"Good news -- we've opened a new ward!" |
An AMHP has a number of powers: one of the most important is
the power to make an application for detention to hospital under Sec.2, 3 &
4 of the Mental Health Act.
The trouble is, this power is meaningless if there isn’t a
hospital identified that can receive the patient.
But let’s be clear from the start: although AMHPs have
responsibility for the overall management of the assessment and subsequent
admission, AMHPs are not responsible for finding a suitable, or indeed, any
hospital bed.
This is stated unequivocally in the Code of Practice (para
14.77)
If the doctors reach the opinion that the patient needs to
be admitted to hospital, it is their responsibility to take the necessary steps
to secure a suitable hospital bed; it is not the responsibility of the AMHP.
While it goes on to say that “in
some cases, it could be agreed locally between the local authority and the
relevant NHS bodies and communicated to the AMHP that this will be done by any
AMHP involved in the assessment,” this is only subject to local agreement.
Usually, the doctor’s
duty to find a bed is delegated either to the local Crisis Team (CRHTT) or a
bed management team, both of which will be employed by the local Mental Health
Trust.
For example,
our local AMHP Service arrangements are for the AMHP to notify the relevant bed management team of the need for a bed.
There are separate bed management teams for adults and older people.
While in the past it was a matter of course that a bed was
available prior to going out to make an assessment, nowadays, it is
increasingly common for AMHP’s to be making assessments under the MHA for
people in the community where no bed has been identified at the time of the
assessment.
This is, of course, because of the huge number of
psychiatric beds that have been closed in the last 7 years. This might not have
mattered had there been a corresponding increase in community mental health
services designed to reduce the need for hospital admission, but as there has
at the same time been an actual reduction in community based front line staff,
this has resulted in an even greater need for patients to be assessed in crisis
and requiring a hospital bed as a matter of urgency.
While the AMHP is often in the firing line, and frequently
receiving flak for the failure to find a bed in an emergency, behind the scenes
the underlying cause for this appalling situation is the failure of the Clinical
Commissioning Groups (CCGs) to comprehend and fulfill their legal requirements.
CCGs were created by the notorious Health & Social Care
Act 2012. They replaced Primary Care Trusts, and are allegedly GP led.
There are three problems with CCGs:
· Firstly, GPs
are not necessarily the best people to be responsible for running an entire
local NHS service. Otherwise, they would have gone into management, rather than
being GPs. This may seem obvious to most people; but not, unfortunately to the
Coalition Government that introduced the changes.
Secondly, CCGs tend not to cover the same geographical area as the PCT’s. For example, our large geographical county used to be covered by one PCT. There are now 5 separate CCGs covering the same area, all with different local arrangements and priorities.
Thirdly, unlike the PCTs they replaced, CCGs seem to be blissfully unaware of their legal duties under the MHA.
In particular, CCGs
generally appear to be ignorant of Sec.140 MHA. As the Code of Practice points
out:
CCGs are responsible for
commissioning mental health services to meet the needs of their areas. Under
section 140 of the Act, CCGs have a duty to notify local authorities in their
areas of arrangements which are in force for the reception of patients in cases
of special urgency or the provision of appropriate accommodation or facilities
specifically designed for patients under the age of 18. The arrangements should
include details of which providers in their area can receive patients in cases
of special urgency and provide accommodation or facilities designed to be
specifically suitable for patients under the age of 18.(para14.78)
Para14.79 of the CoP additionally,
and unambiguously, states:
[NHS England]
is responsible for the commissioning of secure mental health services and other
specialist services. NHS commissioners should work with providers to ensure
that procedures are in place through which beds can be identified whenever
required.
What does this mean? Surely it
means that in emergencies, for example, when an AMHP requires a hospital bed
for a patient who has been assessed to be at intolerable risk if not detained
under the MHA, then there will be a bed available for the patient within the
area covered by the CCG.
It surely also means that when a
bed is required in these circumstances for someone under the age of 18, then a
bed should be available.
And NHS commissioners should be
able to identify secure mental health beds (and other specialist beds, such as
beds for children) “whenever required”.
But as every AMHP knows, this is
not the reality.
There are frequently long delays in
finding and providing beds for patients assessed under the MHA, and these beds
are often hundreds of miles away. Locally, we have had cases of elderly people
waiting so long for a bed to be found that the medical recommendations, which
are valid for 14 days, have expired before a bed is found, meaning that a fresh
assessment has to take place.
There is also a national shortage
of suitable beds for under 18’s. Our local MH Trust has 10 beds for young
people, but there are currently another 30 under 18’s placed in beds outside
the area.
So what can an AMHP do in such circumstances?
In extremis, our local AMHPs have come up with some
interesting solutions to the problem of assessing a patient as requiring
admission under the MHA, but having no bed to admit the patient to. This often involves
use of the Sec.136 suite.
One imaginative example was the case of a 15 year old child,
living at home, whose behaviour was totally out of his parents’ control. The
police were in attendance because of his violence and damage to property. The
AMHP and two doctors assessed, and the doctors provided a medical
recommendation for a Sec.2. There was no bed, but the AMHP felt that it was too
dangerous for the child to be left at home while a bed was sourced.
The AMHP’s solution was to arrange for the patient to be
taken to the local Sec.136 suite. While I was unsure of the precise legal authority
for this transfer, the AMHP considered that it was a case of urgent necessity
for the child to be in a safe place, and it was certainly in the child’s, and
the parents’, best interests.
This remarkably concentrated the bed managers’ minds to the
extent that a bed was found within a couple of hours, and the patient was able
to be detained.
Another AMHP found themselves in a similar situation with
another child. The child could not be left at home because of the risk factors,
but no bed was identified. On this occasion, the bed management team’s solution
to having no suitable children’s psychiatric bed was to arrange for the child
to be admitted, under section, to a children’s medical ward in the local
general hospital. Once a more appropriate bed was identified, the patient was
then transferred.
A recent blog post by Mental Health Cop posits the idea that
there may be another way of facilitating admission. His suggestion is based on
the requirement in Sec.13(1A) if an AMHP is satisfied that an application under
the MHA ought to be made, and that it is necessary and proper for the AMHP to
make it, then “he shall make the application”. This lays a legal duty on the
AMHP to make an application in these circumstances.
He then quotes at length from the biennial reports
of the Mental Health Act Commission, the predecessor of the CQC, which used to
have responsibility for overseeing the practice of the MHA. It is suggested
that “in an emergency the [AMHP] should complete the applications, making it out to a hospital specified by
the relevant health authority in the notice required to be given under Section
140 of the Act, and convey the patient
to that hospital.”
The MHAC is suggesting not just that this is an option available
to the AMHP, but that there is a legal imperative on the AMHP to take such
action.
While this may have a certain attraction to the AMHP, dealing
with a crisis situation, sitting in the home of a patient who really cannot
in all conscience be left there, in practice there are many difficulties in following
this course.
Not least of these is following guidance that relates to a
different MHA (although the MHA is still known as the 1983 Act, it was heavily
amended by the 2007 Act, which removed Approved Social Workers, at whom the
MHAC guidance was directed, and replacing them with AMHPs.).
I would certainly
be reluctant to turn up at a hospital quoting this guidance and invoking
Sec.140, expecting the hospital managers to instantly find a bed.
I am afraid that I don’t think that this is a practical
option for AMHPs to take. Ultimately, I still think the best option in such
circumstances is, whether an application is made or not, to take the patient to
the local Sec.136 suite.
In fact, just yesterday, one of our AMHPs , using a
Sec.135(1) warrant, took an elderly patient to the Sec.136 suite and informed
the bed managers that the patient would remain there until a bed was found. A
bed magically appeared within an hour.
Many thanks for the blog.
ReplyDeleteA few years back while at a conference in London far from home as the nearest relative received a phone call from a AMHP on my mobile, my son was at the local A&E and was assessed under MHA 1983 by the s12 doctor plus other doctor to which they agreed that s2 was required, problem being (my problem)was that the only available PICU bed was in Yorkshire and I live in the South West.
I refused to the bed in Yorkshire and requested that the AMHP find a MH/LD nurse at the hospital to exercise s5(4)nurse holding power while the AMHP applying the requirement of s140 on the CCG and there after speak to the bed manager of the MH trust for in-patient services. About 2 hours later my son was admitted to the local PICU. Knowledge is power.
I have been waiting since 25th August under s136,s2 now for a bed without success.Its bank holiday, nodoby is working...let.me out.There is another female in second room.The same no beds...day of waiting
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