Reminiscences of an out-of-hours social worker #1: Angela

 

While I was a social worker by day, between 1983 and 1997 I also worked one or two shifts a week on the out-of-hours standby duty team. This team, consisting mainly of daytime social workers, dealt exclusively with emergencies and crises that arose outside normal working hours. We covered nights, weekends, and Bank Holidays.

Out of hours, two social workers covered the entire county. It was a large geographical area of over 2,000 square miles, and it could entail a journey of 40 or 50 miles to reach the far ends.

 In the early years, the only means of contacting us was via a pager. If your pager went off, you had to contact a deputising service which then told you what the problem was.

 For several years, the only way of contacting the deputising service if you were out on a call was using a public phone box. You got to know the locations of all the phone boxes in the county, and always had to make sure that you had a pocket full of change.

 We dealt with everything. This covered all the service user groups: children and families, young offenders, older people and people with physical disabilities, as well as people with mental health problems and learning disability. We dealt with anything from child protection referrals, to assessments under the Mental Health Act, and obtaining night sitters or emergency residential care for elderly people.

 For some reason, teenage girls often seemed to present the most intractable problems. I’ll tell you about Angela.

Section 2 or Section 3?

 

The difference between section 2 & section 3, and when it can be *complicated* to decide which one to use. Good for CPD.

Section 2 and Section 3 are the sections of the Mental Health Act that are most commonly used when compulsory detention in hospital is being considered.

Section 2 lasts for 28 days, and its main purpose is to assess a patient in hospital (although it does also permit treatment). Section 3 lasts for a maximum of 6 months, and is for the purpose of providing treatment in hospital. (The recent Mental Health Act review is, however, recommending that this duration should be reduced to 3 months.)

Statistics show a year on year increase in the use of compulsory detention. In the year 2019-20 there were a total of 27,968 admissions under S.2, and 4,043 detentions under S.3.

This video explores some examples of situations in which the choice between which section to use becomes somewhat complicated.

Section 136: A Brief History

 

Section 136 is the only section of the Mental Health Act that does not, at least initially, involve a doctor or an AMHP. It gives a police officer the power the remove someone they believe may be suffering from mental disorder to a place of safety. The purpose of this is explicitly to facilitate the formal assessment of the person by a doctor and an AMHP.

This is how it is currently, and is very familiar to the police and AMHPs.

The official figures for use of section 136 in the year ending April 2020 is 18,665, although the data is incomplete, so it is likely to be higher. This means that on average the power is used over 50 times a day.

You might think that this section was drafted to reflect modern day policing, but in fact Section 136 has a very long history, with origins in Victorian responses to mental illness and poverty.

The Lunatic Asylums Act 1853, for instance, has a section 68. This states:

Every Constable of any Parish or Place...who shall have knowledge that any Person wandering at large within such Parish or Place.… is deemed to be a Lunatic, shall immediately apprehend and take or cause such person to be apprehended and taken before a Justice.

The Lunacy Act 1890 contains similar wording:

Every constable who shall have knowledge that any person wandering at large is deemed to be a lunatic shall immediately apprehend and take or cause such person to be apprehended and taken before a justice.

This remained pretty much the position with regard to dealing with mentally disordered people in public places until the Mental Health Act 1959.

Since the 1890 Lunacy Act, there had been a revolution in the care and treatment of people with mental disorders. The responsibility for assessment was removed from the judiciary and a more humanitarian approach was taken, which involved assessment by a Mental Welfare Officer, who was the forerunner to the Approved Mental Health Professional.

Section 136 of the 1959 Mental Health Act now stated:

If a constable finds in a place to which the public have access a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons, remove that person to a place of safety.

Interestingly, the Mental Health Act 1983 left the wording entirely unchanged. In fact, curiously, although the sections relating to detention all changed – for example, section 25 of the 1959 Act relating to compulsory assessment in hospital became section 2, and section 26 relating to compulsory treatment in hospital became section 3, section 136 remained the same.

There was a widespread belief among Approved Social Workers, as Mental Welfare Officers became, that this was because the police would not be able to remember a new section number, but I am sure this is untrue.

The Mental Health Act 2007, which amended the 1983 Act and replaced approved Social Workers with Approved Mental Health Professionals, did not address section 136.

It wasn’t until the Policing and Crime Act amended section 136 in December 2017 that there was any further change to the wording.

At first glance, the wording does not appear greatly different. Section 136(1) now reads:

If a person appears to a constable to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons... remove the person to a place of safety.

In fact, there was a crucial change to the police power, as, after more than 150 years, there was no longer a requirement that the mentally disordered person had to be in “a place to which the public have access”. Section 136(1A) now says that the power may be exercised “at any place” other than the person’s own home and private property.

The other major change to section 136 was, of course, reducing the length of time that detention in a place of safety for assessment could last. Since 1959, the maximum time was 72 hours; now, reflecting changes in attitudes towards the human rights of mentally disordered people, the maximum length of time has been reduced to 24 hours.

What constitutes a formal assessment under the Mental Health Act?

 

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). This 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 local authority 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 “consider the patient’s case”. This is “with a view to making an application for his admission to hospital”.

[By the way, the Act makes an assumption that not only are all patients male, but that all AMHPs are male, too. As the AMHP Workforce Review for2019 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 local authority cannot instruct an AMHP to make an application. It is their decision alone, but they will take into account any information they consider relevant, and indeed, conduct those enquiries whoever they see fit, in accordance with 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. While an assessment, involving some sort of face to face interview with the patient in accordance with social distancing guidelines, is required, s.136 only states that an AMHP and one 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 clearly relapsing, it is perfectly adequate, and fulfils 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 something as basic as speaking to the referrer, can often result in no further action needing to be taken by an AMHP.

There are clear 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 detention, and may not involve an 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 arealternatives 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 always felt that I was an AMHP 24 hours a day, 7 days a week. 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 Act.

In considering such a request, an AMHP may spend 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, 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 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 Mental Health Act, 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.