This piece was originally published in the DCC-i June 2022 Newsletter.

So, the government will over the next year or so, draft legislation to reform the Mental Health Act (MHA).
 
What is not to like?
They intend to modernise the MHA & promise to make what is basically 1950’s legislation, fit for the 21st century.  The plan is to give patients suffering from mental health conditions greater control over their treatment & to ensure that they receive the dignity & respect that they deserve.
 
This new legislation is going to address the existing disparities in the use of the MHA for people from ethnic minorities. But it is going to keep CTOs #JustSayingLike.

“In 2020-21, black people were four times more likely than white people to be detained under the Act, and over ten times more likely to be placed on a Community Treatment Order.” 
 
What is that all about then?
What about us #AMHPs?
Are we part of the problem or part of the solution?
 
Can I suggest you read this summary by Mithran Samuel over at Community Care & the responses & make of it what you will.
 
I am also not seeing any plan to do anything about poverty, inequality & substandard housing etc. You know the import stuff & Social Determinants of health & the cost-of-living crisis. They want to make it easier for people with learning disabilities & autism to be discharged from hospital. They are also amending the definition of mental disorder and the hope is, that adults and children with learning disabilities & autism, will not be detained in the first place. I applaud the intended consequences, but I do wonder about the investment in community provision & alternatives to hospitals & about the unintended consequences & about things like S.117.
 
Be careful what you wish for, and it’s not just me,  smarter people than me are wondering about this stuff also, see what the ever-learned and plain speaking Lucy Series has to say about it here.
 
They are proposing to change the criteria needed to detain people so that the MHA is only used when it is strictly necessary. When the person is thought to be a genuine risk to their own safety or that of others & they are introducing the notion of therapeutic benefit. So, adults and children will in theory, only be detained when it is thought to be of therapeutic benefit to them.  A certain contested diagnosis springs to mind & something about having capacity & about taking responsibility.
 
Just think about that for a minute, about what that means in practice. I don’t think sending people/children 100’s of miles away to out of area beds is a therapeutic thing. Plus who gets to decide/assess what genuine or substantial risk is? I suspect that is you & me #AMHPlife & a doctor or two. If you can find a S.12 medic in the dark of the night.
 
I don’t ever speak to any #AMHPs, or indeed doctors, who currently think that they are detaining people/children when it is not strictly necessary. I do speak to #AMHPs & Drs & families who acknowledge that they are detaining people/children because there is no other option or alternative available to safely manage/contain risk.
 
Imagine you or I don’t detain someone, because we don’t think there is avtherapeutic benefit & it all goes wrong. I am not sure that I am looking forward to explaining that particular decision (made without the benefit of hindsight & with limited information & under pressure) in the criminal or coroner’s court.
 
There will be more advocacy for people & the Nearest Relative will become a Nominated Person & they will have greater powers to say no & to be consulted about things like CTOs.
 
Who is funding & providing that advocacy?
What does it look like in the real world?
What if the person doesn’t nominate a person? What if the Nominated Person just says no & no & thrice no & they are not helpful & you think they are unreasonable or unsuitable?
 
Those really ill people in HMPs will be transferred to hospitals within 28 days. *If there is a bed. There will be a new form of supervised community discharge, that will allow us to deprive people of their liberty. But only the really risky ones.
 
Remember the MM & PJ cases tell us, that we cannot use the provisions of the MHA (S.7, S.17A or S.41) to deprive capacious community patients of their liberty, even if they are assessed & thought to be really v risky to self or others. What is that going to look & feel like in the real world?
 
People subject to the provisions of the MHA, will be able to appeal to Tribunals more often & they will be given a statutory care & treatment plan. This plan will be written with them & will set out a clear pathway to their discharge. Some plan that, & of course it will do away with S.117 disputes & funding panels & CHC & CCG squabbles over £s & provide housing with the appropriate level of support & sort benefits & deal with the DWP.
 
It seems that the proposed & much discussed extension of Section 5 holding powers to the Emergency Department (ED), is not going to be a thing. The solution to the problem of adults/children being assessed as requiring admission, but there being no bed/hospital willing to accept the #AMHP application, is I was told, going a be none legislative one.
 
I didn’t quite figure out what that answer meant or might look like in a police custody block, when the PACE clock has ticked & tocked. Other than an ever-increasing number of S.136s & other improvised solutions to system dysfunction. It is at this point that I usually mention S.140 anyone?
 
Did I mention that me & Steve Baker our #CrewCop do joint training for #AMHPs & the girls & boys in blue & the odd Bed Manager?
 
Last year (1920/21) in England there were 53,239 civil detentions under the MHA & something like 1,520 new restricted patients admitted to hospital for treatment. It is not 53,239 people by the way. It probably equates to about c.35,000 people & it doesn’t include people detained on S.136. - complicated this isn’t it?
 
While like many, I really do appreciate the work undertaken by Sir Simon Wessely & his team & the MHA really did need updating & I enjoyed v muchly the odd train trip (consultation event). I can’t help but think (unfortunately, I am old enough & was an ASW in 2007), that it is again a missed opportunity to bring about real change. That the problems are not really rooted in the legislation. That it really is about the other stuff - poverty, inequality & substandard housing. About the lack of investment in the community alternatives & early intervention. If we really want to reduce the numbers of adults and children being detained, then we need to stop calling #AMHPs & we need to stop relying on the MHA as the solution to the problem.
 
We do need to think about risk & perception of risk in a different way & we need to support people & families much better. Otherwise, I fear, that me & others, will simply be writing things like substantial & genuine risk on pink forms & writing that it is of therapeutic benefit & that LD dudes & autistic people will attract another diagnosis. I hope that I am wrong. I fear that I might be right #AMHPlife. 

Tony Deane
Principal Social Worker & #GrumpyAMHP
@asifAMHP

​​MDT are 3 letters (words) that I suspect many of us are very familiar with – Multi Disciplinary Team – but what do we mean?​

​For me it raises more questions than answers, things like -

• What does it look like?
• What does it feel like?
• What does it do?
• How does it work & for who?
• Who selects the team?
• Who manages the team?
• Who is the captain of the team?
• Are all the players in the team equal?

 
The aim of MDT working, is to bring together the skills & experience & expertise of all those involved & required to the table, in order to formulate (care plan) & support the person & family in their care.

I would suggest that intuitively we think this should be a good idea & positive & be helpful & there is probably lots of evidence out there that it works when it works. The problem I guess is that all too often it just doesn’t!

The state invests a fair few £s in training various professionals to undertake various roles & functions & some even become experts. I will mostly put the expert conversation & the one about student tuition fees & loans to one side.

When I went to Polytechnic, I was young, had hair & was slimer… it was also free & I had a full grant & I had grand notions & hopes relating to concepts & theories about social mobility & social science stuff. I was pretentious & spotty enough to read Marx & developed ideas above my station, in relation to poverty, inequality & shite housing etc. I also played rugby & drank lots of beer & missed the odd train here & there. I always preferred being part of a rugby team than any MDT.  I even managed to merge the two, and  did an ethnography participant observation study based on a rugby tour. Young drunk men make very unwise decisions & I am glad mobile smart phones were not a thing.  

The MDT is also about assessing & seeking to manage & mitigate risk & sometimes about public protection. Over the years as a social worker, ASW, AMHP & BIA, I have worked in a number of services/teams: AOT, Rehab & Recovery, Forensic Services, Homeless CMHT, CMHT & dedicated AMHP Team.  When I look back over that, I think it is clear, that the MDT sort of works for us as professionals. I also think it’s clear that the good Dr (Consultant Psychiatrist),  is very often the captain of the team. The Team Manger tends to be the coach. The other professionals had demarcated roles & didn’t always agree with the captain or manager or indeed with each other. Depending on the set up, you might have a couple of junior doctors, a sprinkling of CPNs, an OT, a social worker, perhaps a Psychologist & trainee - if you were really lucky. The good Dr would tend to have a medical secretary, the MDT would have had admin support & there might be a number of associate support staff e.g., a nursing or social work or even OT assistant – to do the practical doing tasks.

​I have been to a couple of these conferences now & to be fair, the girls & boys in blue really do appear to get it. They now know what an #AMHP is & does. They mostly know that the “P” stands for “Professional”. They know that the #AMHP has to find a S.12 Dr or 2 & that the #AMHP doesn’t do beds. They know all about S.140 & that NHS compliance with this particular section of the MHA,  is part of the solution. Most of them now know, that S.136 is actually an arrest (preserved power of & not for an offence). They  know that coordinating a Mental Health Act Assessment in custody, too often represents a huge challenge for #AMHPs & they also know that we #AMHPs probably need somewhere to park. 
​They, like you & @seandilleyNEWS, also know (see article here), that the mental health system is dysfunctional & struggles to meet the demands placed on it. They acknowledge that they are sometimes placed between a rock & a hard place & they know who is actually placing them in that position.

The big cheese @DCCRachelBacon certainly appears to understand her brief & she is being ably supported by @BenjaminRoweso1 & Tony Jarred (needs to join @Twitter soon) @metpoliceuk. It isn’t very often, that a wee boy from Derry, gets to sit next to a Deputy Chief Constable.

It struck me as I listened & wandered about the very posh Grand Hotel, just how much these girls & boys in blue cared about this stuff. Police Forces from up & down the country, from over Hadrian’s Wall, from the Valleys & the PNSI were represented & they are all trying to do this stuff better. They are all trying to make multi agency partnership working, actually work. 
​​
So I stood up & did the A to Z of #AMHPing. I banged on about the need for better legal literacy & suggested that people actually need to read the MHA & the MHA Code of Practice & probably the MCA.

​I might have suggested that the girls & boys in blue need more training in mental health. (but to be fair,  the boss pays me to say that 😉) ​