‘AMHPs are being left to improvise solutions to system failures’

Approved mental health professionals (AMHPs) are being left in “legal limbo” as they battle for support for people in mental health crisis, amid a shortage of beds, limited access to section 12 approved doctors, and overstretched emergency services.

A report published by the Care Quality Commission (CQC) today confirmed access to inpatient beds remains the biggest issue for AMHPs.

The report was based on findings from interviews with more than 250 AMHPs and other staff from 23 councils, 10 NHS trusts, and two private providers. AMHPs told the CQC that referrals for MHA assessments were increasing monthly, but in at least 50% of cases AMHPs were unable to complete an application to detain due to a bed not being available.

AMHPs reported that it was easier to gain access to beds out-of-hours, but generally the situation was leading to premature discharge and repeat admissions, the report said.

The CQC said the findings highlighted the disparity in the way AMHP services are being provided across the country, warning that people were not always getting the right support.

‘Improvised solutions’

One AMHP, known on Twitter as AsifAMHP, told Community Care that in his area professionals were at times finding themselves in “legal limbo” as they improvise solutions to system failures.

“We are having to assess people and then walk away because it’s taking hours, days, weeks for a bed to be found. Sometimes the medical recommendations made by the doctor are running out – that’s 14 days without a bed becoming available,” he said.

His team has also seen a rise in patients’ nearest relatives objecting, or thinking about objecting to a detention, because when a bed is found it is based out-of-area.

NHS England has established a national programme to eliminate non-specialist out-of-area placements by 2021. The CQC report found some areas have already made improvements, but in others the availability of local acute care beds remains problematic.

“To us that objection is not always unreasonable,” AsifAMHP said, “but if the person is so unwell or are a risk to themselves or others, then they have to be detained.”

“I am increasingly bothered about the fact that we are involved in this,” he added.

“We are going out to families, saying ‘yes, your loved one is unwell and we all agree they need be detained’, but then we’re taking them hundreds of miles away.”

The MHA also requires doctors and AMHPs to decide that ‘appropriate treatment’ will be available on the ward the person is being sent to, but Mark Trewin, service manager for mental health at Bradford council, said this is no longer straightforward.

“In many areas of the country if you’ve got a bed then it’s no longer about whether it’s an appropriate bed, it’s a bed – and you use it,” he said. “This means that something put into the law to create better outcomes for service users cannot be easily implemented.”

In Bradford it’s rare to be in a situation where there is no bed because of the way services have been redesigned but Trewin agreed AMHPs are often compromised one way or the other when it comes to detaining people under the act.

“It’s very hard to be least restrictive when there’s no alternatives to hospital, when supported housing is reduced and home treatment teams are overwhelmed.

“AMHPs are often detaining people who may not have deteriorated in their mental health if community services had been able to engage with them or provide a safe alternative.”

Delayed assessments

The CQC report highlighted issues with the availability of doctors to assist with assessments. The MHA requires two written medical recommendations, one of which must be from a doctor approved under section 12 as having special experience in treating mental illness, and it suggests the other should be from the person’s GP.

The report found assessments were often being delayed until after 6pm because section 12 doctors were not available until then, GPs were unable to carry out MHA assessments and AMHPs therefore struggled to find a doctor who knew the person.

Trewin, who has recently been seconded to the Department of Health and NHS England as a specialist advisor on social care and mental health, said the AMHPs he manages today rarely see the GP – making that part of the MHA “largely irrelevant” now.

“The Mental Health Act was designed at a time when resources and demand were very different – it made perfect sense back in the 80s, but the situation has changed so radically that aspects of it are not particularly helpful now in a time of austerity,” he said.

One example, also referenced in the CQC report, is the requirement to convey a person to hospital in an ambulance. Trewin said the pressures on the ambulance service mean they are not always available to attend when called.

“Once they’ve signed the papers the person is then the AMHP’s responsibility and they usually have to stay with them until they can transfer the legal power to the ambulance.

“All over the country AMHPs are working late due to various issues – usually caused by cuts to services or pressures of work – and things like this reduce morale.”

AMHPs involved in the CQC research reported that services which had commissioned independent ambulance services with specialist crews had reduced the need for police, handcuffs and dependence on acute ambulance services.

AsifAMHP agreed practitioners cannot continue to rely on the overstretched police or an ill-equipped ambulance service.

“It’s the AMHP’s job to organise it; we have the lawful authority of a constable while doing the assessment, but are not equipped or trained to force someone to come,” he said.

“If we are going to detain people under the act then we need to be resourced to do it properly – and that means dealing with everybody from the willing and informal patients, through to the actively resistant.”

 ‘Change to support conditions for AMHPs’

The CQC report pointed to the government’s independent review of the Mental Health Act as an opportunity for AMHPs to identify some legislative solutions to their concerns, and highlighted other national programmes working to resolve the issues on the frontline.

One example is research undertaken by the Association of Directors of Adult Social Services (ADASS) and NHS benchmarking to gather information about AMHP activity, which has informed a set of recruitment and retention materials for councils.

ADASS president Margaret Willcox, who made raising the profile of AMHPs her presidential priority, said the shortage of inpatient beds was creating “real challenges” for practitioners and urged the government to address the resource issues facing services.

She added: “While local services up and down the country have done what they can to create flexibility within the system to meet local needs, there is no substitute for the investment that adult social care as a whole needs.”

Trewin said that to achieve change that supports improved conditions for AMHPs and better outcomes for service users, consistently good leadership, “brave” commissioning and a commitment to integrated working is required.

“What you need is a whole system approach where all the relevant parties, including the council, the NHS, and the police are working together.

“That is a major challenge in the current financial climate… in Bradford we have partially achieved it, but we are at risk of losing it because of the huge challenges of austerity.”

AsifAMHP added that it’s less about making changes to the MHA, and more about creating integrated services which allow the AMHP to coordinate the two doctors, the ambulance, the police if required, and the bed.

“If you break your leg the ambulance turns up and takes to you to A&E, you might have to wait a few hours, but they will put a cast on it – there is a process that works nearly every time. We need a process around the Mental Health Act that works in the same way.”