Valued beyond doubt

Approved social workers’ skills will
remain essential, regardless of any changes in mental health
legislation, argues Mental Health Act Commission chairperson
Margaret Clayton.

A lot has been written recently, in
Community Care and elsewhere, about the extent to which
social workers are undervalued. But in mental health work their
value is beyond doubt.

Mental Health Act commissioners work to a
two-year cycle involving at least three visits to every trust and
registered mental health nursing home in England and Wales that
holds detained mental health patients. During the visits the
commissioners interview or meet large numbers of patients (more
than 22,000 between April 1999 and March 2001), as well as talking
to consultants, doctors, nurses and other professionals concerned
with in-patient care. At least once in each cycle, local social
services departments are also visited, either jointly with a
hospital or home or in a special visit to social services.

The message that comes through from these
visits is that the role of the approved social worker (ASW) in the
care of patients with acute mental illness is crucial. Almost
without exception, case notes, interviews, and discussions with
users and carers demonstrate that the early and continuing
involvement of a skilled and committed ASW can make all the
difference between a patient being caught up in a revolving door of
short periods in the community interspersed with enforced stays in
acute units, or being able to lead a less restricted life with only
a rare need for in-patient care. Other agencies and professionals
frequently express to commissioners their admiration for the
quality and commitment of ASWs.

The commission’s latest biennial
report¹ draws attention to the specific role of the ASW
in the processes of detention and discharge under the Mental Health
Act 1983. This is not to undervalue the part played by other social
workers who may be part of the multi-disciplinary care team, but to
highlight that the ASW is key to the following tasks under the
act.

– Emergency admissions under section four of
the act.

– The outcome of detention under section 136
of the act.

– The granting of authorised leave under
section 17.

– Arrangements for after care under section
117.

In part of the report dealing specifically
with ASW issues, we made it clear that the ASW role provides a
valuable safeguard against unnecessary admission by bringing a
balancing non-medical view of the best interests of the patient and
the need to use the least restrictive alternative available to
provide care. The ASW is likely to have a greater awareness of the
social context of the patient, particularly if there has been
contact with the nearest relative, and will have a wider knowledge
of the whole range of community facilities. We also said
unequivocally that ASWs play a vital role in the administration of
the act and that if an equivalent role in new legislation is to be
undertaken by a wider professional group the government should
consider carefully how the benefits provided by ASWs may be
protected.

Crucially, whether or not the often mentally
ill and confused people who are brought to a place of safety under
section 136 of the act end up before the courts, are detained in an
acute hospital, or able to be properly cared for elsewhere depends
on the local knowledge and commitment of ASWs. All too often,
police officers who know that someone is in need of care charge
them with a minor offence merely in order to be able to keep them
in comparative safety overnight. This is especially true if the
doctor called in to examine them does not think they warrant
admission under the 1983 act. The assumption is then sometimes made
that it is not necessary to call in an ASW but that the person
concerned must either be released or charged. (Ideally, of course,
the doctor and the ASW will have attended together and made a joint
assessment, but this is not always done.)

The commission has frequently been approached
on this for advice. In the report, we state clearly our view that
if, on examination, a doctor concludes that someone is suffering
from a mental disorder as defined in section 1 (2) of the act,
whether or not this would be of a nature or degree sufficient to
justify detention, the person concerned should continue to be
detained in the place of safety until an ASW has attended and a
decision has been reached on arrangements for further care or
treatment. We hope that this clear statement will help to ensure
that ASWs have an early opportunity to prevent many people from
getting into the downward spiral of either a succession of alleged
petty offences or a life in and out of psychiatric hospitals.

ASWs may well be asking how we think they are
going to take on even more people when they already have heavy
caseloads and plenty of crises. This is, of course, a real
concern.

Some of their burden could be reduced if the
commission’s intention to pay close attention to the operation of
section 136 over the next two years has any effect. We stress in
particular the fact that the act includes in places of safety “a
mental nursing home or residential home for mentally disordered
persons or other suitable place.” Joint approaches to hospital and
social care provision may in future make more such places
available, so perhaps making it easier for ASWs to attend and to
find greater co-operation in finding alternative provision for the
people concerned. We hope that our recommendations for increasing
the number of doctors approved under section 12 of the Mental
Health Act may also reduce the amount of time spent by ASWs in
trying to secure their attendance.

Whether detention under the act is a result of
a criminal or civil process, the likelihood of a detained person
having much chance of resuming life without frequent returns to
hospital is, again, very dependent on the contribution of the ASW
to the multi-disciplinary team responsible for care planning.
Commissioners on visits regularly ask to see a sample of ASW
reports and are impressed by the quality and depth of most of them.
One of our explicit recommendations is that greater use should be
made of the checklist that the commission provides for the issues
which are to be covered. We have frequently been told that these
provide an invaluable guide to all practitioners about the
patient’s background, likely problems, needs, and possible sources
of help and support. A good report can be used as the starting
point for the care programme and for beginning to plan discharge
arrangements from the outset.

Another crucial role that the ASW – or other
social workers who become involved – can play is in ensuring that
patients are not granted authorised leave unless robust
arrangements are in place for their care outside the acute unit. An
unexpected finding in our recent survey of unnatural deaths of
detained patients was that one in five suicides occurs while the
patient is on authorised leave. If even one life could be saved by
the involvement of a social worker in multi-disciplinary
consultation before leave is granted, this would be time well
spent. Unfortunately, leave is often granted without such an input.
This is another point on which we make a strong recommendation for
better practice.

Much more could be said about the skills and
knowledge of ASWs in the humane implementation of the act, but I
hope this highlights why we wanted to add something to the debate
about value. Whatever terminology may be used in the government’s
proposed legislation to reform the Mental Health Act, we believe
that it is essential that the functions of the ASW continue to be
fulfilled. If the ASW or an equivalent person with the same level
of skills, knowledge and understanding of the whole range of
community facilities is not involved, the revolving doors will
either go so fast that people will be crushed by them or they will
halt at the point which no one can escape.

Margaret Clayton is chairperson of the
Mental Health Act Commission.

References

¹ Mental Health Act
Commission, Mental Health Act Commission:9^th
Biennial Report, 1999-2001, The Stationary Office,
2001