inpatients in a psychiatric hospital. They have two children, Nora, aged 3, and Dora, aged 8. Dora has severe learning difficulties. Also living in the family home is Nancy’s elderly mother, Edna, who suffers from severe arthritis and the early signs of dementia.

Prior to the Seebohm changes, 3 or 4 social care workers could be involved with the family. But when I started as a social worker, one person would work with them all.

I liked this idea back then. I was all for the ideal of a social worker working across all the different client groups (people involved with social services were known as “clients”). But in practice it was more difficult. For a start, you had to have a working knowledge of all the relevant legislation, ranging from the National Assistance Act 1948, through to the Chronically Sick and Disabled Persons Act 1970, the Children and Young Persons Act 1969, the Children act 1975, and the Mental Health Act 1959.

It was actually impossible to be equally competent in working with children and families, juvenile offenders, older people, and people with physical disability, learning difficulties and mental illness. In practice, social workers in the team tended to specialise in areas of particular interest. This meant that for over 10 years I had a mixed caseload consisting of child protection work, young offenders, children in care, and mental health.

Over time, I became increasingly interested in mental health and the Mental Health Act 1983, when it replaced the 1959 Act in 1984 (26th September 1984 to be exact). And when my local authority decided to divide social workers into specialist teams in the late 1980’s, I opted to join the mental health social work team.

This coincided with the creation of new fangled multidisciplinary community mental health teams (CMHT’s), where a team consisting of a consultant psychiatrist, a clinical psychologist, an occupational therapist, community psychiatric nurses and mental health social workers all worked together out of a single office base in the community.

I joined such a team, and worked happily in this multidisciplinary way until our local Mental Health Trust abolished locality based teams in 2013. Did this have anything to do with my decision to retire? I couldn’t possibly comment.

There have been enormous changes over the time I have worked as a mental health social worker. Thatcher’s Government introduced the purchaser/provider split in social care provision in the early 1990’s, the practical result of which was to make many social workers little more than contractors for external, private services.

The ideal of mental health service provision based in a single local community centre rather than in mental hospitals survived for many years. It seemed like an efficient and patient/service user centred approach. Our local psychiatric wards generally ran with something like 80% or less occupancy. Our enthusiastic integrated team kept people out of hospital.

But innovations in this model, while on the face of it appearing to be all for the good, in practice had a different effect. These were the Crisis Resolution and Home Treatment Teams, the Early Intervention Teams, and the Assertive Outreach Teams. There were unintended consequences to the creation of such teams. One was that professionals with the greatest expertise tended to join these bright and shiny teams, leaving the CMHT’s with fewer and often less experienced staff.

In our local area, the strong and experienced inpatient nurse team was decimated, as their most experienced staff joined the CRHTT. This had a significant detrimental effect on the ability of ward staff to effectively treat and discharge inpatients.

When new teams set up in Primary Care under the Improving Access to Psychological Therapies initiative were created, our CMHT lost almost half of its most experienced staff to the new service. But IAPT somehow did not have the desired effect of reducing the bombardment rate of referrals to the CMHT.

The other problem with all these new teams was that each had their own gatekeeping requirements. It was often very difficult to get these teams to accept patients from the CMHT’s. Consequently, they had protected and limited caseloads, while the CMHT’s continued to have to take everything thrown at them.

However, throughout this time, it did at least mean that more money was being spent on mental health. Until the radical redesign of the NHS in 2013 and the creation of the Community Care Groups.

Mental health services are now suffering the effects of concealed and not so concealed cuts to funding, both in the NHS in general and in mental health in particular. I still feel uncomfortably clammy when considering the concepts of “clustering” and “payment by results”: harbingers of privatisation, the final dismantling of a joined up mental health service. And of course the savage cuts in benefits for the poor and disabled are having a drastic effect on mental health service users, creating even more demand for a shrinking service.

So I have now decided to retire. But…

It does not mean that I will be spending all my time digging the garden, or reading the Guardian and growing ear hair.

It certainly doesn’t mean I will no longer be an AMHP, masked or not. (By the way, since my identity is no longer very much of a secret, do you think I should now rename myself The Naked AMHP?)

In fact, although I will cease to be a care coordinator, and will no longer have to wrestle with personal budgets and direct payments, I will continue to work as a duty AMHP for a couple of days a week, a role I continue to find worthwhile.

And it doesn’t mean that I’ll stop writing The Masked AMHP blog, or stop running the Masked AMHP Facebook Group (which now has over 1200 members!) or close down The Masked AMHP Twitter account.

But it will free me up to develop other interests. I am an elected member of the steering committee of the Mental Health Faculty of The School of Social Work. I will have more time to attend committee meetings and to work on initiatives designed to protect and enhance the social work and the mental health social work role.

Some will have seen me at AMHP and social work conferences around the country in the last year or so. I will have more time to provide training sessions on a freelance basis. So, if you would like the Masked AMHP to enhance your AMHP or other mental health conference with a personal appearance and presentations on a wide range of topics relating to mental health law and practice – from a practitioner’s perspective – then please contact me via my email or Twitter account.

And maybe, just maybe, if there’s any interest, I might also have time to write a book or two.