The review of the Mental Health Act is taking place during a workforce crisis in mental health services. Recent figures indicate that 10% of consultant psychiatrist posts are vacant, as are 12% of speciality doctor posts, with a 60% increase in the number of full time locums in psychiatry. National strategy to address the mental health staff shortage has focused on recruitment and retention into lower grade posts and roles with limited opportunity for career development, such as Nursing Associates and IAPT (Improving Access to Psychological Therapies) practitioners. A conversation must be had about how we make best use of the knowledge, skills and expertise of our most senior nurses, psychologists and allied health professionals to support people detained under the Act, for example in the role of Responsible Clinician.
The 2007 changes to the Act included a major revision of statutory roles, with opportunities for a wider range of professionals to take on responsibility for certain aspects of the assessment, care and treatment of those detained. The Responsible Medical Officer role was replaced by the Approved or Responsible Clinician, meaning that psychologists, nurses, social workers or occupational therapists could be ‘approved’ to become the named legally Responsible Clinician for specific detained patients if they possessed ‘the most appropriate expertise to meet the patient’s main assessment and treatment needs’. However, between 2007 and 2017, only 56 non-medics have become Approved Clinicians. This is compared to over 6,000 medical Approved Clinicians.
A conversation must be had about how we make best use of the knowledge, skills and expertise of our most senior nurses, psychologists and allied health professionals to support people detained under the Act
Over the past year I have been working with colleagues at Northumbria University and Northumberland Tyne and Wear NHS Foundation Trust to find out more about this select group. Why did they take on this role? What is their experience of working with service users and colleagues as a Responsible Clinician?
So far, our findings show that the non-medical Approved Clinician roles have been adopted in a meaningful way in two trusts in the North East of England, but elsewhere in the country most mental health trusts have no or few non-medical Approved Clinicians. Some people with whom we spoke were the sole non-medical Approved Clinician in their organisation. There are clear reasons for the larger number of non-medical Approved Clinicians in the North East. It was a field-test site for the role, has local professional leaders who have championed the role and has a local academic institution that provides specific training and facilitation of action learning sets for aspiring Approved Clinicians.
There is a sea change afoot, though. During the year of evidence-gathering for our study, we noticed increasing interest in the role from mental health care providers who see it as an opportunity to distribute leadership within their workforce and potentially address the shortage of Consultant Psychiatrists.
We noticed increasing interest in the role from mental health care providers who see it as an opportunity to distribute leadership within their workforce
Despite their limited numbers, we found that non-medical Approved Clinicians are working across the range of psychiatric specialties, from children’s services to forensics to older adults. They tend to be in Consultant Nurse or Consultant Clinical Psychologist posts, holding the Approved Clinician role alongside a number of senior leadership responsibilities. Their motivations were a combination of wanting to improve service user experience and an interest in increasing both their own professional standing and the status of their profession within the field. Becoming an Approved Clinician was seen as a ‘natural next step’ for them as senior clinicians, ‘a natural progression in providing clinical leadership’, and most reported that they enjoyed the role.
Some participants, however, described feeling hindered from taking up the role by a laborious approvals process, far in excess of what is required for medics to be Approved Clinicians. They also expressed frustration at limitations on the role, for example a non-medical AC cannot make a First Recommendation for the use of the Act, which requires two doctors. There were also some accounts of resistance from colleagues to them taking on the role, primarily from psychiatrists but also from nurses.
Some participants, however, described feeling hindered from taking up the role by a laborious approvals process, far in excess of what is required for medics to be Approved Clinicians
If uptake of the non-medical Approved Clinician role is to become more widespread, and to be part of national or local workforce strategies, then we must learn from the experiences of this vanguard group.
Taking on the role of Responsible Clinician for a patient means taking ultimate responsibility for their care and treatment while they are deprived of their liberty. The moral and legal weight of the role cannot be underestimated. As such, it requires adequate peer and senior supervision and training, as well as organisational commitment to shift the balance of power within multidisciplinary teams. There is also a discussion to be had, if the role is taken up more widely, regarding appropriate remuneration and grading for this considerable increase in responsibility. Whilst senior psychologists and nurses may welcome the opportunity to lead care teams and promote psychologically-informed approaches, this should not just be seen as a quick and cheap workforce solution.
Dr Jennifer Oates is a lecturer in mental health at King’s College, London