Almost a decade after the position of approved mental health professional was introduced, the pressures on professionals in the role might never have been greater.
While the number of detentions per year under the Mental Health Act has increased by almost 50% over 10 years, it seems the AMHP workforce continues to shrink, as Community Care’s Freedom of Information request to local authorities shows.
The number of warranted AMHPs fell by 2.5%, from 2,174 at 1 April 2016 to 2,120 at 30 September 2017, across 91 councils which supplied data to Community Care for both dates.
Our research also highlights a continuing failure to bring more non-social workers to the AMHP workforce.
And with some councils reporting concerns about an ageing workforce and the potential to lose more experienced AMHPs in the next few years, the training and recruitment of more professionals to occupy the role is becoming an increasingly critical issue, as is improving the working conditions of those at risk of suffering stress and burnout.
These developments are taking place in the context of widespread funding pressures, both within AMHP services and among partner agencies, meaning any major and transformative investment in this workforce is unlikely.
The information gap
In comparison to the numbers supplied to Community Care, a workforce report published by NHS Digital this month recorded 1,300 workers with an AMHP qualification across 116 councils which responded to a voluntary request for this information from Skills for Care.
This is about half that estimated by the National AMHP Leads Network. There is the possibility that when asking for the numbers of warranted AMHPs, some could be double counted. AMHPs can be warranted and authorised by more than one local authority, though they can only be approved by one.
Greater impetus to tackle these data problems comes particularly from the chief social worker for adults, Lyn Romeo.
She says: “We need to improve data collection to understand how many AMHPs we have. There’s been a lot more focus on the role in the past 12 months. But there’s still a lot more to do.”
Romeo says the Skills for Care return will be among data used to determine mandatory information collection from local authorities, but this probably won’t start until 2020.
Improving data, not just about the numbers of AMHPs but also their work is vital, says Ruth Allen, chief executive of the British Association of Social Workers.
“Data is power,” she says. “If we really start to look at the level of need, how many staff have you got, it then starts to expose the pressures on referrals.”
Allen says the lack of national data about AMHP activity, with statistics instead focused on local services, means “everything is all about how this or that council provides a service”.
“The upshot is that this quite risky and very pressurised work has stayed a bit off the radar,” she adds. “It has been quite convenient at national level to not know what’s happening.”
The number of Mental Health Act detentions has been the only official indicator of demand on AMHPs, but an Association of Directors of Adult Social Services (ADASS) survey in late 2017 aimed to improve the knowledge of overall workload by finding out how many MHA assessments they co-ordinate and details about the referrals they receive.
One reason for the creation of the AMHP role was to improve the professional diversity of the workforce, by making it possible for mental health and learning disability nurses, occupational therapists and psychologists to train.
The government has commissioned the Social Care Workforce Research Unit at King’s College London to gain a better understanding of why other professionals are near absent from the AMHP workforce.
Its Who wants to be an Approved Mental Health Professional?’ project involved interviews with members of the other professions and a survey of AMHP leads, with initial findings due soon.
Allen says there continues to be a “clearer fit” between the training and expectations of social workers and the AMHP role than for other professionals.
She says some local authorities and AMHPs believe it’s important that the role can “provide a countervailing view to that of health professionals” by focusing more on social than clinical perspectives.
“But there have been some fantastic people coming through to that role [from other professions],” she says.
Then there is the fact that responsibility for the service remains with local authorities, meaning more onus on them, not NHS trusts, to invest in training.
Emad Lilo, vice-chair of the National AMHP Leads Network and social care professional lead at the Mersey Care NHS Trust, says health trusts might question why they should release staff for statutory local authority duties when they’re facing their own severe resource pressures.
“I don’t think there’s a shortage of health staff coming forward and keen to do the role,” he says. “But it needs the support of the employers and funding.
“Largely we saw up to 2014-15 very good nurse recruiting and training. But austerity and cuts are having a major impact.”.
Lilo also points to the effects of ‘disintegration’, where local authorities and trusts are withdrawing from services they were jointly funding and providing, particularly under pooled budget agreements made possible by section 75 of the NHS Act 2006.
One high-profile example was Somerset council’s decision two years ago to end the integration of social workers with Somerset Partnership NHS Trust, an arrangement which had been in place since 1999.
Disintegration, combined with resource pressures on the NHS, might prevent some keen health professionals from joining the AMHP workforce.
Karin Orman, professional practice manager at the Royal College of Occupational Therapists (OTs), says the low number of OTs warranted as AMHPs “does not reflect a lack of appetite but challenges due to structural issues”.
While the statutory duty to provide AMHP services lies with local authorities, most OTs with the relevant skills and experience are employed in the NHS.
“Managers are not releasing staff as there is no statutory obligation to do so and releasing staff for training has cost implications for their service,” Orman adds.
The AMHP role is “embedded in the social disabilities model which is in alignment with our values as a profession”, says Orman. However, she says there has not been a government programme of support to “encourage wider recruitment of professions” to become AMHPs.
The 2007 amendments to the Mental Health Act 1983 also created the role of the Responsible Clinician. This replaced the Responsible Medical Officer role and was opened to professions including social work and occupational therapy.
Allen says this role is at a higher level and is broader than the AMHP. “You see some psychologists moving to that role and smaller numbers of social workers,” she says.
Professor John Taylor, a consultant clinical psychologist and associate director for psychological services at Northumberland, Tyne & Wear NHS Foundation Trust, says the British Psychological Society, through its Mental Health Act advisory group, is focusing on the promotion of registered psychologists as Approved Clinicians.
“We consider the competencies for this role, which includes acting as the responsible clinician for detained patients and those subject to CTOs [community treatment orders] and GOs [guardianship orders], is more commensurate with the training and experience of senior psychologists working in (mental) health settings,” he says.
There are also practical challenges facing many who want to train as AMHPs – following at least two years’ post-qualification experience – not least the time it takes to do the course.
Allen says: “We need a relatively stable workforce and to prepare people to get to the point where they are ready to do training. Their positions need to be backfilled so they can be released to do the training.”
Steve Matthews, an experienced practitioner , highlights the impact of the Care Act 2014 in adding to the workload of local authority adult social care departments, which might mean managers are “reluctant to let staff go on training courses”. Four months of the course is full-time and trainees are not available for normal duties. Once trained and approved by the local authority, they probably won’t be available at least one day a week as they’ll be on the AMHP rota.
Pressures on the AMHP workforce are increasing amidst their shrinking numbers.
Experienced AMHPs say delays in receiving police support – not from a lack of willingness but resource pressures – have the potential to place them in more dangerous situations and are increasing anxiety. Ambulances are also taking longer to arrive to take people to hospital, and even when they do, there might not be a bed available for patients who need to be detained, or it could be far away from the local area.
Matthews says: “Cutbacks to police, delays with ambulances and a reduction in beds do make the AMHP role more difficult.”
He says the Mental Health Act code of practice states that different agencies should work together and be able to provide appropriate services and assistance “but it doesn’t necessarily happen”.
Lilo says AMHPs are being “put in a vulnerable position dealing with very distressed people on their own because of diminished support from other agencies who are having to deal with cuts”.
He adds: “I’m still a practising AMHP and have lots of experience but in the last two years I’ve been starting to have a bit of anxiety. There’s a lack of support from the police and ambulance service to convey [patients]. You feel anxious, is something going to go wrong?”
Lilo says there is “no comparison” between the current situation and when he started working as an ASW 20 years ago
“Support from other agencies was more available and accessible. Although we have good working relationships they are tightening it more. And this is a national picture.”
Mental Health Act review
The review of the Mental Health Act, announced last year by Prime Minister Theresa May, might provide an opportunity to push for national reforms to ease pressure on AMHPs.
One of its main objectives is to understand the reasons for rising detention rates, and any recommendations, and subsequent policy and legal changes could impact on AMHPS.
AMHPS are using the review to call for tougher rules concerning the duties of other agencies. In its submission, the ADASS North-West Mental Health Group has suggested the review should consider if the responsibility of the police and ambulance service to support AMHPs should be made statutory and not just be defined in the MHA code of practice.
Ongoing work is focused on the professional status of, and oversight over, AMHPs. The government’s consultation on Social Work England proposes that it would set the criteria for, and approve, AMHP training courses.
A CQC and Department of Health review of the monitoring of AMHP services in 2016 suggested that Social Work England could gain responsibility for developing a national register of AMHPs. though one challenge would be that not all are registered social workers.
These initiatives might positively impact on recruitment and retention, as could Romeo’s intention to put together a workforce development plan for AMHPs in the next year.
But the pressures on the service show no signs of abating and fall directly on the dwindling number of AMHPs available – as well as on those they are trying to protect and provide care for.