Friday, 7 October 2016

How Can We Make the AMHP Role Manageable?

A busy AMHP Hub (all the AMHP's are out on MHA Assessments)
Andy McNicoll’s recent analysis of national AMHP shortages, published in Community Care, revealed a desperate situation across England.

The lack of adequate mental health resources, caused by year on year reductions in funding for Mental Health Trusts, has led to difficulties in finding alternatives to hospital admission, at the same time as a desperate shortage of suitable beds has meant community based services are required even more.

The role of the AMHP is therefore becoming increasingly fraught and stressful. It is hardly surprising that AMHP’s are giving up the role, especially when social worker AMHP’s are also struggling to implement the Care Act.

Para14.35 of the Code of Practice states that:
Local authorities are responsible for ensuring that sufficient AMHPs are available to carry out their roles under the Act, including assessing patients to decide whether an application for detention should be made. To fulfil their statutory duty, local authorities should have arrangements in place in their area to provide a 24-hour service that can respond to patients’ needs.

Unfortunately, “sufficient” is nowhere defined. BASW’s consultation on the Draft Code, back in 2015, observed thatWe often work on a guideline of 1 AMHP per 10,000 population. If this is thought to be a good guideline figure, it may be helpful to state this in the Code.” However, this suggestion did not make it into the final Code.

Hampshire’s total population in 2015 was around 1,350,000. If this guideline were to be applied, Hampshire would require 135 AMHPs to adequately serve the county. However, Andy McNicoll discovered that AMHP numbers had fallen to 46, while at the same time assessments had risen by 12%. Hampshire was working to build this number up to 55, which would still appear to be little more than a third of the numbers ideally required.

Northamptonshire has a population of around 694,000, but has also been losing AMHP’s, currently having only 34, even though assessments rose 19%. If BASW’s recommendation was applied, the county should have at least 94 AMHP’s.

Norfolk’s current population is approaching 900,000. There are currently around 85 AMHPs registered in Norfolk, which is actually close to the BASW’s ideal number. However, with several on long term sickness, or maternity leave, or otherwise unable to practice, the actual number of available AMHPs is less.

The 2016 National AMHP Leads Survey, presented to the AMHP Leads Conference on 19.09.16. does not use BASW’s definition of “sufficient” AMHPs, or indeed suggest another definition. This found that in reality the average number of AMHPs per 100,000 population is 5.7. This would be around half of BASW’s “ideal” number.

Whatever the definition of “sufficient” AMHPs may be, the Community Care article highlights difficulties in retention, through the stress of the role, and having to reconcile normal work commitments, such as implementing the Care Act and managing a case load, with being on an AMHP rota.

There are ways of supporting AMHPs in their role and providing incentives to continue practising. For example, some local authorities provide a financial incentive for being a practising AMHP. This may not, however, in itself be sufficient incentive to undertake the stresses of the role.

The current dire state of mental health services nationally, where there is a national shortage of suitable hospital beds, and where other services, such as the Police and Ambulance Service, are struggling to manage their core duties, makes it difficult, if not impossible at times, for AMHPs to undertake their legal duties, leading to long hours spent trying to organise arrangements for patients who have been assessed.

While the only solution to a lack of resources would appear to be more money, which is to materialise in the current climate of austerity, there are ways in which local authorities can support AMHPs and reduce the stresses of the role. This is through the way that local AMHP services are managed.

Approaches to managing an AMHP service

Nationally, there appear to be three basic approaches to running an AMHP service.

Dedicated AMHP team
This consists of a team of full time AMHPs, whose job is solely to staff the AMHP rota. With such a system, it would be possible to manage with a smaller number of dedicated full time AMHPs.

The advantages of this system are that the team members would not be encumbered with a caseload and can devote their working day to the AMHP role. It also facilitates having a shift system, which might encompass a 24 hour rota.

Disadvantages might include a deskilling of team members, using only their specialist skills and knowledge relating to mental health legislation.

A disparate AMHP rota
This system takes AMHPs from a range of social work (and/or nursing) teams, where AMHPs on duty are situated within their teams, scattered across a geographical area, and are contacted directly when requests for MHA assessments are made.

There are a number of problems associated with working in isolation and receiving requests for assessments directly. One is that you can be bombarded and overwhelmed with requests, if the system is a geographical one, and several requests relate to your specific area.

Another is that you may feel bound to deal with the referral that day, when you are on duty, even though there might be advantages in taking no immediate action.

An example might be a request to assess someone detained under Sec.5(2). This allows for up to 72 hours to assess the patient, who is an inpatient. A patient may be detained under this section when they are an informal patient who impulsively decides they want to discharge themselves.

If you receive a request and assess a patient who has just been placed on Sec.5(2), you may be assessing someone in personal crisis, whereas leaving the assessment for a day or two may give time for the patient to reconsider and decide to remain as an informal patient. So this system could lead to more people being detained under the MHA.

While there are clear disadvantages to patients with this system, there are also disadvantages for the AMHP, who may feel isolated and alone, with no-one to assist when operational problems arise. They may also be expected to accept referrals right to the end of their working day, which could mean working late into the evening.

I worked this system for many years, and our Emergency Duty Team was very strict about not accepting requests before 17:30 hrs. This meant on some occasions having to accept a referral within minutes of the end of the working day.

In my view this system carries a significant likelihood that AMHPs will burn out and decide to hand in their warrants.

Centrally managed AMHP Service
This model consists of a local authority wide AMHP service, with a central “hub”, where duty AMHP’s are based in one or two locations, depending on the geographical size of the area, and where referrals are triaged before being allocated.

This is the system we have operated in my local authority for two years. I like it. Let me tell you how it works.

Our AMHP hub consists of a team manager, who is also the County AMHP Lead. In addition, there are three full time equivalent Practice Consultants, and a business support officer to provide administrative support. The manager and the Practice Consultants are all AMHPs themselves, and take turns on the AMHP rota.

The team is based in a suite of offices based in one of the psychiatric hospitals. One of the county’s Sec.136 suites is based on the same site.

The model has a daily rota of AMHPs, taken from social work and nursing teams across the county – most are based in the central AMHP hub, in a room with the duty Practice Consultant. In addition, because of the geographical size of the county, one is based in the west of the county, and one in the east.

Duty AMHPs are expected base themselves in designated AMHP offices, with the bulk being in the AMHP hub. All the AMHPs have laptops, and there are sufficient docking stations for all the duty AMHPs to be able to log in to the central database.

The AMHP hub is a lively place, where AMHPs can support each other, share problems or practice issues, and discuss various aspects of Mental Health law. And drink coffee and eat biscuits.

Each day, there is a Practice Consultant on duty. Their job is to receive requests for Mental Health Act assessments, to triage and prioritise them, and to allocate to AMHPs if appropriate.

This is a robust and proactive job. I know, as one day a week I am the duty PC (Only one day a week, you ask? Remember, I am semi-retired, I only work two days a week, one day as a duty AMHP, and one day as a PC).

Some requests clearly require the allocation of an AMHP. These would include Sec.5(2) on a hospital ward, where an assessment has to take place within 72 hours, and Sec.136, which generally cannot be discharged without the involvement of an AMHP. Sec.136 detentions always take priority. They would also include patients detained under Sec.2, where the hospital psychiatrist wants to detain them under Sec.3, and requests relating to patients in police custody.

Some requests require more investigation before a decision is made whether or not to conduct a formal assessment. The duty PC will see what available information there might be about the person. They may ring the referrer, to establish what action has been taken prior to the request, with a focus on establishing that all less restrictive options, in accordance with the first principle of the Code of Practice, have been exhausted prior to making the referral.

Sometimes these conversations can become difficult, especially if the PC has made a decision not to accept the referral (you can see a sample in a previous blog post). But the PC needs to make sure that any request does actually require the involvement on an AMHP; the need to protect a scarce resource is important.

This system also allows the PC to prioritise requests. Often, there is no great urgency in the assessment. There may be a week or more before a Sec.2 expires, allowing plenty of time to undertake an assessment under Sec.3. A Sec.5(2) allows 72 hours to undertake an assessment. And of course, with a dire shortage of beds, even if an assessment takes place, the AMHP may not be able to complete the section papers because there is no bed.

(As a current example, I am aware at the time of writing that there are 8 dementia patients awaiting a dementia bed. There are frequent requests to assess dementia patients in care homes. How can this be treated as requiring an urgent response, if there may not be a bed available for one or two weeks?)

This system permits the service to protect AMHPs to a considerable extent. It means that fewer AMHPs have to go out at the end of their working day. It often means that referrals can be stacked and dealt with first thing the next morning, making it more likely that the assessment would be concluded within the normal working day. The duty PC is also available on the phone to offer advice and support to the AMHPs out in the field.

This system has a further advantage: the management team, with direct day to day experience of the AMHP role, are ideally suited to provide professional AMHP supervision, to ensure that AMHPs maintain their Record of Achievement in order to meet reapproval requirements, and to maintain quality control. An example of this is that it is one of the duties of PCs to sign off AMHP reports, meaning that every report is read by a PC, and any practice issues can then be identified and managed within professional supervision.

It also means that specific operational issues, such as bed shortages, issues with police and ambulance response times, etc, can be flagged up, and taken forward to higher level multi-agency meetings for resolution.

The evidence so far is that this approach can help to maintain staff morale, to provide an environment in which the AMHP role is supported and valued, to reduce “burnout” and to aid in staff retention and maintain an effective AMHP service.

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