Monday, 18 December 2017

So you think you have what it takes to be an AMHP? The Masked AMHP’s Christmas Quiz!

The AMHP of the future?
Warning: Contains gratuitous examples of reprehensible practice.

Lots of people want to be AMHPs – they’re attracted to the glamour and status of the role, the reverence with which they’re regarded by psychiatrists, police and other professionals, not to mention the greatly enhanced salary that the role attracts.

But quite simply, not everyone is cut out to undertake this complex and demanding task.

So, despite the wishes of those who devised it, I’m exclusively revealing the top secret questionnaire that AMHP courses use, which is designed to identify those who are likely to make good AMHPs, and to exclude those who just aren’t going to make the grade.

Here are some typical scenarios that AMHPs are likely to encounter in their practice, with 4 possible answers.

You have assessed Kylie, a woman with bipolar disorder, at home, and have made the decision that she needs to be detained under the MHA. However, there is no bed. You are concerned about leaving her because of possible risks. While you’re waiting for a bed, do you:
a)    Attempt to get the Crisis Team to keep an eye on her in the meantime.
b)    Offer to put her up in your spare room.
c)     Secure her firmly to a chair with duct tape.
d)    Go home and open a bottle of wine.

You are planning to conduct an assessment of Derek at his home, but you have reason to think that he may resist and become violent. You ask the police to attend to assist, but they refuse. Do you:
a)    Obtain a warrant under S.135(1) MHA which gives a constable the power to enter the property, if needs be using force.
b)    Go to the house and call through the letterbox, offering to buy him a drink if he lets you in.
c)     Go round the back of the house with a crowbar, break in through a window and secure him firmly to a chair with duct tape.
d)    Go home and open a bottle of wine.

You have assessed Jessica at home, decide she needs to be detained, and for once there is a bed. However, Ambulance Control tell you that it will be at least 4 hours before an ambulance will arrive. Do you:
a)    Wait patiently for the ambulance, in order to ensure that she is safely dispatched to hospital
b)    Pop her in the back of your car and take her yourself, playing soothing music during the journey.
c)     Flag down a passing car, telling them you are an undercover agent, secure her in the back seat with duct tape and give instructions to the driver on how to get to the hospital.
d)    Go home and open a bottle of wine.

You’ve been called to assess Joanne, who is on a medical ward. Although there is nothing medically wrong with her, she is completely mute, so when it comes to interviewing her, she does not say anything. In order to fulfil your duty to interview in a suitable manner, do you:
a)    Explain the purpose of the interview and the importance of hearing her own views about what she would like to happen.
b)    Fluff up her pillow, get her a cup of tea and a doughnut, and stroke her hand while at the same time talking about fluffy kittens in order to get her to relax and open up.
c)     Secure her to the bed with duct tape and threaten to waterboard her if she doesn’t talk.
d)    Go home and open a bottle of wine.

Robert is detained under S.2 for assessment in a psychiatric ward, and the psychiatrist is recommending a S.3. You feel that continuing detention is justified, but the second S.12 doctor disagrees. Do you:
a)    Have an extensive discussion with both the doctors in order to reach a consensus of opinion.
b)    Take the dissenting doctor to the hospital canteen, buy them a cup of tea and a doughnut, and talk about kittens.
c)     Take the dissenting doctor into a side room, secure him to a chair with duct tape, and threaten to give him an acuphase injection unless he changes his mind.
d)    Go home and open a bottle of wine.

You’ve assessed Sylvia in hospital. She is currently detained under S.2. She has a long history of schizophrenia, and is prone to relapses, and you and the doctors have decided she needs to be detained under S.3 for treatment. However, her husband, who is the Nearest Relative, has objected to this. Do you:
a)    Decide to go to court to have him displaced as Nearest Relative.
b)    Take the husband out to a tea shop, buy him a lovely cream tea, and have a long chat with him until he changes his mind.
c)     Secure the husband to a chair with duct tape and threaten to pull his finger nails out with pliers unless he agrees.
d)    Go home and open a bottle of wine.

Donald lives a long way away, and has been removed from a train in your area and detained under S.136. He is in the S.136 suite. You have assessed him and conclude that he needs to be detained under S.2 for assessment. You contact the bed manager, who states that, as the patient is registered with a GP outside the Mental Health Trust’s area, they have no responsibility to find him a bed. The S.136 detention will run out in 6 hours. Do you:
a)    Find out where he’s from, contact the bed managers for his area, and try to get a bed in his home area.
b)    Put him up in your spare room.
c)     Break into the bed manager’s office, secure him firmly to a chair with duct tape, and suggest he finds a local bed straight away, while you wield a lump hammer in a threatening manner.
d)    Go home and open a bottle of wine.

How did you score?

Mainly A’s – You’ve definitely got what it takes to be an AMHP.
Mainly B’s – You’re a lovely person, but too lovely to be an AMHP
Mainly C’s – Erm, have you thought about a career in MI5?

Mainly D’s – You’d make a lousy AMHP, but you’re ideally suited to a job in the Conservative cabinet.

Sunday, 10 December 2017

Should GP’s be involved in MHA Assessments?

It is a disciplinary offence for a GP not to have
a stethoscope around their neck at all times
An AMHP recently emailed me about whether or not a patient’s GP should be involved when they are being assessed under the Mental Health Act. The argument among the emailer’s AMHP colleagues appeared to revolve around whether an attempt should invariably be made to contact a GP and have them involved in the assessment if at all possible, or whether doing this without consulting with the patient first would amount to a breach of confidentiality.

I’ll deal with these two issues separately.

Does contacting a patient’s GP in relation to a MHA assessment amount to a breach of patient confidentiality?

In my view, this is an absurd position to have. The Reference Guide states:

AMHPs must… be satisfied that detention in a hospital is the most appropriate way of providing the care and medical treatment the patient needs. In making that decision, AMHPs are required to consider ‘all the circumstances of the case’. In practice, that might include the past history of the patient's mental disorder, the patient’s present condition and the social, familial, and personal factors bearing on it, the other options available for supporting the patient, the wishes of the patient and the patient’s relatives and carers, and the opinion of other professionals involved in caring for the patient. (para 8.32)

The AMHP therefore has a duty to obtain as much background information as possible about a patient in preparing for a MHA assessment. The AMHP explicitly needs to consult with a wide range of people, and since a patient’s GP may know them very well, it would be ridiculous not to at least make an attempt to contact them. Indeed, it is often the GP who has initiated the request. The Code of Practice confirms: “AMHPs should also consult wherever possible with other people who have been involved with the patient’s care” (para 14.69)

It just does not make sense professionally to withhold information relating to their patient from a GP, and indeed the Code goes on to say:

Having decided whether or not to make an application for admission, AMHPs should inform the patient, giving their reasons. Subject to the normal considerations of patient confidentiality, AMHPs should also give their decision and the reasons for it to… the patient’s GP, if they were not one of the doctors involved in the assessment (14.100)

While the Code does bring up issues of confidentiality, I do not think the GP is one from whom such information should be withheld. Potential breaches of confidentiality are more likely to arise when consulting with, or obtaining information from, neighbours or other interested parties not related to the patient. In accordance with para14.100, our local AMHP Service writes to the patient’s GP to give the outcome of a MHA assessment as a matter of course.

Should GP’s be involved in MHA Assessments?

GP’s are mentioned in the Code of Practice, but only in relation to limited functions under the MHA. For example, in relation to the function of Second Opinion approved doctors (SOAD) when it suggests that a GP may be consulted in connection with a part 4A certificate (for authorising treatment). GP’s are also mentioned in para 34.12, in relation to constructing an after-care plan under the Care Programme Approach.

However, both the Reference Guide and the Code of Practice stress the importance of assessing doctors having previous knowledge of the patient in question. The Reference Guide states:

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. (para 8.40)

Para 14.73 reiterates this virtually verbatim. While this may be the patient’s community psychiatrist, their GP will of course also qualify. It does not matter if the GP has only treated them for physical ailments.

If it was the GP who referred the patient for a MHA assessment, I will try to speak with them about the reasons for the referral, and ascertain whether there may be any physical factors affecting the person’s presentation, and of course, whether the GP has referred them first to the Crisis Team or Dementia Intensive Support Team, as this would constitute less restrictive options.

If it appears there is a need to conduct a formal assessment, I will see whether or not the GP is able to take part in the assessment. If the GP has a particularly good relationship with the patient, and many do, it could be very advantageous for the GP to attend the assessment.

This, however, is where the AMHP may encounter problems. In practice, GPs are frequently unable, or unprepared, to attend an assessment. They generally have other pressing commitments, such as their surgery. However, they will often be able to provide a medical recommendation. This saves having to find two S.12 doctors to attend the actual assessment.

In my experience, GPs will generally find time to see the AMHP at their surgery and provide time to complete a medical recommendation (although as most GPs rarely get involved in providing medical recommendations, they will need help with completing the form legally.)

Involving the GP in the process certainly fulfils the Code’s recommendation to have a doctor with “previous acquaintance”. Indeed, it can perversely often be even more difficult to get the patient’s own consultant to attend the assessment, or even to provide a medical recommendation.

So it is certainly preferable to involve the GP if possible, as the alternative is the less desirable option of having two S.12 doctors who do not have previous acquaintance. Indeed, the MHA and the Code are so clear about the importance of this that if neither of the doctors had previous acquaintance, an AMHP has to give detailed reasons on their application explaining why it was not practicable.