I am utterly honoured that Professor Louis Appleby, the National Director of Mental Health and Criminal Justice, has agree to write a post for the blog – what a coup!? He is an exceptionally well regarded clinician and academic who directly advises the Government on these issues and is a seriously regarded, key player in our national debate.
I am grateful he found the time to write this piece: if you look at his research output as Professor of Psychiatry at the University of Manchester and follow him on Twitter – @ProfLAppleby – you’ll probably wonder where he finds the time.
WHAT IS REALLY GOING ON WITH SECTION 136?
When I was training as a psychiatrist, it was my job as on-call doctor to see people brought to hospital by the police under Section 136 of the Mental Health Act. Not once did the police get it wrong: every person was extremely ill – paranoid, hallucinating, acutely psychotic. Without exception they needed to be admitted and detained under Mental Health Act powers. Then, as now, I admired the police for their readiness to help vulnerable people in crisis.
But I was also worried. What about the less clear-cut cases? People with lesser degrees of mental illness or complex disorders that made decisions to convey or admit more difficult. Maybe the police were applying too high a threshold.
Since then, the use of s136 has dramatically changed and become a concern to psychiatrists and police alike. Figures from the NHS Information Centre – the best source of data we have – show a recent doubling of the number of people taken to hospital under s136, from 7,035 in 2007-8 to 14,902 in 2011-12. How can this be explained? Mental illness has not become twice as common. Services for mentally ill people in crisis have never been more active or better funded. Something else has caused this increase – and on this, the figures on what happens next are revealing.
Most of the people taken to hospital are not then re-detained by mental health staff. In 2011-12, only 18% were admitted under the Mental Health Act. Not only that, but as the use of s136 has increased, the percentage re-detained has gone down. These are people thought by the police to be ill enough to be taken to hospital against their will, under legal powers. Why are four out of every five – 11,567 people in 2011-12 – found by clinicians not to need further use of those powers when they get there?
The information collected on the Mental Health Act does not provide the answer. It tells us nothing about how many agree to admission or referral to mental health clinics. It has no details on the clinical decision-making that lies behind the statistics. So we are left with a simple fact: the health professionals do not see the need to admit compulsorily most of those who have been brought to see them compulsorily.
This does not mean the police are wrong to be concerned about those people. It suggests that awareness of mental ill-health is now much greater in the police than it once was – the threshold problem that I was worried about years ago has gone. But as a result it seems that many people who are now taken to hospital do not have the kind of clinical condition that mental health services see as an urgent priority.
So the first solution to the s136 problem is a broader range of services, a better set of options for both the police and for mental health services to make use of. There is much discussion at the moment on the use of police custody as a place of safety – everyone agrees that it should be reduced to a minimum. But the two problems have to be considered together. We cannot just transfer the s136 cases from custody to hospital if many of them should be handled differently in the first place.
Section 136 is a shared problem for the police and mental health and it must have a shared solution. That means joint planning of services, training and troubleshooting in individual cases. Commissioners of mental health care must ensure there are adequate s136 facilities available in health settings. Mental health professionals should assess patients promptly, to prevent the hanging around that frustrates police colleagues. The Care Quality Commission should insist on better data and closer monitoring. Both police and mental health have a professional duty to understand each other’s perspective and not to denigrate each other’s practice.
Behind the debate about s136 lies a more fundamental question: what are the mental health responsibilities of the police? How much mental health work should they do? Many police officers I have met are clear that dealing with mental illness is a natural part of their modern role. Others believe the opposite, that it gets in the way of “real” policing. But that cannot be right. Mental illness is common, as is substance misuse and personality disorder. Society is finally facing up to how common mental ill-health is. People whose work is with the public – teachers, housing staff, prison officers, politicians – need to see mental illness as within their remit. Anything else is discrimination. The police meet people with mental illness as suspects, witnesses, victims and – let’s not forget – colleagues, and with the right skills this part of the job can be a source of reward and pride.
The Mental Health Cop blog won
- the Mind 2012 Digital Media Award, in memory and in honour of Mark Hanson.
The Awards celebrate the “best portrayals of and reporting on mental health in the media.”
- a World of Mentalists 2012 #TWIMAward for the best in mental health blogs.
It was described as “a unique mix of professional resource, help for people using services and polemic.”