The elephant in the room in adult social work is often a cat

elephant in the room

Firstly, thanks to @Harr_Ferguson for the title which was inspired by this tweet:

I remembered this tweet today whilst driving home and reflecting on having heard several stories this week from amazing social work colleagues where pets featured in a critical role.  The colleague who, having tried to engage with someone through their letter box had the dog set on them.  The parents who were walking the dog every night past their son with a learning disability who was living independently in his new home to reassure them that he was OK.  The mum and son with very complex communication needs whose face lights up when he sees the family dog come into the room.  And finally, the amazing colleague who was planning to finish for the weekend only after they had sorted out 11 cats and 3 dogs so that the person they were supporting could feel safe enough that their pets were cared for to accept a period of convalescence and recovery from a period of acute ill health.

Social care is full of evidence to suggest that pets are associated with psychological and emotional well being.  Something that we could perhaps pay more attention to in adult social work.  Dr Sara Ryan (yes Connor’s mum) has written a really thoughtful paper on how pets are important members of the families they belong to and yet how often they are unseen by the “professional” in the room – it’s here if you want a read:

Sara’s paper reminds us that as social work practitioners, it is far too easy for important family member to become invisible when they are sat right in front of us – an observation which Harry Ferguson has written about in his brilliant piece about the unbearable complexity of social work decision making in the British Journal of Social Work.  See here:

In our induction for Newly Qualified Social Workers, we often talk about a real case which we got very wrong.  The lady had 20 cats.  We thought we knew best.  We thought we could see something as professionals that she couldn’t about her life and experience.  We took her away from everything she knew, everything that was important to her in her life.  The result was that she deteriorated very quickly.  It is telling, that when we talk about the lady with the cats, we only talk about her cats as a passing, almost jokey remark at the start of the story.

And if you want to know just how wrong we can get it in social care – see the case of Fluffy the Cat whose 91 year old owner was removed from his home and unlawfully deprived of his liberty in a care home leaving his beloved cat behind.

Today, pets have featured heavily as we have reflected on this week, appearing in several of the stories which I have heard being told as part of the end of week come down.  All social workers will recognise the end of week come down.  It is the really important bit of the week when social workers take care of each other and the complexity of the decisions they have supported people to take.  It is the moment where social workers use story telling to reflect about the week which has past and as the social work office winds down, it is the process which enables practitioners to go home without carrying the weight of every potential risk with them into the weekend.  Without that moment of story telling, social workers, the best social workers, the ones who will be back fighting for people’s human rights once they have rested and recovered, will often spot the small things they have missed during the heat of the busy week.  That is the time when the pets emerge.

Today, as we told our end of week stories, we heard of that we had seen 11 cats and 5 dogs.  We spotted something we didn’t know before, something we didn’t previously notice about what is important to the people we are supporting.  And when we next speak to them, because of that moment of insight, we will be able to include in our conversations with them that they have another member of their family that we are interested in.

And crucially, we had a moment of laughter and mutual support which came out of that recognition – because we are pet owners too and we know what our pets mean to us. In that moment you become less professional and more human and you are closer to the person you are there to support.  Which is a really good thing.

This week, however, I am left with unanswered questions which I leave me unsettled – what happened to the lady’s cats?  What if we got it wrong?  What if it was being removed from her beloved cats that was the tipping Point?

Honestly, I will never know what happened to the cats.  But we do know what happened to the lady with the cats, we moved her, leaving her cats behind, she became very distressed and after a long and lonely 6 months on various hospital wards she died.  It was traumatic for all concerned.  Including the social worker who has never forgotten her.   To quote Professor Ferguson “The powerful impact of unbearable levels of complexity and anxiety on social workers requires much greater recognition.”

Have a safe weekend to all our EDT and hospital weekend colleagues working this weekend.








On Friday 200 of us came together in York from across the country to talk about social work, social justice and working together to to uphold the universal character of human rights as enshrined within the UN Convention on the Rights of the Child and the UN Convention on the Rights of Persons with Disabilities.

We would like to invite you to join us here –

and here #SWisHumanRights – highlights video

My Kingdom for an AMHP


Guest Blog from @asifamhp

I have been an AMHP now for a number of years. The job has changed, the organisations that I work with have been restructured several times. The politicians have come gone. Through it all the cases keep coming.

AMHPs inhabit a twilight zone in the gap between the NHS and Social Care. We fill the gap between H&SC and the Police.  Too often AMHPs are stuck in the middle of interagency partnership working not actually working very well. AMHPs have lots of responsibilities and duties.  Ultimately as AMHPs we exercise legal powers to remove a person’s liberty (it’s the AMHP that make the application to detain (“section”) people not the doctor).

This is a lot of power; remember the person has usually has done nothing wrong.

An AMHP can go to a Magistrates Court to get a warrant that allows the State to enter homes uninvited (using the big red police key if required) and if necessary use force to remove a person to a Place of Safety. But an AMHP cannot direct or instruct a medic or police officer to turn up.  AMHPs also can not require an ambulance to be dispatched to convey someone from their home to the now almost mythical hospital bed.

In my current role as dispatcher of AMHPs, I have become acutely aware of the difficulties faced by my colleagues and I am concerned that our voices and opinions are not often heard or valued. The role of the AMHP is a vital one but I fear that it is one that is almost invisible.

Coordinating a Mental Health Act Assessment is all too often a problem solving exercise in terms of sorting a hospital bed that does not exist. I worry about working with partner agencies that are unwilling or unable to help. These are practical problems that present AMHPs, in often very challenging and sometimes risky situations, with a huge amount of heart and head ache.

The difficult bit should be the engaging with the person and their family,making the decision to detain or not, however all too often it’s the other stuff that is the difficult bit. The stuff that everyone else assumes and takes for granted will be there.

BTW if required, a hospital bed is the doctors job to sort – honestly it is!

Countless policy initiatives try to sort out Mental Health.  There has been a Mental Health Task Force, a Crisis Care Concordat, a 5 Year Forward View, most weeks another report is published highlighting system failure. But acheiving Parity of Esteem for mental health with physical health still feels some way off yet.

The lack of value given to mental health becomes acute when I am coordinating Mental Health Act Assessments. I often find that I have to find a Section 12 medic whilst also trying to do the assessment. That’s a bit like an ambulance having to find a paramedic on route to a Road Traffic Accident.  And that’s before we even talk about hospital beds for someone who is really ill and needs one.

I invite you to contact your local CCG ask them about the arrangements/contract they have with your local Ambulance Trust in relation to the conveying of patients that require admission to hospital? Better still ask them about the arrangements they have in place for the conveying of someone who is detained and in legal custody, but resistant and objecting? Ask the CCG about how much they are spending on placing people out of area in private (for profit) provision and then ask them if they have read the MHA or Code of Practice? Ask them and your local NHS MH Trust if they are familiar and complying with the duty imposed on them by Section 140 of the Mental Health Act? While you are at it, ask your local Acute Trust if it’s Emergency Department is a Place of Safety? There are lots of other questions worth asking if you are interested.

A Mental Health Act Assessment is many things, all bundled up into a big fat mess sometimes. But people tend to forget that it is also a legal process and AMHPs are at the heart of that. The starting point should be the Mental Health Act itself (Guiding Principles and all) and the Code of Practice. I wish more people involved in all this would actually read them and adhere to the Code of Practice in particular.

I fear that Psychiatry is overly reliant on coercion and has developed an erroneous understanding of risk assessment and risk management that reflects and reinforces stigma.  I also worry about big Pharma and its link with psychiatry – but for another time/blog.

The role of the AMHP is to reduce risk.  This is not an exact science, no one wants to be blamed when things go wrong and they do go wrong.  However we must guard against moral outrage and panic when things go wrong.  We need to think about evidenced based practice. We also need to remember what we do impacts on the people, sometimes in negative and damaging ways. We need to be given the time to think about our decisions as AMHPs properly and to be supported to do this in the least restrictive manner possible. Far too often a mental health act assessment is seen as a solution to a problem, when perhaps the solutions  is something else.

Medics are too quick to reach for the MHA and are completing too many Medical Recommendations. They are then exiting stage left and all too often have no idea where the bed is. I can think of no other branch of medicine where the highly trained and very well remunerated expert is allowed to leave others to get on with it. I also believe that AMHPs are making too many Applications to detain people and again that this is multi layered issue that needs to be properly analysed.

Conversely I see people who should remain in hospital being discharged too early to “unblock a bed” and then being assessed and readmitted very quickly. At the heart of this is the lack of sufficient, appropriate inpatient bed provision and lack of investment in community services.  The commissioning arrangements for mental health are not good enough leaving children and adults too often being placed often 100s of miles away from home, in private (for profit) provision.

For the most part my AMHP colleagues, up and down the county, are extraordinarily committed and skilled individuals.  It is an absolute privilege to witness how many of them go about an extremely challenging and at times risky task with humility and humour. Many go way beyond what could or indeed should be reasonable expected of them.

Do we always get it right? No we don’t.

The MHA is a very complex piece of legislation requiring AMHPs to make often very complex decisions, in difficult circumstances, without necessarily being in possession of all the facts and under pressure from various interested parties. Being an AMHP is not an exact science. It takes a fine/funny blend of skill, knowledge, experience, values, support and luck to develop an AMHP who is able to successfully and safely undertake the task. Please don’t take the invisible AMHP for granted. Throw in the MCA interface and it is an almost an impossibly complex job to do.

I have been unlucky/privileged enough, depending on your view of the world, to have assessed three generations of one family. That really was a moment for me to take stock and to wonder about the broader issues in terms of inequality of opportunity, substance misuse, nature V nurture and the whole medical V social model.  Working with that family I really wondered about the role and purpose of psychiatry and my part in that as an AMHP.  AMHPs see often very real and often harsh realities of everyday life and the impact of multiple layers of economic disadvantage, oppression and inequality of opportunity.

AMHPs, as people, are also shaped by our own history and experience of life.  AMHPs like everyone else have personal experience, either directly or indirectly, within their family or friendship groups, of mental health issues. I really like the “those of us” inclusive statements when I hear people talk about experiencing mental health difficulties/distress/illness. AMHPs have to be able to be firm and keep positive. Like other AMHPS, I have over the years had to coordinated some very challenging and difficult MHA Assessments. I have been out with the armed response unit, been on rooftops, been assaulted and called all sorts of names.

As an individual I am reasonably robust and have a well developed sense of humour. I have also managed (I hope) to hang on to “the what” initially motivated me to become a Social Worker and this helps me deal with and manage some of the challenges that I face. I have also been lucky enough during my career to date, to have had some very motivated and skilled colleagues who have supported and encouraged me. I think of them warmly and I am in their debt. I have met some very lovely people and families on my travels.

As AMHPs we are often asked to do “something”  when appropriate we use the MHA to detain an individual or in the case of a Community Treatment Order to place restrictions on their choice/liberty. Equally importantly we decide not to detain or restrict.

We often meet people at a low point in their lives and when they are in crisis and distressed. This can be very difficult for them and us; at times it can be very stressful or just plain ugly. It can also, over time, have an impact on you as an individual. I am not sure that that is fully appreciated by our employers, but I am grateful that I have colleagues who understand this.

Moving forward I think AMHPs might be exceptionally well placed to be in demand. However there are fewer of us and we are getting older together as a group.  I wonder who is planning for and thinking about the next batch of invisible AMHPs. Most people have no idea what an AMHP is or what an AMHP does and unfortunately that includes some who should.

With that increasing popularity/demand for AMHPs, I hope comes some recognition and interest in all things AMHP and with that, a voice that might be heard. I hope that voice echoes and advocates for the people and families we work with. Because what really concerns me about being invisible is that the cloak of invisibility is also wrapped around the people and families we work with/for. Very often at the point of crisis in mental health, it is an AMHP that is required & sent for.

Now is the winter of our discontent

Made glorious summer by this sun of York;

And all the clouds that lour’d upon our house

In the deep bosom of the ocean buried……………. An AMHP an AMHP, my kingdom for an AMHP!

Hold the front page

Mary PoppinsThere is a scene at the end of Mary Poppins where the Banks Family go to fly kites together.  It is a joyous scene, celebrating a family with a renewed identity, purpose and open to possibilities about many exciting futures.  But it’s also really quite sad as it marks the moment where Mary Poppins realises how much she cares about the Banks Family just at the point when they don’t need her any more.  She gathers up her bag and quietly floats away presumably to another family in need.  The mix of emotions on display are really familiar to social workers.  As is the decision to walk quietly away from a successful intervention, leaving the family or the person to determine how they frame telling their story to the world.

For several weeks now there has been a lively debate taking place about the media image of social work following an episode of Dispatches featuring a Social Worker calling themselves Vicky. There are concerns within the profession that the constant barrage of negative media images about social work is resulting in people leaving the profession.  Some voices argue that we must step up and that individual social workers should tell their story about why they entered the profession and what it is that drives them.  The thing about Mary Poppins though, is that you never find out her back story, and crucially, that never detracts from the movie.  You never stop and think, oh if only there had been a bit all about Mary.  As deeply frustrating as it is that the media continue to only tell negative stories about social work, that doesn’t mean that individual social workers should be rushing to fill the press with their story.

There are lots of factor which influence retention within the profession, level of professional autonomy, access to resources and CPD, the professional relationships between agencies in the sphere of practice that social workers operate and most importantly alignment of the values of the employing organisation with social work values.  Media image however, there isn’t much evidence that negative media has quite the effect many appear to be assuming it does.  Given the extent of media coverage of the role of social workers in the cases of Victoria Climbie, Baby Peter, Winterbourne View, Stephen Neary, Connor Sparrowhawk and in the most recent of tragedies Liam Fee, it would surely be hard to find any social worker who has qualified in the last 10 years who wasn’t aware of the media image of the profession when they joined.

The thing that Mary Poppins reminds us, is that it isn’t our story to tell, it belongs to the person we are there to support.  If they choose to include in how they want their story telling that a social worker was involved, then we should be honoured to respect their decision.  However, the really hard thing about social work is that in most cases, the real test of the success of the social work intervention is that the person no longer wants or needs to acknowledge the social work. Good social workers get that.

A while ago a script writer made contact who was looking at making a six part TV drama ‘about social work’. The conversation with the writer was fascinating.  She wanted to know stories ‘about social workers doing social work’ and the impact it had on them. We decided that we couldn’t help her.  Our ‘best’ social work stories were essentially not ours to tell. Social work stories include the family in absolute crisis following a ‘honour killing’ which claimed the death of one family member and the incarceration of many others; a young mother admitted to hospital under a section following the death of her baby; a man ‘escaping from a care home’. These were stories and experiences that were vivid, powerful influences shaping our practice.  But they weren’t what the writer wanted. She wanted to know the impact on us of being involved in complex case work, what we felt and our role in ‘dealing’ with the pressure. Whether its part of social work training or our particular approach to practice, this isn’t something that we could articulate. It wasn’t important.  The effect of experiencing other people’s lives genuinely didn’t feel like a story we could tell.  Only the people we have worked with know if their lives were any better as a result and only they have the right to tell their story however they chose to frame it. People who experience social work are the ones who should be telling the media what social work is, both good and bad.

A palliative care social worker told us that good social workers are like chameleons. They blend in. You don’t often see them its enough for people who need social work to know they’re there and that’s enough recognition for the social worker too.  Thinking about it, Mary Poppins had chameleon like qualities, her carpet bag of social work having moved on from the traditional contents (day care, home care, respite, supported living) to a more exciting range of  modern options (Direct Payments, Individual Service Funds, Personal Health Budgets, Integrated Personal Commissioning).  You can still find if you look deep enough into the bag her spoon full of sugar.

But social work isn’t about looking down a deep hole at someone, turning on a blue light  and inviting the paparazzi around to film the drama unfold.  Social work is about getting into the hole with the person to give them the leg up so they can wherever possible scramble out of it clinging onto whatever dignity remains. If the person tells someone of the great work of the social worker then that’s great, if they don’t then that’s great too. It doesn’t lessen what the social worker did.  Social workers have their moments of fame. They know their worth. They are honoured at least one night every year when they have an award ceremony. The Queens honours list regularly includes social workers. But for the rest of the time they are OK going under the radar acknowledging that ‘their story’ was never really theirs in the first place.

If we are really critically reflective, is the desire to sell positive social work through the press really about us trying to get a message out that ‘we are here, please fund us?’. If it is then lets be honest. In times when food banks are reporting increased usage, records of people are requiring mental health care & the numbers of safeguarding referrals are reaching epic proportions we need to rejoice and celebrate social work. Our unseen, unheralded social work, is keeping more children and adults safe and alive. But hold the front page, we don’t want it.

Mary Poppins intervention in the lives of the Banks was mesmeric. But in the end, only the Banks knew about the magic she brought into their lives.  Having made that difference, she blended into the background and floated off.   No headline required.


Rip it up and start again


This week is Dementia Awareness Week – the theme this year is: Remember the Person.

Weaknesses in the ability of people and/or their carers to hold so called ‘system’ leaders into account for upholding their rights is a stubbornly persistent issue in health and social care.  We seem to have an endless supply of shocking evidence where the ‘system’ failed to remember to see, hear and value the person, such as the abuses which took place at Winterbourne View (2012), Mid-Staffordshire (Francis 2013) or most recently the failure to investigate the deaths of people in the ‘care’ of NHS Southern Health Foundation Trust reported in the #Mazars report (2015). Perhaps even more worryingly however on a daily basis in social care we uncover evidence that people are experiencing poor care and support which ignores their wishes, feelings and beliefs. The daily churn of health and social care organisations, operating institutional routines that are the way things are done in that organisation, have always been done and no one wants to change them, legitimises people being treated as though they don’t have the same human rights as everyone else. For older people with dementia who are poorly enough to need a stay in hospital, this can result in really poor outcomes.

As commissioners we are told our role is to design responsive, high quality, accountable health and social care ‘systems’.  The ultimate test of such systems has to be the extent to which they are ethical – as measured by how well people’s human rights are upheld by the system.  Back in 2011 The Health Service Ombudsman published the Care & Compassion  Report on the outcomes from 10 investigations into the experiences of older people within the health care system.  The report findings were of a stark contrast between the principles and values of the NHS and the reality of the care and support received by people who were within the health system.  In 2016 the Ombudsman has just published a further report on the issue of how people experience the health care system – a Report into the Investigations of Unsafe Discharges from Hospital.  The report details the avoidably distressing experiences of 9 people, the most serious of cases which illustrate the gap between good practice and the reality of  hospital discharge processes and the system of care and support.  The underlying structural, organisational and practice issues which the report highlights will take more than just leadership vision and calls to accelerate pace if we are to see real, sustainable change to the fractured and institutionally abusive system exposed by the Ombudsman.

Social work training encourages that social workers and commissioners make an explicit connection between people’s outcomes from our interventions and ethical, moral practice.  Any judgement of the quality of social work and social care commissioning should clearly include practice being held into account by the people we are here to serve.  Being open to critically reflect on our practice with people can only strengthen the moral purpose and intellectual nature of social work and adult social care.  Strengthening of both is essential if we are to tackle the structural and routinised institutional abuse which people are experiencing and are able to legitimately make moral claims about the case for change.

The Ombudsman identifies four serious issues about how people experience the health and social care system: people being discharged before they were clinically ready to leave hospital; people not being assessed or consulted properly before discharge; relatives and carers not being told that a family member had been discharged; and people being discharged with no home care plan in place, or being kept in hospital due to poor coordination of services.  All four of these issues feel familiar and live issues in cases we are managing today to support a sustainable transfer of care home from hospital.  They are reflective of a system which needs to reconnect with its purpose and re-find its compassion as evidenced through flexibility, empathetic behaviour and enabling people to feel safe and exercise control over their daily lives.

Social work is rightly proud of its disruptive tradition.  Ultimately however, all the money in the world generated through what ever ‘personalised’ resource allocation system we can dream up as commissioners will only buy a person a service, not a dignified life.  Whilst obviously the most powerful voice will always be the person who experiences care and support (who else knows what happens in a care home or supported living setting at 3am when no one else is there to watch) there is an overwhelming weight of evidence telling us that we are long overdue major system disruption.  It is starting to feel like it is time to say – enough is enough – let’s rip it up and start again with a whole new way of doing this.  A more cooperative way of working together with the person at the heart of their own system.


It’s more complicated than that….


Monday 18th April 2016 marks to the start of a campaign on the part of families who have a member of their family in an Assessment and Treatment Unit (ATU) – see for the standards that define an ATU.

3,000 people.  Members of 3,000 families who love them.

As commissioners and social workers, in our local authority next week we will be asking ourselves the question – who do we know about in an ATU who we have responsibility for and what are we doing to get them home?

That we have to start by asking the question – who do we know about in ATUs – matters in a way that will no doubt frustrate those of you who are taking time to read this blog.  You would reasonably expect, rightly so given Care Act responsibilities, that we should automatically know who is an ATU.  However, given the routes into ATUs, as local authority commissioners we don’t necessarily do so, which leads to the near invisibility of people who are detained in in-patient settings – see and

There are several reasons for this, which are not given as an excuse, but hopefully will help shed some light on some of the issues faced by social workers and local authority commissioners which other, clever people than us, can help us with.

Firstly, the lead commissioners for placements in ATU’s aren’t from Local Authorities.  Inpatient admissions for adults with a learning disability are commissioned by health services (NHS England and/or the CCG).  CCG commissioning leads responsible for inpatient admissions, are also usually the people who lead on commissioning of Continuing Health Care funded community support.  Sometimes the Ministry of Justice are also involved.

Inpatient Commissioners

Health commissioners do not as a matter of course share details with Local Authority commissioners about who they have placed where.  There are lots of explanations for this – but I suspect the most important one is that on a day to day basis CHC is the fault line which divides health and social care.  CHC is the single biggest barrier to integrating a seamless, personalised support model around the person which puts them in full control of their support.  CHC is controlled to the nth degree – see the really quite odd policy position of CCGs “creating a local Personal Health Budget offer” for how you can choose to spend your PHB- – either you are in control or you aren’t – an “offer” defined and limited by commissioners is not personalisation as self-advocacy groups define it.   The conflict on the front line generated by very different, deeply held assumptions between health and social care about who should be in control of defining what support is offered to get someone home, and crucially who has to pay for it, isn’t conducive to building the sort of trusting relationships required to foster cultures of collaboration.

Secondly, CCG commissioners don’t talk about ATU’s – they talk about “tiers” of health services to “manage” inpatient admissions.  4 tiers.

4 tiers

And at the top of the 4th tier, there are 6 catagories….  Confused yet…?  Still with me…?  See the Royal College of Psychiatrist’s explanation of why ATU isn’t a good description for forensic inpatient services as it is ‘more complicated than that’ –

category 1: high, medium and low secure forensic beds

category 2: acute admission beds within specialised learning disability units

category 3: acute admission beds within generic mental health settings

category 4: forensic rehabilitation beds

category 5: complex continuing care and rehabilitation beds

category 6: other beds including those for specialist neuropsychiatric conditions

As a local authority social worker or commissioner the focus of any discussion with a CCG CHC Lead who is tasked with arranging for a discharge from an ATU is about how commissioners arrange for people to ‘step down the tiers’.  This is code for how people move through the funding system from the NHS to social care paying for the person’s support.  This is particularly important given the Transforming Care agenda – to qualify for what NHS England have oddly chosen to call ‘dowry’ funding (I find the use of the word dowry to be a very odd one indeed in the context of getting people home from hospital), people need to have been resident in an ATU for over 5 years.

4.44 dowries

According to Chris Hatton’s figures – only 17% of people currently in ATUs would qualify for these funds.  Clarity over how the support home is going to paid for the other 83% of people is a hugely important issue if we are to be able to make it happen for the 3,000 people who just want to go home.  If I was a policy maker, I would do something very simple – I would mandate CCG spend on learning disabilities into the Better Care Fund (the finance data was collected last summer by NHS England so they know what they need to do to make this happen….)

So, what could you do as a social worker or local authority commissioner during the week:

  • Read and make space to reflect on the 7 Days of Action blog 
  • Find out how many people in your Local Authority are placed in ATUs
  • Of these, find out how many meet the definition for support to get home under the national Transforming Care programme
  • Ask who the allocated social worker and commissioner are who is working to get the person home
  • Speak to those workers and ask them, what specific plan is in place to get the person home and what can you do to help them make this happen
  • As a team, ask the CCG commissioners to confirm exactly how many people are the CCG are aware of within ATUs – and to confirm this number with NHS England who need to confirm it with the Ministry of Justice
  • Don’t be confused by the noise – it is only complicated if you chose to let it be

Find out more