By Steve Chamberlain
The Covid-19 pandemic is causing major disruption in multiple areas of our lives and the Coronavirus Act 2020 gives the government considerable additional powers to restrict movement and amend legislation in an effort to control and contain the spread of the disease.
Mental health services are particularly affected by schedule 8, which gives ministers the power to amend the Mental Health Act 1983 (MHA) if the situation deteriorates and local authorities and the NHS are at risk of being unable to fulfil their statutory responsibilities. It is important to note that schedule 8 will not be enacted without further ministerial order. So for the time being we are working with the MHA as it stands.
There has already been considerable discussion about how to respond to existing duties in the context of the risks of infection to both professionals and the public in the course of statutory assessment processes.
MHA assessments are required when it is considered that a person is sufficiently mentally disordered to need compulsory admission to hospital for their health or safety, or to protect others. An assessment typically requires the person to be assessed by two doctors and an approved mental health professional (AMHP).
The assessment could take place in the person’s own home, in a psychiatric ward, a general hospital ward, a police station or wherever the person happens to be. The nature of the assessment is almost inevitably highly pressured and emotionally laden, as the person will be in mental health crisis, there will be significant risks and a decision is being considered to deprive someone of their liberty.
Quality of communication crucial
This makes the quality of the communication crucial, in order to ensure a thorough and lawful assessment. The whole process of the MHA assessment is governed by rules set out in the MHA and its code of practice. Before making a decision whether or not to detain a person, the AMHP must interview them “in a suitable manner” (section 13(2), MHA).
AMHPs have always considered a face-to-face interview to be the only way to interview “in a suitable manner”. But with the onset of the Covid-19 pandemic and the risks of infection, increasing consideration is being given to video interviews. However, while they are being used in other contexts there are no guidelines for MHA assessments.
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MHA assessments throw up particular challenges. The AMHP has overall responsibility for co-ordinating the assessment (code of practice, 14.41). It is their job to ensure the various professionals and agencies are involved in a timely manner. They must also ensure to the best of their ability the person is aware of the process, of their rights and is given the opportunity to express their wishes and feelings. All this while a person is experiencing a mental health crisis.
When a person is exhibiting possible symptoms of Covid-19, they pose a particular infection risk to the professionals present. Even without symptoms, we are told that people can be infectious, so an apparently healthy person provides no guarantee against infection. Equally, professionals may pose a similar risk to the individual. Government policy is clear. To reduce infection we must maintain distancing guidelines.
MHA assessments frequently take place in uncontrolled and cramped environments: people’s front rooms, police cells, A&E side rooms. It can be difficult to guarantee a suitable distance, particularly when a person in mental health crisis may be acting unpredictably.
Are video assessments the answer?
So how about completing assessments by video link? Is that the answer?
As far as I’m aware, no one had piloted or tried video interviewing prior to this pandemic, but it appears that it is starting to happen in some areas, and in limited circumstances. Just within the past two weeks, some services have been starting to produce guidelines for their staff.
I’ve never been comfortable with the idea of video interviewing in this context, but no one has ever needed to consider it seriously before now. Or maybe I’m a dinosaur stuck in the 20th century.
Starting with the basics, the doctor must “personally examine” the patient and the AMHP has to be satisfied that they can interview in a suitable manner, and to defend that if challenged, in court if need be. The definition of “personally examine” continues to be discussed, but I will currently focus on the role of the AMHP.
I believe there are circumstances when this would be possible using video, and other times when it would be out of the question.
There appear to be three main issues:
- Technology (hardware and adequate reception)
- Sufficient support for the interviewee
- The impact on the interviewee of the use of technology
Hardware is a major issue for many services, but perhaps only because it has never been considered. The purchase of a tablet is fairly cheap in the current scheme of things. Many services have wifi capability providing reception.
What about data protection? The NHS has recently issued guidance about information governance in the context of Covid-19 Advice to health and care professionals includes encouragement of videoconferencing, including the use of commercial products such as Skype or WhatsApp. The guidance goes on to remind professionals to be cautious about confidentiality issues as with any other communication.
‘Trusted others’
The support issue is trickier. Increasing numbers of people are highly IT literate but an MHA assessment is very different to a simple conversation.
To look at two rather extreme examples, there would be no question of being able to video interview a person with advanced dementia who was on their own with no support.
However, for someone with a ‘trusted other’ (either professional or informal), who could support the person and ensure the AMHP is able to communicate verbally and maintain good visual contact, then I don’t see why it can’t work.
This could happen in a variety of environments: psychiatric ward, general hospital ward, police station, even someone’s own home. The ‘trusted other’ would need to be able to cope with the process and the AMHP would need to be proactive in managing it.
Thirdly it depends on the impact of the technology on the individual.
The AMHP will need assess whether the process of communication via video will impact negatively on the person’s responses and their reactions. For example, if someone has delusional thinking which focuses on technology, I think it would be very difficult to interview the person by video, and to consider it to be “in a suitable manner”. On the other hand, being interviewed by a person (or a team) in full PPE may be equally or more disturbing.
I’m becoming more accepting of the possibility of video interviews for MHA assessments, but only in the right context and with effective support. I think the demands of the current crisis are such that it is inevitable that video interviewing will happen with increasing frequency, and by the time we come out at the other end we will have developed some guidelines.
Steve Chamberlain is chair of the AMHPs leads network. He is writing in a personal capacity.
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Friend scribing but struggling to keep concise so please bear with. Written from position of P.
Thank you for getting AMHP community to weigh up but aside from what you refer to, how on earth can ANY amhp currently agree that a MH ward isn’t now often the most unsafe and most restrictive setting possible. .
They are covid hotbeds run by nurses with NO physical healthcare training let alone the barrier nursing required. How many AMHPs recommend instead that P is supported in their OWN home with a suitably qualified PPE trained personnel given that would in all likelihood be safest and least restrictive for many. Nursing agencies are still working. Trust bank staff too.
It doesn’t matter in normal times that you send us to dangerous settings where it is possible to spend weeks without a single staff interaction. Where many of us end up sectioned because crisis care is woeful. How can the above situation be an automatic disconsiderstion? Cheaper than the cost of a night in a psych hospital.
So, is there an obligation to consider the suitability of a setting anyway? For e.g. no AMHPs we know ever consider taking P out of their disability accessible home into an inaccessible ward with NO care plan for assistance in ADLs. Apart from the HRA breaches ( which don’t apply if am dead). So are you required to consider this now ( rather than the s12 seeking the bed)?
You can’t adequately and safely assess people unless it is f2f. If we put this inconvence aside you certainly can’t argue that a psych ward isn’t a guaranteed serioius risk to physical and MH. No access to a dr ( pts simply don’t get this in usual times). Being placed there confirms you are trying to kill me and MH is on the covid cull list ( a term being widely used). My MH gets worse , stay is longer with all associated risk.
Hostile ward staff because for me and so many they are anyway but now they have NO or little PPE and VERY little idea of how to use it so aren’t going near pts. Several Trusts using segregation because they don’t know what isolation means in terms of infectious disease. Which AMHPs are even thinking on these lines when least restrictive being applied?
No psych wards am aware of zone each ward even if they could. They wouldn’t know what that meant.
And then, if you have FULL visor PPE my symptoms of distress and confirmation MH staff are imposters are off the scale.
Why can’t the AMHP make recommendations about what is considered the least restrictive option if admission recommended? Just as why can’t they add disability adaptations in normal times why can’t they add P needs to be provided with their OWN PPE and support to use? RGNs and acute care HCAs employed who know about physical healthcare.
Why can’t they state that they must be nursed in line with PHE guidance in ALL respects which at least then I might believe at some point wards aren’t there to kill people causing as much distress as possible.
I believe P should be provided with PPE. Wherever we are. No one in MH seems to even consider offering this at assessment. If you are going to force me in to an environment that may well kill me ( and if on clozapine exponential risk) then at least build in the protection robbing me of visitors and advocates has taken away. Including the right of access to physical healthcare and infection control measures.
This is terrifying in MH. Not only did far too many Trusts literally close their doors in crisis care for the 1st couple weeks those who can’t be supported on telephone or zoom are getting NO support. And then we are punished further because MH Trusts and local authorities think it is better to herd us in to killing wards rather than look at risk assessment differently.
Please can AMHPs make the recommendations needed to keep the most vulnerable safe. Even if MH Trusts ignore it maybe heralds the shift for the future that is needed.
I’m an AMHP. I found your message thought provoking. In all sincerity.
I try very hard to find a way not to make an application, even if I have received med recs, in normal times (before covid). I continue in this manner
From my experience recently the staff in mental health hospitals are competent with PPE
But your heartfelt points are heard by me and I am sure my colleagues
Best wishes to you
I think you have to move with the times. HBPoS’ often have CCTV and two-way communication to the room. It would take very little to adapt them so that the service user can see the assessing team You would probably need additional facilities what about rooms at GP’s surgeries instead of A&E?
That would leave the community assessments which could take place in the home with some forward planning ,
Thanks
Thank you for this thought provoking article. Taking it one step on from interview, the AMHP might need to arrange for the conveyance of the patient (s6), in some cases access will be required via a warrant (s135) with AMHP, Dr and Police in attendance. The AMHP also has the responsibility for securing the persons home, and ensuring the safety of their pets, practicalities that cannot be done at a distance. Assessments under the MHA often require some level of contact beyond the interview. The dignity issues of arranging the persons belongings in a bag to take to the hospital, is something AMHPs take seriously, balancing this responsibility the spread of Covid-19 is difficult. Whilst this might be mitigated by video interview, as you point out much of the necessary human contact in terms of empathy and care might be lost in the digital transaction.
How we balance remote working to keep safe the people and professionals is difficult, whilst legal principles must be upheld, the ethical dilemmas raised by remote working are important to debate, despite calls for practical solutions to meet the very real concerns expressed by patients and professionals. How can we realistically achieve distance when much of the AMHP role is aligned to ensuring the safety and well-being of the patient from the point of referral/assessment through to admission?