Thursday, 29 November 2018

The Approved Mental Health Professional Workforce Briefing

I always like some tasty statistics, and what could be tastier than the briefing on the Approved Mental Health Professional Workforce in England, which has just been published.

A brief document, amounting to no more than 5 pages, it nevertheless contains some fascinating figures (at least to me) relating to numbers and demography of AMHPs.

As 92% of local authorities responded, it is a comprehensive description of the state of AMHPs in England. For a start, it can be said with a high degree of certainty, that there are 3,900 AMHPs in England.

Despite the Mental Health Act 2007 opening the AMHP role to nurses, occupational therapists and psychologists, as well as social workers, the overwhelming majority of AMHPs are still social workers. 95% are social workers, compared to only 4.5% who are nurses. The remaining 0.5% are occupational therapists. Oh, and there is actually one clinical psychologist.

A recent post on the Masked AMHP Facebook Group enquired how many AMHPs were full time. This document identifies that 23% of AMHPs work on a full time basis, while the remainder practice on a part time basis, in conjunction with their substantive post, whether that be as a social worker or mental health nurse. This second group would tend to be on a rota, perhaps on a weekly basis.

The report notes that “overall, AMHPs are more likely to be male, older and white than the whole social worker workforce”.

For example, while 10% of social workers as a whole are under 30, only 2% of AMHPs are under 30. This doesn’t surprise me. Most people do not make a decision while still in secondary education that they want to go into social work, but tend to make this decision later in life. A typical social worker would tend to be in their mid to late 20’s by the time they train. Then they would have to have at least 2-3 years post qualification experience before they’d even be eligible to train for the AMHP role.

The majority, 68%, are aged between 30 and 54. Which means that 30% of the current AMHP workforce are aged 55 or more. This is potentially worrying, as many of those (me included) are approaching retirement age, so it could mean that there will be a shortage of AMHPs in the future, unless there is a vigorous programme of encouraging social workers, nurses, and others, to train and practice as AMHPs.

There’s also a notable discrepancy in the gender of AMHPs. While 81% of social workers are female, only 71% of AMHPs are female. Perhaps female professionals are deterred from training as AMHPs by the perception of the riskiness of the role?

There is a curious discrepancy between the numbers of white AMHPs and those from a black or minority ethnic background. While 23% of social workers are non white, this falls to only 15% of AMHPs.

There are some interesting figures relating to the length of time professionals have practiced as AMHPs. This seems to indicate that, once qualified, AMHPs tend to remain in the role. 57% of AMHPs have been in the role for 10 years or more, and 19% of AMHPs have been practicing for 20 years or more.

This is where I modestly reveal that I have been a practicing, MWO, ASW and AMHP for a total of 37 years. I honestly don’t know where the time’s gone.

There are even figures about the pay of AMHPs compared to social workers as a whole. In England, AMHPs receive an uplift in pay of 9% compared to non AMHP social workers.
There are no national policies relating to the recompense of AMHPs for the highly skilled and often arduous work that they do. While most local authorities offer extra increments or honorariums for being on an AMHP rota, there are still some that don’t.

Lyn Romeo, the Chief Social Worker for Adults, concludes the report by saying: “Detention rates are increasing and AMHPs are dealing with challenging contexts as the prevalence of mental ill health episodes are increasing.”

She goes on to say:

We know that detention rates of people from Black and Minority Ethnic backgrounds are disproportionately high, so we need to think how we can ensure that the AMHP workforce reflects the population of people we are serving.

Since the Mental Health Act Review is specifically addressing this issue, among many others, and is imminently due to present its conclusions for reform to the Prime Minister, it is to be hoped that some at least of these discrepancies can be resolved.

Wednesday, 7 November 2018

Should euthanasia be permitted for people with mental disorder? The case of Aurelia Brouwers

Aurelia Brouwers

In August 2018 the BBC published an article online about a woman in the Netherlands called Aurelia Brouwers. The full article can be found here.

Aurelia was quoted as saying:

I'm 29 years old and I've chosen to be voluntarily euthanised. I've chosen this because I have a lot of mental health issues. I suffer unbearably and hopelessly. Every breath I take is torture…

The article went on to explain that in the Netherlands euthanasia is permitted if a doctor is satisfied a patient's suffering is "unbearable with no prospect of improvement" and if there is "no reasonable alternative in the patient's situation".

Although most euthanasia candidates in the Netherlands have terminal or otherwise untreatable medical conditions, 83 people with mental health issues were subject to euthanasia in 2017. Only around 10% of requests for euthanasia from people with psychiatric conditions are approved.

Aurelia said:

When I was 12, I suffered from depression. And when I was first diagnosed, they told me I had Borderline Personality Disorder," she says. "Other diagnoses followed - attachment disorder, chronic depression, I'm chronically suicidal, I have anxiety, psychoses, and I hear voices.

The psychiatrist who approved the decision to end Aurelia’s life, Dr. Kit Vanmechelen, said:

 You must have done everything to help them diminish the symptoms of their pathology. In personality disorders a death wish isn't uncommon. If that is consistent, and they've had their personality disorder treatments, it's a death wish the same as in a cancer patient who says, 'I don't want to go on to the end.'

On 26th January 2018 she was given the poison that would kill her and took it.

Readers of this blog will know that I continue to be troubled by people with mental disorders either being allowed to die,or facilitating their deaths.

Assisted suicide, which is what euthanasia is, remains a criminal offence in the UK, so cases like Aurelia Brouwers cannot happen here. That is not to say that there are no cases of assisted suicide, but the incidence of such cases is low.

According to the Crown Prosecution Service, between 1st April 2009 and 31st January 2018, there were 138 cases referred by the police that had been recorded as assisted suicide. Of these 138 cases, 91 were not proceeded with by the CPS. 28 cases were withdrawn by the police. This is an average of only around 15 per year.

The CPS website states:

There are currently two ongoing cases. Three cases of assisted attempted suicide have been successfully prosecuted. One case of assisted suicide was charged and acquitted after trial in May 2015 and seven cases were referred onwards for prosecution for homicide or other serious crime.

One such case was that of Kevin Howe. He was a friend of Stephen Walker, who while drunk, asked him to buy him some petrol so he could set fire to himself. He duly obliged, and Stephen fulfilled his promise. Stephen did survive, but Kevin Howe was found guilty of attempted assisted suicide, and received a 12 year prison sentence.

Another case was that of Lyndsay Jones. She was an acquaintance of Philip Makinson, who was suffering from severe depression and had already tried to kill himself by cutting his wrists. She was a heroin addict, and at his request and with his consent provided him with what she knew to be a fatal dose of heroin. She was convicted of manslaughter, and received a prison sentence of 4½ years.

It is significant that both these cases involved people with mental health problems rather than terminal illness. In one of these cases, the person who “assisted” the person wishing to kill themselves did so with deliberate malice. According to the CPS, it is less likely to lead to a prosecution if the person assisting “was wholly motivated by compassion”. In these situations, this was certainly not the case.

However, there are situations in which people with mental disorder have been permitted to die, either through no action being taken to save life, or through a decision of the courts to cease lifesaving treatment.

One such, of course, is the case of Kerrie Wooltorton, which I have discussed at length in two blog posts, most recently in June 2018. Kerrie took a fatal dose of antifreeze, and because she had written an advance decision to withhold treatment, the doctors in the A&E department allowed her to die. I am thankfully not aware of any other incidences in which an advance decision has been made, or allowed to stand, for a person with mental disorder.

There have also been Court of Protection decisions relating to people with mental disorder, where a decision has been taken to cease lifesaving treatment. One, the case of C from 2015, concerned a woman with narcissistic personality disorder who did not wish to continue treatment for the effects of a serious overdose because she had “lost her sparkle” and no longer wanted to live.

There have also been two other cases, the case of X and the case of W, both of whom had anorexia nervosa, where the decision was made not to continue with forced treatment for their disorders.

There is an essential difference between a regime in which someone with mental disorder can legally be assisted to end their own life at their request, and one where it is necessary for a court to make a situation specific decision regarding whether or not to continue to provide lifesaving treatment for the consequences of a mental disorder.

With the former, there is always the risk that a clinic specialising in assisting suicide, which presumably would expect to receive payment for the service, may not be sufficiently rigorous in deciding whether or not someone has the capacity to make a decision that will end their life. Indeed, it could be possible for a rogue clinician to encourage people to die.

There are several examples of doctors and nurses who have deliberately killed their patients. A British one is of course Dr Harold Shipman. Another currently in the German courts is Niels Hoegel, a nurse who has admitted killing at least 100 patients under his care.

My basic position stands, which is that no-one who wants to end their life because of their mental disorder should be permitted to do so if it can be prevented. This is one of the basic principles that informs my practice as an AMHP. Furthermore, the resources should be in place to reduce completed suicide as much as possible.

In October 2018, Jackie Doyle-Price was appointed as Minister for suicide prevention. This was in response to the fact that suicide is now the leading cause of death in men under 45 years in age.

Unfortunately, despite the recent announcement that £2 billion is being provided for mental health services, this is not actually new money, and in view of the leaching away of funding for mental health care over the last 8 years, even if it was all spent on improving services, it would be unlikely to significantly improve suicide prevention.

The Government report, Preventing Suicide in England, published in January 2017, stated that “the latest data shows that people who have died by suicide who have been in contact with mental health services is estimated to have increased to 1,372 in 20146 from 1,329 in 2013.”

The most recent NCISH Report for 2018 into Suicide and Safety in Mental Health reported that “in England the number of patient suicides in 2016 was similar to the previous two years but the patient suicide rate fell as patient numbers increased.”

This report suggested “10 ways to improve safety” in this helpful diagram.

It is clear that current services are failing miserably to provide these essential safety strategies, and it is unlikely that the current Government, Suicide Minister or not, has the motivation or will to make a significant difference to suicide prevention.