The dilemmas faced by Devon’s approved mental health professionals (AMHPs) and their senior managers two years ago will be familiar to many frontline practitioners.
“It felt like AMHPs were stretched so tight. People were worn out and some good people were leaving. In that situation you have to be brave and create capacity”
Recruiting AMHPs was proving tricky. In the face of unfilled vacancies, teams were left with little option but to use agency staff to plug gaps in rotas. Some social workers that had taken jobs on the understanding they would train as AMHPs later decided they were unwilling to.
Staff retention was also an issue as staff felt the stress of juggling caseloads and statutory Mental Health Act duties. Some social workers felt isolated in medically-dominated NHS teams. Far from unique to Devon, these concerns have been – and still are – reported by AMHPs in many areas across England and Wales.
“It felt like individuals were stretched so tight. People were worn out and some good people were leaving. In that situation you have to be brave and create capacity. That was really the starting point in our own thinking,” explains Robert Lewis, the practice manager at Devon’s Central AMHP team.
A new model
Devon’s senior leadership team – from Devon County Council and Devon Partnership NHS Trust – knew it had to act, not least to ensure that the local authority continued to meet its statutory Mental Health Act duty to ensure a sufficient number of AMHPs are available locally. They asked the AMHP leads, including Robert, from Devon’s seven rota areas to explore potential solutions.
“The AMHP leads knew what we wanted in terms of quality. We also wanted to maintain a presence in each local area as we didn’t want to isolate our AMHPs. But we needed some way of building capacity and meeting the day-to-day challenges that we were facing,” says Robert.
After weighing up the pros and cons of a number of structures, including setting up a daytime emergency duty team, the AMHP leads proposed a new ‘hub and spoke’ service model designed to build frontline capacity.
The ‘hub’ would be a central AMHP service staffed by practitioners. This team would support the AMHPs “out in the field” in Devon’s local areas by centrally taking on tasks such as referral management, liaising with emergency duty teams, checking the availability of doctors for assessments, and managing locum capacity.
Crucially, as qualified practitioners, the central AMHP team staff could also be deployed to provide urgent back-up when needed, for example if an on duty AMHP was tied up at a difficult assessment or there were issues over rota cover.
“If someone’s had a long, difficult shift we can now say ‘finish your report, go home, protect yourself and take your time back”
Looking outside of social work for inspiration
In devising the model the team looked outside of social work for inspiration. Robert had remembered a conversation he had with a bus driver years ago. The driver told him how the bus service knew it was likely to have two or three people off sick each day, so it built in extra capacity by having drivers on duty who could step in to cover routes.
“There might be a day when no-one was off ill so he’d use that to get on with paperwork and other jobs. But, if as was highly likely, someone was off sick or on leave then he’d jump in and do their run. That sat with me for quite a while,” he says.
The local authority and mental health trust liked the look of the central AMHP service model and supported Robert and colleagues to make it happen (“there were real nerves on the first day we became operational,” he recalls). After a successful pilot, the central AMHP model was made a permanent arrangement last year.
Practitioners have responded positively to the change. Findings from a survey of 47 Devon AMHPs show that 96% feel the central AMHP model has made referrals “safer for patients and professionals”, 94% feel more supported under the model and 95% feel the redesign has improved duty cover for their teams.
“Individual AMHPs that might have felt isolated in rural teams, coastal teams, towns now feel part of a whole service. It is a service designed by and run by AMHPs and we use the strengths of that,” says Robert.
As AMHPs themselves, the practitioners who man the central service are careful to preserve the autonomy and independence of AMHPs in the field. While the central team will help to manage referrals for locality AMHPs, they are always clear that decisions on how to handle each case is down to the individual practitioners.
Another team principle is a commitment to protect colleagues “when excessive stress or difficulty is observed”.
Robert refers to a recent example of an AMHP who had a late night finish after starting at 9am with a difficult case. In the past, he says, that AMHP could have been “out on their own without a central point of support” and could be waking up to face another full duty shift the next day.
“Whereas now we have the central team capacity, we’re able to say ‘finish your report, go home, protect yourself and take your time back’. We can step into the breach,” he says.
At a time of budget constraints across the public sector, how did the team secure the resources to build capacity?
Some resource was freed-up by more effective deployment of locums, says Robert. Another boost came from the fact a local partnership agreement between the local mental health trust and the council defined what an “accepted level of AMHP workload” looked like.
“It was something like 45% of time should be AMHP dedicated and 55% should be caseload,” says Robert. “It allowed us to number crunch and work out what an AMHP’s caseload should be and also the resource the AMHP service should get from each vacancy.”
In addition to boosting frontline AMHP support, Robert points to a number of other “gains” that have come with the new model.
AMHP leads from the local areas are working more closely, the central team has helped streamline communication between daytime and out-of-hours AMHP teams, and managing locum deployment centrally has led to a “more effective use” of agency staff.
The redesign has also boosted the profile of AMHPs within both the local authority and mental health trust locally, he says. But, despite the improvements, challenges remain.
“We still have significant vacancies; the pressures are still there, it is still a struggle at times, but the work feels safer, better supported with a stronger AMHP presence in the organisation,” says Robert.
What would be his advice to AMHP leads looking to redesign their services? Robert says that one thing is to look for the “marginal gains” that can be made in order to support colleagues.
“The pressures are still there but the work now feels safer and better supported with a stronger AMHP presence in the organisation”
It is a phrase he first came across when a couple of his friends who are cycling fans were raving about how David Brailsford, the boss of the Sky cycling team (victorious in the last two Tour de France races), had revolutionised the sport in Britain. Brailsford had talked about how his team looked at “every single percentage and half percent” of what they did.
“I realised that’s what we had done,” says Robert. “We had looked at every single aspect of our core business as AMHPs. We looked at all the little 1% things that put pressure on staff – like inputting referrals for example.”
“Some of the feedback we’ve had from things like the survey have really validated the work of myself and the amazing efforts of two colleagues,” he adds. “We’re all AMHPs and this whole process has been about AMHPs being able to do their job better and having more space to do it.”Andy McNicoll is Community Care’s community editor