An essential part of the role of the Approved Mental Health Professional is to ensure that the person they have just assessed is admitted to hospital. Having made a decision that someone needs to be admitted, whether informally or under a section of the MHA, the next step has to be to make suitable arrangements for “conveyance”, as the Act likes to call it.
However, the physical act of getting a patient to hospital once an AMHP has assessed them can be fraught with legal, ethical, logistical and practical difficulties.
The Reference Guide (para2.66) states: “A duly completed application for admission provides the authority for the applicant, or anyone authorised by the applicant [the AMHP], to take and convey the patient to the hospital named in the application”. It goes on to say (para 2.68): “Patients being taken and conveyed to hospital on the basis of an application for admission are considered to be in legal custody, and the applicant, or the person authorised by the applicant (as the case may be), may take steps accordingly to prevent the patient absconding.”
This clearly places the AMHP in a position of considerable power (and responsibility). The AMHP is responsible for ensuring that the patient reaches hospital safely, and can exert, or instruct others to exert, proportionate force or restraint if necessary. In the words of the Code of Practice (para 11.14) “Where AMHPs are the applicant, they have a professional responsibility to ensure that all the necessary arrangements are made for the patient to be conveyed to hospital.”
The Code of Practice devotes a whole chapter (Chapter 11) to “Conveyance of patients”. This chapter begins: “Patients should always be conveyed in the manner which is most likely to preserve their dignity and privacy consistent with managing any risk to their health and safety or to other people.”
Local Authorities have guidance for AMHP’s on how to convey to hospital. This guidance frequently states that all patients should ideally be transported by ambulance, although where the patient is likely to be aggressive or unpredictable, the police can be enlisted to arrange transport.
While there may be sound reasons for using an ambulance to transport a patient, the Code of Practice does not actually prescribe this. What the Code actually says is: “AMHPs should make decisions on which method of transport to use in consultation with the other professionals involved, the patient and (as appropriate) their carer, family or other supporters. The decision should be made following a risk assessment carried out on the basis of the best available information.” (para 11.16)
Factors to be taken into account include availability, distance to be travelled, the physical and mental state of the patient, the patient’s wishes, the views and wishes of the relatives, the risk of absconding or violence, and “the impact that any particular method of conveying the patient will have on the patient’s relationship with the community to which they will return”.
All this means that an ambulance may not always be the most appropriate means of transport. The CoP, para 11.21 notes: “AMHPs should not normally agree to a patient being conveyed by car unless satisfied that it would not put the patient or other people at risk of harm and that it is the most appropriate way of transporting the patient. In these circumstances there should be an escort for the patient other than the driver.”
While I would stress that all AMHP’s have to make their own decisions based on the particular circumstances of the patient, regular readers of this blog will be aware that there have been occasions when I have made a professional decision to transport the patient in my car.
Something I often find quite effective, providing I am confident that the patient is not likely to be aggressive, is to give the patient an element of choice, so that they do not feel completely overpowered by the process they have endured.
Once the decision has been made to detain the person, and the paperwork has been duly completed, I will of course inform them of the decision and of their rights to appeal against that decision. At that point, it is likely that they will continue to object, saying that they do not want to go to hospital. I will then tell them that admission is unavoidable, but that they have a choice between going in an ambulance or being taken to hospital by car.
If they choose to go by car, then I ensure that I have at least one escort with me, such as a relative, a professional colleague or an AMHP trainee, and arrange for the patient to sit in the back seat, directly behind the front passenger seat, with the escort sitting next to them.
Of course, if they decide against either choice, then they will go by ambulance. A detained patient will always end up in hospital – even if they abscond while waiting for transport to arrive.
Frequently, the patient will steadfastly maintain that they will not be taken to hospital under any circumstances. They often argue this right up until the moment when the ambulance crew enter the house – at which point they quietly pick up their overnight bag and step into the ambulance. I suppose that there is a part of them that either realises that admission is inevitable, or that recognise that it is really in their interests to be admitted.
I have said before on this blog that the arrival of someone in a uniform, whether it be a police officer or a paramedic, often seems to have a miraculous effect on a patient’s resolve and cooperation.
Where the patient still refuses to get into the ambulance, it is almost always the case that a few minutes persuasion (sometimes half an hour or more of repeating that it is unavoidable) will result in them stepping into the transport.
Sometimes the AMHP simply absenting oneself from the immediate vicinity allows the ambulance crew to assist the patient into the ambulance.
On rare occasions it may be necessary to enlist the assistance of the police. In my experience, in less than five per cent of cases does it become necessary to use any significant force to get the patient into the transport.
Having made a decision that an ambulance or police transport is required, this is far from the end of the process. AMHP’s will be very familiar with the difficulties that can arise from using the police or the ambulance service.
There are two problems that can occur at this point. One is the potential conflict between the Act’s guidance on conveyance to hospital and the Local Authority’s guidance on conveyance on the one hand, and the police and ambulance service guidelines on the other.
In practice, this means that police may be reluctant to attend in the first place, and even more reluctant to provide police transport or police assistance with transport.
The ambulance service may also be reluctant to transport a patient who has even a history of aggression, never mind be presenting as resistant on assessment.
AMHP’s can also often be frustrated by the ambulance service on the one hand insisting that police be present when risk has been identified before they will agree to attend, and the police on the other hand being reluctant to attend until the ambulance arrives. This can create logistical nightmares; some of my AMHP colleagues have found that trying to coordinate the simultaneous attendance of both the police and an ambulance can lead to many hours of delay, especially if shift changes are involved.
And if the patient has to be taken to a hospital many miles away – well, there have been times when I’ve had to wait 4-6 hours before transport has been sorted.
The other problem is the priority given to MHA admissions by ambulance services. Our local service typically gives two hours as the expected time of arrival, and even though an AMHP may regard it as of urgent necessity for a disturbed and distressed mental health patient to be admitted to hospital, the ambulance service does not give it the same priority, and ambulances on their way to the AMHP can often be diverted to what are considered more high priority calls.
Our local ambulance service has a cunning ruse to meet their targets for delays by often sending a single paramedic in a car, who then makes the assessment (surprise, surprise) that it is unsafe to transport the patient, and insisting on an ambulance with two crew – which is what you asked for and expected in the first place.
Among my AMHP colleagues, delays involving ambulances are one of the major problems encountered in discharging their duties, to such an extent that such delays are monitored.
All of which can make it very tempting for an AMHP to decide to take the patient to hospital themselves.