I have a role supporting the families of people with mental illness. In our area the AMHP service is known to be under great pressure because of staffing problems etc. For the past year or so they have got into the habit of quoting Least Restrictive Alternative as a reason not to do a MHA assessment. Last week they gave this as a reason not to respond to a NR request for a MHA assessment under S 13 (4). As an experienced MH professional my view is there is nothing intrinsically in breach of the Least Restrictive Assessment if a MHA assessment happens. An assessment cannot be restrictive in itself, it seems to me. What can be restrictive is the decision following a MHA assessment (eg itās right to admit informally if the patient will co-operate with this. I think the LRA principle is being stretched much too far because of āresource issuesā. And of course it is a principle, not an instruction. Has anyone else come across this problem which in my area is causing considerable frustration?
Might not be considered ideal and there are obviously significant factors to take account, but I am surprised that more NRās are not asked to consider making applications.
Are they providing a written answer Jonathan? If they arenāt, they should do. I would hope that any response is clearly personalised to the situation of the individual and if it isnāt your clients may wish to raise the issue with the AMHP Lead or the DASS of the local authority involved. AMHPs need to āconsider the caseā for an assessment, so asking for one wonāt automatically result in a face to face assessment- but I would expect a reasoned argument and alternative plan to be presented. Claire
Thanks Claire, that makes sense.
I am still interested to know if anyone agrees with my definition of Least Restrictive Alternative. Maybe not!
This investigation from a few years ago agrees with you. āThe teamā being referenced here is the investigation team:
We are of the view that there exists within the phrase āconsider the caseā a clear responsibility to undertake some form of assessment.
If though, the AMHP in passing the āprocess and procedureā for undertaking an assessment of Mr Kās mental health is of the view that this constituted a least restrictive option, then it is the view of the team that this falls foul of the intention of the decision-making flowing āfromā and after an assessment.
A very interesting discussion, I must say.
Firstly, AMHP services all over the country are engaged in a massive piece of work that started about a year ago, involving a review of what Section 13(1) āConsider the caseā means to them. Matt Simpson, who ran the Bournemouth University AMHP training course and also completed a PhD paper on this subject, was the pioneer in this process, though not the only significant thinker. Sadly, he died just over a year ago but the whole process is being discussed and considered in all AMHP services around the country. Matt cautioned AMHPs about leaping straight in with a full MHA assessment with two section 12 doctors. He would often go and visit the referred person himself alone and managed to divert the person from having a full MHAA. John Mitchell, AMHP Lead in Devon Partnership Trust/Devon CC took over the process and wrote an 82 page paper on it last Spring.
It is true to say that AMHPs all over the country, especially those triaging referrals, are stepping back and examining all the features in a case before putting through the referral for the full MHAA process. Multi-Agency Risk Assessment Management meetings can often be a way for those around the referred person to discuss the risks.
Gillian Robinson, before she returned to Australia in October 2023, when she was AMHP{ Lead in London Borough of Barnet, developed a āCause for Concernā system where all new referrals were discussed by a multi-disciplinary team of NHS, LA and voluntary sector people. Admissions to hospital reduced by 50% within 12 months.
So I think that Jonathanās suspicion that his local AMHPs were using āleast restrictive alternativeā as a way of not assessing might need re-examining, though I donāt know his area or AMHP service so cannot give a definitive statement.
Lastly, the statement by the investigation team that Nick Woodhead refers to. āConsider the caseā is exactly what it says - consider all the factors in the case. This can consist of all the usual assessment processes AMHPs deploy already - reading case notes in both health and social care records, speaking to any professionals or key agency staff involved, speaking to the family members, etc. I think the vast majority of AMHPs and AMHP Managers would want to at least undertake their own assessment of the social care circumstances prior to ceasing the process towards the full MHAA.
My final point is that all this activity has been partly driven by the decimation in mental health services since George Osborneās disastrous and catastrophic June 2010 budget. After local authority social services budgets were cut by over Ā£25 billion from 2010 to 2020, 3500 mental health inpatient beds were closed, NHS MH trusts experienced massive difficulties in recruitment of nurses to staff their CMHTs and CRHTTs, gigantic demand was prompted by Brexit, Covid 19 and the other affects of austerity budgets on the welfare state, voluntary sector organisations, etc, the whole picture has resulted in many hard-pushed agencies, with very little resources, deciding to refer to AMHP services because they think that those services have experienced the least cuts and therefore have the staff to undertake them!! AMHP services have been fending off these sorts of referrals for a long time and will continue to do so.
Thanks for these replies. Iām aware of the move to use a multi-disciplinary forum to decide when a full MHA assessment is needed. I also agree about the catastrophic effect of the 2010 /11 budgets from which health and social care budgets have never recovered. I donāt agreed with your final comment about why people refer to AMHP services so much. The services and families that I know make such referrals because of very genuine concerns.
I am still interested in whether it is right to use Least Restrictive Alternative as the sole reason not to do a MHA assessment. It tends not to be explained at all leaving the referrer v puzzled and frustrated.
Tks for attaching the report, Nick.
It describes a situation where the AMHP does not organise a MHA assessment which is v similar to what Iām dealing with this week.
Just for clarification Jonathan, I meant referrals mainly from NHS mental health teams not families.
OK, thanks Neil.
I think that resource issues are very very different to least restrictive principles.
I will often not move forward to a face to face service user interview with doctors (perceived, but not explicitly documented in law, as an MHA assessment) if I can identify measures that can be implemented to reduce the need for interview and potential detention, this can also include speaking with the patient alone, liaising friends/family or with local services. Interview by an AMHP with two doctors to potentially write medical recommendations, is an intervention in itself that can be inherently stressful and impactful on a service user, the interview alone can escalate a potential need for detention. If an NR makes a request, the AMHP service should respond in writing with rationale why decisions were made.
Iād defo recommend reading the paper on s13 by Dr Matt Simpson and John Mitchell. However the s13 considerations are an entirely separate process to any limiting resource issues, which should be separately discussed with your local AMHP service.