Role and benefits of [non-medical] Approved Clinicians
- [non-medical] Approved Clinicians bring added value to the mental health workforce, when taking overall responsibility for treatment and care of service-users.
- Please see the headings below this section, or the Community Care article, for a brief synopsis.
- More detailed information can be found in the Non-Medical Approved Clinician CTO Pilot Report.
- Miles is interested in securing a substantive position as an Approved Clinician, within the NHS or third sector.
What added value do [non-medical] Approved Clinicians offer, to senior clinical practice?
The development of a more diverse Approved Clinician workforce is government policy.
Prior to amendments to the Mental Health Act, 1983, only Doctors could hold ultimate responsibility for the treatment and care of mental health service-users. The Responsible Medical Officer’s role was renamed the Responsible Clinician; this reflected an aspiration to develop a more diverse workforce, involving senior psychology, nursing, social work and OT clinicians applying for Approved Clinician status. All Responsible Clinicians must apply for and retain their Approved Clinician status.
Although enshrined in legislation in 2007, the development of New Ways of Working has been slow in East Anglia and many other parts of the country. Notable exceptions include:
1. Northumberland Tyne & Wear NHS Foundation Trust revised their five year plan in 2015, to ensure that 20% of their Approved Clinician workforce came from allied healthcare backgrounds.
2. Nottinghamshire Healthcare NHS Foundation Trust started a specialist training programme in 2017. They are supporting 10 [non-medical] staff to achieve Approved Clinician status.
3. St. Andrew’s Healthcare launched their ASCEND programme in April 2017. St. Andrews are aiming for 20% of their Approved Clinicians to come from allied healthcare disciplines, during 2017/2018.
As of 1.1.2015, there were 32 [non-medical] Approved Clinicians in England and Wales.
Service improvements, arising from the early development sites in England
The first 3 [non-medical] Approved Clinician – from Cumbria & Northumberland – were approved in 2010.
Improvements in Northumberland included the discharge of all bar one service-users from a low secure learning disability ward and the re-modelling of the rehabilitation and community LD services. Nursing staff also reported an increased role in complex decision making.
Other encouraging developments have occurred in Cumbria, where a Nurse Consultant is a Approved Clinician for a dementia in-patient ward. There has been a reduced prescribing of anti-psychotics and benzodiazepines. Section 3 MHA applications, following admission, have been reduced. Autonomous decision making and an up skilling amongst front-line staff has simultaneously occurred, in connection with various clinical initiatives. Re-admission rates have been reduced and there has been a subsequent reduction in in-patient bed numbers.
Nurse Consultants/Approved Clinicians in Staffordshire have reported a reduced level of re-admissions for service-users subject to Community Treatment Orders and a reduced use of seclusion and lesser restrictive practices on a learning disability ward.
The above developments have freed up Consultant Psychiatrists time, to concentrate upon the most complex cases and other developmental initiatives.
Norfolk and Suffolk NHS Foundation Trust’s (NSFT) initial pilot
Following interest from experienced NSFT clinicians, a local working party entitled ‘Approved Clinician / Responsible Clinician: New Ways of Working’ was set up in 2012.
Miles France gained Approved Clinician approval in February 2013 and Annette Duff, a Nurse Consultant within Secure Services, was approved in June 2014.
An initial pilot was started on 1.10.2013; Miles France was the Responsible Clinician for a group of CTO service-users in central Norfolk Adult Service Line. Although service-user numbers were originally set at 12, by the end of the pilot he had responsibility for 23 service-users and a further 9 was planned (4 further hospital discharges and 5 from re-aligned Norwich CCG surgeries).
The design of this pilot involved a naturalistic comparison, retrospectively and prospectively. Each period was for 18 months, prior to and from the point when the pilot post holder became the service-user’s Responsible Clinician. Each service-user acted as their own control and most were automatically entered, other than for sound clinical reasons.
Consultants Psychiatrists’ understandable concerns – about losing familiarity with the functions of being the Responsible Clinician for CTO service-users – were accommodated.
This reduced Consultant Psychiatrists’ workloads, as previously alluded to. Front line staff developed an increased role in complex risk management decision making, feeling more confident about taking positive risks.
Some very supportive feedback from service-users, hospital managers and front line staff – viz the [non-medical] Approved Clinician role – can be found in the final report.
There were also very positive quantitative outcomes, including a dramatic reduction in in-patient bed usage, reduced substance misuse and increased use of meaningful activities.
Not surprisingly, the KPIs reflected the statutory objectives viz Community Treatment Orders: the maintenance and rehabilitation of service-users within the community:
- Re-admissions – including CTO recalls and CTO revocations – plus the number of mental health (MH) bed days used.
- SUIs and other adverse outcomes (involving healthcare and statutory agencies).
- Social engagement and meaningful activities.
- Harm minimisation & significant reductions in substance use, in the post pilot period.
- The number of service-users discharged off CTOs, during the post-pilot period.
- The number of face-to-face Community Consultant hours, for CTO service-users.
Unfortunately, after NSFT developed financial difficulties and went into special measures, it was not financially possible for the pilot post to be regularised into a substantive role (as had been planned).