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
that “We 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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