“If we get the evidence base for it, this pilot has the potential to shatter the glass ceiling that exists for social workers and other allied health professionals working in the mental health field,” says Miles France.
We are discussing an 18-month project that has seen France appointed as the first social worker in England to take on the role of approved clinician (AC) – one of mental health care’s most senior clinical roles.
ACs have various duties under the Mental Health Act, including becoming the ‘responsible clinician’ for groups of patients (effectively this means taking on overall responsibility for treatment and care). For the pilot scheme, France will oversee the care delivered to a group of people on community treatment orders (CTOs).
“That’s one part of a complex role but, effectively, the buck stops with me,” France explains.
Prior to landmark changes introduced under the 2007 Mental Health Act, the AC role (previously known as the ‘responsible medical officer’) was restricted to consultant psychiatrists. But, just as the 2007 Act opened up the old approved social worker role to a wider group of professionals, the legislation also allowed social workers, psychologists, psychiatric nurses and occupational therapists to train as ACs.
People that present in crisis to mental health services often do so because of psychosocial emergencies, rather than psychiatric ones. Social workers have frontline experience of dealing with that
A milestone for British mental health care?
At the time, the British Psychological Society hailed the move as a “milestone in the history of British mental health services” and in recent years a number of psychologists have trained as ACs. Yet France, an approved mental health professional (AMHP) and a senior social worker with Norfolk and Suffolk NHS Foundation Trust, is the first social worker in England to take on the role. What made him want to do it?
“The main driver was a belief that we could provide services at least equally as well as medical colleagues in certain areas of mental health practice. The evidence base shows that people that present in crisis to mental health services often do so because of psychosocial emergencies, rather than psychiatric ones,” says France, who took up his post in October.
“That’s not to say psychiatric emergencies don’t occur – of course they do – but the precipitating factors frequently involve housing issues, relationship breakdown, loss of jobs, benefit changes. Social workers are ideally suited to handling that, they have the frontline experience. AMHPs are also well versed in managing high levels of risk, within a positive risk taking framework.”
‘The wider development of social work’
We are hopeful that there will be a lot of positive gains resulting from this pilot, for patients and their carers
Another strong personal motivation was the chance to address the lack of opportunities currently available for social workers to take on senior clinical roles in mental health, says France. Across the country nurse consultant posts and consultant psychologist posts exist in many NHS mental health trusts. Consultant social worker posts are far rarer. If France’s pilot is successful it could help the non-medical AC role become a viable career development option for many other social workers.
Senior management at the trust have been very supportive of the pilot project and France’s appointment has been broadly welcomed by colleagues too, he says.
“Most people have been really positive. They can see the logic in how this is progressing. There was a feeling that, in some cases, the best fit doesn’t always involve having a doctor as the patient’s responsible clinician. Some wanted to see the wider development of social work too,” says France.
Nationally there have been some concerns voiced that non-medical ACs will still depend on a lot of consultant psychiatrist input, leading to role duplication. France says that some psychiatrists in his team have been “really supportive,” but admits that a small number of medics have raised these concerns with him. How does he respond?
“By and large the answer to whether role duplication will happen due to various overlaps is mostly not. From time to time non-medical ACs will need to consult with psychiatrists as and when it’s appropriate. But there’s a difference between seeking advice on important issues and role duplication,” says France.
Feedback from other pilots
There could be plenty of positives to the scheme too, according to early feedback gathered by France on the impact of other non-medical AC trial schemes. His scoping exercise found that:
- In Cumbria, a nurse consultant based at a dementia in-patient unit has helped reduce the use of psychotropic medication to rapidly tranquilise patients and helped staff take on a greater level of clinical responsibility.
- In Northumberland, two ACs with psychology backgrounds have supported the discharge of long-stay learning disability patients from secure services back into the community and been instrumental in developing postgraduate training for other non-medics who want to take on the role.
- In Staffordshire, a recently retired nurse consultant noted a reduced level of seclusion with learning disability in-patients, after increasingly using behavioural management techniques rather than medication. Another nurse consultant working with patients on CTOs has observed a reduced use of recall and revocation.
“These are just some examples. We are hopeful that there will be a lot of positive gains resulting from this pilot, for patients and their carers, but the problem is that there is currently a paucity of published evidence from such service reviews, be it nationally or locally,” says France.
The impact of France’s pilot scheme will be evaluated after six, 12 and 18 months of operation. The 12-month report will evaluate service user experience, carer experience and staffing experience of the pilot and map them against national guidance and a series of key performance indicators – such as hospital readmission rates, length of stay and uptake of employment or training.
A thorough report at 18 months will consider whether non-medical ACs could be rolled out in different areas of the trust.
Does France hope that more social workers will follow in his footsteps and explore the possibility of training as an AC?
“I hope so. There’s already some interest from other social workers and AMHPs, so that’s really positive. I also hope that a wider group of professionals will take this role on too – I have some excellent nursing, nurse consultant and consultant psychologist colleagues who are interested,” says France.
“I hope that in time we might also see non-medical ACs working on working age acute wards, dementia care wards, and within learning disability and secure services.”