Out of Area Beds {OAPs & OATs}

Frustratingly in my both my professional and personal experience, it remains a little-known fact in wider society that it is Approved Mental Health Professionals who hold the legal power to detain a patient under The Mental Health Act 1983 (MHA).

Psychiatrists can recommend that a patient be admitted to hospital under The Act, but they do not have the legal authority to deprive a patient of their liberty. Interestingly, this legal myth can be perpetuated by psychiatrists themselves as was recently evidenced on the Radio Four series Is Psychiatry Working? when Dr Femi Oyebode spoke about detaining patients.

Please note that when discussing the detention of patients both in my practice and for the purposes of this blog I consciously do not employ the word “sectioned” which I contend to be both an ugly and misleading phrase.

The independence of the AMHP role was emphasized by Lord Bingham, when he suggested in the East London & City Mental Health NHS Trust vs Von Brandenburg case {2003}, that the lumping together of the Approved Social Worker with the assessing doctors should be resisted.

I think this independence is crucial when contemplating the very troubling long-term issue of people in mental health crisis being routinely placed in hospitals considerable distances away from their local area, support network and family.

In 2016 the Government announced that their stated aim was to end inappropriate out of area placements by 2021. In addition, in the same year The Crisp Commission discussed the detrimental impact of out of area beds. Furthermore, Dr Adrian James {Royal College of Psychiatrists} has spoken about the “scandal” of out of area placements. [NB; Royal College of Psychiatrists: Policy Briefing; June 2022]

Despite the stated intentions of Central Government, the figures remain stark. For example, between April 2020 and March 2021 there was a 79% increase in the use of inappropriate beds. In addition, there were 605 inappropriate placements at the end of March 2022.

Sadly, this practice means that patient care becomes more expensive. For instance, it cost to the NHS £102.3m in the twelve months up to March 2022. [Reference: RCP Policy Briefing; June 2022]

I have recently been involved in convening and conducting assessments under The Act which have resulted in people being detained in hospitals a significant distance away from their support systems. On a human level, as this is what we are before we are AMHPs, I have found this process to be extremely distressing as I feel that I am adding to the person’s burden as well as to that of their family/Nearest Relative. Furthermore, in one particular case, I received very strong push back from the bed management team which was a clear reflection of the pressure that they were under at the time. They suggested that if the application wasn’t made then the patient could be waiting for an additional 5-7 days before another bed would become available. Before making my application, I contacted the patient’s Nearest Relative who reluctantly “agreed” to their relative being conveyed a substantial distance from their home as their judgement was that the patient was becoming increasingly distressed with their extended stay in a very busy and noisy Accident and Emergency Department. The Nearest Relative’s very pragmatic approach assisted me to ultimately feel more comfortable with my decision.

Furthermore, there appears to be no consideration given by Integrated Care Boards {Previously Care Commissioning Groups} as to how patients will be able to effectively utilize their section 17 leave as part of their recovery, if they are admitted to care hundreds of miles from their home and support networks.

I would like to use this blog to suggest a call to arms to my fellow AMHPs, given that we are the applicants who hold the power to detain someone, that where appropriate, we should start to resist this pernicious culture of sending people all around the UK.

This practice would never be contemplated or allowed if we were considering people with significant medical health needs. The term “parity of esteem” introduced by the Conservative led Coalition Government {2010-2015}, which refers to people with complex mental health needs having the same access to health services as people with physical health needs, currently rings rather hollow.

Clearly this approach by AMHPs would need to be considered on a case-by-case basis as would the risk that the person poses to either themselves and/or others. In addition, due to the current bed crisis we will undoubtedly have to consider how long a person has been waiting in Accident & Emergency, the Health Based Place of Safety, Police Custody, or their own home following the completion of their assessment. Furthermore, we may need to consider how urgently the person requires psychiatric treatment. Surely it must be reasonable for AMHPs to question whether sending a patient hundreds of miles away from their home area is arguably providing them with appropriate treatment.

In addition, it could be argued that this current practice of placing people many miles away from their homes families and wider social networks comes within the scope of Article Three of The Human Rights Act [1998] which states that no one shall be subjected to inhuman or degrading treatment? 

Furthermore, Article Eight of the HRA considers a person’s right to respect for family and private life. The Munajz judgement [2012] highlighted that when a patient is detained and their liberty has been restricted their Article Eight right should still be respected. And as professionals we should consider the Article Eight rights of the patient’s families and carers when we are considering placing their loved one a considerable distance away from them.

I was involved in a Mental Health Act assessment whereby I declined the initial “offer” of a Section 140 inpatient psychiatric bed as it was a substantial distance from the person’s home and his family. The patient was already in a place of safety which meant that the situation was less pressured than if they’d still been in the community. Fortunately, I wasn’t put under any undue pressure by the bed management team to make my application. In my experience, it is vital to develop an effective relationship with the bed managers so that your concerns as an AMHP are properly heard and respected. This case is a reminder that a crucial part of a bed manager’s role is to create beds and not simply to identify them. Interestingly, on this particular occasion I did not seek the support of my Manager and upon reflection I wonder whether this is because of my own interpretation of what independence means when I’m practicing as an AMHP. However, I would contend that it is more a reflection of the limited power that I perceive any AMHP Manager would have in this particular scenario. The ultimate outcome was that the Mental Health Trust was able to identify a bed that same day within the person’s local area.

With the Bolam principle [Bolam vs Friern Management Committee-1957] in mind, which refers to acts being in accordance with a practice accepted at the time by a body of professionals, I would be very interested to hear the views of other AMHPs who, as a collective professional body, maybe able to start to appropriately push back when we are faced with the prospect of a patient being conveyed to a hospital many miles away and all the added distress that this will entail.

Naturally I accept that Mental Health Services are being placed under increasing pressure. For instance, there was a 30% increase in the number of under 18s in contact with mental health, learning disability and Autism services between 2019/20 and 2020/21. [The Guardian: 27/12/2022]

However, as I have highlighted AMHPs have the sole legal authority to detain patients under The Act and we should be using this power creatively as a strategy to fight back in the interests of patient care, their dignity, and their human rights.