The number of approved mental health professionals (AMHPs) in England shrank by 3% from 2020-22, amid rising numbers of detentions and government plans to expand the workforce.
There are currently an estimated 3,800 practising AMHPs, down from 3,900 two years ago, said Skills for Care, in its latest briefing on the professional group.
The figure – extrapolated from submissions from 125 of the relevant 148 local authorities – is the lowest since the workforce development body started publishing the dataset in 2018.
It comes with the number of detentions under the Mental Health Act 1983(MHA) – each of which requires an assessment by an AMHP – having risen by 4.5% from 2019-20 to 2020-21, according to NHS Digital figures.
Need for more AMHPs
While Skills for Care estimated that there were currently 1,870 full-time equivalent (FTE) AMHPs in England, government plans to reform the MHA would require an additional 101 FTEs by 2028-29.
This is because it expects AMHPs to have expanded duties in relation to community treatment orders – which place requirements on patient’s treatment after leaving hospital – and new advance choice documents, which enable people to make decisions about their future treatment.
The plans are set out in the Draft Mental Health Bill, which is being scrutinised by a parliamentary committee, after which the government is likely to proceed with full legislation to reform the MHA.
The fall in the number of AMHPs nationally masked significant regional variations with modest growth in London, the North East and the West Midlands and falls elsewhere, reaching 9% in the South East and 7% in the South West.
The South East also had far fewer AMHPs per 10,000 people (0.54) than the other eight regions, with the North West having almost twice as many (1.02).
Workforce pressures
The briefing also highlighted longer term concerns about the sustainability of the AMHP workforce, most of whom (79%) are employed by councils, with 17% in the NHS and 4% agency or freelance.
As was the case in 2020, 95% of AMHPs were social workers, with just 5% from the other three professions who are statutorily able to carry out the role: nurses, occupational therapists and psychologists.
Also, the workforce remains older than adult social workers in general, with 31% of council-employed AMHPs aged 55 or over – as in 2020 – compared with 23% of local authority adult social workers.
The pay premium that local authority AMHPs carry also seems to have fallen, from £3,500 in 2018 and £2,700 in 2020, to £2,00 in 2022. AMHPs had a median salary of £38,900 as of September 2021, compared with £36,900 for adult social workers in local authorities.
In terms of retention, Skills for Care estimated that 17% left their roles from 2020-21, with 12% leaving local authority practice altogether, 4% moving to a new role within the same authority and 2% changing authority.
Action to tackle recruitment and retention
Last year, the Department of Health and Social Care (DHSC) found an extra £1.2m to train AMHPs in England to address workforce shortages.
In a foreword to the Skills for Care report, DHSC mental health social work lead Jason Brandon said this had made “a positive contribution to support additional candidates identified for AMHP training across 2021-22”.
Brandon, who is based in the Office of the Chief Social Worker, said it was working with partners including the AMHP Leads Network to implement the 2019 national workforce plan for AMHPs.
This set out a number of measures to improve the recruitment and retention of AMHPs, including for councils and their partners to:
- Have a clear plan for the number of AMHPs needed across adult mental health, children’s, learning disability and older people’s services.
- Tackle disparities in AMHP salaries, leave or benefits and ensure professionals are paid at senior practitioner level.
- Carry out regular audits of AMHP morale, pressures and workloads and resolve problems identified regionally.
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Correlation between retirees and reduced AMHP numbers. It really isn’t rocket science.
We need pan -London Amhp services which will reduce unnecessary warrant processes from one LA to another. We need one authority who can give Amhp warrants and practice all over London. One Amhp should be able to carry out mental health act assessment across London. Reduce time and money and create stability. Now every borough has to do their own Amhp warrant
I used to be an ASW many years ago. The knowledge, expertise, responsibility and working conditions of the AMHP role are vastly under-rated. I wouldn’t even consider doing it for less than 45K. I have been paid that as a team leader, which was a walk in the park compared to the AMHP job.
When you were an ASW you weren’t the sidekick of doctors. When you were an ASW using a S12 doctor was a rarity because you had the authority and the confidence to insist that a GP came to the assessment of their patient. When you were an ASW you made sure all concerned complied with the MHA. As an AMHP you fret about beds before you even accept the referral. As an AMHP you have your S12 pal who you use routinely. As an AMHP you aren’t really that bothered about the law much less actually listening to the nearest relative because you are ever so “busy”. So I disagree. As a team leader you have to balance many demands on top of invariably dealing with staff who take their assumed exceptionalism to every conversation. AMHPs are the funnel through which people in real disress are corralled into hospital before that pint or coffee your psychiatrist pal promised you. No autonomy, no authority, just going through the tried and tested routine. Comparing an ASW to an AMHP is akin to equating a bicycle to an elephant.
As a non-AMHP sharing space with them my observations are that the “complexity” of AMHP seems to be about organising a hospital bed, organising transport for admission and organising police attendance for the assessment. I am not sure what the specialist training for those are or what social work skills they require. Ofcourse not being able to.identify a bed or get police or an ambulance must be stressful but I wouldn’t say that it is so unique that it is under appreciated. Any one of us non-AMHPs have tasks which also cause us stress. It seems to me admissions have been rising expodentialy because AMHPs only seem to leave our office once their numerous disscussions about whether the referral is appropriate concludes that admission is the likely outcome. I have only ever witnessed a discussion about an alternative to admission being whether the family or partner can look after the distressed person. I am not convinced any increase in AMHP numbers will reduce admissions given the narrow interpretation they seem to have about their role.
I am an AMHP and believe I have a broad application of the role; this includes asking myself “what is mental illness in relation to the person I am seeing, taking positive risks when considering the benefits and burdens of admission, disagreeing with doctors on a regular basis, and seeking to consider the person as a person not a diagnosis, and seeing that person in their social circimstances and considering what might be the social determinants of their distress. AMHP work is challenging, fraught with dilemma (as is all social work) and can be very rewarding at times
Finding beds and arranging transport is a bureaucratic task that is necessary if admission is required but is just a task. AMHP work is a whole lot more than that. In the same way social work is more than the “tasks” that are necessary to the role
The stats on the ever increasing numbers of detentions does not support that AMHP work hasn’t ossiffied into a bureaucratic task though. It’s simply not the case that our society is causing such distress that mental illness as defined by the MHA has soared. I care about epidemiology not anecdotes. So either detention is now the inevitable outcome because the threshold for AMHP intervention is narrow in the way Maureen describes or psychiatrists are over dignosing. Either way AMHPs are in the equation. Those of us who are a bit critical of what AMHP practice, to us, has become don’t deny that their work is challenging and perhaps a balancing of dilemmas. What we ask is whether these get taken to the assessment from the office discussion. My personal and professional experiences suggest infrequently.
Increasing detention rates have a number of components- very short admissions and discharge perhaps before p is ready, leading to re admission, Cheshire west (so patients who were previously voluntary as they did not object now must be detained as they lack the requisite capacity to consent), a massive decline in community resources due to austerity, so people don’t get support in the community, I could go on.
I believe with the bed shortages in fact psychiatrists are less and less willing or wanting to admit not the other way round.
It’s easy to be sceptical of AMHP work from the outside. But I work very hard as an AMHP to be critical in assessments and this includes not making an application despite receiving two medical recs if I think there is an alternative plan, and have done this on a number of occasions. It also includes reasoning with doctors about what is and isn’t mental illness if a nature or degree etc.
I completed my undergraduate dissertation on mental health legislation and the role of the ASW then AMHP was key in balancing the medical model. And I try very hard to put this into practice as do my colleagues
Maybe see if you can go on a few assessments with different AMHPs and see what you think ?
Actually I have only several occasions all of which inform my comments. I have also been on the other side of the process and have that experience too. My comments are not a personal attack. Observation and experience including the many surveys of the assessed and their families suggest something different. Great if you balance your practice in the way you describe but I also know that you know not all of your colleagues do this. In my experience at least most of the AMHPs in our service are like Westminster Lobby journalist. Veneer of independence but actually too close to those they are meant to scrutinise.
As a fulltime AMHP, i totally disagree with this!
It is absolutely necessary for all those ‘discussions’ to take place when determining whether a MHAA is appropriate or whether there is a least restrictive option in the individual’s best interests.
Rather than making derogatory comments about your understanding/ misunderstanding of the role and overhearing AMHPs taking calls in your office, maybe you could arrange to spend some time shadowing your AMHP colleagues to gain knowledge of what the AMHP role actually entails when they ‘leave the office’
Maybe after having observed the ‘specialist’ skills and knowledge that AMHPs apply to every part of the assessment process/procedure, may enable you to enhance your understanding of the role?
Particularly if the AMHP has already been working all day before the assessment request comes in 5 minutes before they are due to finish their shift, followed by them having to wait many hours for transport if the individual is detained and an admission is needed ( if a community assessment, usually sat in their car if risks to them from the individual within the property, very often without food, drinks and toilet facilities).( and this is only one of many scenarios)
I am deeply disappointed that a none AMHP professional would disrespect their AMHP colleagues in this way
AMHPs constantly tell us that they are independent and challenging. The proof is in the action. So I ask, how often do AMHPs refuse to make an application when both doctors have made a recommendation for admission?
I have – on a number of occasions. I have also been able to persuade doctors on a number of occasions that in fact a recommendation is not needed
Go on some assessments with colleagues if you can and see what you think?
these days no-one want to use the ‘least restrictive’ principle and there were very few psychiatrists / S12s that would not wish to cover themselves. Crisis teams do not want to take the risks either and so by defult almost, people are sectioned.
About 2/3rds of course the time
53,239 detentions from 150,000 MHAAs
I left the job after 12 years as the responsibility was too great together with the poor support and community resources. Many referrals were coming in due to little enough preventative work being undertaken by already stretched community teams.
waiting for bed and ambulance and police (and warrants) were also a reason for me saying ‘enough is enough’ as the situation was going to get worse – and it did!
But you see I have. And even if I hadn’t your assumption that I am ignorant of the nuances of the issue is precisely why we never stop asking questions. If this was the appropriate forum I could describe the disquiet felt at the internalisation of lacking capacity, imparement and so forth by AMHPs as if they are stone clad is precisely why the medical model isn’t challenged in the robust way I experienced ASWs challenging psychiatrists about their medicalisation of mental illness. AMHPs will always say they have to comply with MHA and MCA ofcourse. Expediency, service cultures, weakness of management, the numbers on the referral board all contribute to how assessments are framed and conducted. But what would I know, I’ve only been a mere social worker for 28 years.
I take your point; I suppose I can only speak for myself- lacking capacity and mental disorder are social constructs – I am very aware of this. But AMHPs complying with the MHA doesn’t mean agreeing with doctors or using medical recs, any more than when they were ASW’s.
And its a fair point – Liz – I can’t speak for my colleagues – but for myself.
The temptation to comply with the medical model is strong; but it isn’t what I am there for.
But yes – I suppose the model is very strong, as are the structures around it – so it’s actually good to be challenged and reflect some more on this.
In my humble opinion, having read the critiques from several respondents in this thread, and having been an ASW and now AHMP for 29 years (and social worker for 35) I think that there are complex issues underpinning the increase in compulsory detentions to hospital.
When I first trained as an ASW in the early 1990s there were lots of resources around the country that enabled people with mental health difficulties to get help aside from the statutory NHS services. The voluntary sector was very strong, especially in the metropolitan cities, and some pioneering work was being done. I didn’t realise how much I took those resources for granted until, after George Osborne’s 2010 budget, financial collapse hit local authorities and, to a lesser extent, the NHS. So as an ASW I usually had some alternatives to admission to try to arrange in any given community-based assessment. I know I would wait for 14 days on some occasions to see if some of those community resources (often family and friends) could prevent admission and this was well before CRHTs came into being in the early 2000s. New Labour made massive investments in mental health services, including trying to tackle racial inequalities through the Delivering Race Equality in MH strategy 2004 – 2010.
Another factor that many current AMHPs seem not to have picked up is what Conservative government policy did to social services which affected the AMHP role. Social Work Qualification courses were told by Michael Gove to stop teaching anti-discriminatory and anti-racist practice. AMHP qualification courses became much more legalistic and less practice-focused. Then, as one respondent has already referred to in this thread, Baroness Brenda Hale brought in the famous Cheshire West judgement on deprivation of liberty. That had a gigantic effect on detentions in hospital for people with learning disabilities and especially people over 65. It also had some effect on working age adults’ detentions too. The whole legal framework for AMHPs became such that, apparently being detained under the MHA 1983 gave people so many rights to appeal, etc that it was the best thing for them!!!
Meanwhile the NHS mental health services were decimated by the Tory government from 2010 to 2017 and nearly 3,000 inpatient beds were closed across England and Wales. Also the removal of the mental health nurse training bursary in 2016 by Osborne was disastrous for the system and, 6 years later, has led to a massive shortage of RMHNs. The pandemic made things even worse! Nowadays, our AMHP service gets referrals at an increasing rate month by month because CMHT staff are non-existent and cannot do home visits to support their patients. AMHPs are a well-funded part of the mental health system because Local Authorities have a duty under the MHA 1983! You also have many psychiatrists, due to relentless stress and overwork, wanting to get out of CMHTs and work in the private sector, or at least away from the front line. Long gone are the days of my ASW work when the consultant for the patient being referred would be likely to be the lead s.12 doctor in the CMHT and the GP would often be the second s.12!! The person who said that the AMHPs have their s.12 doctor mate is probably true because there are so few doctors willing to undertake MHA assessments at all that we use the same ones all the time!
Finally don’t forget that there has been a huge increase in the number of young people coming through the system who have been diagnosed with various neurodiverse conditions, especially ASD. There is an increasing cohort of young people with both ASD and Complex Delayed Post Traumatic Disorder (or EUPD in the medical model) who are so disturbed by their childhood experiences that they present to mental health services very frequently and take up a lot of AMHPs’ time in assessments even if not detentions. The pandemic definitely increased adolescent mental health problems on an exponential level and it contributed to an overall increase in anxiety and low level paranoia amongst working age adults too, some of which has fed into increased detentions to hospital.
So all these factors play a big part in the AMHPs’ work and many original principles and values have become dissipated over these last 12 years, which is not a surprise or shock to me at all. The various criticisms made in some of the comments in this thread about AMHPs not challenging doctors should be seen in the context I have described. I cannot see things getting better but only worse. It would be good if some secret millionaires turned up and bolstered the system because this government definitely won’t!!
To a large extent I agree with Neil. But there is always a but! New Labour introduced management consultants, McKinsey as the favoured firm, into the NHS and to ‘modernise’ mental health services. Their fees swallowed up most of the investment. My service in Lodon alone paid £175,000 for 6 weeks of consultancy. So I cannot agree that there was a huge investment into direct services under New Labour on a scale. We can argue about the causes/reasons for the increase in young people coming into mental health services ofcourse. My view is that the reframing of genuine distress and unhappiness as mental health conditions is something we should question. It’s mainly girls who are being brought into psychiatric services and we should ask why? I was born and brought up in a country where political prisoners were treated as having a mental illness inorder to invalidate their activism. When eventually the regime collapsed the rate of mental illness and hospital treatment dropped significantly. We should be cautious when presented with these narratives in our country. As is the case with AMHP training becoming a legalistic checklist so mental health nurse training. I used to teach on a combined health and social care degree and saw how nurse training became more about treating mental illness rather than a broad nursing skills.