What constitutes a formal assessment under the MHA?

An assortment of hats, some of which may or may not be AMHP hats

There are regular discussions among AMHPs as to what constitutes a formal assessment under the Mental Health Act. The main argument is along the lines of: has an assessment only taken place once an AMHP and two doctors have interviewed the patient?

Even more contentiously, I have come across AMHPs who have considered that, even if both an AMHP and two doctors have interviewed the patient, if a decision is then made not to admit the patient, it was not a real assessment, and they did not therefore have to write a report.

I am of the view that it all depends on whether or not the AMHP has their AMHP hat on at the time they are considering whether or not a particular person needs to be admitted to hospital under the Act.

Assessments under the MHA all begin at s.13(1) MHA. S.13(1) states:

If a local social services authority have reason to think that an application for admission to hospital or a guardianship application may need to be made in respect of a patient within their area, they shall make arrangements for an approved mental health professional to consider the patient’s case on their behalf.

AMHPs do not generally drive around looking for someone to detain under the MHA. All assessments begin with a formal request to assess someone with the explicit outcome of detaining them in hospital. This can come from a wide range of sources: GP’s, hospitals, community mental health professionals, the police, ambulance crews and relatives.

Once a LA has received such a request, the task of taking the request forward is delegated to an AMHP.

The crucial wording, mentioned in both s.13(1) and (4), is that the AMHP should “consider the patient’s case”. This is “with a view to making an application for his admission to hospital”.

[A slight pause here, to consider the wording of the above quote. The Act makes an assumption that not only are all patients male, but that all AMHPs are male, too. As the AMHP Workforce Review which I reviewed in January noted, 69% of AMHPs are female, and only 31% male. So it goes.]

The AMHP is acting as a free agent. The Act explicitly states that a LA cannot instruct an AMHP to make an application. It is their decision alone, and they will take into account any information they consider relevant, and indeed, conduct those enquiries whoever they see fit, taking into account the requirements of the Act.

S.13(2) makes it clear that before making any application the AMHP “shall interview the patient in a suitable manner and satisfy himself that detention in a hospital is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need.”

It is very common for AMHPs, once they have received a request, to immediately arrange for two doctors to attend an assessment. However, there is no legal requirement to convene such an assessment team as the first step.

An obvious example of where this is not necessarily indicated is a request to assess a patient detained by the police under s.136 MHA. While an assessment, involving a face to face interview with the patient, is required, s.136 only states that an AMHP and a medical practitioner must conduct that assessment. It says nothing of two medical practitioners.

Bearing in mind that only around 1 in 10 of people detained under s.136 are subsequently admitted to hospital, unless there are very clear reasons to justify involving two doctors in the assessment, for example, where the patient is well known and is known to have been deteriorating in their mental state, it is perfectly adequate, and fulfills the legal requirements, for an AMHP to only use one doctor, albeit one who is s.12 approved.

In AMHP hubs, which are managed by an experienced AMHP who triages all the requests and decides whether or not to allocate the request to an AMHP for further consideration, a few simple enquiries, including speaking to the referrer, can often result in no further action needing to be taken by an AMHP.

There are clearly situations in which an AMHP will need to convene a full assessment. Such situations include detention under s.136, a hospital detention under s.5(2), or a request for a patient already detained under s.2 MHA for assessment to be detained under s.3 for treatment.

But there are many situations where a formal request may not result in either detention, or indeed any admission. Requests from nearest relatives, while they have to be acted on, frequently do not result in convening two doctors and an AMHP to assess the patient.

There is a reason for this in the Act. As the Reference Guide points out:

AMHPs must be satisfied that detention in a hospital is the most appropriate way of providing the care and medical treatment the patient needs. In making that decision, AMHPs are required to consider ‘all the circumstances of the case’. In practice, that might include the past history of the patient's mental disorder, the patient’s present condition and the social, familial, and personal factors bearing on it, the other options available for supporting the patient, the wishes of the patient and the patient’s relatives and carers, and the opinion of other professionals involved in caring for the patient. (para8.32)

The Code of Practice goes on to say:

Before it is decided that admission to hospital is necessary, consideration must be given to whether there are alternative means of providing the care and treatment which the patient requires. This includes consideration of whether there might be other effective forms of care or treatment which the patient would be willing to accept.(para14.7)

An AMHP must always have in their mind the basic nature of their role:

to provide an independent decision about whether or not there are alternatives to detention under the Act, bringing a social perspective to bear on their decision, and taking account of the least restrictive option and maximising independence guiding principle.(para14.52)

I have always felt that I am an AMHP 24 hours a day, 7 days a week. But it all depends on whether or not I have my AMHP hat on. If I am on duty, and I am allocated a request, then I definitely have my AMHP hat on. Everything I then do in response is as an AMHP, and acting under the MHA.

In considering such a request, an AMHP may spend a several hours before reaching a decision as to whether or not to call on two doctors. They may speak to relatives, and other professionals involved with the patient. They may read case notes and reports of other AMHPs who may have assessed the patient in the past.

And of course, they may speak to, and interview the patient themselves.

Something I like to do, if at all possible, especially when I receive a request from a Crisis Team or community mental health professional, is to conduct a joint visit with a professional who knows the patient, to make an assessment as to whether or not they are likely to require admission to hospital.

Often, alternatives to admission can be found. It is also possible to reach the conclusion that as an AMHP, wearing my AMHP hat, that in any case the threshold for detention is not reached, and admission to hospital under the Act is not appropriate. That would be my decision, as an AMHP. So why would it be necessary to involve further assessment with doctors, if that decision has already been made?

It can, of course, also work the other way. When I worked within a multidisciplinary community mental health team, there were times when I would visit a service user as their social worker or care coordinator, but based on the person’s presentation, suddenly find my AMHP hat slipping on, and realising that a formal MHA assessment was going to be necessary.

So my basic argument is that when an AMHP is acting as an AMHP, in accordance with their legal duties under the MHA, those actions equate to a formal assessment under the Act, whether or not one or more doctors have been involved in that assessment, and whatever the outcome.