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Memorandum submitted by the ASW Leads Network (MH 66)
'When I first started working as an ASW 20 years ago, I seemed to spend a lot of my time arguing to keep people out of hospital. Now, I seem to spend at least as much time arguing to get people into hospital when they need to be there as I ever do looking for alternatives.' Long term ASW, London.
'every member will have dealt with constituents whose lives have been affected, often tragically, by mental illness.' The Secretary of State for Health -Ms Patricia Hewitt 16th April 2007
So how long do you think it would be reasonable for one of your constituents, who was suicidal or perhaps threatening to harm someone as a result of mental illness, to wait for assessment and admission under the MH act?
2hours? Maybe 4hrs? 24hours?
How about 2 weeks?
'One inner London borough reported a delay of one week in the case of a forensic person whom concerns about high risk to others had been reported including specific threats to a named person. In the one week delay, the service user had seriously assaulted the person he had stated he would assault.'[1]
'The police started to limit their support to Thursdays only, and with a large group of officers, and a limited number of assessments on that day. During this period we had a couple of near misses where men we were wanting to assess with police involvement were arrested and presenting a high risk to others in the time we were waiting for a police 'slot' to become available.'[2]
The modernisation of mental health services has made great progress in making sure that where ever possible people who don't need to be admitted to hospital can be supported in the community. But where people do need to be admitted, serious problems are arising across the country in accessing beds.
'I wish first to emphasise the Government's objectives, which are to make sure that people with serious mental health problems receive the treatment that they need;' Rosie Winterton Opening of committee 24th April 2007
Despite the Governments' good intentions, unless the practical problems that beset admissions are resolved, they will fail in their central objectives - to make sure people who need care receive care, and to make sure that the public and the service user are protected where necessary and appropriate.
'Our starting point is that if the person's mental condition, whatever its cause, is putting them or others at risk sufficient to warrant detention in hospital for treatment, then there should be no arbitrary obstacles to the Act being used.' Lord Hunt of Kings Heath Report Stage, House of Lords 19th Feb (column 970)
47,000 people are sectioned every year. 27,000 of those people are admitted from the community into hospital. All those assessments are managed by Approved Social Workers, and it's the ASW together with service users and carers who faced the dilemma and risks of lack of access to beds, police or ambulance support - even though they have little power over the resources.
What we want: amendments to section 6 and section 140 MHA
We want · all services that are involved in admissions to hospital[3] to have to work together, · all services (led by the PCT) to draw up local, binding protocols on how to admit people (including special groups such as Young People and People with a Learning Disability) and publish them · To ensure that informal patients are treated with equal respect and urgency to those on section.
The amendments we have tabled focus on these issues by1. Ensuring that the AMHP can make an application as soon as it is appropriate to do so by shifting the responsibility for the person from the ASW/AMHP to the Trust as soon as an application has been signed - thus producing pressure and organisational motivation to resolve the issues over beds and conveyance to hospital.
2. Setting standards to ensure all local services cooperate and develop plans that support admissions to hospital where they are necessary and appropriate, by putting this into statute. The requirement to have agreed policies with the ambulance service and police have existed in the Code of Practice since 1999, this has not resolved the problems that exist because until the patient arrives on the ward, the trust has limited responsibility for them
Access to Police Support: page 6
'Police response for higher risk clients is in fact longer than for low risk clients. A level 2 response or higher can take up to a wee[4]k or is only done on certain days of the week.'
'Assessments needing tactical /firearms officers can only be booked alternate weeks, and can be cancelled at short notice.' Timely access to police support is a key issue that must be addressed rapidly to protect the public and the service user.
Access to Beds: page 9
'Up until last week I would have said that we in the North East rarely encountered serious conveyance and transport issues but last week we had four police officers, Consultant, ASW & GP all engaged all afternoon at considerable cost whilst messages on bed availability changed constantly from "yes we have a bed" to "oh sorry we don't" to 'yes we found one' then again 'no we haven't' (different views on use of leave beds between consultants & ward managers). By the time one was found (a private bed at £800 per day some 50+ miles away) the Chief Inspector had already instructed all police to leave - he had had enough. It was another 24hrs before Police support was available, which left a vulnerable client at risk on his own in the community.' ASW Lead Northeast England
Beds for specialist groups of service users: page 12
'The most challenging assessments are often with young people or people with learning difficulties. This is not because of the assessment process so much, as the fact that few specialist resources are willing to admit in an emergency and when they do admit, many want the patient to already be subject to section 3 of the act. Clearly, this is not appropriate if this is the young person's first presentation. Young people are most likely to end up on adult wards because nowhere is willing to take them in an emergency.' ASW lead London Beds for informal patients: page 13'I was told by the crisis team it wasn't possible for my son to be admitted to the local psychiatric unit unless he was on section. I was amazed when we succeeded in admitting him informally.' Carer North London
'Most of our admissions are sent to private hospitals out of areas because of lack of local beds. Local matron refuses to accept voluntary admissions.' ASW south west England
Conveyance to hospital: page 15'I recently had to wait for several hours for the ambulance because they needed the police to attend at the same time. I waited from 16:00 hrs until 21:00 hrs. During this time the patient became increasingly agitated and distressed.'ASW east Anglia
Change is possible. The motivation to change is the issue.
That is the purpose of the proposed amendments - to provide motivation to large organisations such as the health service, to persuade them to resolve these growing problems. Large organisations appear to respond best to targets or corporate risk. It hasn't been possible to set targets, therefore the only option is to pass over the risks associated with admission more firmly to the Health Service who control resources such as beds and transportation and away from the ASW/AMHP who has little control over either.
1: Background to submission
The ASW Leads Network was set up in 2006, to represent the views and concerns of senior managers and trainers within mental health service who manage ASW services or run training consortiums on behalf of Local Social Service Authorities. Through those ASW leads, we have also been able to reach out to front line ASWs and gain their views and opinions on the difficulties they face at the coal face of mental health work. We have a National Membership, and have worked with the British Association of Social Workers to ensure that our views and concerns were expressed during the debate in the Lords. The amendments were based around the following areas that ASWs had told us were of concern to them:-
· Maintaining and supporting the independence of the ASW/AMHP role · Ensuring access to police support where it is necessary to facilitate safe admission to hospital · Ensuring timely access to beds and conveyance to hospital when admission is necessary · Issues related to training and retaining staff
Background
Approved Social Workers (ASW's) are involved in approximately 47,000 formal admissions every year. 27,000 of these assessments involved admissions from the community into hospital. The remaining assessments involved people already in hospital where access to beds and other resources are less of an issue.
The issues that the ASW leads have focused on are therefore the practical problems that are encountered at the interface between the community and the hospital - on making sure that assessments continue to be conducted in a fair and supportive manner, and the factors that currently make assessments more dangerous and stressful for all involved - the problems that stand in the way of people getting the help that they need. 2: Access to Police Support
'Police response for higher risk clients is in fact longer than for low risk clients. A level 2 response or higher can take up to a week or is only done on certain days of the week.'
'Assessments needing tactical /firearms officers can only be booked alternate weeks, and can be cancelled at short notice.'
The quality of support available from the police has improved year on year - ASW's appreciate the professionalism that is now available. However, increasing concerns are being expressed about the accessibility of that police support. In some areas of London, for example, ASW's are waiting up to 2 weeks for support to execute warrants under section 135 of the mental health act, and where risks are greater (for example, where the person who needs to be assessed is known to have access to weapons such as knives and guns), the wait is the longest.
We welcome the opportunity to work with ACPO to draw up national guidelines, but remain concerned about how these guidelines might be interpreted at a local level, as experience in London has shown that the recent guidelines around the use of s135 have not resulted in any significant changes in behaviour.
Additionally, we are concerned that parliament has not addressed one of the central difficulties identified initially by the MET Police, that there is a lack of clarity around the legal position of staff such as Ambulance Personnel and the Police when they enter premises in support of the ASW/AMHP conducting the assessment.
'The Police say that they don't always ask for a s135 warrant, but in practice when the risk assessment comes back that's what they ask for, even in situations where ASWs wouldn't be able to justify asking for it.' ASW Lead North London
Delays can also occur where someone is assessed and placed on section whilst on a medical ward - for example after an overdose.
'The client was assessed and placed on section 3 after admission to a medical ward following an overdose. This was on the 2nd March. The client didn't want to go to the psychiatric ward, and police support was requested. The police risk assessment was faxed off on the 6th March, but it took until the 13th March for the police to provide the necessary escort.' ASW lead Central London
What the law needs to determine:
To remove the obstacles that make admission more difficult by making sure statue and regulation stipulates · Policies on admission should be drawn up and published as a legal requirement - the code already tells all services to cooperate and draw up polices but this hasn't been enough to resolve difficulties people are experiencing. · Setting standard response times for the police, so that requests for support with a community assessment (with or without a s135 warrant) should be ideally be dealt with within 48 hours, and in no longer than 5 calendar days. · That any delays should be reported and monitored via Trust and LSSA incident reporting systems (and that these incidents should be highlighted during external inspections). · Setting standard response times for admissions to hospital (no more than two hours between the end of an assessment and arrival on the ward) · Monitoring those standard times by inserting times on the section papers and admission papers for BOTH formal AND informal patients · That wait times above 2 hours should be reported as incidents by trusts and incident reporting systems (and that these incidents should be highlighted during external inspections).
3: Getting people safely into hospital following assessment.
'I always feel the bit between completed forms and arrival is probably the time where things could go wrong for the ASW in terms of others not having to share the responsibility.' ASW lead East London
Once an assessment has been completed, if the patient is in the community they have to be safely transported to hospital. The ASW's responsibility continues until the person arrives on the ward and, if the person has been placed on section, the legal responsibility for the person lasts until the receiving hospital has accepted the papers - this is despite the fact that a lone ASW has little control over the two resources that determine how quickly admission is possible:- · access to beds and · control over the means of conveyance - ambulance support.
These two issues will be dealt with in turn.
Access to Beds
'Up until last week I would have said that we in the North East rarely encountered serious conveyance and transport issues but last week we had four police officers, Consultant, ASW & GP all engaged all afternoon at considerable cost whilst messages on bed availability changed constantly from "yes we have a bed" to "oh sorry we don't" to 'yes we found one' then again 'no we haven't' (different views on use of leave beds between consultants & ward managers). By the time one was found (a private bed at £800 per day some 50+ miles away) the Chief Inspector had already instructed all police to leave - he had had enough. It was another 24hrs before Police support was available, which left a vulnerable client at risk on his own in the community.' ASW Lead North East England
'Service users are moved from one hospital to another and then maybe onto another because of bed shortages. This affects continuity of care. They are treated by a different consultant and by a team who often do not know them.' ASW South East England
Given the resources that have been channelled into the Health Service, MPs may not be aware of these acute shortages of beds that some mental health trusts are grappling with. This is particularly worrying given the fact that by the time most people are assessed under the mental health act, other resources such as crisis resolution teams have already been tried. The person is therefore often more unwell than they may have been in the past when admitted, and more likely as a result to have to be admitted on section. It is also ironic that at a point where 'Our health, Our Care our Say guidance' is encouraging the commissioning of more locally based services, in mental health services, services users and their carers face travelling excessive distances and being treated by unfamiliar practitioners, because of lack of local beds.
Timely access to beds has become an increasing problem as the policy of 'community is best' has ignored the fact that there are times when people DO NEED ASYLUM; they need a safe place to recover, resolve the problems they are experiencing. Current funding shortages are leading to further closures of inpatient beds - despite evidence of bed occupancy levels above 100% for many trusts.
'By the time we get to assess people, there is often no other option as the crisis team has already been tried, and failed, and the person themselves is often far more unwell.' ASW South West England
In law, it is the responsibility of the health trusts to find appropriate beds. In practice, often the ASW finds themselves arguing to ensure a bed is available. Not having a bed either leads to ASWs having to delay assessments until one becomes available, or being in the position of having completed an assessment but unable to make an application because this must be made to the hospital that the person will be going to, and not the trust who are responsible for finding the bed. Either situation 'hides' the fact that there is a person in the community who is so unwell that they need admission to hospital either for their own health because they are a risk to themselves or because they are a risk to other people.
'ASW's remain in a difficult situation. Whilst we are aware of the duties of the PCT under S140 of the MHA 83 to inform the social services authority the whereabouts of the hospitals who are able to accept patients in an emergency it does not place a 'duty' on the hospital to accept the patient.' ASW Home Counties
'You are less likely to detain because of the pressure on beds. Objectivity is compromised' ASW Central England
There is no current incentive on funding authorities to make sure beds are available in an emergency. S140 of the act provides a duty on trusts to inform LSSA's where patients should be taken in an emergency, but in practice many trusts get around this requirement by simply refusing to say where the place for emergency admissions is - and with LSSAs increasingly disinterested in the issues for ASWs there are often few people with sufficient authority to insist they change this stance. In fact, in the face of NHS budget deficits Mental Health Trusts have often been expected to bear the brunt even if they themselves are not at fault, and a national loss of beds to make the books balance is currently in progress. This will clearly make the situation worse.
A mental health assessment in the community is no less an emergency than an assessment in A&E, and people being assessed there should have a right to expect equally prompt service, and clear time limits for admission.
3 :Beds for special groups of patients
The government has focused its attention on ensuring that people in need should not be turned away solely on basis of having the wrong 'sort' of mental health problems. However, the government's aims will not be met if focus is not also paid to the issue of provision of resources particularly making sure resources intended for mental health reach mental health services.
Two examples of issues follow:
People with personality disorder
''Tim' was a well known patient, one of the few I have worked with who would fit into the category of having a 'dangerous psychopathic personality disorder.' He had a history of violence, and had in the past held hostages. He was brought to the hospital one afternoon after problems in his personal life led to a decline in the stability of his mental health. Both myself and the doctors, including his consultant, wanted to admit him to stabilise his condition. We did not feel it would be safe to admit him onto an open ward where the lack of structure, number of other vulnerable patients and lower staff ratios were likely to increase the risks of a violent outburst, but no PICU (Psychiatric Intensive Care Unit) would accept him because he had a personality disorder. This was despite assurances that we felt this should be a short term, structured admission. After 8 hours of fruitless searching, faced with the prospect of a risky admission to an open ward, we reluctantly decided to allow him to go home with his partner. He was admitted the following day and discharged again within 72 hours.' ASW central England
Children and Young People
'The most challenging assessments are often with young people or people with learning difficulties. This is not because of the assessment process so much, as the fact that few resources are willing to admit in an emergency and when they do admit, many want the patient to already be subject to section 3 of the act. Clearly, this is not appropriate if this is the young person's first presentation. Young people are most likely to end up on adult wards because nowhere is willing to take them in an emergency.' ASW lead London
The s140 amendment provides the Government with the opportunity to direct all PCT's and local services to work together to ensure that all service users - including those from disadvantaged groups such as those with personality disorders, young people, and people with learning disabilities, can be admitted in a timely fashion to suitable services, especially in an emergency.
Targets have proved successful in ensuring that large organisations such as the NHS do focus on issues of public importance - such as wait times in A&E. As we have already suggested, a mental health assessment should be seen as much an emergency as an A&E visit, and be monitored accordingly.
We would suggest that in the case of Mental Health Act assessments, times should be inserted onto applications forms and admission forms, and trusts be expected to record and report on any admissions that take more than 2 hours to facilitate. The collection of data could be achieved via existing mental health act administration systems.
Informal Admissions
'The setting up of the assessment was no problem, I arranged for 2 consultants, including a forensic specialist as we were dealing with a patient subject to s48 of the Act, to join me at the specialist hostel. The assessment went well and with the support of the hostel manager, the patient agreed to informal admission. The problems came with access to the bed. The bed manager in the neighbouring borough (who had a bed ready on the PICU ward) then said that if this man wasn't on section not only could he not go to the PICU, but that he would have to go via the crisis team to access a bed on an open ward. As this was out of hours, the crisis team refused to leave the borough to assess, and once the ambulance service heard that he was not on section, their response time dropped from 2 to 6 hours (with no guarantee). Having gone around in circles for a couple of hours on this matter, at 4am I gave up, arranged for extra help to be brought into the home during the remainder of the night, and left it to the day time team to sort out.' ASW London
ASWs are often put in the difficult position of working towards the least restrictive option, yet also knowing that by doing so the admission will be seen as less 'urgent' and likely to be significantly delayed.
'I was told by the crisis team it wasn't possible for my son to be admitted to the local psychiatric unit unless he was on section. I was amazed when we succeeded in admitting him informally.' Carer North London
'Most of our admissions are sent to private hospitals out of areas because of lack of local beds. Local matron refuses to accept voluntary admissions.' ASW south west England
'I was asked to undertake an assessment on a man who had been seen by a colleague 24hrs earlier. He was in a medical bed after making a serious attempt on his life. My colleague had completed the assessment, and made it very clear in her report that although he was agreeing to informal admission, in her view he otherwise met the criteria for admission and she would have placed him on section 2 had he not agreed. It took more than 24 hours to locate a bed, by which time he was refusing to go. I could not help wondering whether his informal status had contributed to the lack of urgency in locating a bed, and his subsequent sectioning under the act.' EDT social worker Central London.
The assumption seems to be that if a patient is not on section, they are therefore not 'that bad', and as a consequence their access to support and treatment is curtailed. Therefore we would recommend that informal admissions following a mental health act assessment should also be monitored using a form with the times of the ending of the assessment and the admission to hospital specified and collated, and subject to similar time limits to formal admissions.
4: Conveyance to Hospital
'Wherever possible an ambulance should be used. Otherwise a police vehicle suitable for conveying such a patient should be used.' Code of Practice 11.7
'We need a co-operative and collaborative approach rather than competitive atmosphere between ambulance and police.' ASW midlands
Conveyance issues provide significant problems for ASWs. In some areas, ASWs are not allowed to request ambulance support prior to concluding an assessment. In others, ambulance support is booked in advance, and if the ambulance isn't there when the assessment starts, the police may leave.
Either approach can prove problematic. In areas where pre-booking isn't allowed, significant delays can occur.
'Ambulances will not be provided until application is completed (up to 4 hours delays), causing stress for users, carers and ASW's, and increased risk to all.' ASW midlands
In areas such as London, where pre-booking of assessment and ambulances in more common, problems occur because even pre-booked ambulances can be redirected if more 'urgent' assessment requests come in. With police teams of 6 officers common in some central London assessments, plus section 12 doctors each being paid £170 per assessment to attend, abandoning an assessment is costly both in financial terms and in terms of the stress and risk to the service user and their carers.
'Ambulance and police are needed at the same time - one gets called away then the other cannot proceed. The ASW gets caught between the 2 services.' ASW central London
In most areas, a fully equipped emergency vehicle is used. This causes problems because, understandably, next to a call about a heart attack, a request for transportation after an assessment is seen as less urgent. The problem with this, however, is that the request for transportation can be constantly 'knocked' down the list of priorities. In some areas, trusts have devised other forms of transportation for assessments. However, it appears that few trusts are as motivated to resolve the issues. It is arguable that in most cases such a fully equipped ambulance is not necessary. Trained staff and a suitable vehicle are essential, but an emergency ambulance may not be.
The other issue can be about who should transport, and who should intervene to carry a passively resisting patient out of their home and into an ambulance. Increasingly, ambulance staff are being told they should not physically intervene with patients - when there is clearly no risk of aggression and the client is too depressed to get up and out of bed. This causes tension with the police who become frustrated and resentful if they feel their expertise is being 'misused'. In some areas the police are now refusing to convey patients because they feel that their good will is being abused by the ambulance services. This has lead, for example, to people who have been assessed in custody waiting many hours before transfer to their allocated beds.
If transport is needed over long distances (for example, when there is no local bed available) ASWs can get caught in the middle of an argument about who will pay. Occasionally, there have also been problems when ambulance staff have 'insisted' that the ASW travel in the back of the ambulance with the patient as an escort. Not surprisingly, this has led to incidents of assault where the patient (understandably angry about the detention) has lashed out at the ASW. ASWs are not trained in control and restraint and it is not their job to physically intervene with people. It is their job to coordinate assessments, make balanced and informed decisions about the need for admission and arrange their safe and supported admission to hospital. To do so, ASWs do use their authority and their powers of persuasion, but the psychological impact of a uniform on the behaviour and acquiescence of the service user should not be underestimated. No one expects that the doctors should stay or intervene physically with patients so it is slightly bizarre to hear it being advocating for the ASW or AMHP to take on that role. If one thinks about the fact that the average ASW is female and in her mid to late 40's one can understand why suggestions that the ASW should be using physical restraint methods are being met with such scepticism!
However, it is not a foregone conclusion that the problems with ambulance support can't be resolved. In some areas, such as the south western trust of North Somerset, Bristol, South Glos, wilts, Swindon, and Bath, the trust have already moved to a new system using a private contractor working as part of a tender. Although the system is still new, it seems to be popular.
'The thought of returning to the ambulance trust doesn't bear thinking about. Apart from their being under-resourced and always liable to pull out at the last minute, they have also refused to use any kind of physical control either to get the person into the transport or to restrain potential absconders even if people are detained. This will also lead to problems when urgent conveyance is needed for incapacitated persons under the MCA who require urgent treatment and/or conveyance to hospital.' ASW lead South West England
5: Independence
When surveyed, the most important issue for current ASW's was the maintenance of the Independence of the Approved Role. Traditionally, the ASW provides the 'balance in power' in the mental health act assessment process. It is they who make the final decision as to whether or not to make an application under the act. This 'creative tension' within the assessment process is essential in human rights terms[5], but has been put under greater stress as ASWs have moved to be co-located in multidisciplinary mental health teams.
The development has brought both advantages and disadvantages to the assessment process. These are perhaps best described as operating on a continuum between arguments related to 'welfare' and those related to 'liberty'. In welfare terms, teams who assess together with staff who know service users well are best placed to make decisions about the levels of risk it is possible to take in a particular case. In terms of liberty, unless the staff within the assessment teams are able to act confidently and independently in the judgements they make, there are risks of such teams becoming collusive. The best teams operate within a framework of mutual appreciation and respect. However, Parliament has the task of setting the minimum permissible levels for practice, to ensure that the both the liberty and welfare needs of all of its citizens are respected. Safeguards are therefore essential if this important role is not to be subverted or lost due to other pressures.
We have appreciated that the effort Ministers went to in the Lords to reassure ASW's of the importance that they placed on the independence of the role, and are keen to work with the bill team to develop guidance for employers, but also want to register our continued concerns about the lack of formal structures to ensure that people undertaking the AMHP role continue to be supported to make independent decisions.
Whilst the majority of ASW's continue to be directly employed by LSSAs,[6] and see this as a significant guarantee of their continued independence, senior managers are increasingly employed directly by trusts, and can be faced with conflicts of interest where, for example, they are responsible for both an ASW service and inpatient beds.
Many trusts have been considering setting up TUPE arrangements to bring existing ASW's directly under their management control, but this has caused concern both amongst ASWs (many of whom see the move as an assault on their independence) and amongst senior managers because of the potential costs of such transfers. Transfers to Trusts would bring social workers within the new pay structures of the NHS, and although bandings are set locally, early indications suggest that a band 7 setting would be most likely given the responsibility of the role and current pay structures. However, the top of the band 7 pay band is between 2 and 5k higher than current social service pay bands. Nationally, with a potential 4,000 employees open to transfer to the trusts, the annual costs would increase between 8 and 20 million pounds. Even if only a few people start to be paid on band 7 contracts the potential for equal pay claims is substantial and worrying. Additionally, Trusts would be taking on the pension risks of a group of workers who demographically are closer to retirement than other groups of workers. This has raised particular concerns for those seeking foundation trust status.
The Government has also shown creditable commitment to the training of Approved Workers, and provided that clear guidelines can be drawn up around the selection of suitable candidates, and the training itself continues to be rigorous, these processes will provide a positive start for people seeking to take on the role in the future.
However, in order to build on the good start provided by training, support structures need to be in place in the workplace to ensure staff are able to continue to work independently.
'The Bill makes it clear that an AMHP carries out their functions on behalf of the LSSA. This underlines the independence of the AMHP from the trust that may employ the doctors who also examine a patient's case for admission. It also ensures that the responsibility for providing that an AMHP service is in place still clearly lies with the local social services authority, whether or not it chooses to enter into arrangements with another body, such as a trust, to provide the service.' Baroness Royall of Blaisdon - for the Government Hansard 17th Jan 2007
Although a lot of emphasis has been placed by the government on the fact that the AMHP will be undertaking assessments on behalf of the LSSA (and this being a protective measure for the AMHP's independence), there are currently no mechanisms to monitor how effective this relationship is, and whether LSSA's are currently meeting their obligations in relation to the service. Indeed, there are currently no performance indicators related to the ASW service at all, and it has been suggested that introducing any related to the AMHP service is impossible. This is regrettable given the important governance role the PI's have in relation to setting and monitoring LSSA policy and practice. It is also concerning that there appears to be an element of double messages - on the one side insisting that AMHPs will be working 'on behalf' of the LSSA, whilst on the other making it clear that this would not prevent local authorities and trusts from making arrangements about the deployment of staff, or helping LSSA's to focus on the issues by making it clear that regulatory bodies will be focusing on these issues. However, is this sufficient to ensure that LSSA's do take their role in the AMHP service seriously? And what processes need to be set in place to ensure than minimum standards are maintained?
Mechanism to ensure the Independence of the AMHP is maintained:- To ensure that the independence of the ASW/AMHP role and service is protected by · including Performance Indicators in the reporting mechanisms for LSSAs on the quality and availability of different aspects of AMHP services including: 1. availability and quality of initial and refresher training (as detailed in the proposed regulations) 2. the effectiveness of warranting and re-warranting procedures (as detailed in the proposed regulations) 3. the availability of AMHP services out of hours to all relevant care groups 4. the availability of advice and support for the law, including appropriate legal advice · ensuring that the senior manager responsible for the AMHP service in any particular area is directly accountable to the LSSA to ensure that such managers are not subject to a conflict of interest (for example, by being responsible for both the AMHP service and inpatient beds)
Summary of questions we feel would needed to be addressed if no changes are forthcoming:[7]
- An AMHP assessment is requested and admission seems likely but there is no bed available - Should they go out and assess anyway? Make a waiting list? Report this as a local incident?
- The AMHP, having assessed, believes that an application ought to be made and therefore has a duty to make one, but there is no bed available or the PCT has not fulfilled its Section 140 duty to identify the hospital able to take admissions - Should they simply leave the service user and the carer, whatever the risk?
- The AMHP gets to hospital with the patient but admission is then refused and no bed is immediately available elsewhere -Legally, their authority to detain and convey the patient could be said to lapse if the hospital refuses admission. How long should they wait? What happens if the police and ambulance staff insist on leaving? Should they not also leave and allow the service user to do so too?
- A bed is offered outside the area but police and/or ambulance are unwilling to take the patient there. - What authority does the AMHP or the director of social services have to resolve this?
- The AMHP thinks s/he may be at risk during an assessment but is unable to get a satisfactory guarantee of police protection. - Should they continue to assess? What if they decide not to, even knowing that the carer and family are unable to cope any longer?
- Police or ambulance assistance is withdrawn during the course of an assessment. - Should the ASW leave too, whatever the consequences for the patient, their carer and the community?
- Either police or paramedics refuse to lay hands on a passively-resistant patient. - Is it either the job of the doctors or the ASW/AMHP to do this? They will be alone, and are not trained to carry people. They wouldn't be insured to do so and could cause themselves damage. Should they just leave the person there?
- The police insist on a S135 warrant even where access is not being denied. - If that is the only way the police would be involved, what should the ASW/AMHP do? Should they provide misleading evidence to court to get a warrant and avoid a potentially dangerous delay in the process?
- The circumstances do not meet the statutory criteria for the issue of a warrant under s135. - For example, the person is in a hotel room, and the hotel owner is happy to give you access, and you are concerned about risks to the public whilst you wait?
-- The man who needs admission has agreed to informal admission, but the hospital say the only bed is on a Psychiatric Intensive Care Unit ward and they will only take people on section. You know if you don't section him, he could wait many hours for a bed to be found and is already very distressed. What do you suggest the ASW does? Compromise on law and principles but get an unwell person safely admitted? Or not?
May 2007
[1] Survey of London ASW Leads [2] ASW lead, North London [3] PCTs, Mental Health Trusts, Local Social Service Authorities, the police, and ambulance services [4] quotes from ASW leads survey - London [5] Phil Fennell, report to the Cross Party Human Rights Group March 2007 [6] 4% of ASW nationally are directly employed by the NHS, according to the ADSS National Survey from 2006 [7] most previously submitted to the DOH |