AMHPs and Stress

Back in January, Zarathustra posted a link to a survey for AMHPs on stress and burnout. This was for a piece of research being conducted by Janine Hudson, an  AMHP studying for an MSc in Mental Health Social Work at King’s College, London.

AMHPs are Approved Mental Health Professionals who, according to Wikipedia are ‘trained to implement coercive elements of the Mental Health Act (1983) as amended 2007’ so we (because I am one myself) make decisions with requisite recommendations from medical professionals, about whether someone needs to be admitted to hospital and treated without their consent. There are other roles for example in relation to Guardianship and Community Treatment Orders and certain tasks that are reserved for AMHPs legally but we have specific training around Mental Health Legislation and the implementation of it.  It is a role which does demand particular expertise, sensitivity, compassion and intellectual rigour to conduct well.

Janine and Dr Martin Webber who co-authored the study were  generous enough to share with us here (AMHP Survey 2012)  and while I am not entirely surprised by her results, I was saddened that my own gut impressions seemed to be more than just gut impressions.

Over 500 AMHPs responded to the survey and as many as 43% met the threshold for ‘common mental disorder such as stress and anxiety’. The threshold for burnout was much lower but it does raise the question about the amount of support and consideration given to practising within this particular role in local authorities in particular – whose responsibility warranting them (us) remains – but also within employing NHS Trusts. One of the aims of the study was to determine any differential in stress levels experienced by social work AMHPs and non-social work AMHPs but the findings were that there were still very few non-social work AMHPs and there was little differential. Locally, I know that there have been some issues around funding of non-social work AMHPs as it is a duty of the local authorities to provide sufficient AMHPs and as money is stretched, NHS Trusts have seemingly been less keen on sending people to train for a significant period.  It will be interesting to see how that picks up over the years but as the purpose of extending the role to non-social workers in the first place (we used to be Approved Social Workers and it was a reserved role which only social workers could take) was that there were too few AMHPs, it seems that issue hasn’t really resolved itself fully yet, four years after the switch.

71 AMHPs responded that the work as an AMHP had not had an impact on their non-AMHP role, however most of those worked in dedicated AMHP services because for the rest, the issue of managing AMHP and non-AMHP tasks with no workload concession, an increase in unpaid hours and pressure of work were contributing factors to increased stress.

I have certainly found personally that the AMHP work I carry out encroaches substantially on my ‘regular’ work as the amount increases. I am sometimes called out at very short notice to carry out assessments and these assessments take priority over all the other work I do due to the urgency and statutory nature of the tasks.  I have missed and moved visits at short notice and I can’t use any excuses to service users I work with (because obviously I can’t discuss my other work with them) so I apologise profusely and humbly but my stats aren’t as good as my colleagues in the same team and this is challenged. It is an additional pressure but any mention of removing some of my caseload responsibilities are met with a sad and sympathetic sigh. It’s just not happening!

Sadly familiar too, were some of the difficulties raised in terms of working and organising assessments across different services particularly as resources are stretched. Availability of ambulances, doctors and police are all  factors  in trying to manage and organise an assessment and certainly a factor that I recognise however the overriding issue was one of a lack of available beds.

Personally, I have found this to be much more acute as a issue over the last year and is getting increasingly worse. It isn’t wholly unrelated to the local Trust closing down wards to ‘save money’ however it has led to a massive increase in the provision of private beds at higher cost and further distance. This is the kind of ‘strategic decision’ that makes you wonder about the way snap decisions were made.

The impact on the patient is significant but it is also increasing stress levels in members of staff.

Generally, the research study indicates that AMHPs broadly feel unsupported in the role – except (perhaps unsurprisingly) by other AMHPs but in terms of management support/supervision/debriefing, it can vary significantly.

The report concludes that employers should do more to recognise the important and often difficult role that AMHPs take and reward with workload relief and a pay differential that acknowledges how much other professionals are paid for the work too.

My thoughts on reading this survey are that I’m unsurprised. I think it’s hard to explain to someone who is not involved in the role what exactly it entails but there is an enormous amount of responsibility taken  by the AMHP and it does feel to me, personally, that this is not appreciated or understood by my employing organisation. I wonder if there is a general awareness of some of the stresses that can be placed on an AMHP (and I’m absolutely sure every AMHP has been in this situation) when there is a great deal of distress after a decision to admit has been taken and the doctors have gone and we are waiting for the ambulance – maybe with the police, maybe not – but there’s a great deal of responsibility being handed to the AMHP at that point. It’s important that we are given substantial support.

My best support has definitely come from other AMHPs.

Saying that, while I won’t ever say I enjoy the role because depriving someone of their liberty is a very difficult, challenging and distressing process – the learning that I have done as a part of being an AMHP  has been significant – in terms of my understanding of mental illness and in terms of my practical application of the Mental Health Act, Human Rights Act and Mental Capacity Act.

Being an AMHP has made me a better social worker without any doubt and being an AMHP has and does make me reflect constantly on what the ‘system’ does and doesn’t do to those who come through it – and my role within that system.

However benefiting from the knowledge doesn’t mean that we shouldn’t get greater support for the role. That’s clear from this report and thanks to Janine for sharing her research with us. I hope that it will be disseminated widely to all local authorities who engage AMHPs and if you are an AMHP or know one, take it to your next forum meeting and discuss it.

In order to care and plan best for others, we really do need to look after ourselves and our own mental wellbeing.

photo by kelvin255 @ flickr

Broadening access to Independent Mental Health Advocates

The statutory role of the Independent Mental Health Advocate (IMHA)  grew from the 2007 amendments of the Mental Health Act in England and Wales (with a start date of 2009).  IMHAs have particular status in terms of rights to information and access that other advocates may not have within Mental Health services.  Currently commissioned by PCTS, from 2013, Local Authorities will take over commissioning of IMHA services and the right and access to good services is intended to be a safeguard within compulsory mental health services.

Last week, Community Care reported on a study conducted at the University of Central Lancashire about the use and understanding about the use of Independent Mental Health Advocates (IMHAs)  among Mental Health Professionals in England. The study has (not, I suspect, coincidently) come at a good time for the change in commissioning arrangements and a look at where things are and where they should be going.

The article itself draws attention to the conclusions that

Some professionals saw advocacy services “as challenging, even irritating and inappropriate”, the research found. One professional told researchers advocates were “amateurs meddling” and a “bloody nuisance”. Others, particularly approved mental health professionals (AMHPs), supported advocacy “but had little or no direct experience” of service users using it.

As a Mental Health Professional (and AMHP) who has had some experience of uses and referring to IMHAs, I was disappointed by this initially. Particularly the terms with which advocates were mentioned. ‘Nuisance?’, I hope so. ‘Meddling?’ well, why on earth not? Surely being a nuisance to professionals and meddling is exactly what a decent advocate should be doing – however I would find the distinction between so-called ‘mental health professionals’ and ‘amateurs’ as advocates offensive and an indication of scant respect. Respect at every level in mental health services, social services and health services has to exist.

Community Care in a blogpost have put together some of the quotes pulled from the report by social workers and AMHPs in relation to advocates which makes interesting reading alone.

My experiences have been mixed to be brutally honest. Working predominantly with people with cognitive impairments which are significant and may not be able to instruct an advocate, I’ve found our IMHAs who have come from a mental  health advocacy background, have been less than understanding of the need for non-instructed advocacy skills. I have been told following a referral I made, that they would not work with ‘Mr Brown’ because he has an advanced dementia and they were only able to do what he asked as his advocate.

I felt some of the attitudes I’ve seen by a couple of our IMHAs towards older adults with cognitive impairments have been less than positive – and I do feel quite protective towards my client group and want to ensure equal access. If only, I have thought to myself on many occasions, our IMCAs (Independent Mental Capacity Advocates) were also our IMHAs (I can’t praise our IMCAs highly enough – even (or perhaps especially) – when we disagree!).

I am always (in a nice way, of course) a little jealous of the advocates I work with. I think their job has a lot more credence than mine in some terms because while I can advocate for my clients to a point, there’s a point at which I am a part of the oppressive systems that need to be advocated against.

I understand that and respect it. I’d certainly not see advocates as any less ‘professional’ than other members of the team I work in. There has to be a distance though – which doesn’t need to stop us being friendly, personable and pleasant to each other – but does demand that sometimes we will be coming from different angles. That’s important to protect the rights of those being advocated for.

The report itself can be read here.  It explains the context of. It explains that access to an IMHA service which should be offered to everyone who is subject to a detention over 72 hours or a Community Treatment Order/Guardianship – is sparse which particular under-representation in the following areas

There was a strong consensus that those who need the IMHA service the most,access it the least. Specific groups of people that may be under-served by IMHA
services are:
 People from BME communities
 People with learning disabilities
 Older people, with dementia
 People who are hearing impaired or deaf
 Children and young people
 People on CTOs
 People placed out of area

And the issues which have coloured my own personal experiences of using IMHAs was mentioned in the report

The development of IMHA services is based on a model of instructed advocacy provided by mainstream advocacy providers. This may inadvertently disadvantage qualifying patients who have specific needs including people from BME communities, older people, children and young people and those with sensory impairments ..

Furthermore

There was little evidence of commissioning based on needs assessment and equality impact assessment and there was evidence in the case study sites that specific needs had not been considered. In particular, gaps were evident in relation to people from BME communities, people with learning difficulties, older people, children and young people. Further, it was evident that generally service users, particularly qualifying patients, were not being directly involved in the commissioning process or in
monitoring contracts.

So it would be unfair of me to lay the blame at the lack of capabilities of particular advocates and more on the commissioning process which sees ‘Mental Health Patient’ as a block group of people with similar needs and commissions accordingly.

The report makes a number of useful recommendations and is a good read for anyone involved and engaged in the provision of mental health services in England and Wales, whether as a professional, user, advocate, carer or commissioner.

The role of the advocate was strengthened by legislation and it is important that the benefits are not lost. I have seen such incredibly useful work done by advocacy services locally that my main gripe is that there should be an equality of access and opportunity for all who are treated compulsorily by mental health services in society.

I want more ‘nuisances’. I want more ‘irritants’. I want more challenges.

That’s what an advocacy service should be about.

pic by sparkypics at Flickr

Integration and Disintegration between Health and Social Care

There has been a lot of talk about the need for greater integration between health and social care. It’s been happening for as long as I’ve been in social care.

It seems obvious to me anyway, that as long as there are different pots of cash between health and social care, the proverbial ‘buck’ will continue to be passed and the differences in the funding systems has potential to lead to great distress in terms of services delivered.

While NHS services remain free at the point of delivery, social care services are means tested and chargeable and the line between ‘health’ needs and ‘social care’ needs relating from health needs can be very complex.

The answer is integration. Integration of budgets and integration of costs. Integration so that savings made by preventative work today in social care are evidenced in the budgets of the health service – and vice versa. A poor and speedy hospital discharge in order to protect hospital beds may result in a excessive needs in relation to social care. A lack of provision of social care may lead to greater health needs. It seems obvious.

But this is not new. However, in mental health services we possibly have some of the highest levels of integration between health and social care – for the moment.

As a local authority social worker, I (with some of my colleagues) am seconded into the local Mental Health Trust, working alongside NHS employed colleagues.

The position of embedding social workers in NHS trusts has been a long one and was needed for a number of reasons. It may be that there is a genuine feeling that embedding social workers in Community Mental Health Teams improve outcomes for users. It is a move away predominantly medical models of mental health and an acceptance and understanding that social models of illness and disability have a place around the ‘table’ in a multidisciplinary team.

I genuinely believe that as a seconded member of staff, I have a slightly different ‘take’ on some of the hierarchies that seem to exist within the NHS structure. I rather enjoy challenging doctors and I think most of them quite like being challenged too – it’s all respectful of course but from a basis of a different branch and approach of expertise. While understanding that all members of a CMHT, whether doctors, nurses, occupational therapists or psychologists, can work towards social models – the training of a social worker is quite unique in this setting and adds something very different to the mix of the team.

The other reason that led these integrated teams to exist was related to the provision of ASWs (Approved Social Workers as they were) under the 1983 Mental Health Act (pre 2007 amendments).

Local authorities were responsible for employing  and authorising Approved Social Workers in their areas. This led to the ‘secondment’ system working.

However with the 2007 amendments the new AMHP (Approved Mental Health Professional) role did not need to be employed from outside the NHS. So with the NHS being able to employ their own AMHPs and AMHPs no longer needing to be Social Workers, the absolute need for secondment waned and some Trusts have seen it as an opportunity either to TUPE the social workers into the NHS Trusts and employ them directly – or to ‘disintegrate’ teams and move Social Workers back into Local Authority Teams. This, you see, both can save money for LAs who have been paying for the social work staff in these Mental Health teams while not entirely convinced they are getting ‘value for money’ in terms of the new targets they have around ‘personalisation’ – particularly as take up from mental health users has been traditionally poorer than take up in some of the more ‘traditional’ local authority adult teams.

The problem with disintegration is that it is both counter-intuitive in terms of the less concrete targets that might exist and is potentially counterproductive – we should be working together in the most seamless way to provide and deliver services to users who deserve better systems which work. We need to work in Community Mental Health Teams which have a strong dose of social work-trained professionals because we bring a unique perspective to the role and can temper some of the push towards overmedicalisation  or pathologising of mental health.

So where now? Some local authorities and NHS trusts are ‘divorcing’ while the rest of the sector glibly bangs drums about ‘integration’.

Personally, it feels like the move towards and away from integration can only be won on the arguments of cost in terms of cash.

Unfortunately there’s an ethical consideration about cost in terms of better care, better treatment and better delivery of services which is being lost.

Social Work and Health need to integrate not disintegrate – in all areas but the implications of the divorcing that is happening in mental health needs to be pushed to the front of the agenda.

Survey on AMHPs and Burnout

Approved Mental Health Professionals practising in England needed to complete a survey about stress and burnout.

The survey aims to determine whether there is a difference in experiences of stress and burnout between the professional groups that perform the AMHP role. The study has been approved by King’s College London Psychiatry, Nursing and Midwifery Research Ethics Subcommittee (REC reference number PNM/11/12-23). It is the first survey of its kind since the AMHP role was introduced and with your help we hope it will yield some useful and valuable data.

It is important that AMHP’s from all professional backgrounds complete the study. However we would particularly like to encourage those from a non-social work background to take part as they are still relatively small in number. An information sheet containing further details about the study is displayed on the first page of the online questionnaire. If you would like to read more about and or complete the survey please click on the link below:

https://www.surveymonkey.com/s/stressandthestatutoryrole1

Thank you in advance for your time and support.

(This message was posted at the request of Janine Hudson, an Approved Mental Health Practitioner and MSc student in Mental Health Social Work at Kings College London)

Meanwhile..

While Z has been writing up the fantastic post about the Mind New Media awards, I’ve also been busy.

As well as contributing to the new College of Social Work blog here I’ve also written up ‘how I became an AMHP’ for the Guardian Social Care Network and have written a guest post on a new blog ‘Connecting Social Care and Social Media’ here about why I think social workers should use social media.

And while I’m at it, a heads up and thanks to Max Neill who included this site in  his Carnival of Personalisation in Health and Social Care which is an interesting link to a wide range of sites that relate to the issue of changing delivery of services in Adult Social Care and increasingly Health services.