Integration and Disintegration between Health and Social Care

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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.

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AMHP training – What it is and How it is – A Review by the GSCC

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The GSCC published a report yesterday (pdf)  which is a a review of their inspections of AMHP (Approved Mental Health Professional) courses. My experience of my training as an Approved Social Worker (as it was when I trained) is that, without doubt, it was the highest quality training course I have ever undertaken. It was tough. Very tough. But it needs to be. The role of making such important decisions which affect the liberty of those who are in moments of need, illness and distress is not something which can be glossed over.

In some ways, I’m surprised there isn’t an equivalent, high quality, intellectually rigorous post-qualification course in children’s services before social workers are able to remove children – maybe it would be too costly – but it’s an interesting reflection on the ways in which the different ‘streams’ in social work have progressed.

The report reflects on the GSCC role in approving AMHP training, despite the fact that the training is no longer restricted solely to Social Workers (Psychiatric Nurses, Occupational Therapists and Clinical Psychologists are also able to train up to this role).

There are some interesting tidbits in the summary that caught my attention. There are 22 AMHP courses running in England. Of those who have undertaken them (936 since 2008 when the switch from ASW to AMHP occurred) there have been 936 people who have completed the course. 84% of those completing the course have been social workers and 15% nurses (I’m presuming the overlap is down to some people who are dual trained – I’ve come across a few people who are both nurses and social workers). There have been no psychologists training (surprise) but there are some OTs ( I have personally met one OT AMHP) but it is given as <1%.

The gender breakdown is a 70% female to 30% male of those who have completed training. It would be interesting to compare this with the Social Work training as a whole.

So what are the courses like?

Recruitment is generally by employer sponsorship and some areas have been better at promoting cross professional access to the training than others. There have been issues regarding payments and increments which more often than not have affected whether a nurse or a social worker might be put forward by employers to train but the universities have been willing to accept applications across the eligible professions.

There are very low ‘fail’ rates, possibly due to the selection which would take place in-house before a candidate is interviewed by the university.

Content I’ve had a few people ask ‘how long’ the training to be an AMHP is and explain how it was in the course I did but different courses manage the learning in different ways. For example, I did a full time course. The actual requirements are 600 hours of study with at least 150 of those hours as taught. It is delivered at ‘Masters’ level – but usually needs a ‘top up’ of other modules (which may or may not be offered’ to make a ‘full’ Masters degree.

The emphasis on knowledge of mental health law was considered in the report as it is fundamental to being an AMHP. Universities assess this knowledge in different ways, between exams – either open or closed book – case studies or classroom work.  As an AMHP it is necessary to continue to attend legal updates regularly.

Training in safeguarding legislation as it pertains to children and adults also has to form a part of the course.  This may be a precondition to attending the course – ensuring that this training has been undertaken ‘in house’. It’s also important that Mental Capacity, Equality and Human Rights legislation is covered.

It is also a requirement that social perspectives on mental distress is covered sufficiently.  Indeed, the report comments that while

Traditionally social workers have been viewed within mental health services as the champions of the social perspective model of mental distress

This has needed to be covered extensively in the AMHP training as other professions are being drawn in. Interesting perspective though when you consider the move in some areas to shifting social workers OUT of mental health teams and what that might mean.

But back onto the topic at hand.

User/Carer Involvement in Courses This was an area I felt was strong and particularly useful in the course I undertook. I think it is also worth noting that social workers can be users and carers of mental health services too and certainly the course I was on some people attending the training self-identified as such which was really very useful for us to gain these perspectives.  Formally though, 20 out of 22 courses met the requirement for involving users and carers in the training of AMHPs.

Universities used different models from commissioning teaching directly to drawing on a pool of identified users and carers to participate or commissioning a local user network to be involved in course planning and assessment.  Only half the courses involved users on the selection panels. I was surprised this wasn’t higher.

Being Approved The ‘approved’ part of the name comes back with the Local Authority when the course is completed and we would go our separate ways. Different local authorities have different ways of approving but it is always for a maximum of five years before re-approval is necessary.  Most graduates were approved within three months of finishing the course – that was the case within  my LA where I was expected to conduct a specific number of assessments with an experienced AMHP and then come to a panel with my reflections and face another legal test before being approved. However some LAs will approve more quickly than others.

Practice Assessors – AMHP candidates are ‘on placement’ and have a supervisor who themselves, are an AMHP. Few courses require any qualification from their Practice Assessors (other than. of course, being an AMHP themselves). I’ve never taken this role on specifically for AMHP training but it’s something I’m vaguely interested in doing at some point. Interestingly the GSCC acknowledge that these roles of ‘practice assessors’ may be underappreciated by the universities and the GSCC is recommending that some of the ‘Practice Educator’ standards for Social Workers extend into AMHP training.

The report makes interesting reading for anyone who is curious about the AMHP role and what the training actually involves. Reading it made me reflect both on my role as an AMHP and the training I undertook and continue to undertake to carry out the role to the best of my ability.

Actually, it made me quite proud. I know I’m biased but it is a rigorous system but it was the best training I ever did. It’s not a role I’d say I like or enjoy but it is something I feel I can do with sensitivity, thought and care.

There is a strange kind of ‘camaraderie’ among AMHPs that I’ve not experienced in any other situation. Possibly because it’s so hard to explain to other people what we do and how and why we do it.

photo Eric E Johnson Flickr