Thursday, 26 April 2018

Are AMHPs an Emergency Service?

AMHPs of the future?
Working as I do in an AMHP hub, where part of my job is triaging requests for assessments under the Mental Health Act, I quite often receive requests for “urgent” assessments.

One example was a community mental health nurse who had visited Geoffrey, an elderly man, at the request of his GP. The concern was that he was paranoid and possibly had dementia.

The nurse was ringing from the home of the next door neighbour, an equally elderly and frail couple, as Geoffrey lived in sheltered housing. Geoffrey had demanded to be let into their home at 7.00 in the morning, complaining that his house was being bugged. He was refusing to leave, and was presenting as distressed and agitated.

For this reason, the nurse was requesting a MHA assessment. Immediately.

I began by trying to unpick the exact nature of the crisis.

Did Geoffrey have a mental disorder? The nurse was unable to answer, as they had not been able to assess him.

Would Geoffrey agree to informal admission to hospital? The nurse had not actually asked him this.

After some more questioning, it appeared to me that the presenting problem was that Geoffrey was refusing to leave the frail neighbours’ home.

I pointed out that it would take 2-3 hours to arrange an assessment involving an AMHP and two doctors; possibly longer, if the GP, as a doctor with previous acquaintance, was going to be involved.

The assessment itself could take an hour or more, and if, after the assessment, it was concluded that Geoffrey did need to be detained in hospital, there could be a wait of, at best, several hours, but more likely several days, before a bed could be found.

Even if a bed was available, it could be several more hours before an ambulance might arrive to convey him.

In other words, the presenting problem was not something that could quickly be resolved by invoking the Mental Health Act.

I suggested that what needed to happen first was for Geoffrey to return to his home next door. Once there, the actually crisis, which was the distress being caused to his neighbours, would be resolved, and it might then be easier for the nurse to interview Geoffrey, and explore less restrictive options, such as reviewing his medication, involving a home support service, or informal admission.

But what if Geoffrey refuses to leave? the nurse wanted to know.

I suggested that as he was in the neighbours’ home without consent, then the police might be able to persuade him to leave. They could also consider use of S.136 if Geoffrey was not in a private residence.

The nurse was clearly not happy with this advice, and the conversation ended.

An hour or so later, it transpired that the police had attended and Geoffrey had returned home. The nurse had then been able to talk to him about admission to hospital, and he had agreed to this.

As the nurse had some concerns about his physical health, she called the GP out, who concluded that on reflection he probably had a urinary tract infection, and arranged for him to be admitted to a medical ward.

Oddly, the nurse had not phoned the AMHP hub back to inform us of this outcome.

The point I am making by recounting this story is that the Mental Health Act is not equipped, or indeed intended, to deal with real emergencies.

The police, fire and ambulance services are designed to respond to emergencies. In the event of a serious road traffic accident, appropriate emergency services will prioritise and endeavour to be at the scene within minutes. Once there, they have the equipment to be able to release people if they are trapped, and provide emergency treatment.

But responding to requests for MHA assessments is a much more leisurely affair.

S.136 is an certainly an emergency power, but it is firstly for the use of the police. It can be invoked in cases where the police encounter a situation where a person appears to be mentally disordered and to be in a situation of high risk.

Examples might include where someone has taken an overdose and is refusing treatment, or where they are attempting to jump off a bridge, or where they have seriously injured themselves.

For the AMHP, however, who is legally required to formally assess a patient detained under S.136, there is no such need for an instant response. However there is a deadline, as S.136 can generally only last for a maximum of 24 hours, during which time an AMHP and a doctor have to assess the patient, and make the necessary arrangements for their admission to hospital if necessary.

This is a tight schedule, and always takes top priority when notification is received, but it cannot really be described as an emergency.

S.4 is another example of emergency Mental Health Act powers, where an application is made using only one medical recommendation.

The Reference Guide states that “In exceptional cases, it may be necessary to admit patients for assessment as an emergency before obtaining a second medical recommendation.”(8.46)

In such a circumstance, the application must state that “it is of urgent necessity that the patient should be admitted and detained for assessment, and that compliance with the normal procedures would involve undesirable delay.”(8.47)

AMHPs traditionally rarely use S.4. In 36 years of practice under the MHA 1983, only 3% of assessments I have undertaken have resulted in detention under S.4, and the majority of those were in the early years of the MHA, when it was often impossible to arrange for a S.12 doctor to attend a community assessment, and assessments sometimes had to be done with only the GP.

I’ve written about some of the occasions when I have used S.4 here, here, here & here.

Of course, even if you decided to use S.4, it is still dependent on the availability of a bed, and then the availability of an ambulance to convey the patient once detained.

So, what I am getting round to saying is that a MHA assessment cannot provide a quick fix for an acute situation of risk. Even if an assessing team can arrive to assess the patient within a couple of hours, it may still take at best 4 or 5 hours more to ensure the patient is tucked up safely in a hospital. A seven hour response time would not be considered adequate for an ambulance called to a cardiac arrest, or a police officer called to a serious road traffic accident.

Unfortunately, mental health professionals, care home managers and others often seem to think that AMHPs can instantly solve their problems. An example is when the behaviour of an elderly person with dementia cannot be managed by a care home. The problem may be more to do with the person having been wrongly placed, or there being insufficient resources to manage that behaviour.

AMHPs are not an emergency service precisely because the MHA requires AMHPs to consider all options before even deciding to conduct a formal assessment. The first guiding principle for AMHP practice in the Code of Practice is to always explore the least restrictive option:

Where it is possible to treat a patient safely and lawfully without detaining them under the Act, the patient should not be detained. (1.2)

It will necessarily take time to establish this, more time to set the assessment up, and then an unpredictable length of time to arrange a bed and conveyance. If a patient is likely to come to serious harm while this process is going on, then other emergency services, such as the police or ambulance service may need to be involved.

While those services may be circumscribed by legal limitations, the police in particular have legal powers, including those under the MHA, that allow them to respond assertively to situations of high risk in a way that an AMHP cannot.

I can’t conclude this post without mentioning one more situation when the AMHP finds themselves up against a severe time limit. This is when a hospital ward rings the AMHP at 16:00 hrs on a Friday afternoon to request assessment of an inpatient under S.3, whose detention under S.2 expires at midnight.

The favourite saying of one of my AMHP colleagues is: “A lack of planning on your part, does not constitute an emergency on my part."

Referrers and AMHPs should be mindful of that.

Wednesday, 11 April 2018

The Ins and the Outs of Guardianship

S.7, guardianship, is not the most extensively used of sections in the Mental Health Act. Indeed, as you can see from the NHS Digital graphic above, new and ongoing guardianships have declined by over 50% since 2003-4.

The purpose of receiving a mentally disordered person into guardianship is for the guardian, usually the local authority, to be able to exert certain powers. These are outlined in S.8(1):

(a) the power to require the patient to reside at a place specified by the authority or person named as guardian;
(b) the power to require the patient to attend at places and times so specified for the purpose of medical treatment, occupation, education or training;
(c) the power to require access to the patient to be given, at any place where the patient is residing, to any registered medical practitioner, approved mental health
professional or other person so specified.

There are reasons, however, why guardianship is not that popular. Perhaps the main one is that these powers are not really enforceable. While S.18(3) does allow someone absent without leave to be taken into custody and returned, in practice these decisions tend to be undertaken as a best interests decision under the Mental Capacity Act. [With thanks to Richard Jones for pointing out an earlier error, which I have rectified]

Similarly, while you may be able to take someone to a day centre for “occupation, education or training”, you could not actually force that person to participate.

Another reason is that the person in question, while not needing to have mental capacity, needs to have some basic understanding of the powers of guardianship and to essentially be in agreement with it. If someone is clearly indicating by their behaviour that they are not prepared to comply with the requirements of guardianship, then the Code of Practice suggests that guardianship is probably not appropriate.

Community Treat Orders, in contrast, have far greater powers to compel treatment and residence.

In practice, guardianship tends mainly to be used for people lacking capacity, either because of dementia or learning disability.

When one reads the relevant sections of the MHA, it becomes clear that, as with S.2 & 3, a guardianship application has to be made by an AMHP (or the nearest relative) on the medical recommendation of two doctors. The doctors would complete either Form G3 (joint medical recommendation) or G4 (single medical recommendation. The AMHP would then complete Form G2, actual application.

Unlike S.2 & 3, however, this is really only the start of the process. The local authority has to decide whether or not to accept the person into guardianship. Procedures for this process vary between LA’s but will tend to require a fairly protracted process, which will commence even before the application is made.

But there is another, perhaps simpler and more streamlined way to complete guardianship.

This is tucked away in S.19. S.19(1)(a) states:

(a) a patient who is for the time being liable to be detained in a hospital by virtue of an application under this Part of this Act may be transferred to another hospital or into the guardianship of a local social services authority or of any person approved by such an authority.

The Reference Guide goes into some depth about this:

Patients may also be transferred to guardianship from detention in hospital,
with the agreement of the responsible local authority … On transfer, part 2 patients are treated as if subject to a guardianship application accepted on the day they were admitted to hospital on the basis of the application to which they were subject immediately before the transfer.( 28.141)

This also works the other way:

Patients subject to guardianship can be admitted to hospital in the same way as anyone else, without having to be detained under the Act. Likewise, they may also be detained under the Act on the basis of an application for admission under part 2 like anyone else, but there is also a specific procedure for transfer from guardianship to hospital. (28.144)

In this situation, apart from having to make the necessary arrangements with the local authority to agree to receive the person into guardianship, all that needs to be done is for the patient’s responsible clinician to complete form G6.

This reads in part:

Authority is hereby given for the transfer of [full name of patient] who is at present liable to be detained in [name and address of hospital] to the guardianship of [name, and address of proposed guardian] in accordance with the Mental Health (Hospital, Guardianship and Consent) Regulations 2008.

I only know about this because our local authority has recently been involved in a guardianship request for a patient detained under S.3 in which this transfer procedure was used. There was some nerdy excitement in the AMHP hub at this discovery.

While preliminary investigations need to be made by an AMHP, including the reasoning for the transfer, and involving other members of the local authority, this does appear to be a much smoother way of achieving the objective.

However, it's not quite so smooth in the other direction. An AMHP and two doctors would still need to assess and complete the paperwork for a S.3 if the person needed to be readmitted to hospital.