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.
Good post. I entirely agree that it's perplexing that people try to regard 'negative' assessments as never having been assessments at all. The English dictionary probably defines an assessment as a systematic inquiry to determine an issue or ascribe a status. I often thing that the Social Work dictionary of received ideas probably define 'assessment' as something like filling in a form to grease the wheels of bureaucracy after you've made you mind up. I've spent some time lately considering cases in the Court of Protection and can attest that lawyers and judges assume the former definition is the correct one and that I've heard them genuinely shocked and blindsided by the latter definition!
ReplyDeleteSorry for the typos
ReplyDeleteSo when considering a MHAA, but standing it down as alternative options found is this a MHAA?
ReplyDeleteTo an extent it depends on the amount of work undertaken, but essentially - yes.
DeleteSometimes recording what you aren't doing is just as important as recording what you are doing. As a CFR I went out to a lady in a care home who is 97 years young. Quite a few people in the home have a DNAR form. (Do not attempt resuscitation) She had a little letter from the doctor that said something like "We have discussed with Mrs Smith whether a DNAR would be appropriate, and have decided it is not appropriate at the current time". Also very useful, and a nice way of putting the decision in writing.
ReplyDelete