My Kingdom for an AMHP

Guest Blog from @asifamhp

I have been an AMHP now for a number of years. The job has changed, the organisations that I work with have been restructured several times. The politicians have come gone. Through it all the cases keep coming.

AMHPs inhabit a twilight zone in the gap between the NHS and Social Care. We fill the gap between H&SC and the Police.  Too often AMHPs are stuck in the middle of interagency partnership working not actually working very well. AMHPs have lots of responsibilities and duties.  Ultimately as AMHPs we exercise legal powers to remove a person’s liberty (it’s the AMHP that make the application to detain (“section”) people not the doctor).

This is a lot of power; remember the person has usually has done nothing wrong.

An AMHP can go to a Magistrates Court to get a warrant that allows the State to enter homes uninvited (using the big red police key if required) and if necessary use force to remove a person to a Place of Safety. But an AMHP cannot direct or instruct a medic or police officer to turn up.  AMHPs also can not require an ambulance to be dispatched to convey someone from their home to the now almost mythical hospital bed.

In my current role as dispatcher of AMHPs, I have become acutely aware of the difficulties faced by my colleagues and I am concerned that our voices and opinions are not often heard or valued. The role of the AMHP is a vital one but I fear that it is one that is almost invisible.

Coordinating a Mental Health Act Assessment is all too often a problem solving exercise in terms of sorting a hospital bed that does not exist. I worry about working with partner agencies that are unwilling or unable to help. These are practical problems that present AMHPs, in often very challenging and sometimes risky situations, with a huge amount of heart and head ache.

The difficult bit should be the engaging with the person and their family,making the decision to detain or not, however all too often it’s the other stuff that is the difficult bit. The stuff that everyone else assumes and takes for granted will be there.

BTW if required, a hospital bed is the doctors job to sort – honestly it is!

Countless policy initiatives try to sort out Mental Health.  There has been a Mental Health Task Force, a Crisis Care Concordat, a 5 Year Forward View, most weeks another report is published highlighting system failure. But acheiving Parity of Esteem for mental health with physical health still feels some way off yet.

The lack of value given to mental health becomes acute when I am coordinating Mental Health Act Assessments. I often find that I have to find a Section 12 medic whilst also trying to do the assessment. That’s a bit like an ambulance having to find a paramedic on route to a Road Traffic Accident.  And that’s before we even talk about hospital beds for someone who is really ill and needs one.

I invite you to contact your local CCG ask them about the arrangements/contract they have with your local Ambulance Trust in relation to the conveying of patients that require admission to hospital? Better still ask them about the arrangements they have in place for the conveying of someone who is detained and in legal custody, but resistant and objecting? Ask the CCG about how much they are spending on placing people out of area in private (for profit) provision and then ask them if they have read the MHA or Code of Practice? Ask them and your local NHS MH Trust if they are familiar and complying with the duty imposed on them by Section 140 of the Mental Health Act? While you are at it, ask your local Acute Trust if it’s Emergency Department is a Place of Safety? There are lots of other questions worth asking if you are interested.

A Mental Health Act Assessment is many things, all bundled up into a big fat mess sometimes. But people tend to forget that it is also a legal process and AMHPs are at the heart of that. The starting point should be the Mental Health Act itself (Guiding Principles and all) and the Code of Practice. I wish more people involved in all this would actually read them and adhere to the Code of Practice in particular.

I fear that Psychiatry is overly reliant on coercion and has developed an erroneous understanding of risk assessment and risk management that reflects and reinforces stigma.  I also worry about big Pharma and its link with psychiatry – but for another time/blog.

The role of the AMHP is to reduce risk.  This is not an exact science, no one wants to be blamed when things go wrong and they do go wrong.  However we must guard against moral outrage and panic when things go wrong.  We need to think about evidenced based practice. We also need to remember what we do impacts on the people, sometimes in negative and damaging ways. We need to be given the time to think about our decisions as AMHPs properly and to be supported to do this in the least restrictive manner possible. Far too often a mental health act assessment is seen as a solution to a problem, when perhaps the solutions  is something else.

Medics are too quick to reach for the MHA and are completing too many Medical Recommendations. They are then exiting stage left and all too often have no idea where the bed is. I can think of no other branch of medicine where the highly trained and very well remunerated expert is allowed to leave others to get on with it. I also believe that AMHPs are making too many Applications to detain people and again that this is multi layered issue that needs to be properly analysed.

Conversely I see people who should remain in hospital being discharged too early to “unblock a bed” and then being assessed and readmitted very quickly. At the heart of this is the lack of sufficient, appropriate inpatient bed provision and lack of investment in community services.  The commissioning arrangements for mental health are not good enough leaving children and adults too often being placed often 100s of miles away from home, in private (for profit) provision.

For the most part my AMHP colleagues, up and down the county, are extraordinarily committed and skilled individuals.  It is an absolute privilege to witness how many of them go about an extremely challenging and at times risky task with humility and humour. Many go way beyond what could or indeed should be reasonable expected of them.

Do we always get it right? No we don’t.

The MHA is a very complex piece of legislation requiring AMHPs to make often very complex decisions, in difficult circumstances, without necessarily being in possession of all the facts and under pressure from various interested parties. Being an AMHP is not an exact science. It takes a fine/funny blend of skill, knowledge, experience, values, support and luck to develop an AMHP who is able to successfully and safely undertake the task. Please don’t take the invisible AMHP for granted. Throw in the MCA interface and it is an almost an impossibly complex job to do.

I have been unlucky/privileged enough, depending on your view of the world, to have assessed three generations of one family. That really was a moment for me to take stock and to wonder about the broader issues in terms of inequality of opportunity, substance misuse, nature V nurture and the whole medical V social model.  Working with that family I really wondered about the role and purpose of psychiatry and my part in that as an AMHP.  AMHPs see often very real and often harsh realities of everyday life and the impact of multiple layers of economic disadvantage, oppression and inequality of opportunity.

AMHPs, as people, are also shaped by our own history and experience of life.  AMHPs like everyone else have personal experience, either directly or indirectly, within their family or friendship groups, of mental health issues. I really like the “those of us” inclusive statements when I hear people talk about experiencing mental health difficulties/distress/illness. AMHPs have to be able to be firm and keep positive. Like other AMHPS, I have over the years had to coordinated some very challenging and difficult MHA Assessments. I have been out with the armed response unit, been on rooftops, been assaulted and called all sorts of names.

As an individual I am reasonably robust and have a well developed sense of humour. I have also managed (I hope) to hang on to “the what” initially motivated me to become a Social Worker and this helps me deal with and manage some of the challenges that I face. I have also been lucky enough during my career to date, to have had some very motivated and skilled colleagues who have supported and encouraged me. I think of them warmly and I am in their debt. I have met some very lovely people and families on my travels.

As AMHPs we are often asked to do “something”  when appropriate we use the MHA to detain an individual or in the case of a Community Treatment Order to place restrictions on their choice/liberty. Equally importantly we decide not to detain or restrict.

We often meet people at a low point in their lives and when they are in crisis and distressed. This can be very difficult for them and us; at times it can be very stressful or just plain ugly. It can also, over time, have an impact on you as an individual. I am not sure that that is fully appreciated by our employers, but I am grateful that I have colleagues who understand this.

Moving forward I think AMHPs might be exceptionally well placed to be in demand. However there are fewer of us and we are getting older together as a group.  I wonder who is planning for and thinking about the next batch of invisible AMHPs. Most people have no idea what an AMHP is or what an AMHP does and unfortunately that includes some who should.

With that increasing popularity/demand for AMHPs, I hope comes some recognition and interest in all things AMHP and with that, a voice that might be heard. I hope that voice echoes and advocates for the people and families we work with. Because what really concerns me about being invisible is that the cloak of invisibility is also wrapped around the people and families we work with/for. Very often at the point of crisis in mental health, it is an AMHP that is required & sent for.

Now is the winter of our discontent

Made glorious summer by this sun of York;

And all the clouds that lour’d upon our house

In the deep bosom of the ocean buried……………. An AMHP an AMHP, my kingdom for an AMHP!