Reductions in Mental Health Act (MHA) detention numbers are masking increased demand for approved mental health professionals’ (AMHPs) services and unmet need for care.
That was the warning from the AMHP Leads Network after official data showed that MHA detention numbers in England fell by 7.7% on a like-for-like basis from 2021-22 to 2022-23, following a 5.7% drop the year before.
In the vast majority of those cases, an AMHP – who is typically a social worker – will have made an application, with the recommendation of two doctors, for the person to be detained following an assessment.
Increased demand for AMHP services
However, though detention numbers have fallen, the network said AMHP services were reporting increased demand year on year.
Under section 13 of the MHA, councils must engage an AMHP to consider a person’s case if it has reason to believe that an application may need to be made to detain them in hospital or taken into guardianship.
Network co-chair Christina Cheney said the number of such section 13 requests for consideration was growing. This appeared related to “significant pressures on all community and crisis mental health services who, unable to meet demand themselves, will often refer on for assessment by an AMHP”.
AMHPs, she added, were “rising to the challenge” of finding alternatives to detention for people in crisis by mobilising the support structures around them. However, this work was not being captured by the official figures, published by NHS England, she warned.
Lack of beds ‘preventing necessary detentions’
A second issue was that AMHPs were finding it harder to admit people to hospital when detention was necessary “for sheer lack of beds”, leaving significant unmet need, she added.
“While AMHPs work hard to prevent detention being the outcome of an assessment, they report that frequently when it is the only safe option, it often is not possible because no bed is available,” said Cheney.
“In these circumstances, people are often left at risk, admitted to acute hospital or held for long periods in A&E, police custody or at home.”
Concerns echoed by ADASS and NHS leaders
The network’s concerns were echoed by the Association of Adult Social Services (ADASS) and the NHS Confederation’s Mental Health Network, which represents sector providers and commissioners.
“AMHPs do a great deal of work finding solutions to meet our needs, protecting our rights and ensuring that we are only detained when we are acutely mentally ill if necessary, which has in part led to this reduction,” said ADASS’s joint chief executive, Cathie Williams.
“But there is a growing need for support for mental illness and it’s hard to see that the lack of availability of local, specialist acute hospital care isn’t impacting on social work and health professional decision making.”
Meanwhile, Mental Health Network chief executive Sean Duggan said: “Mental health leaders will be cautious about celebrating a drop in detention as these are actually likely to hide a level of unmet need due to the sector facing huge increases in demand since the pandemic against little additional funding.”
Calls for better AMHP data
All three bodies called for data to be collected on demand for AMHP services and on practitioners’ activity, in order to improve planning of mental health provision.
Cheney said: “In order to learn more about trends in mental health need and our services response to it, we must gain a full picture of the work going on under the Mental Health Act, not just a record of times when detention has been used – this is less than half the picture.
“The network is working to support proposals to develop and implement a national AMHP data set and we need support from government to ensure this is achieved.”
This was echoed by Duggan, who added: “To more accurately gauge the level of demand services are facing across different parts of the system we would need wider data to show the number of requests for detention made by approved mental health professionals (AMHP).”
Williams said that ADASS was “actively working with Department of Health and Social Care colleagues in the hope that this ‘missing data’ can be made available at a local and national level in the future”.
30% workforce gap
The calls come with the AMHP workforce in England having remained stable since 2018, with between 3,800 and 3,900 practitioners in post, according to successive surveys of local authorities carried out by Skills for Care.
However, in its 2023 survey, the workforce development body found that councils would need to increase the number of full-time equivalent AMHPs by 30% to fully staff their services.
There are also concerns about the impact on health and social care services of a new national policy for the police to only attend mental health incidents when there is a suspected crime or significant safety risk.
The AMHP Leads Network, charity Mind, the Local Government Association and the Royal College of Psychiatrists are among those to have voiced concerns that Right Care, Right Person is being implemented too quickly for mental health services to respond to the ensuing increase in demand.
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Our team shares office space with the AMHP service. The demand on them is intense and they have vacancy issues. It’s clear though that perhaps due to those pressures the pressure they put on referrers and families is at times brutal. Professionals can give as good as they get from the service but families less so. This is obviously anecdotal but it appears standard for AMHPs to ask families to cope, look after and safeguard relatives before any response is arranged. Lack of workers, lack of resources and lack of beds are real issues but so is expecting as a matter of course that families, friends, neighbours being first responders, support networks and safeguarders. We should highlight pressures on services but we should also acknowledge that expecting families replace professionals as a matter of course is wrong.
Why are we as a profession so wed to the medical model of mental health intervention? Hopefully positive results from the large randomised control trial on Open Dialogue services in the South of England will be forthcoming to allow for a genuine alternative model of service to be explored.
Families are wedded to the medical model because they know from experience that the claimed alternatives are social workers telling them they should cope, look after, safeguard, counsel the person they are asking help for. Services love the medical model because it costs them little in funds and avoids having to develop strategies and properly funded support networks. AMHPs love the medical model as they get to play doctors without the training or the responsibility for diagnosis. Win win for services, AMHPs, doctors. Added bonus for professionals in dumping massive responsibilities on families, friends, neighbours and then smugly pretending that all of this is giving choice and autonomy to the unwell person. If I wasn’t a social worker and former AMHP I might regard all of this as an abrogation of professional responsibility.
Is the medical model so cost effective if the average psychiatric bed costs £2,000 a day plus? And the average Psychiatrist salary is £100,000 plus?
Medical model is cost effective for adult social services because the cost of beds and inpatient care is on the NHS. The salary you quote is for Consultant Psychiatrists at the top of the pay band and there are around 300 Consultant vacancies. Care outside of inpatient settings,however defined, is never cost effective either given that what little alternatives there are to relatives, friends and neighbours, is mostly provided by private contractors. Medical model isn’t cost effective but the burden put on families is crushing so until our so called alternative to admissions lift that pressure off families, they will want it. Just as they value CPNs as their more consistent contact. Hand on heart what are we offering as an alternative to all of that?
https://www.kmpt.nhs.uk/information-and-advice/open-dialogue/
I’ve worked under the MHA since 1996 and have never pretended to be a doctor ,or had the inclination to do so. Medical model – what is this exactly? I’ve worked in a crisis service / MH setting for 30 years and it costs them a helluva lot of money to find beds , they (NHS colleagues) work very hard to provide an alternative to hospital as part of their gatekeeping service, with admissions being the last resort if the least restrictive option is not feasible, or if there are family members / spouses etc that they cannot manage even with 7/7 home based support and so on
I don’t disagree with wh’at you are saying Tahin at all, but I am always puzzled why AMHPs are singled out for particular criticism. It is the systems around people and their carers that are broken, and you are right this sends those most in need of care into a hospital bed. These are social, economic and political failings. Not something that AMHPs, CPNs or doctors have any control over.
I have never met any AMHPs who are ‘playing at doctors’. Diagnoses are recognised as constructs which have aa variable use to either the person being ‘treated’ or the professionals trying to do so. Pyschiatry is well aware of this itself. This is not a medical model versus social model situation and it is overly simplistic and somewhat lazy to think it is.
What I do see is workers – nurses, social workers, AMHPs, Doctors who are completely worn down by a shortage of resources, and systems that exacerbate this.
Lets focus on the real problems here – poverty, inequality ( health and otherwise) and political indifference and ineptitude and stop bashing our colleagues and each other.
Not bashing, not denigrating, not out to make disparaging comment. I was an AMHP so I know the constraints within which practice takes place. I comment on AMHPs when I read a narrative that portrays colleagues as mere cogs made to act against their training and so forth by circumstances, resources, demanding managers and disinterested professionals. I don’t like the we are autonomous but we are also powerless responses depending on the discussion. All of us graft to do the best we can but the price of open discussion is honesty. I know a good few AMHPs who patronise non-AMHP colleagues by parading their “medical and legal knowledge” to assert their specialness. Status matters to a lot of AMHPs perhaps as a survival mechanism against other colleagues burdening them with expectations they can’t meet. I always railed against that when I was an AMHP and criticise it now I’m a mere social worker. For me it’s not enough to bemoan lack of resources, bad management and power dynamics without challenging the choices made by those in charge who create the environments we work in. Nothing can change and political expediency will always win if we do not have honest discussions. I also know that unless we own our part that when we choose to look away the services we deliver remain inadequate. Acknowledging that we often knowingly add to the the strains faced by families through the mantra of no beds, lack of resources is not bashing collagues. That is my experience as an former AMHP and current social worker. Not that it should matter in a professional forum but my parents know all too well what services expect of them to care for and supervise the medication of my brother. So when I referenced “hand on heart” it wasn’t a rhetorical question.