Wednesday, 28 June 2017

How to Become an AMHP

The Masked AMHP's AMHP Warrant. Honest
Members of the Masked AMHP Facebook Mental Health Forum quite often ask what is entailed in becoming an Approved Mental Health Professional. I also get a number of people emailing me asking about it. Here, then, are some guidelines about the process.

Who is eligible to become an AMHP?

In order to be eligible to train as an AMHP, you have to be a qualified professional. Eligible professionals are social workers, mental health nurses, occupational therapists and clinical psychologists. Professionals will need to have at least 2 years post-qualification experience in order to be considered for training.

The Health and Care Professions Council (HCPC) is responsible for approving training courses for AMHPs. They state:

The criteria for approving AMHP programmes are designed to equip individuals with the threshold skills necessary to engage in safe and effective AMHP practice. They set out the processes and procedures that education providers delivering AMHP training must have in place, and the knowledge, understanding and skills that an individual must have when they complete their AMHP training.

AMHP training courses are almost invariably provided by universities. They may take different forms, and be of different lengths, but will generally last for between 6 and 12 months. They may be part-time, or have a combination of part-time and full-time modules. A practice placement, during which trainees are placed with AMHPs and take part in Mental Health Act assessments, is an essential and integral part of the training process.

At present, there are 20 universities and training consortia providing a total of 32 different qualifying programmes. All the courses are at postgraduate level, and the successful candidate will be awarded a range of qualifications: from a Postgraduate Certificate to a Postgraduate Diploma up to a MA or MSc degree.

How do I get onto an AMHP course?

The Code of Practice, para14.35, states that local authorities are responsible for ensuring that sufficient AMHPs are available to carry out their roles under the Act”. Your employing authority must therefore maintain an AMHP service that can fulfil their legal obligations. The local authority will therefore be responsible for paying the course fees and would have to authorise you to undertake the training. This would generally involve writing some sort of reflective piece relating to their experience and desire to train as an AMHP, as well as a formal interview involving the local authority and the academic lead of the course.

What if I don’t have a local authority prepared to give me the training?

I have to say that it is almost impossible for someone to train independently as an AMHP. 

Almost.

While nearly all courses will refuse to take an independent student, the course on which I teach did take such a student this year. They, of course, had to pay the full cost of the course out of their own pocket, and also pay for a placement with the local authority sending students to the course.

At the end of the course, unless the student was prepared to work for the local authority as an AMHP, they would not actually be approved, but would be given the necessary evidence to show a prospective employer that they have successfully completed the qualifying training.

What does the training entail?

I teach on one of these AMHP training courses, so I will describe in more detail this particular course. The course is based within the university School of Social Work.

The course is at post-graduate level, and successful candidates receive a Postgraduate Diploma and will also receive credits towards a Master’s degree.

There is an initial part-time period of occasional days in university from October to December, then a full time segment from February through to June. There is a month of intensive teaching of the law and practice relating to AMHP practice and mental health, then a two month placement period, during which the candidates are placed with AMHPs and have to shadow at least 6 MHA assessments during the course of the placement.

The AMHP trainees then have to produce a portfolio, which must include evidence supporting a range of competencies, which are stipulated in the HCPC guidance. These competencies cover seven broad areas of practice: 
  • knowledge
  • autonomous practice
  • informed decision making
  • equality and diversity,
  • communication,
  • collaborative working, and 
  • assessment and intervention.

There is also a Law Test, which consists of case studies covering a cross section of the sort of assessments that AMHPs are likely to encounter, with questions designed to elicit the AMHP’s knowledge of law and practice.

Phew! Then what?

This is not, however, the end of the process. The HCPC points out:

Successful completion of an approved programme only makes an individual eligible to be approved to act as an AMHP. Only those who have completed approved training and have been approved to act as an AMHP by a Local Social Services Authority in England may perform the functions of an AMHP.

This means that, having completed the course, the LA in which they will be practicing has a panel meeting, during which each candidate if formally approved. They will then be issued with a warrant.

In our local authority, the newly warranted AMHP is then expected to undertake three Mental Health Act Assessments, during which they will be shadowed by an experienced AMHP. They are then deemed to be fully competent to practice independently.

Thursday, 15 June 2017

The Meaning and Implications of “Previous Acquaintance” for Mental Health Act Assessments

You need two doctors when conducting MHA assessments
The use of doctors when conducting assessments under Sec.2, 3, or 4 of the Mental Health Act has to be done with care. The MHA stresses the importance of these medical practitioners either having special experience of mental disorder, or knowing the patient being assessed.

Sec.12(2) MHA states:
Of the medical recommendations given for the purposes of any such application, one shall be given by a practitioner approved … as having special experience in the diagnosis or treatment of mental disorder; and unless that practitioner has previous acquaintance with the patient, the other such recommendation shall, if practicable, be given by a registered medical practitioner who has such previous acquaintance.

The medical recommendation forms for Sections 2, 3 & 4 require doctors to state whether or not they had had "previous acquaintance". There is a pre-printed statement on these forms stating “I had previous acquaintance with the patient before I conducted that examination”. This is a default statement, which has to be crossed out if the doctor has not had previous acquaintance.

The Code of Practice expands a little on the issue of previous acquaintance:
14.73 Where practicable, at least one of the medical recommendations must be provided by a doctor with previous acquaintance with the patient. Preferably, this should be a doctor who has personally treated the patient. It is sufficient for the doctor to have had some previous knowledge of the patient’s case.
14.74 It is preferable that a doctor who does not have previous acquaintance with the patient be approved under section 12 of the Act. The Act requires that at least one of the doctors must be so approved.

The intention of the MHA is that the ideal assessing team would consist of the patient’s GP, who would be intimately acquainted with the patient, but who probably would not also be Sec.12 approved, and a Sec.12 doctor, who is likely to be a psychiatrist, but who may not have previously had contact with the patient.

However, in my experience, it is increasingly difficult to get a patient’s GP to attend a MHA assessment, whether in the community or in a hospital, as they are invariably too busy and understandably unwilling to abandon their surgery for what could be a protracted assessment process.

This increasingly means that the AMHP has to use two Sec.12 doctors. The AMHP may be fortunate if one of these has had previous acquaintance with the patient.

All of this raises two issues: what is meant by the term “previous acquaintance”, and what are the consequences of using two doctors, when neither of them have had “previous acquaintance”?

The AMHP’s application forms for Sec.2 & 3 has a statement saying:
If neither of the medical practitioners had previous acquaintance with the patient before making their recommendations, please explain why you could not get a recommendation from a medical practitioner who did have previous acquaintance with the patient.

If this is the case, then the AMHP must write a detailed explanation on the form justifying this omission.

The Reference Guide says this about previous acquaintance, which is the closest any of the guidance comes to giving a definition of “previous acquaintance”:
At least one of the doctors should, if practicable, have had previous acquaintance with the patient. Preferably, this doctor should have treated the patient personally, but case law has established that previous acquaintance need not involve personal acquaintance, provided the doctor in question has some knowledge of the patient and is not ‘coming to them cold’.(para. 8.40)

In fact, the Reference Guide likes this statement so much that it is repeated word for word later on, in para 28.41.

Ann R (By her Litigation Friend Joan T) v Bronglais Hospital Pembrokeshire and Derwen NHS Trust [2001] EWHC Admin 792 is perhaps the case law to which this is referring.

In this case, Ann R was a new patient to the GP in question. He had attended a meeting relating to the patient (but not relating to her mental health), had visited her for 5 minutes, and had scanned, but not read her medical notes. The Judge in the case held that prior “personal” acquaintance was not required. The GP had some knowledge of her background prior to the MHA assessment, and this was deemed to be all that was required.

In another case, TTM v LB Hackney [2010] EWHC 1349 (Admin), TTM attempted, among other things, to declare that their detention under Sec.3 MHA was unlawful on the grounds that neither doctor had “previous acquaintance” with the patient.

This was based on the fact that two doctors without “previous acquaintance” had provided the recommendations, even though doctors who knew the patient  were available. It was argued that external doctors were chosen because there was a division of opinion in the treating team. The court concluded that this was reasonable and took into account what was in the patient’s best interests, and therefore there was no breach of Sec.12(2). 

Not satisfied with the overall judgment, TTM took the case to the Court of Appeal (TTM (by his litigation friend TM v (1) London Borough of Hackney; (2) East London NHS Foundation Trust; (3) Secretary of State for Health [2011] EWCA Civ 4)

While the Court of Appeal upheld much of the patient’s case, they still concluded that there was no Sec.12(2) breach on the grounds that it had been reasonable to obtain two external opinions given the divergence of views between the treating doctors.

To summarise: there is no requirement for a doctor to have detailed knowledge of a patient in order to establish “previous acquaintance”.  It is enough to have had brief contact, perhaps in connection with a medical examination for an ear infection some years ago, or even a telephone conversation with the patient. Indeed, it is enough simply to have read the patient’s medical notes.

There are a number of valid circumstances in which an assessment can legitimately take place without a doctor with previous acquaintance. One example is an assessment I undertook just a few days ago. The police detained a man under Sec.136 following reports that he was knocking on neighbours’ doors and attempting to enter properties in the middle of the night.

The police were unable to use a Sec.136 suite in the patient’s locality as a place of safety, as the local one was occupied. They therefore took him to a place of safety elsewhere in the county 30 miles away.

It was impracticable for the GP  to attend because of the distance involved, and as the patient had had no previous involvement of any sort with secondary mental health services, there wasn’t a psychiatrist with previous acquaintance. I therefore used two local Sec.12 doctors to conduct the MHA assessment.

A similar situation may also occur when someone is detained under Sec.136 while elsewhere in the country, and where a patient requires assessment under the MHA in the middle of the night, it is very common for there to be no doctor available who knows the patient.

So it is just as well that there are justifications to the use of two doctors without previous acquaintance, otherwise the AMHP’s local authority could be liable to pay compensation for unlawful imprisonment.