Working in a busy AMHP office triaging requests for assessments under the Mental Health Act, I am driven to conclude that often an AMHP’s role is as guardian and upholder of the law.
We can receive requests from a number of sources. They can come from a GP, or a care coordinator in a mental health team, or a mental health liaison nurse working in a criminal justice or medical hospital setting, or a psychiatric ward, or even a care home manager. They can also come from the police, either because they have detained someone under Sec.136, or because they have arrested someone who subsequently appears to be mentally disordered.
And of course, the nearest relative has a right under Sec.13(4) to request an assessment under the Mental Health Act. Although not quite: the Act actually states that the local authority must “make arrangements… for an approved mental health professional to consider the patient’s case with a view to making an application for his admission to hospital”, which isn’t the same thing.
These requests are not necessarily appropriate. More than that, our service is increasingly finding that requests for formal assessments under the MHA may not be triggered only after all other alternatives have been exhausted, but rather because of a shortage of suitable resources, or a failure of the system, or even because the referrer is reluctant to do their job.
Sometimes requests come from the duty worker in a community mental health team. They have taken a concerning call from a relative, or a GP, but either the care coordinator of the patient is on leave, or the patient has been referred to the team but a shortage of staff has meant that they have not been allocated a worker.
Sometimes requests come from someone such as a care home manager who believes that a MHA assessment is a fast track way of getting someone assessed by a psychiatrist.
And sometimes relatives contact the local community mental health team to express concerns about the mental health of their relative who is a patient of the team, and the person they contact advises them to request an assessment under Sec.13(4).
Here are a couple of real conversations I have had with referrers.
The Mental Health Professional
Referrer: I’m a nurse in the Early Intervention Team. Jeremy, who’s 19, was referred to us by his GP, and I gave him an appointment to see him at our office today. I am referring Jeremy for a Mental Health Act Assessment.
Me: And what are your concerns?
Referrer: His mother has given me a lot of information about his behaviour, which appears to indicate he is psychotic.
Me: His mother?
Referrer: Yes. Jeremy refused to come to the assessment, but his mother did, and I had a long conversation with her about the problems.
Me: But you haven’t actually seen him? We would expect someone making a request for an assessment under the Mental Health Act to have seen the patient first.
Referrer: But he won’t come to an appointment.
Me: Have you considered going out to see him?
Referrer: Oh, that’s not necessary. I’ve made my assessment, and he definitely needs a MHA assessment.
Me: I’m just a little surprised you feel that a conversation with his mother, without actually having made contact with Jeremy, is sufficient evidence to justify an AMHP and two psychiatrists knocking on his door.
Referrer: I’ve made a professional decision that he needs a MHA assessment, so it’s your job to go out and assess him.
Me: But Jeremy hasn’t actually been seen by a doctor or a mental health professional.
Referrer: Are you questioning my professional ability to make an
Me: But all you’re basing your assessment on is reports from his mother. I really think you should make an effort to see him before making a decision about referring him for a MHA assessment.
Referrer: But his mother says that he won’t see anyone. And anyway, I’d be concerned that he might be aggressive if I went to see him.
Me: You haven’t convinced me that Jeremy needs a formal assessment under the MHA. But I’ll tell you what I’ll do. I can arrange for one of our AMHP’s to go out with you for a “look see”. Then at least there’s been an effort to actually see the patient. And we can take it from there.
Referrer: But I’ve made a professional decision that Jeremy needs an assessment under the MHA. There’s no need for me to go out to see him.
Me: Bangs head on table repeatedly
GP: I’m requesting an assessment under the Mental Health Act for one of my patients, Giles. He’s in his 60’s, and he’s got terminal cancer which is metastasising, and Parkinson’s Disease. I arranged for our palliative care nurse to arrange to see him. When she rang up, he told her that he didn’t want to see anyone, and was going to cut the cancer out himself, since no-one was doing anything about it. We know he’s got a knife, which he keeps under his pillow, he’s told us about it before.
Me: So has anyone actually seen Giles?
GP: The nurse has spoken to him on the phone. His usual GP saw him a week ago.
Me: But on-one’s seen him today? Because we would expect a doctor to have actually seen the patient before referring for a MHA assessment. From what you’ve told me, his current behaviour could be the result of physical illness. If the cancer is metastising, it might be affecting his brain and thought processes. The Parkinson’s Disease could also be affecting his mental state.
GP: So you’re suggesting I go out and see him to see if there’s something physically wrong with him?
Me: Yes. He might need to be admitted to a medical ward rather than a psychiatric unit. And he might even agree to an admission to hospital. That needs to be explored before we go down the MHA route, which should only be considered once all less restrictive options have been tried.
GP: But I’m frightened to go out in view of the fact he has a knife and he expressed aggression to one of my nurses.
Me: You could ask the police to accompany you if you have concerns about your safety. After all, if an AMHP went out to assess, they’d probably want the police with them in view of what you’ve told us.
GP: That’s a good idea! I’ll go out with the police, see if he’s physically ill, and then I can get back to you if I think the main problem is mental illness.
(The GP contacted the AMHP service the following day to let us know that he didn’t after all need a MHA assessment, as the problems were mainly physical, and he’d been admitted to a medical ward.)
In response to the level of referrals which were deemed inappropriate, our AMHP Service has developed a protocol for referring, which has been circulated to all organisations who may refer for MHA assessments.
Among the requirements are:
- For patients unknown to secondary services, the GP should first have seen the patient and considered alternatives.
- For patients known to community teams but unallocated, that team should have made efforts to see and assess the patient first.
- The referrer must have seen and spoken with the patient, or the patient must have been seen by another professional worker and advised of the concerns, unless there are clear, defensible reasons not to do so.
- If the referrer is not a Clinical Team Leader/ Team Manager or senior worker then they will be expected to have discussed the referral with a senior member of their team in order to rule out alternative support or treatment options. For example:
o Has the referrer considered a referral for a Social Care Assessment and/or Carer’s Assessment?
o Has the referrer considered or made a referral to the Dementia Intensive Support Team or the Crisis Resolution Team to avoid an admission to hospital?
o Has the person’s Crisis Contingency Plan to avoid admission been implemented?
o Has the referrer considered and discussed with the patient an informal admission to hospital?
o Has consideration been given to use of Mental Capacity Act and guiding Principles, including issues of capacity and consent?
o Have all least restrictive alternatives to detention under the MHA been considered?
This brings me back to my initial statement at the beginning of this post. The Mental Health Act is designed to protect the liberty and other human rights of those deemed to have a mental disorder, to prevent coercion and forced hospitalisation if at all possible. A Mental Health Act assessment is therefore the last resort.
The AMHP Service should not be regarded as an emergency service. (This statement may surprise many, but in genuine cases of emergency, for example, someone standing at the top of a multi-storey car park threatening to jump off, getting an AMHP and two doctors to attend at that point would serve no useful function until the immediate crisis had been resolved via other emergency services.)
The Code of Practice states as its first guiding principle that the least restrictive option should always be tried first:
Where it is possible to treat a patient safely and lawfully without detaining them under the Act, the patient should not be detained. Wherever possible a patient’s independence should be encouraged and supported with a focus on promoting recovery wherever possible.(para1.1)
It goes on to say:
Commissioners, providers and other relevant agencies should work together to prevent mental health crises and, where possible, reduce the use of detention through prevention and early intervention by commissioning a range of services that are accessible, responsive and as high quality as other health emergency services.(para.1.3)
So this protocol merely draws attention to the guiding principles of the MHA, and in particular para1.3.