Approved mental health professionals (AMHPs) were used ‘inappropriately’ during the first wave of the pandemic because community services either closed down or were not seeing people face-to-face, a new survey has found.
The survey findings, which also revealed confusion around the use of personal protective equipment (PPE), have prompted calls from a social work leader to bolster the health and safety of AMHPs, an older workforce with a significant number of Black Asian and minority ethnic (BAME) staff.
The survey, commissioned by the British Association for Social Workers (BASW) England and the Department of Health and Social Care (DHSC), was answered by 100 AMHP leads across England and sought to understand the impact of Covid-19 pandemic on AMHP services during the first lockdown period (March-June).
It highlighted a range of issues faced by AMHPs during this time, including difficulty accessing the ambulance service, which forced some services to use private ambulance transport, as well as legal and ethical reluctance to use video technology to conduct Mental Health Act (MHA) assessments, despite government guidance permitting this in certain circumstances.
‘Inappropriate’ use of AMHPs
Most respondents reported increases in Mental Health Act assessments during the lockdown (almost 60%), while almost half said they had increased further still since restrictions were eased in July.
However, a significant number of leads surveyed said they felt AMHP services were “fulfilling a function that had previously been undertaken by community teams” during the first wave of the pandemic.
Respondents said that withdrawal of face-to-face visits and monitoring by services including community mental health teams led to requests for MHA assessments which wouldn’t otherwise have been made and didn’t warrant consideration of detention in hospital. This was borne out by the widespread reporting of an increase in referrals for Mental Health Act (MHA) assessments which didn’t result in a full assessment, with many leads pointing out that the practice contravened the MHA principle of using the least restrictive option. One respondent said:
“Because Crisis and the AMHP’s were the only two services seeing people face to face, if crisis did not know what to do, they immediately referred to us, the community referred to the AMHPs without seeing the person, as did the elderly teams, almost all these referrals were inappropriate as the least restrictive option had not been considered.”
AMHP leads network chair Steve Chamberlain echoed the point that AMHP and crisis services were “about the only people that continued to see people face-to-face”, adding: “As a result, I think there was some concern that AMHP services were were being used inappropriately.
“Maybe at times [AMHPs were used] as a way of getting to see somebody face-to-face, even though they may not need have needed that very high intense level of restriction involved, simply because community services weren’t going out to see people due to lockdown restrictions.”
Concerns over AMHP safety
The report highlighted the challenges of social distancing during an MHA assessment where, typically, two doctors and an AMHP are required to sit together with a person who may be experiencing significant distress or agitation
Chamberlain said many [MHA assessments] were done in people’s front rooms, A&E side rooms, police cells “which are very restrictive environments in themselves”.
Despite challenges at the beginning of the lockdown, the survey found most services were eventually able to access PPE but the amount and type varied considerably.
Chamberlain said this was of particular concern given the demographics of the AMHP workforce. A Skills for Care report, citing figures from the National Minimum Data Set for Social Care for 2018, found that 32% of social worker AMHPs were aged over 55, compared with 22% of all social workers, and 70% of AMHPs aged over 45 as against 51% of social workers. Fifteen per cent of AMHPs were from a BAME background.
“We’ve got a significant number of AMHPs who are BAME, while AMHPs are also an older group of professionals than the rest of their colleagues in social work, so I think there are real health and safety issues there that need to be thought about as we go into further lockdown restrictions,” said Chamberlain.
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However, many respondents highlighted the ineffectiveness of wearing masks in a role working with people potentially suffering from a range of serious mental illnesses, where face-to-face communication was vital, though there was support for using see-through face masks or reusable face shields as a way of addressing these issues.
‘Powerful legal and ethical reluctance’
Despite the challenges of face-to-face assessments and the government issuing guidance in Ma suggesting remote MHA assessments using video technology could be “legally robust”, the survey found a “powerful legal and ethical reluctance to use digital methods”.
While 61 respondents (58%) reported having used digital technology, 20 specified that they were only used in relation to community treatment orders (CTOs), rather than in relation to admission to hospital. Only a small number of respondents felt that these assessments worked well.
Chamberlain said the survey demonstrated AMHPs were very reluctant to go down the video assessment route.
“Some wondered whether it was legally appropriate but also had ethical and professional concerns, given the fact you’re considering taking away somebody’s liberty, is it right? Is it ethically correct? Can you do a proper assessment when you’re talking to somebody on the phone?”
Variable technology and wifi availability further complicated the matter, he said.
“My strong view is that we really need to think very carefully and have a detailed conversation about the pros and cons of this because it’s not going to go away, with the way technology is developing, it’s going to become more and more of an issue.”
Services forced to use private ambulances
As well as the lack of availability of community services, one-third of respondents reported difficulty accessing ambulance support to transport people to hospital.
Some areas were forced to use private ambulance services due to the unavailability of the NHS service, while a number of respondents said the London Ambulance Service withdrew from providing transport for mental health patients without consultation.
Difficulty getting support from emergency services to transport people to hospital isn’t a fresh issue, but it became more acute during the lockdown, Chamberlain said.
However, he added that the lockdown threw into focus the fact ambulances transporting mental health patients is “a waste of resources”.
“My view is that a tiny, tiny minority of admissions to psychiatric care need a fully-fledged paramedic ambulance, you do need skilled staff and you need a secured transport of adequate size and space, but you do not need defibrillators and a fully trained paramedic.”
He urged the NHS to explore how it could provide good, secure transport with skilled staff to avoid using ambulances needed for medical patients.
Probe needed into ‘inappropriate’ use of AMHPs
Responding to the report, Maris Stratulis, BASW England’s national director, said: “We need to consider if and why AMHP services were fulfilling a function normally undertaken by community mental health services and question inequalities of access to support services and the impact of PPE and health and safety of the workforce.”
Joint chief social worker for England Mark Harvey praised AMHPs for adapting to the challenges of the pandemic, while also dealing with a rise in requests for Mental Health Act assessments.
“This report will help the government, local authorities and NHS colleagues to work together to improve support for AMHP services and implement lessons learned.”
The report’s recommendations included:
- Mainstream services should maintain face-to-face contact with service users to provide ongoing support and to enable them to identify any deterioration in their health.
- AMHPs need clearer guidance on the use of PPE to ensure they can engage effectively with people during assessments.
- Bespoke guidance should be provided on the appropriate use of digital technology by AMHPs, addressing professionals’ concerns about its use in assessments.
- The development of a national strategy to provide appropriate transportation of detained patients to hospital.