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 actual 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 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.
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.
You appear to have been somewhat disingenuous in picking the worst example of an "urgent" MHA assessment. A nurse requesting in such a way needs speaking to closely. What you haven't addressed is when nurses or doctors made an urgent request for an acutely unwell person who is often a risk to themselves or others. Such people are often held on a wing and prayer somewhere wholly inappropriate, usually A&E. Yes the police could 136, but to what end? They need assessment and treatment rapidly, not, as often the case, a 15 hour wait for an AMHP to sort an assessment. The real world has moved on, I would suggest AMHP services have to as well, which doesn't prevent you from properly considering least restrictive options.
ReplyDeleteI am not suggesting that AMHPs do not respond to urgent requests, just that many requests that are considered urgent by the referrers are not best resolved by invoking the MHA. AMHPs do respond to situations of risk in A&E etc, and in the good old days such matters as availability of suitable beds may not have been the issue they are today. My main point is that AMHPs cannot be relied upon to sort out crises that are at least in part due to cutbacks in essential services. And I'm afraid that the 15 hour delay is most likely after the assessment , when the AMHP is pursuing non existent beds or waiting for ambulances that are gridlocked outside A&E depts.
DeleteCan a patient admitted to a medical ward under S136 then be detained on S5.2 and if yes which section has the priority over the other?
ReplyDeleteAs s.136 is a police emergency holding power, no-one can be admitted to a ward under s.136. They can be taken from one place to another, eg from a s.136 suite or a public place to A&E, but it gives no power to admit. The police could stay with them until assessed under the MHA, in which case they could then be detained under the MHA (possibly to a medical ward). I guess a s.136 patient could agree to be admitted informally to a medical wad for a medical condition, but normally in those circumstances they'd be held in A&E until a MHA assessment had taken place. S.5(2) really has no part in this.
DeleteJust come across this post today and it cross references with Mental Health Cop who inducates that AMHP’s should respond/proceed in an “emergency” situation and be prepared to do so. If evidence proves that assessment is necessary and the patient meets the criteria and that evidence indicates that compulsory detention is necessary (no alternatives) does this suggest that although AMHP’s may be fully aware that there is no bed available in there local psychiatric hospital the AMHP ought to apply to hospital managers regardles
ReplyDeleteIt's a perennial dilemma. The bottom line is that it's impossible to complete an application without the name of a hospital, and if the hospital does not have a bed, the managers would have no obligation to accept the patient.
DeleteThank you very much for your time and reply. Just venting I suppose from North Wales (where the exception has become the rule and every patient is admitted out of area) usually on the 14th day of the second med rec. There is an expectation by the health board that they have 14 days to source the bed when we as AMHP’s often request an immediate admission given unmanageable risk
ReplyDeleteAgain thank you for your time
Sorry not every patient but a significant majority. Got a bit carried away while typing and sipping my Crème de menthe. Regards NW
ReplyDelete