Approved Clinician frequently asked questions June 2017 Sue Ledwith, Dr Nicholas Todd, Dr Bruce T. Gillmer & Professor John L. Taylor
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Approved Clinician frequently asked questions Q. What is an Approved Clinician and a Responsible Clinician? A. Responsible Clinician (RC) is the Approved Clinician (AC) who has overall responsibility in terms of the Mental Health Act 1983 (as amended by the Mental Health Act 2007) for a patient s case, including those who discharged from hospital but who remain liable to be detained (e.g. those on a Community Treatment Order (CTO). An AC is a person approved by the Secretary of State for Justice for the purposes of the MHA. ACs not acting as RCs have some other responsibilities under the Act, e.g. holding powers, review of patients in seclusion. Q. What does an Approved Clinician and a Responsible Clinician mostly do? A. The key responsibilities of an RC are: As an AC, to review decisions made concerning seclusion and long-term segregation of people detained in hospital. The role can also involve an AC who is not that patient s RC. Likewise to exercise the doctor s holding powers for an informal patient. As an RC, to ensure that a person who is detained subject to the MHA is assessed and appropriately treated in conditions that are necessary for the purpose of alleviating or at least preventing deterioration in their mental disorder and any associated risk to themselves or others. This includes renewal of detention, discharge, approving leave and making CTOs. The principles which guide decision making around detention are outlined in the Code of Practice for the MHA1983 revised 2015. To be accountable for the legality of decisions made affecting a person s liberty in a First-tier (Mental Health) Tribunal or Managers Hearing where a RC s decisions are subject to examination by a judge, solicitor, or trained independent lay persons. To correctly and legally complete the documentation supporting decisions concerning a person s detention. The limits to the responsibility of an AC or RC who is not a medical practitioner include: All ACs and RCs can only authorise decisions within their professional competence. Psychologists have to be HCPC registered and demonstrate their capability from their knowledge, skills and training to meet the requirements of the RC role. So, for example, whilst the psychologist holds overall responsibility for the patient s care, where decisions need to be made about psychotropic medication, a medical AC will assume responsibility for that aspect of treatment in collaboration with the RC. It is sometimes thought that only medical ACs can recommend initial detention. In fact ACs and RCs, irrespective of profession, have nothing whatsoever to do with the initial detention. These roles only come into play post-detention, when the most appropriate available AC should be allocated in the particular case to be that patient s RC. It is true that initial detention requires two medical recommendations, one of whom must be a section 12 Approved Doctor. Section 12 approval is quite distinct from AC approval. Approved Clinician frequently asked questions 1
Q. How can psychologists become Approved Clinicians? A. The Secretary of State for Health has delegated the function of approving ACs in England and Wales to regional Approvals Panels (see list below). All applicants are required as a minimum to attend a two-day training course approved by the Secretary of State. Employers will have individual policies to guide and support individual clinicians seeking AC approval. The process will include developing a portfolio that meets the requirements of a regional Approvals Panel. The British Psychological Society provides a Peer Review service, which provides formative advice about a portfolio prior to submission, for a nominal fee. Although it is not required, it is advisable to have participated in a learning set to support development of the portfolio and to have undertaken a course of formal learning in applied mental health law. Q. Why should psychologists consider taking on these roles? A. If you are considering applying to become an AC/RC here are some factors to consider: The extended roles of AC/RC to professions other than medicine is a statutory manifestation and cornerstone of New Way of Working. The overarching potential benefit is the enhanced clinical leadership within the multi-disciplinary team. Importantly, taking on these high profile leadership roles can promote a perceived shift in the traditional role, paradigms and culture that can benefit services and service-users. Some potential benefits include: The ability to influence systems from a different perspective; Psychological understanding of systems and group behaviour; Embedding psychological formulation within decision making and risk management; Greater promotion of therapeutic risk taking; Psychological understanding to inform decision makers, and; Best fit for people who require psychotherapy as their primary treatment. Some potential disadvantages include: Personal and professional anxiety and both intra- and inter-professional resistance to change which needs to be carefully navigated. There may be perceived or real workforce and cost implications in that additional psychology (back-fill) and medical (as AC support) input may be required in addition to the psychologist AC. However new models of clinical leadership and working outside of the traditional psychological role and the sheer additional AC workforce can usually offset these concerns. A lack of nationally agreed implementation guidelines for non-medical ACs has led to some variation in regional Approvals Panel policies. However, the Department of Health led National Reference Group for Approved Clinicians and Section 12 Doctors has developed guidance for Regional Approvals 2 The British Psychological Society
Panels concerning eligible professionals (like psychologists) seeking approval by the portfolio route. This has greatly improved uniformity for applicants. Psychologists may feel too closely identified with coercive practice. At this stage most psychologists can choose whether to take up the AC/RC role. However there is an increasing trend to include these roles in senior psychologist post job descriptions and/or job plans. Psychologists may see the role as too closely linked to psychiatry, especially as the AC role may require co-working with a medical colleague for parts of a person s detention. Paradoxically by widening these roles beyond what was exclusively a psychiatric function psychologists may be better able to promote and enhance psycho-social approaches to patient care. The nature of the AC role may reduce the capacity for reflective practice. This assumption is baseless in that psychology, by its nature is a reflective science and it is incumbent in taking on new professional roles to reflect deeply on the interface of law and psychology; issues concerning power, autonomy, coercion and freedom are daily questions facing the (psychologist) RC. There may be competing duties of care if a psychologist is working as a therapist and AC/RC as there could be an inherent power differential in relation to the person subject to detention. The BPS position is that as an RC a psychologist should not concurrently be a patient s therapist. However, in working therapeutically as a RC a psychologist can bring new models and theories to bear on that function and look for legal means to therapeutic ends. Q. What has the implementation and uptake of this role been nationally? A. The implementation of this role across all of the Mental Health Trusts in England has been uneven regionally and limited nationally. An absence of central funding and training (until it was set up independently of government), affected the ability for psychologists to take up this role. There has been a gradual take-up of the AC/RC role by eligible professionals other than medical practitioners. Within Trusts where this has taken hold, a critical mass has enabled psychologists to begin to influence workforce shape and assessment and treatment models. A freedom of information request in July 2015 of all 53 Mental Health Trusts in England identified: Nine (17 per cent) of Mental Health Trusts were actively supporting psychologists to become approved clinicians, three with a specific organisational policy referring to non-medical responsible clinicians and five who had consultant psychologists who were approved clinicians acting as responsible clinicians. The North East of England had the most appointed responsible clinicians in any one area nationally, all located within the same Mental Health Trust. In June 2017 there were 54 non-medical ACs in England and Wales, over half of which are psychologists. A similar number are currently estimated to be in preparation. Approved Clinician frequently asked questions 3
Q. What are the likely terms and conditions of the role? A. AC status and deployment as an RC is a role and not a job in its own right and therefore the nature of work that a psychologist might undertake in this role should be set out in their individual job plan, ancillary to the post-holder s substantive job description. The 2015 freedom of information request identified amongst the five Mental Health Trusts who had psychologists who were ACs and appointed as RCs revealed that: There was an agreement that the responsibility would only be suitable for a psychologist who was at a consultant grade, i.e. employed on Agenda for Change grades 8c, 8d or 9. There was disagreement on the remuneration that should be offered for the additional responsibility, considered by the majority of trusts as commensurate with that of a consultant psychologist on Agenda for Change grades 8c, 8d and 9. However, a minority of trusts were offering one band higher if consultant psychologists undertook the additional responsibility and one trust had a specific job description and person specification that they had matched under agenda for change as band 8d. This remains a contentious issue. The initial cohorts of psychologist ACs in the North East assumed RC responsibilities without prejudice to terms and conditions. Seven years on they have yet to have resolution of the remuneration accorded these additional responsibilities. It is the case, however, that these roles/responsibilities have been secured on the basis that the broader AC/RC role is highly valued within trusts where there are problems with psychiatry workforce capacity. Q. How do I find out more? Guidance for Registered Psychologists in Making Applications to the British Psychological Society Approved Clinician Peer Review Panel 2016 https://beta.bps.org.uk/node/450 Learning sets available in the Approved Clinician Training Programme, Northumbria University contact Helen.Kingston@northumbria.ac.uk Approval panels contact details available from the Royal College of Psychiatrists website http://www.rcpsych.ac.uk/pdf/regional%20panel%20contact%20 List%20-%20March%202017.pdf Authors Sue Ledwith, Approved Clinician, Clinical Tutor, Doctorate Clinical Psychology, Staffordshire University. Dr Nicholas Todd, Clinical Tutor, Doctorate in Clinical Psychology, Staffordshire University. Dr Bruce T. Gillmer, Approved Clinician and Consultant Clinical Psychologist, Northumberland, Tyne & Wear NHS Foundation Trust. Professor John L Taylor, Approved Clinician and Chair, BPS MHA Advisory Group. 4 The British Psychological Society
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