Thursday, 27 October 2016

How difficult can it be to get an ambulance to convey a detained patient to hospital?

I’m going to tell you a horrifying, but also a tedious and frustrating, true story. It’s all about trying to get an ambulance to transport an elderly man with dementia detained under the Mental Health Act from a care home to a hospital.

The fact that the hospital is a private hospital 100 miles away from the care home should be immaterial…

What ought to happen when a person, any person, is assessed under the Mental Health Act follows a particular routine.
1. Arrangements for the patient to be assessed are made. This includes notifying the bed managers that a bed may be required, and arranging for two doctors, at least one of whom must be Sec.12 approved, to attend with the AMHP.
2.The assessment takes place.
3, A hospital is identified that will accept the patient.
4. Arrangements are made for the patient to be conveyed to the hospital. An ambulance is usually the most suitable mode of transport.
5, The patient is conveyed to hospital and admitted.

The chronic nationwide shortage of psychiatric hospital beds, in our area especially for people with dementia, is now routinely meaning that the assessment process is suspended after step 2. It can be days, or even weeks, before a bed can be found and admission arranged. It is now very common in our area for this particular private hospital to be used almost as an additional ward for our local dementia patients.

This hospital often visits the potential patient before making a final decision, which can take several days in itself, and if the patient is fortunate enough to be considered suitable, the hospital requires that they be admitted before 13:00 hrs on the day of admission.

But even once a bed is identified and the patient can be formally detained under the MHA, we have been encountering problems with the local ambulance trust.

Where a patient is in a care home, and the receiving hospital requires admission before 13:00 hrs, it makes sense to order the ambulance in advance, the previous day.

That’s where our AMHP hub first encountered problems.

It was my job as the duty Practice Consultant (see my previous blog post for an explanation of what a PC is) to ring the ambulance service and order the ambulance.

However, I was told in very clear terms that the ambulance service was an emergency service, and could not be booked in advance. They could only dispatch an ambulance on the day, using the “traffic light” protocol agreed between the AMHP service and the ambulance service.

Briefly, this arrangement prioritises the response times. A “red light” means that the patient is seriously distressed, the situation is critical, and they need to be taken to hospital as soon as possible. The ambulance will try to arrive within 30 minutes.

An “amber light” means that the patient is less distressed, and the ambulance will endeavour to arrive within two hours, while a “green light” means that the patient is settled and in a safe place, and the ambulance will then arrive within four hours of  being requested.

Generally, this system works well, although even for “red light” requests, ambulances can still be diverted to more urgent calls, such as cardiac arrests. I can’t complain about this.

I pointed out that, as it was a “green light” request, if the AMHP service made the request at 08:45 hrs, at the start of the working day, if the ambulance did not arrive for 4 hours, then it would be impossible for the ambulance to get the patient to the hospital before the admission deadline, as the journey would take at least two hours.

But the ambulance service were not to be swayed, as the request was not within what they were contracted to provide.

In the end, my PC colleague who was on duty the following day had to ring the ambulance service from home at around 07:30 hrs in order to ensure that the ambulance would arrive in time to transport the patient the two hour journey to the hospital. In the event, the ambulance arrived at 10:45 hrs and dropped off the patient at the receiving hospital 5 minutes before the admission deadline.

This was clearly an untenable situation, so our AMHP hub manager spent several days negotiating with the relevant Clinical Commissioning Group (CCG), who actually make the contracts with the ambulance trust, as to how this sort of situation could be avoided in future.

By the time I was duty PC the next week, an agreement had been reached.

The CCG contracts manager gave instructions that we were to ring a different number when wishing to arrange an ambulance in these circumstances. This was the number of the patients booking line. These ambulances were part of the local ambulance trust, but this particular service allowed routine booking of ambulances to transport patients in a range of situations.

As it happened, another patient was in identical circumstances, so it was again my job to arrange for an ambulance to convey him to the same hospital by 13:00 hrs the following day.

I rang the number, explained that the CCG contracts manager had told us to do this, and requested an ambulance for 09:00 the next day.

The call handler was non-plussed. He went off to consult with several different people during the course of the call, before finally giving me not one but three reasons why they could not or would not convey this patient.

Reason #1 Their service was not contracted to convey patients detained under the Mental Health Act.

Reason #2 As both the hospital and the care home were private, this meant that the patient was not an NHS patient, and they would not in any case transport such a patient. (The fact that the hospital was being paid by the mental health trust/CCG, and hence the NHS, to receive and treat the patient appeared to make no difference).

Reason #3 Even though their contract was with a CCG that explicitly covered the town in which the patient resided (it was in the name of the CCG), they didn’t actually, really, cover that area, as it was in another county.

So I rang the CCG’s contracts manager and explained the difficulty I was having. She suggested I spoke to the contracts performance manager in the mental health trust.

I spoke to this officer, who admitted that there appeared to be a gap in the contract, and told me to leave it with them.

Somewhat to my surprise, an hour or so later I received a phone call from another call handler at the ambulance booking service. He took all the necessary details of the transport request, including his current medication regime, the fact that he was being prescribed lorazepam 4 times a day, and the fact that he was frail and would need wheelchair transfer. It was arranged that the patient would be collected from the care home at 09:00 hrs the following morning. I was even given a booking reference number.

Success at last! Sanity had prevailed!

Ah. An hour later I received a call from the patient ambulance booking manager. They had discovered Reason #4: their service was not contracted to take sedated patients. We would therefore have to make a request tomorrow morning.

So it was again left that my colleague the next day had to make an early morning phone call to the usual ambulance service number.

They initially tried to give a Reason #5 why they could not transport the patient. This was on the grounds that the hospital, being in another county, was outside the area they covered. However, this was withdrawn when it was pointed out that the ambulance trust covered a very large geographical area which explicitly included the county in question.

They didn’t seem to be able to come up with a 6th reason, so eventually an ambulance crew picked the patient up and took him to hospital within the required time scale.

What’s the significance of this in the wider scheme of things?

This sorry failure to meet what would appear to be a straightforward request exemplifies a far deeper problem in the NHS:  privatisation by stealth.

This has been happening gradually for many years. It goes all the way back to Margaret Thatcher’s government in the early 1990’s, which brought in the NHS & Community Care Act 1990. Among other things, this introduced the concept of the purchaser/provider split in the provision of social care, which was explicitly designed to encourage the use of private services. Whereas before, home care was provided in house, the Act required at least 80% of home care to be purchased from private organisations.

In mental health, NHS trusts have been operating under various guises for many years, opening the way, at least in theory, for trusts to compete with each other in an internal market to provide services, while the introduction of clustering and “payment by results” in 2013 made it possible for packages of care and treatment for mental disorders to be “sold off” to private companies prepared to offer specific services. I discuss this in more detail in this blog post.

The Health and Social Care Act 2012 disposed of Primary Care Trusts and replaced them with Clinical Commissioning Groups, supposedly led by clinicians, whose function was to purchase services from NHS Trusts – or indeed, private companies prepared to offer these services. Companies such as Virgin Care have stepped in and provide a range of health services, relieving the NHS of billions of pounds in the process.

Apart from these private health care companies, there is now a well-established internal market within the NHS. While ostensibly this is designed to facilitate provision of services, in practice this does not necessarily happen. The example I have given highlights the problems with this artificial division of budgets.

The problems I encountered in obtaining transport for a detained patient are entirely due to this bizarre internal market. The local Ambulance Trust, which is of course part of the NHS, has a range of contracts with the Clinical Commissioning Groups within its area.

These contracts are not necessarily to provide a blanket ambulance service, but are written in such a way that very specific services are offered, and if a request does not fit with the wording of the contract, then the service will not be offered.

It has long been established that the local ambulance trust will not convey patients out of its area, and will not convey patients requiring restraint. The AMHP service then has to rely on private ambulance services, at huge expense to the CCGs.

Another local example of what would appear to be a nonsensical interpretation of a contract is that the local ambulance service will convey a patient detained under Sec.135(1) to a place of safety for the purpose of assessment, but if the patient is then detained  under the MHA and needs to be conveyed to a hospital, this transfer is not covered by the contract.

It is difficult to understand how this system is of benefit to patients, and how it might save the NHS money.

Friday, 7 October 2016

How Can We Make the AMHP Role Manageable?

A busy AMHP Hub (all the AMHP's are out on MHA Assessments)
Andy McNicoll’s recent analysis of national AMHP shortages, published in Community Care, revealed a desperate situation across England.

The lack of adequate mental health resources, caused by year on year reductions in funding for Mental Health Trusts, has led to difficulties in finding alternatives to hospital admission, at the same time as a desperate shortage of suitable beds has meant community based services are required even more.

The role of the AMHP is therefore becoming increasingly fraught and stressful. It is hardly surprising that AMHP’s are giving up the role, especially when social worker AMHP’s are also struggling to implement the Care Act.

Para14.35 of the Code of Practice states that:
Local authorities are responsible for ensuring that sufficient AMHPs are available to carry out their roles under the Act, including assessing patients to decide whether an application for detention should be made. To fulfil their statutory duty, local authorities should have arrangements in place in their area to provide a 24-hour service that can respond to patients’ needs.

Unfortunately, “sufficient” is nowhere defined. BASW’s consultation on the Draft Code, back in 2015, observed thatWe often work on a guideline of 1 AMHP per 10,000 population. If this is thought to be a good guideline figure, it may be helpful to state this in the Code.” However, this suggestion did not make it into the final Code.

Hampshire’s total population in 2015 was around 1,350,000. If this guideline were to be applied, Hampshire would require 135 AMHPs to adequately serve the county. However, Andy McNicoll discovered that AMHP numbers had fallen to 46, while at the same time assessments had risen by 12%. Hampshire was working to build this number up to 55, which would still appear to be little more than a third of the numbers ideally required.

Northamptonshire has a population of around 694,000, but has also been losing AMHP’s, currently having only 34, even though assessments rose 19%. If BASW’s recommendation was applied, the county should have at least 94 AMHP’s.

Norfolk’s current population is approaching 900,000. There are currently around 85 AMHPs registered in Norfolk, which is actually close to the BASW’s ideal number. However, with several on long term sickness, or maternity leave, or otherwise unable to practice, the actual number of available AMHPs is less.

The 2016 National AMHP Leads Survey, presented to the AMHP Leads Conference on 19.09.16. does not use BASW’s definition of “sufficient” AMHPs, or indeed suggest another definition. This found that in reality the average number of AMHPs per 100,000 population is 5.7. This would be around half of BASW’s “ideal” number.

Whatever the definition of “sufficient” AMHPs may be, the Community Care article highlights difficulties in retention, through the stress of the role, and having to reconcile normal work commitments, such as implementing the Care Act and managing a case load, with being on an AMHP rota.

There are ways of supporting AMHPs in their role and providing incentives to continue practising. For example, some local authorities provide a financial incentive for being a practising AMHP. This may not, however, in itself be sufficient incentive to undertake the stresses of the role.

The current dire state of mental health services nationally, where there is a national shortage of suitable hospital beds, and where other services, such as the Police and Ambulance Service, are struggling to manage their core duties, makes it difficult, if not impossible at times, for AMHPs to undertake their legal duties, leading to long hours spent trying to organise arrangements for patients who have been assessed.

While the only solution to a lack of resources would appear to be more money, which is to materialise in the current climate of austerity, there are ways in which local authorities can support AMHPs and reduce the stresses of the role. This is through the way that local AMHP services are managed.

Approaches to managing an AMHP service

Nationally, there appear to be three basic approaches to running an AMHP service.

Dedicated AMHP team
This consists of a team of full time AMHPs, whose job is solely to staff the AMHP rota. With such a system, it would be possible to manage with a smaller number of dedicated full time AMHPs.

The advantages of this system are that the team members would not be encumbered with a caseload and can devote their working day to the AMHP role. It also facilitates having a shift system, which might encompass a 24 hour rota.

Disadvantages might include a deskilling of team members, using only their specialist skills and knowledge relating to mental health legislation.

A disparate AMHP rota
This system takes AMHPs from a range of social work (and/or nursing) teams, where AMHPs on duty are situated within their teams, scattered across a geographical area, and are contacted directly when requests for MHA assessments are made.

There are a number of problems associated with working in isolation and receiving requests for assessments directly. One is that you can be bombarded and overwhelmed with requests, if the system is a geographical one, and several requests relate to your specific area.

Another is that you may feel bound to deal with the referral that day, when you are on duty, even though there might be advantages in taking no immediate action.

An example might be a request to assess someone detained under Sec.5(2). This allows for up to 72 hours to assess the patient, who is an inpatient. A patient may be detained under this section when they are an informal patient who impulsively decides they want to discharge themselves.

If you receive a request and assess a patient who has just been placed on Sec.5(2), you may be assessing someone in personal crisis, whereas leaving the assessment for a day or two may give time for the patient to reconsider and decide to remain as an informal patient. So this system could lead to more people being detained under the MHA.

While there are clear disadvantages to patients with this system, there are also disadvantages for the AMHP, who may feel isolated and alone, with no-one to assist when operational problems arise. They may also be expected to accept referrals right to the end of their working day, which could mean working late into the evening.

I worked this system for many years, and our Emergency Duty Team was very strict about not accepting requests before 17:30 hrs. This meant on some occasions having to accept a referral within minutes of the end of the working day.

In my view this system carries a significant likelihood that AMHPs will burn out and decide to hand in their warrants.

Centrally managed AMHP Service
This model consists of a local authority wide AMHP service, with a central “hub”, where duty AMHP’s are based in one or two locations, depending on the geographical size of the area, and where referrals are triaged before being allocated.

This is the system we have operated in my local authority for two years. I like it. Let me tell you how it works.

Our AMHP hub consists of a team manager, who is also the County AMHP Lead. In addition, there are three full time equivalent Practice Consultants, and a business support officer to provide administrative support. The manager and the Practice Consultants are all AMHPs themselves, and take turns on the AMHP rota.

The team is based in a suite of offices based in one of the psychiatric hospitals. One of the county’s Sec.136 suites is based on the same site.

The model has a daily rota of AMHPs, taken from social work and nursing teams across the county – most are based in the central AMHP hub, in a room with the duty Practice Consultant. In addition, because of the geographical size of the county, one is based in the west of the county, and one in the east.

Duty AMHPs are expected base themselves in designated AMHP offices, with the bulk being in the AMHP hub. All the AMHPs have laptops, and there are sufficient docking stations for all the duty AMHPs to be able to log in to the central database.

The AMHP hub is a lively place, where AMHPs can support each other, share problems or practice issues, and discuss various aspects of Mental Health law. And drink coffee and eat biscuits.

Each day, there is a Practice Consultant on duty. Their job is to receive requests for Mental Health Act assessments, to triage and prioritise them, and to allocate to AMHPs if appropriate.

This is a robust and proactive job. I know, as one day a week I am the duty PC (Only one day a week, you ask? Remember, I am semi-retired, I only work two days a week, one day as a duty AMHP, and one day as a PC).

Some requests clearly require the allocation of an AMHP. These would include Sec.5(2) on a hospital ward, where an assessment has to take place within 72 hours, and Sec.136, which generally cannot be discharged without the involvement of an AMHP. Sec.136 detentions always take priority. They would also include patients detained under Sec.2, where the hospital psychiatrist wants to detain them under Sec.3, and requests relating to patients in police custody.

Some requests require more investigation before a decision is made whether or not to conduct a formal assessment. The duty PC will see what available information there might be about the person. They may ring the referrer, to establish what action has been taken prior to the request, with a focus on establishing that all less restrictive options, in accordance with the first principle of the Code of Practice, have been exhausted prior to making the referral.

Sometimes these conversations can become difficult, especially if the PC has made a decision not to accept the referral (you can see a sample in a previous blog post). But the PC needs to make sure that any request does actually require the involvement on an AMHP; the need to protect a scarce resource is important.

This system also allows the PC to prioritise requests. Often, there is no great urgency in the assessment. There may be a week or more before a Sec.2 expires, allowing plenty of time to undertake an assessment under Sec.3. A Sec.5(2) allows 72 hours to undertake an assessment. And of course, with a dire shortage of beds, even if an assessment takes place, the AMHP may not be able to complete the section papers because there is no bed.

(As a current example, I am aware at the time of writing that there are 8 dementia patients awaiting a dementia bed. There are frequent requests to assess dementia patients in care homes. How can this be treated as requiring an urgent response, if there may not be a bed available for one or two weeks?)

This system permits the service to protect AMHPs to a considerable extent. It means that fewer AMHPs have to go out at the end of their working day. It often means that referrals can be stacked and dealt with first thing the next morning, making it more likely that the assessment would be concluded within the normal working day. The duty PC is also available on the phone to offer advice and support to the AMHPs out in the field.

This system has a further advantage: the management team, with direct day to day experience of the AMHP role, are ideally suited to provide professional AMHP supervision, to ensure that AMHPs maintain their Record of Achievement in order to meet reapproval requirements, and to maintain quality control. An example of this is that it is one of the duties of PCs to sign off AMHP reports, meaning that every report is read by a PC, and any practice issues can then be identified and managed within professional supervision.

It also means that specific operational issues, such as bed shortages, issues with police and ambulance response times, etc, can be flagged up, and taken forward to higher level multi-agency meetings for resolution.

The evidence so far is that this approach can help to maintain staff morale, to provide an environment in which the AMHP role is supported and valued, to reduce “burnout” and to aid in staff retention and maintain an effective AMHP service.