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.”
Key recommendations
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.
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Whilst we welcome the report this seriously dangerous abuse of practice could have been highlighted within a couple of weeks. Those at the raw and violent end of MHAAs were reporting this within days.
Carers dumped on with no thought to their health told to choose between their own jobs, lives, commitments and provide 24hr never ending care or risk sending loved one hundreds miles away with NO access to healthcare at ANY level where the rate of death of covid has run at significantly higher rates than that of the general population. Or professionals.
Can we ask at what point AMHPs actually directly challenged their community AND crisis colleagues who here are STILL refusing to see pts face to face in many situations? And, for the record, in the London region many crisis teams have refused point blank to see pts regardless. Community teams this Trust still refusing f2f in most cases – knowing full well many pts cant manage remote support.
The Equality Act requirements- still in place- totally ignored.
Here all 3 EDs were turning away ALL MH pts . We mean ALL. The so called crisis hub was not set up for weeks after the EDs blocked care – a fact the MH Trust have finally publicly admitted. Now the hub demands severely unwell pts, often unable to use or without a phone, call ahead to book their life threatening emergencies in.
We haven’t noticed any local AMHPs challenging this policy and practice. Which directly leads to more requests for MHAAs. So why so silent- is it a interprofessonal problem? More evidence of silo mentalities?
Those of us family and supporters of loved ones subjected to this level of trauma and abuse – because this is what any MHAA is let alone when tney happen because the community team have gone AWOL – have been saying for years AMHPs failure to challenge the system THEY work in severely harms.
Maybe covid will lead to more centralised AMHP hubs who won’t feel so conflicted challenging community teams they then won’t be embedded in. Wondering if this research threw up any differences between the AMHP models out there?
The silo mentalities that exist in MH settings has been intensified during the pandemic. If the divide between community ( what community?) and acute wasn’t already bad enough, the difference of approach between local authorities who AMHPs here are employed by and NHS is stark. The attitude towards need for PPE reflected in this.
What is missing from these MH conversations is the actual real risk of covid to the person subject to referral and assessment. Have any of you ever counted up just how many responders, assessors and professionals an individual will be exposed to on the acute pathway? And then how many professionals on a ward?
On a pathway count done a few years back the average for someone then detained on a s2 was 88.
88 people with no or inadequate PPE.
We are not aware of a single person being offered PPE in the home and few in a HBPoS, despite being in close proximity of detainers for hours or days.
Black people already way over represnted in MHAAs with they and the Asian population at much higher risk of contracting and dying of covid. Then sent to covid infected wards.
If we could actually shift the focus on to the safety of the individual- including assessment of where they would be sent- then much would be improved. Less requests for MHAA, less ppl reaching crisis point, less close proximity multiple contacts.
And less discussion about inappropriate triggering video recording of MHAA which for many the mere presence of will escalate symptoms.
Within 2 weeks of lockdown the local Trust were told by those trying to contact MH services, how to fix up . And , as is usual, totally ignored.
Covid isnt going anywhere so why haven’t MH services got their act together?
Repeated welfare checks kill.
Repeated unwarranted MHAAs kill.
Being sent to a psych ward now more likely than ever to kill .
And those are the reasons why AMHPs should be confronting their colleagues and mend those bridges between professions so that the vulnerable aren’t harmed any further by this complete utter preventable mess.
If AMHPs want less unwarranted referrals then they have to speak up on site at the time.
Not wait for the professional body to do so months later.
Presumably when people were sent to “covid infected wards” the AMHP made the application on the basis of them needing detention and admission so not sure what the point is here. If however AMPHs have colluded in admitting people to hospital when there is no grounds for detention or because they were purely acting to deprive someone of their liberty due to lack of community resources, they would be breaking the law, practicing un-ethically and causing harm. I have no doubt AMHPs have reasons to gripe but it’s not always the fault of other services if you choose to collude in bad practice.
If there are legal, ethical, practical and presumably safety concerns over use of technology to distance AMPHs from the people they are assessing, why the need for further discussion? Just say no and justify it professionally. Not everything in AMPH world has to be difficult.
Poor AMHPs, in the front line, isolated, heroically holding people together while every other service gorges on strawberries and cream. It’s as if nobody ever suffered from harm through the inaction and incompetence of AMHPs. Too many inquiries highlighting your failures to list here. Circumstances change but the picture remains the same: you are not as precious or invaluable as you think.
During the first lockdown…….like many social workers I continued to work…. including face to face. I see that as a duty…I don’t expect praise or a badge! There’s never been much thanks for the work we do, lets face it!
As an AMHP i take the role very seriously, the training is very rigorous nowadays, and i do not have any fear in challenging the use of the MHA to ensure it is being used for the clients benefit and not the provision of services…covid or no covid!
We can push the blame about if we like. There are bad eggs in all services but lets not tar everyone with the same brush. There are good people out there….working hard to do the right thing by others.
I am thankful for the other AMHPs, social workers, CPNs, psychiatrists….mental health support workers and all other professionals on the front-line currently trying to support people with resource pressures.
We are all in the same boat and have to support each other…..
I am by no means expecting sympathy from others for the work I am here to do. We have PPE and can crack on with it…..
You can’t work in a system but not be a part of it though can you AMHP’s. If severe harm is done you also contribute to it. Instead of accusing others of going “awol” how about telling us how many people have come to harm or caused harm because they haven’t met your referral “threshold’. As for silo mentalities, you are the champions at demarcation. I wonder how many hours and days you have spent arguing over jurisdiction and where the person originates from while they are suffering and facing harm? A little confession, I write as a central London AMHP. Sorry for the disloyalty.
Well said Melua and a but harsh Andy but tend to agree with you also. If there is blame to be given then blame our bosses not fellow workers.
Even before Covid, there were many inappropriate referrals due to poor preventative work by community teams – the AMHP service has been dumped on as due to no real work being undertaken, it gets to a point where it is too last and hospital admission is now necessary.