S136 assessments – one or two doctors?

By Illegal Left-Eye (pseudonym)

In my AMHP Service, we almost always attend s136 assessments with two doctors. This is regardless of whether the person to be assessed is known or unknown. I can see how this approach developed and set in over time, likely out of a combination of expediency and defensive practice based on an assumption that having more assessors equals a more robust or comprehensive assessment. I think this practice (and the logic underpinning it) is problematic on a number of levels. My view is that routinely attending s136 assessments with two doctors is at best a frequent waste of resources, one which potentially negatively impacts the experience of the person being assessed. At worst, is it in essence an abuse of power?

After all, assessment under s136 is not confined to assessing whether the person should be detained under the Act, far from it. A s136 assessment is not a ‘typical’ Mental Health Act assessment in that respect. As it states clearly in paragraph 16.25 of the Mental Health Act Code of Practice about s136s, ‘[T]he purpose of removing a person to a place of safety in these circumstances is only to enable the person to be examined by a doctor and interviewed by an AMHP, so that the necessary arrangements can be made for the person’s care and treatment’ (my italics added). The final, italicised clause in this sentence is crucial in conveying that the responsibility of the AMHP and the doctor goes beyond the narrow remit of determining if the person requires admission to hospital or not, by detention or otherwise. It is of paramount importance that AMHPs clearly record how they have fully considered these necessary arrangements for the person’s care and treatment, particularly where the decision is to discharge the s136 so that the person returns to the community, which indeed, is most of the time. In my area, around two-thirds of s136 assessments result in community-based care and treatment arrangements i.e. something other than admission to hospital. Of the other third, a proportion are admitted to hospital on an informal basis, leaving less than a third requiring detention under the Act and, therefore, assessment by two doctors. 

Therein perhaps lies the main reason why we may routinely attend with two doctors: to save us the time and the bother of securing the services of a second doctor in the event that the first doctor is minded to write a medical recommendation. Yet this doesn’t strike me as a very good reason. As stated, most of the time the person being assessed will be discharged home anyway. In the less frequent cases where a medical recommendation is written, I wonder is it really too much to ask to only secure the services of a second doctor at that point?

You may ask, ‘does it really make any difference to quality of the assessment or to the experience of the person being assessed to simply have a second doctor present just in case? It’s only one extra person in the room after all. Why does it matter?’ I think it does matter for the following reasons. Firstly, the interview should take place as soon as possible after the person’s arrival at the PoS – this is clear guidance in 16.27 of the Code of Practice. Trying to find a second doctor can and often does contribute to unnecessary delays in attending the Place of Safety to complete the s136 interview. Such delays are bad for the person and are also bad for the Place of Safety resource. Not to mention the not insignificant financial implications of paying for a second (usually independent) doctor.

Secondly, there appears to be a widely held view that it would be ‘safer to go with two’. I do contest this notion. Making good decisions with (and about) people first involves having good conversations with them. From my experience it is generally easier to have a good conversation in a s136 assessment with fewer assessors. What matters is not the quantity of assessors but the quality of the assessors! Therefore, having a Trust doctor rather than an independent s12 doctor as your accompanying assessor is likely to be important. That is not to say that there aren’t some excellent independent s12 doctors out there (there certainly are) but it is more about ensuring the requisite experience in psychiatric assessment, as well as ensuring accountability and oversight around the decision-making lies within the Health Trust.

Sadly, risk incidents involving significant harm do sometimes occur after s136 discharges regardless of whether the interview process involved one or two doctors. Clearly documented evidence that a high level of thought and care went into the ‘necessary arrangements for a person’s care and treatment’ is essential should our decisions come under scrutiny. And of course, good, robust assessment also involves what you do as an AMHP outside the interview space too. We need to work systemically as AMHPs, not see and assess people as if they exist in a vacuum. In this sense, capturing the voices and knowledge of those who know the person (whether friends, family, GP, care co-ordinator to name a few) and involving them in the discharge care arrangements and communicating any risk are likely to be important actions in safe and effective discharges from Places of Safety.   

Thirdly, and most importantly, it is likely to be a more person-centred and more human experience to be seen by two people rather than three. In Louise Blakely’s co-produced research on experiences of MHA interviews, participants described being interviewed by three or more professionals together as ‘daunting’, ‘intimidating’, ‘oppressive’ and a ‘terrible pressure’. (See the blog post ‘The Barrage of Three’ on this site). A greater number of assessors was linked to feelings of powerlessness including a sense of not being heard and not being involved in decision-making. Of course, assessment by an AMHP and two doctors is sometimes necessary but why do it routinely when it is not even in the guidance as being the purpose of a s136?

This is where I think it can make such a difference for an AMHP to take the time to see a person in a Place of Safety on their own without the medical assessor(s) before the s136 interview formally takes place in order to make a connection with the person of concern on a more human level – this is what John Mitchell describes as ‘aiming to be human before I become an AMHP’.  We can often establish better rapport and better dialogue with a person by taking the time to properly listen and by avoiding or mitigating their sense of being judged by a panel of powerful professionals. One’s ability to gain a more well-rounded and shared understanding of what is going on for the person may well be enhanced by this ‘less is more’ approach.

I can appreciate that AMHPs and doctors who are new to MHA work may well feel more comfortable with a ‘safety in numbers’ approach and there may well be local policies in place which standardise a two doctor approach. And clearly there will be occasions when the referral information in relation to a s136 assessment is of such concern or complexity that it may be entirely appropriate and proportionate to take a second doctor from the outset. This case by case judgement from individual AMHPs is not in question – what I am calling into question is the practice of routinely attending s136 assessments with two doctors whatever the circumstances. As John Mitchell writes in his excellent piece on s13(1) and notions of what constitutes ‘assessment’ more broadly under the MHA, ‘Accepting the “two doctor” assessment as the default model wastes scarce resources. The quality of assessment may suffer as, crucially, may service user experience. We should recognise when assessment is about meeting the needs of professionals’. This applies to s136 too.