The AMHP role was increasingly being seen as impossible to manage alongside other tasks, such as care co-ordination. Recruiting AMHPs and Trainees was problematic as a result, with around 30% of AMHP posts remaining vacant. Devon, like other authorities, was struggling to provide a sustainable, effective and efficient AMHP workforce that had the flexibility and capacity to meet its statutory requirements. The benefits of this new system and to the staff who have worked so hard to conceive it, and make it a reality, have been many. For individuals brought into consideration for compulsory treatment and care, they now have a flexible and responsive AMHP service dedicated to the role that is able to cope with fluctuating volumes of referrals. For those individuals’ families and carers, the service has been able to provide more opportunity for follow up and advice around their rights under the Mental Health Act 1983. While in many respects it is still early days in the life of this service the differences have been clear
What We Did
In September 2015 the daytime Approved Mental Health Professional (AMHP) provision in the Devon County Council/Devon Partnership NHS Trust (DCC/DPT) moved to a new service delivery model. Building on earlier developments and a set of re-design principles created by the AMHPs themselves, small dedicated AMHP teams were introduced in key areas across the county replacing the traditional duty rota model. Supported by a ‘one number’ line for referrals, advice, and back-up each locality team became empowered to define and direct its own work according to local need; whilst simultaneously maintaining a flexible commitment to core AMHP business within the wider service.
The need for change had been clear for some time and reflected the national picture. Year on year increases in referrals for AMHP involvement meant the system had become overloaded and potentially unsafe. A lack of available resources often left AMHPs in intolerable positions when trying to carry out the role, with little support available to them. The rural nature of parts of Devon left colleagues professionally isolated and AMHP work was often hidden within a larger health-dominated partnership. The council area itself is the third largest in England and Wales, providing services for nearly 800,000 people; the very geography of the county itself sometimes acting as a significant hurdle to securing a timely response. Daytime services in 2015 received over 1600 requests for AMHP involvement, out of hours a further 400. For each of these referrals there was a real person, often in urgent need with significant complexity to their situation. The role of the AMHP is to not only consider whether compulsory action is required, and to undertake that action when indicated, but also to promote individual’s human rights and steer colleagues and others away from overly restrictive and sometimes damaging interventions to something more appropriate and proportionate.
The AMHP role was increasingly being seen as impossible to manage alongside other tasks, such as care co-ordination. Recruiting AMHPs and Trainees was problematic as a result, with around 30% of AMHP posts remaining vacant. Devon, like other authorities, was struggling to provide a sustainable, effective and efficient AMHP workforce that had the flexibility and capacity to meet its statutory requirements.
The benefits of this new system and to the staff who have worked so hard to conceive it, and make it a reality, have been many. For individuals brought into consideration for compulsory treatment and care, they now have a flexible and responsive AMHP service dedicated to the role that is able to cope with fluctuating volumes of referrals. For those individuals’ families and carers, the service has been able to provide more opportunity for follow up and advice around their rights under the Mental Health Act 1983. While in many respects it is still early days in the life of this service the differences have been clear.
Toward the end of 2016 the service was nominated for the national Social Work Team of the Year – Adult Services Award, with supporting statements from other mental health teams, consultants, police and liaison services. The service won that award and was recently featured in the Chief Social Worker’s Annual Report for 2016-17 as an example of a model of good practice in adult services.
As will be demonstrated below, the positive impact upon a staff group that was under huge pressure has been significant. This is now a service and a job people want to be part of.
Wider Active Support
AMHPs work with people of all age groups who experience mental disorder and all services that support them. They are routinely engaged in work with police, general hospitals, ambulance services, CAMHS, older people and learning disability services, and working age mental health services. Within mental health services, they work closely with the consultant group, community and crisis teams, and other specialist services (such as eating disorder and complex psychological need). This new service design, and the AMHPs that have been freed up to work more creatively within it, are now able to reach out and represent the role of the AMHP, the local authority and human rights.
Through a newly introduced management structure, the AMHP service is now able to attend multi-agency and multi-disciplinary forums, make daily inroads onto psychiatric wards and crisis teams, and prioritise risk strategy and professionals meetings. One of the more rewarding aspects of the new service is the notion of it being a ‘learning environment’, where partners are able to spend time to understand the role and the legislative basis behind what AMHPs do. Increasingly representatives of the service are now undertaking training sessions for health colleagues, police, section 12 doctors, other local authority teams and – currently being developed – sessions for service users and supporters on the legal frameworks that their care is held within, along with the rights and protections that form part of that law.
This new AMHP service is increasingly being seen as indispensable, not just for the statutory work it must carry out, but for the support and direction it gives other parts of the service on a wide range of issues. Other examples of where the Daytime AMHP Team is working more effectively and jointly with partners are detailed below.
Central to the success of the design and eventual running of the service was securing AMHP and partners’ ownership of the design throughout the process. This was very much a ‘bottom-up’ project that evolved out of simple discussions, supervisions, appraisals, local AMHP forums and county-wide consultations.
A number of informal and formal events were part of the change process and the decision to change was one that was developed over time, and not rushed to as an attempt to solve a clear difficulty. ‘Listening into Action’ sessions with AMHPs, social workers, and operational managers ensured that the discussion was held under an organisational framework. Alongside preferences expressed through both online surveys and the Devon AMHP Conference, a favoured model began to emerge. Importantly in developing that model as much attention was paid to the small details as the over-arching structure and design. It was understood that without meaningfully supporting the individual carrying out the role no change could be considered successful.
Out of the various multi-level discussions a set of service development principles were established as to what a new service should look like, what those working within in could expect in terms of professional development, support and –importantly in AMHP work – physical, psychological and professional safety. Backed unanimously by AMHPs at conference, this set of principles anchored the project and acted as the yard-stick against which success could be judged.
Taken from the consultation on Daytime AMHP Service Re-design, authored by the staff themselves:
AMHP Service Re-design – Principles – Professional practice and personal well-being – Structure, governance and communication – Professional development –
Professional practice and personal well-being
1. The AMHP service structure should be configured to optimise support to AMHPs to ensure their safety and well-being and to minimise the need for ‘out of hours’ lone working.
2. The AMHP service structure should support AMHPs to carry out all aspects of their role in order to provide continuity for patients, their supporters, and those professionals involved in their care.
Structure, governance and communication
3. The AMHP service structure should promote ‘localism’ to ensure that the AMHP service remains connected with, and is integral to, local service delivery.
4. AMHP services should be accessible to all mental health service areas and not be limited to adult mental health teams.
5. Referral management of the daytime AMHP service should continue to be held centrally and be run by AMHPs.
6. The AMHP structure should promote clear understanding and protocols between daytime and out of hours AMHP services.
7. There should be clear service-level agreements with neighbouring authorities and their AMHP services.
8. A ‘lead AMHP officer’ should be empowered to advocate the independence of the AMHP role and inform decision-making at senior levels within DCC and DPT.
9 . AMHPs should be represented at all levels of decision-making that impact on AMHP practice; including liaison and connection with outside agencies.
10. There should be a culture of open and honest communication within AMHP services.
11. The AMHP service should be seen as an open learning environment in order to help promote social models of mental health and social care and rights-based agendas.
12. Pathways into AMHP training routes for social workers must be consistent with DCC’s career structures, be clear, and sit alongside non-AMHP social work post qualifying routes. Routes into AMHP training should be clear for non-social work professionals.
13. The AMHP structure should enable those with the Best Interest Assessor status to practice under the Mental Capacity Act, should they wish; and reciprocal agreements reached to enable ‘dormant’ AMHPs to return to AMHP practice should they wish.
14. The AMHP service structure should recognise and support those AMHPs who have skills and roles outside of AMHP work.
Looking Back/Challenges Faced
With the service being viewed as fundamentally successful, it is difficult to conceive of attempting anything dramatically different. It was not always an easy process, as a key component of the work was trying to convince the organisations that this could be a beneficial and worthwhile change. While it was an organisational priority, it sat very low down amongst a number of very significant other changes and priorities that were going on at the time. It could quite easily have disappeared.
Probably the most difficult aspect of the project was fixing on what the bottom-line budget could, would or should be. With AMHPs holding multiple roles a lot of careful calculation, negotiation and information had to be balanced to ensure that, while building a new service was the aim, the new service could not be created to the detriment of other parts of the service.
Trying to convince team leaders that they wouldn’t be losing an AMHP but gaining a service was not easy in the earlier stages. Those AMHPs were key members of their existing teams. Again the secret to over-coming this was communication – setting up individual meetings with team leaders and managers to explain the rationale for change as well as the benefits of it was vital. That this was the right change appears borne out by no-one calling for a return to the old days.
The viability and sustainability of the AMHP service was a key aim of the service. The high levels of vacancy, staff burn out and problems recruiting trainees placed the service at high risk. Through the introduction of two key elements – a new management structure and a bolstered Trainee AMHP role those risks no longer sit on the organisation risk registers.
The AMHP management structure moved us away from a professional lead model (where the Lead AMHP had no control over resources or staff) to a managerial one, where professional leadership becomes a key part of the service and its on-going development. The new management structure has, by extension, introduced a new career pathway for the first time for AMHPs in the authority. This has enabled a sense of progression being possible and ensured that AMHPs do not now have to always look elsewhere when seeking managerial positions.
Complimenting this is the newly introduced Trainee AMHP position. Historically new trainees were selected from mainly community mental health teams, and were exclusively social workers. The net effect of this style of recruitment was that these trainees still ‘belonged’ to their teams and not the AMHP service or provision. This meant they were rarely prioritised for pre-AMHP course experience and shadowing. It also meant that consolidating the role on return from completing the Masters-level course, was very difficult – as the priority was for team managers to put newly qualified AMHPs back into rotation for case carrying as quickly as possible.
With the new Trainee role, candidates have often been exposed to the role, and the principles behind it, through the ‘learning environment’ approach of the new AMHP service way before posts have even been advertised. On successful appointment to a Trainee post, the individual is afforded around six months to fully immerse in their locality AMHP team before joining the university-based AMHP training course; undertaking multiple shadowing opportunities, increasingly representing the service where appropriate, and agreeing a programme of exposure to areas of mental health practice that they would not ordinarily be exposed to. The University has fedback very positively about our candidates, commenting on how well-balanced and prepared they are for the course. Devon’s AMHP Trainees are routinely the highest marked and most likely to pass without the need for re-sits or re-submissions for law exams and assignments in the South West.
This new structure is now attracting people back to a role that was, until recently, viewed as unworkable and undesirable. It has also begun to attract candidates from other professions for the first time, expanding the knowledge base of our service.
Evaluation (Peer or Academic)
Evaluating AMHP services is difficult. There are no national standards for AMHP services, as AMHPs’ decision making is judged individually against the legislation, codes of practice and case law. Much is peer led. In introducing this new service we have been able to ensure that every two months each locality team is able to step out of frontline practice for the day to focus on service and professional development together. There is constant attention given to our systems and their effectiveness.
Nationally there is a drive to evaluate services and bring in greater regulation. The Devon AMHP Service is contributing to this work through attendance at the National Steering Group and work with the Department of Health and others.
This model has attracted a lot of interest from other authorities faced with the same sort of challenges we used to face. While it is clear that each authority has to develop a service to its own demographic and the realities on the ground of how services are currently set up, what has been appreciated by others is the ‘how we changed’, more than ‘what we changed’. The ground-floor-up approach, the establishment of principles for change and some of the structural issues have been adopted externally.
Below is some data from an evaluation of the first year of the new service by those AMHPs working within it.
In October 2016 the daytime Approved Mental Health Professional (AMHP) service ran an in-house survey in order to establish how those AMHPs working within the reorganised service felt about key aspects of their new working arrangements one year on:
• The survey found that 87.5% of respondents felt that the new service was “much better” compared to the previous model. The remainder indicating that it was “better”.
• 70.8% of respondents felt that the role was now “much more manageable”. The remainder felt that it was “more manageable”.
• 96% felt that the role was now “much less stressful” or “less stressful”.
• 88% indicated that when carrying out the role they felt either “much safer than I did before” or “safer than I did before”.
• 73.9% of respondents rated as “excellent” the support available to them from colleagues. The remainder described the support as “very good”.
• 79.1% rated the support available from the new AMHP management team as “excellent” or “very good”.
The response rate amongst the staff group was 86.2%, providing an excellent overview of progress from the point of those most affected by the change.
When mapped against the original service design principles developed by the AMHPs themselves, the vast majority of aims have been met and the hoped-for benefits realised. There is now an increased focus on the role and a greater sense of being part of a service with a stronger identity. There is more time to reflect on the role. The external resource pressures are still there, but having more support within an AMHP service has significantly reduced the sense of isolation and associated stress. Building the system was one thing, but ultimately it is the staff themselves that makes it work.
When asked whether relationships had improved between AMHPs and health colleagues (such as crisis teams and wards), 68% felt that relationships were “much better than before”; 24% “better than before”. The feedback from health colleagues and external partners has been really heartening, with the flexibility and dedication of the AMHPs themselves singled out for praise. By centralising some of the more administrative AMHP aspects of the role, AMHPs’ capacity and response times to urgent situations have greatly improved. More effective joint working is enabling earlier consideration of least restrictive options or, conversely, ensured that necessary intervention happens much more quickly.
For those subjected to the processes of the Mental Health Act, often when at the lowest points in their lives, improvements of this kind may never be felt directly. What we can say is that responses to crises are timelier, that the AMHP considering their case is more likely to be better supported and more robust than before, and more able to focus on the individual’s situation and that of those around them.
One of the benefits of setting up a service like ours is the ability to offer ourselves up to help take the burden off of other teams and parts of the service. There are two prime examples of this:
Firstly as a service we were able to offer to take over the governance and management of the social supervision of so-called ‘offender patients’ in the community post-discharge from secure hospitals. This has enabled care co-ordinators, who often had to balance this public protection role with care arrangements and provision, to be freed up to concentrate on their primary functions. It also ensures that social supervisors have a more robust support network and body of expertise when required. It has also helped reduce the risk to the organisation, as social supervision sat variously across the teams with no real focus or oversight.
Another example of where the service has been able to share work is by stepping forward to run the police advice-line on behalf of the Street Triage Service. Street Triage had significant recruitment issues and through localised discussions and negotiation, the daytime AMHP service have been able to provide through its referral management system a quick response line to police officers who are considering using section 136 (police holding powers). By having AMHPs able to influence and discuss a person’s situation, background/health record checks and so on, it has augmented the work of Street Triage to reduce the use of section 136 and improved day to day relationships with police colleagues.
What is clear that these two offers of support to other parts of the service could never have happened before the establishment of this team. As the AMHP service consists of a number of small locality teams, it has also been possible to make local arrangements that suit those communities – for example, in one area there are two privately run residential schools for children with behavioural and mental health issues. That locality team has been able to develop relationships to minimise the need for the use of the Mental Health Act, by getting involved in discussions early. No other part of the county has such a need and we have been able to be flexible in our approach to working in partnership as required.
Is there any other information you would like to add?
AMHP practice is often misunderstood. Viewed from a number of differing perspectives, AMHPs can be seen as simply ‘box-tickers’ and ‘rubber-stampers’ for medical decisions, through to people overly fixated on what the law says and blocking professionals from pursuing their preferred interventions. For many experienced practitioners, it can still come as a surprise that it is in fact the AMHP that makes the final decision about a person’s detention, with the ability to reject the recommendations of doctors.
From within AMHP practice the role is much clearer. AMHPs operate within a legal framework of human rights. They are part of a set of legal safeguards that protect, as well as often empower, those in difficult situations due to their mental disorder. The independent decision making component of the role means that the AMHP can sometimes be the only practitioner felt able to take positive risks in order to maintain the individual’s autonomy, often against a backdrop of sometime paternalistic and pathologising practice that locates the ‘problem’ in the individual, rather than viewing the situation more broadly.
Having the final say in the outcome of a Mental Health Act assessment and the authority to make decisions without being directed takes time, dedication and character. For years those carrying out the role have been worn-down and eroded by multiple demands, uncertain leadership and a developing legal framework that is a full time job in itself to keep a track of. In order to do their job, AMHPs have to hold the individual as central to their considerations; while simultaneously trying to secure the attendance of doctors, ambulances, police; supporting the needs of carers and families, trying to engage individuals who have pulled away from services, and working within limited resources. While none of these factors have changed, the introduction of this service – designed by those who work within it – has shown that it is possible to prepare and support each other to be able to cope with situations that in isolation can seem intolerable. It is hoped that this increased focus and professionalism in the role is benefiting all who come into contact with the service, not least for those who work in it.