The AMHP, Like the ASW, Has a Central Responsibility for Co-Ordinating the Assessment Process

APPENDIX A

Workforce Review – Adult Mental Health Practitioner Service

Responsibilities of the Local Social Services Authority

BACKGROUND

A primary responsibility of the Local Social Services Authority (LSSA) is to provide the Adult Mental Health Practitioner (AMHP) service and ensure that there are sufficient AMHPs available in their area to provide access to a 24 hour service.

LSSAs have a number of key duties in relation to AMHPs who undertake assessments on their behalf, these include:

 Ensuring that all AMHPs have access to professional supervision and support in their role as AMHPs  Provide a minimum of 18 hours of refresher training, relevant to the AMHP role each year – as determined by the local authority  Responsibility for the health and safety of AMHPs whilst they are undertaking assessments on their behalf  Responsibility for professional competence in their role as AMHP, and for removing or suspending their warrant as necessary  Legal indemnity whilst undertaking the AMHP role  Access to legal advice whilst carrying out AMHP duties

ADASS recommends that LSSAs maintain at least one directly employed senior manager or officer who has knowledge of the AMHP role and/or service to ensure that AMHPs have access to independent advice and support and to act as a ‘champion’ to highlight any problems identified by AMHPs, and to protect the role’s independence where the source of the problem may be within the substantive employer’s control.

Approved Mental Health Practitioner role

The AMHP has a central responsibility for co-ordinating the Mental Health Act (MHA) assessment process, considering the need for admission and pursuing alternatives to the use of compulsion wherever possible, and whilst working in partnership with other professionals, reaching an independent judgement about whether the use of compulsion is necessary and appropriate. They are the applicant in the process and as such have personal liability for the judgements made.

In summary, the AMHP has a number of statutory powers and duties:

 Co-ordinate MHA assessments and arrange conveyance to hospital or implement any alternative care plans  Respond to S136 detentions in a police station or the 136 suite at the hospital  Make Community Treatment Order (CTO) applications and agree to revoke or extend a CTO  Supervise section 37/41 patients in the community and produce 3 monthly reports for the Ministry of Justice  Apply to Court for section 135 warrants if necessary to obtain entry to premises  Apply for Guardianship/Guardianship renewals

1  Consider a request for a MHA assessment from a nearest relative and, if the AMHP decides not to make a recommendation, to inform the nearest relative of the reasons why in writing  Apply to the court to displace the nearest relative if the criteria apply  Produce a statutory report on completion of an AMHP assessment

AMHPs therefore undertake a mix of planned and unplanned work, and the service has to have the capacity to respond to both. AMHPs also provide expert advice and support for other professionals preparing reports for Tribunals and Managers Hearings.

Historically AMHPs have provided awareness training on the MHA and the AMHP role to social workers who provide back up support to AMHPs on the duty rota and to colleagues and teams within the department. Those sessions have usually been well attended and relied on as a valuable means for building knowledge and confidence in this complex area of work. Unfortunately the training has not taken place for some time due to the reduction in AMHP numbers and the subsequent increase in workloads.

CURRENT SITUATION

Current position in relation to the AMHP service in Middlesbrough

At the 31st April 2015 Middlesbrough Council had 13 AMHPs located in the following teams: 10 of these are on the emergency duty rota. The remaining 3 pick up the majority of the planned statutory work across mental health services.

Team No. of No. of Funding AMHPs AMHPs on the rota Lakeside (Affective Disorder) 1 1 MBC 1x recharged to TEWV Parkside (Psychosis) 3 3 MBC

Woodside (Older People’s 1 1 MBC Mental Health) Forensic LD 2 1 tbc

Forensic MH 2 2 1 x MBC 2 x recharge to TEWV Criminal Justice Liaison 1 1 SLA

BIA Team 3 1 3x MBC/SLA

TOTAL 13 10

One of the AMHPs in the Forensic Mental Health Team will commence leave, followed directly by maternity leave, on the 15th of August 2015 for up to 12 months.

2 From mid-May the same AMHP was taken off the rota as per risk management procedures.

The level M Principle Practitioner/AMHP in the Older Persons Team has obtained a Level L post in Redcar/Cleveland with a salary increase of approximately £5,000 per annum. Based on this evidence and previous experience it is highly unlikely that any external AMHPs will apply for this position.

By the end of July 2015 the number of AMHPs on the rota will be down to 8.

Of the 3 AMHPs not on the rota 1 is Lead Officer for Mental Health /MCA/DoLS and AMHP duty rota manager. The other 2 pick up most of the planned work including, treatment orders, Guardianship application’s across all social care and not just across Mental Health services. This group also provide support and guidance to generic services re a variety of mental health issues including S117 after care, reviews of CTO’s and Guardianship orders and assistance with Tribunal/ Managers reports. They will also undertake Mental Health Act assessments in crisis situations.

On the 7th July 2 of the 3 AMHP’s not on the rota informed that they intend to relinquish their AMHP warrant’s due to volume and ever increasing complexity of the role. The consequence being that the majority of planned work will now have to be picked up by the emergency duty rota.

2 social workers will have completed the AMHP training programme in June 2015 although they will not practice independently until November/December 2015.

4 social workers have been identified to attend the next intake of the AMHP training programme but will not practice independently until November/December 2016.

AMHP ACTIVITY

Between April 2013 and April 2014 128 statutory assessments were undertaken.

Between April 2014 and April 2015 188 statutory assessments were undertaken.

The increase in statutory work over the last year is due mainly to the Cheshire West judgement that came in to force on 19th March 2014. TEWV’s mental health legislation committee has also recorded that activity under the MHA remains relatively high across all areas and services across the Trust.

Number of AMHPS employed by Middlesbrough between 2012 and 2015

January 2012 21

January 2013 18

January 2014 13

January 2015 13

July 2015 9

3 Local influences

There are particular factors which add to the volume and complexity of AMHP activity in Middlesbrough:

 Community Mental Health Profiles are available, which are designed to give an overview of mental health risks, prevalence and services at a local, regional and national level.

Middlesbrough scores worse in many key areas compared to the England average. Examples are in relation to the wider determinants of health, the percentage of adults with depression and the rate for hospital admissions for mental health.

 Tees, Esk and Wear Valleys NHS Foundation Trust have located some regional services at the Roseberry Park site in Middlesbrough which has impacted on the demand for mental health services

 The Chester West Judgement which came into effect on the 19th March 2014 has resulted in an increase in the detention of incapacitated individuals.

 Section 40 of the Care Act 2014 makes changes to the ordinarily residence rules which will impact on 117 after care duties and responsibility for the Mental Health teams.

Personal Liability

AMHPs are responsible personally for their decisions and actions. The LSSA provides indemnity but any legal action in relation to an MHA assessment is taken against the AMHP personally. This is unlike any other area of work within social care, both children and families and adult social care. This personal liability extends even after a person no longer works for the authority.

Potential future impacts on the role

The responsibility for undertaking an AMHP assessment rests with the LSSA within the area the patient is at the time of the request. This has significant implications for Middlesbrough Borough Council as it covers two large hospitals, James Cook University Hospital and Roseberry Park. If a patient from Durham is in a hospital bed in Middlesbrough, then legal responsibility for the assessment rests with Middlesbrough.

In the past, Middlesbrough Council has had a Cross Boundary Agreement with the LSSAs that are covered by the TEWV area. Within this, each authority has said that they will undertake their own MHA assessments even though the person may not be within their home area at the time; therefore Durham would undertake the assessment for a Durham resident in a Middlesbrough bed.

4 However recent legislation and codes of practice place a greater emphasis on where the person resides at the time of being assessed under the Mental Health Act. This is likely to make other LSSA’s less willing to sign up to future cross boundary working agreements resulting in a further increase in statutory assessment requests for Middlesbrough mental health services.

There is also evidence of increased legal challenges against the AMHPs, as solicitors pursue this area of work.

 On-going difficulties in response from the Police and Ambulance service continue to have a major impact on the process of MHA assessments. For examples the process of the assessment from start to finish is between 2 and 3 hours. However, the waiting time for Police/Ambulance attendance can result in the process taking 6-12 hours. During this time the AMPH is often left to manage what can be a volatile and risky situation.

FINDINGS

The findings of this review suggest that the AMHP service delivers a complex range of statutory duties and is now struggling to provide an effective and efficient service.

There are historical issues locally in relation to the employment and retention of AMHPs, mainly to do with remuneration. All AMHPs in Middlesbrough are qualified as Level L Social Workers and receive a supplement of £2,000 per annum if they participate on the rota.

The salary and supplement paid to Middlesbrough AMHP’s is well below that paid by other authorities in the North East Region.

AREA SALARY

Newcastle Senior Practitioner pt. 41 (£35,662) to pt. 44 (£38,405) Durham Advanced progression pt. 39 (£33,857) to pt. 43 £37,483) Stockton Advanced progression pt. 39 (£33,857) to pt. 42 (£36,572). Senior Practitioners pt. 42 (£36,572) to pt. 45 (£39,268) Hartlepool Advanced progression pt. 41 (£35,662) to pt. 45 (£39,267) Gateshead Advanced progression pt. 40 (£34,746) to pt. 43 (£37,483) plus 2 increments North Tyneside Advanced progression pt. 39 (£33,857) to pt. 43 (£37,483) Northumberland Advanced progression pt. 40 (£33,998) to pt. 44 (£37,578) plus extra allowance if work after 8pm (separate from EDT work). South Tyneside Pay an additional 2 increments to salary up to max pt. 42 (£36,521). Senior AMHPs are higher. Redcar Pt 44 (£38,405) to pt. 46 (£40,217) with specific job description Darlington On scale £34,000 to £39,000 (approx.) Middlesbrough Pt 37 (£31,846) to pt. 38 (£32,778) to pt. 39 (£33,857). Plus a £2,000 supplement paid per annum. Sunderland Proposed scale £24,472 - £35,662 plus 2 increments.

5 Areas of concern

In January 2012 Middlesbrough had 21 AMHPs. By the end of June/July 2015 we will have 9 with 8 on the rota.

The consequence of having only 8 AMHPs on the rota will mean that AMHPs are expected to be on the rota 3-4 days per week. This creates major pressure for the individual AMHP and their teams who already manage high risk caseloads. The demands of the role also place significant pressures on the work life balance of the AMHP, an example of this is that a high majority of MHA assessments take place or continue outside of working hours.

The increase in planned statutory work having to be picked up by the rota or mental health teams will have a significant effect on ability of mental health social work teams to provide a safe and effective service

To date the rota has been covered due mainly to the goodwill of AMHPs. However the increasing demands placed on AMHPs both from the rota and daily case management work cannot be sustained.

The main reason for the number of AMHP’s leaving Middlesbrough is the discrepancies in salary compared to the other authorities within the Northern Region. Over the last 4 years Middlesbrough has lost 7 AMHP’s to Redcar and Cleveland. All 7 had completed their AMHP training whilst employed by Middlesbrough.

We currently have 2 K grade social workers about to qualify as AMHP’s, however they will not be ready to work independently until November/December 2015. However finance have informed that funding is not available to upgrade to level L

Cost Upgrade from level K to L £1,100

4 social workers have identified to attend the next AMHP training programme but it will be November/December 2016 before they are able to practice independently as an AMHP.

The current AMHP service in Middlesbrough is only able to function because of the loyalty and goodwill of the remaining AMHPs. In November 2013 an AMHP report as part of the Workforce review highlighted that the reduced number of AMHP’s was of real concern. At that time we had 13 AMHPs. We now have 9 which clearly place Middlesbrough Council at significant risk of not being able to fulfil its statutory duties under the MHA 1983.

OPTIONS APPRAISAL

OPTION 1

6 Do nothing, the consequence of doing nothing is that more AMHP’s will leave Middlesbrough this would result in the Middlesbrough AMHP service being unsafe to practice and therefore unable to meet the statutory requirements under the MHA 1983. Cost Nil

OPTION 2 (short term)

Increase the market supplement from £2,000 to £4,000 per annum to reduce the real and immediate risk of more AMHP’s leaving the authority.

Cost 9 AMHPS = £22,500 per annum including on costs

OPTION 3 (long term)

Increase the AMHP salary in line with other authorities

Cost = As a starting point, increase of 2 increments for each AMHP £2,252 per annum including on costs

Continue to send a minimum of 4 social workers a year on the AMHP training programme until we have sufficient numbers to provide a safe and efficient service.

Cost AMHP training per social worker £2,500

Encourage social workers from generic teams to undertake AMHP training to ensure a wider knowledge base and expertise of the MHA within all service areas.

RECOMMENDATIONS

Both option 2 and 3 will need to be considered to improve the employment and retention of AMHP’s within Middlesbrough to ensure the authority has sufficient AMHPs to fulfil its statutory duties.

Option 2 requires immediate attention to minimise the risk of losing more AMHP’s to other authorities, this will also help to provide the incentive to continue practising as an AMHP and recognition of the demands, complexity and personal risk of the role.

Option 3 will need to consider a more strategic approach to the employment and retention of AMHP’s, such as, increasing the salary via an incremental provision that works towards compatibility of salary with other authorities, consider extra leave days or/and the provision of an AMHP team that consumes all of the mental health work.

Vanessa Fryer Lead Officer Mental health/MCA/DOLs