Community Care is a specialist publication for those who work in social care, including Approved Mental Health Professionals. They recently published an article covering comments made by the AMHP Leads Network, to whom I’ve been privileged to present in the past. The article focusses on the difficulty faced by AMHPs in coordinating and completing Mental Health Act assessments given the unique role our AMHP colleagues play in that process. If you don’t know much about the AMHP role or those who go AMHPing, consider a previous post of mine to understand it but suffice to say this: in all of the many presentations I’ve done on this topic, I think the only time I received a spontaneous round of applause was at an AMHP Lead event in Liverpool where I commented on my admiration for those who do the role. I said something about them having all the responsibility without being able to direct of command all of the resources required and being left in the middle, often on their own, to ring master a circus — responsible for everything and in charge of nothing.
The main argument of the AMHP Leads Network is the “lack of duty on partner agencies to support Mental Health Act assessments” (MHAA) and it’s certainly true. In order to convene an MHAA, an individual AMHP may need to assemble two doctors (one of which must be section 12 approved) and potentially a nurse from a community mental health team who knows the patient, the police service (either to execute a s135 MHA warrant or to prevent a Breach of the Peace) and an ambulance crew (for conveyance to a Place of Safety or hospital). They may also need a locksmith (to drill out the lock instead of the police applying their rather crude ‘key’ to the door and destroying it to gain access) as well as someone who may be able to take care of the patients’ pet(s) if they have any and crucially of all, the AMHP will have been playing various types of games in advance / during / after the MHAA with the local NHS bed manager to identify a bed for the patient to go to, in the event they are sectioned?
AMHP services are struggling to recruit and retain at the moment so if you fancy taking care of the issues in the last paragraph for a modest salary that belies the responsibility involved, then you can probably find vacancies most places you look if you have the correct qualifications!
THERE’S NEVER NOT A BED
So let’s start with the issue of beds: more than once in my time I’ve heard it argued – indeed I’ve heard it shouted (at a senior police officer, actually) — “there’s never not a bed”! Yet here we are, with those who most keenly need to know, telling us there is all to often there is no bed to which a MHA application may be made for patients who need it. Most police officers know this: it’s why officers are often waiting for hours or days in various kinds of hospital situation for the AMHP to be told by the NHS from where the bed will come, to allow an application to be made. It’s why we sometimes hear of AMHPs making applications under s2 MHA to hospitals which have a Place of Safety in it, so a person may be held there beyond the 24hrs afforded by section 136 of the MHA until the bed is properly identified and the patient transferred.
There is an obligation on Integrated Care Boards to commission beds and a specific obligation on them under section 140 MHA to identify hospitals which can receive patients urgently, but our AMHP Lead colleagues are clearly signalling here those duties are honoured more in the breach, than anything else.
They also point out the difficult position regarding “section 12” doctors – no NHS organisation carries a responsibility to ensure the availability of a s12 doctor for those situations which always demand one. All admissions under s2 or s3 MHA require a s12 doctor and during the daytime, it’s often possible to source a registrar or consultants who is s12 approved. But try doing that at 2am on a Tuesday in a rural area for a MHAA that is required somewhat urgently. I’ve known AMHPs talk about making 35 phone calls, literally, in order to find that no doctor is willing to help. These recent AMHP lead comments are making the case for there being a duty on NHS organisations to ensure availability, which doesn’t seem unreasonable given the absence of such a specialist could and does prevent the state discharging article 2 responsibilities relevant to keeping people alive.
And don’t forget: if there is a delay identifying the bed, another AMHP may need to re-assess the patient to be able to make the MHA application, because unless the original AMHP is still available hours or days later, the subsequent AMHP must by law satisfy themselves the application is required.
OUT OF AREA TRANSPORT
The list keeps going: there is no duty on any organisation to assist an AMHP with out-of-area transport. You can probably imagine why an ambulance service which is struggling to service 999 calls for life-threatening emergencies is reluctant to commit a crew to a 200-mile round trip to another region to admit a patient. In any event, paramedics rarely agree to take legal responsibility for detention during conveyance of any distance, so if there is the slightest chance someone may refuse to be transported, it may lead to requests for the police to support that conveyance and be declined for similar reasons. Some forces have policy they will not convey outside their own force area and certainly they will not do so alone (which is in keeping with the Code of Practice, in all fairness to those forces – people should not be conveyed by police vehicle, unless in an unavoidable emergency situation).
So the poor old AMHPs are often left with their own ability to escalate, persuade or beg help from these various parties. Not a job I would fancy, in all fairness and full kudos and credit to those who do it.
Finally, the comments point to something most people know: mental health related demand is rising and more than once authoritative source is pointing to meltdown and crisis in mental health services, even beyond that which was known to be there a decade or more ago. MHA admission are going up, use of s136 MHA is going up, services have been restricted and cut back and we’re seeing the emergence of initiatives which are designed to push back against the consequential demand which flows to criminal justice and emergency systems. I’m not sure where this goes from here, quite honestly but I suspect such overwhelming demand on the system or sub-systems means it’s long since become a game of pass the parcel, so when the worst occurs, everyone can try to distance themselves from the responsibilities that a coroners court will inevitably highlight; and already has in all too many tragic cases.
Good luck to those ladies and gents who go out each day AMHPing — you have my respect and admiration for what you‘re prepared to do, staring from the centre at a system at a critical point in time after it evolved to leave you responsible for everything and in charge of nothing.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2023
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 