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.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2013
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 
Marvellous news. Thank you for all that you are doing to highlight these issues
can only speak for local area but we have had a dedicated 136 suite now for 4 years but only recently told that we MAY get funding so it can be staffed rather than having to hope a nurse of the ward can do it. We still don’t have a reliable way of recording 136 patients to enable any analysis of the figures, which have contributed to our increased workload as AMHPs. There needs to be an agreed national set of guidelines for all involved parties, only this week we were told that the Trust lead was saying that intoxicated patients should be taken to the police station rather than 136 suite, no mention of A+E. Oh and our crisis team still understaffed but not all gloom as they are now recruiting 7 extra band 6s for it which shows how understaffed it is.
I’d absolutely LOVE to have an hour of that person’s time. Intoxicated to cells without proper triage of risks – brilliant! And then after the death in custody (remember, half of ALL police deaths in custody are people with MH problems), it will be said that they should have been clincially triaged or been in A&E.
Only this week, a custody sergeant was VERY lucky not to lose his job for detaining such a person in the cells after been found guilty of gross misconduct. IT AIN’T HAPPENING anywhere that I’m the duty inspector. And you can tell them so.
I can assure you that i made the point that an intoxicated person should be at A+E where if required medical care is immediately available and the police stay there if risks indicate the need and kept on making it until i was told we needed to move on and i will keep on making it.
I think it’s right that police deal with s136 and other MH issues they come across as professionally as possible, and accept that this is part of our duty to the public. That said, I think it’s equally right to question how much of this workload is occurring because other state agencies have failed in THEIR duty.
You’re right to say that protecting the public is what the police are for – however we (and our budgets) are not a bottomless pit of resources and money that can be used to alleviate budgetary problems in the NHS. I can sympathise with officers who don’t consider it traditional police work to be sitting with a mentally ill person for hours in A&E because the MH ward refuses to assess anyone who has even heard of alcohol, or has a scratch on their hand, etc etc.
Police generally accept that almost everything is in our remit – however that doesn’t mean other agencies shouldn’t be trying harder to head some of these problems off at the pass…
I’d cheerfully put up with the uphill struggle getting S136s assessed if the local MH secure ward would stop letting ‘vulnerable’ or ‘dangerous’ involuntary patients smoke outside (and thus run off) every day!
I have endured a number of bad experiences involving Police officers and am happy to admit that this experience has caused me some bias. However, surely medical staff disagreeing with forceful detention against a persons will in 82% of cases clearly shows that something is very wrong and that officers are misusing the powers given to them. Perhaps using s136 is an easier to do than whatever the proper alternative is.
There are various problems with the stats quoted, which Professor Appleby alludes to: firstly they are in no way collected consistently. Secondly, they are not analysed consistently. For example, a psychiatrist on Twitter this morning has expressed surprise because in his experience “the vast majority” of people arrested by the police s136 are detained in hospital. In my area, 40-50% are detained. Finally, criticism that 136 not converted into detentions = failure is manifestly wrong. I’ll blog a response to this post at a later time.
At least 80-90% of the 136s that I’ve been involved with are admitted by the MH staff. That seems to be consistent amongst my colleagues, although I accept that my information is mostly anecdotal.
In my experience police officers would prefer NOT to exercise their powers under S136 – as Prof. Appleby bemoans, some don’t feel it’s the best use of their time. Whether that’s the right attitude or not – it’s safe to say that the use of S136 generally means there ARE no alternatives, and that no other agency is willing or able to step in at that time.
I don’t pretend to think we get it right all the time, but I don’t believe there’s an epidemic of gleeful sectioning going on – even if you assume malice and wilful disregard for people’s rights and well-being, there’s just no benefit in it for us.
136 is easier than a ‘proper’ alternative? Try the other way round. If I arrest for an offence I could be back out on the street in a few hours, 136 and that’s my shift gone and possibly an officer from the next group tied up too. Nobody in my force like to section people because of how resource intensive it is.
I am sure Professor Appleby and MentalHealthCop have read “‘Concepts of Disease and the Abuse of Psychiatry in the USSR, (with Alex Smirnoff and Elena Snow), British Journal of Psychiatry 162, 1993” which reports how detention of dissidents in psychiatric hospitals was commonplace in the Soviet Union and – particularly disturbing – many ordinary psychiatrists actually believed that those whose symptoms were nothing more than harbouring dissident beliefs were suffering from a form of schizophrenia.
The former Labour government tried make something similar happen here in the UK not very many years ago.
http://nationalpsychosisunitsurvivor.blogspot.co.uk/
In response to a comment raised about letting patients smoke outside – you do not see anyone outside in t his horrific place where they use the most weak and vulnerable patients to experiment on.
http://www.northamptonchron.co.uk/news/health/northampton-hospital-drug-trial-could-save-uk-1bn-1-4645897
Take a look at this – I was so disgusted that I wrote to this paper.
If Professor Louis Appleby read the books by Dr Candace Pert, Molecules of Emotion, Dr Ann Blake Tracy, Prozac Panacea Pandora, Professor David Healy Pharmageddon, Dr William Walsh – Nutrient Power – perhaps he will learn and have a better understanding – this explains why patients return time and time again to the wards – it is the drugs that cause the violence, aggression, Hitler like syndrom, dream like state during the day where patients act out their nightmares. “It has long since been known that serotonin reuptake inhibiting drugs cause severe violence and aggression or suicidal thoughts. I have seen such shocking things through having a daughter who has been frequently admitted into hospital. I feel so sorry for patients and feel that the complaints procedures through the PHSO and CQC are failing so many. As for the hospitals they cannot wait to discharge patients . Sometimes the more difficult the patient the quicker they wish to wash their hands of that patient. I have seen my daughter suffered from Akathisia, an extreme reaction to the drug Seroquel 800mg and just dumped back into the community with no regard for health and safety. I have complained to the GMC, the CQC and PHSO, none of them could care less and they have all shut down their cases and washed their hands. I actually begged at one time for my daughter to be held at the police station as I felt this was safer than the ward where staff sit in their offices ignoring patients who knock at the window. They come out to dish out the drugs and this is all the care is about. I have seen activities cancelled time and time again at local level. As for the Maudsley they had better facilities but I do not think that my daughter got to use any of them. She was so ill when they dished out the Clozapine and still is she can hardly walk. You may ask what diagnosis – that is a good question – there are several which shows they do not know what they are doing. THE CARE SYSTEM HAS TRULY FAILED MY DAUGHTER AND IS ABSOLUTELY APALLING. I am challenging the care system and will be taking matters to court soon and I am being treated like a criminal. I know the training is excellent in the police towards the mentally ill as I was training to be a police officer myself. Sadly I had to give up because there was one problem after another with my daughter – she kept going missing and in desperation I appointed a private orthomolecular psychiatrist and this did not go down too well. After 14 mind altering LSD like drugs, my daughter is not well and under the private sector and now I intend to challenge the whole of the care system. I would like to see Open Dialogue Approach as in Tornio Finland – there they treat patients with respect. There is no such thing as forced drugging and Treatment Orders. They are successful in their approach and the Police can learn a lot by watching the videos produced by teams of mental health experts in Tornio Finland and I would like to send my daughter there where there is decent care, where families are included. There is supposed to be NICE guidelines – where are they when the above links show shocking abuse is going on. What on earth is the CQC doing about it. I got banned in no time by the Maudsley as the patients liked me going on the ward. I brought lots of information for the psychiatrist to read but instead of reading how things should be done – as promised a drug free period of assessment by Prof Murray, instead she glot Clozapine and Metformine and that is for Type 2 Diabetes but has been given for weight loss OFF LABEL.
They did this in such a deceitful way not telling my daughter properly and I got to find out and then I myself got labelled by a team who were far from professional and I saw one wear his name badge back to front. I have documented this all in my website. The police should be visiting these wards to get to know the patients. Perhaps the police could involve themselves in some activities with the patients. There were no visitors at the research hospital Bethlem only me and they did not like it especially when I offered to arrange activities as there was nothing to do at weekends and I would have liked to get some celebrities down there.
The reason the same patients return time and time again to the wards is a combination of they cannot cope and function on the drugs that actually cause psychosis in themselves and they become isolated in the community. There is nothing for them to do virtually and there is not enough care and support. When someone has been in hospital for 2 years they need a greater level of care and support but social services do not give this level of support and the wards themselves are not safe places – who bothers to investigate incidents happening to patients. My daughter’s face was covered in bruises – I am not happy – I as a mother want some answers. I am not the only one – I am in touch with many people who feel the same way.
The person who is mentally ill has suffered extreme abuse -this is not always the fault of the family although they are quick to blame everyone but themselves – instead of counselling they are given labels and drugs. There are no scientific tests to prove what causes mental illness but I can vouch for the fact that it is something traumatic, sometimes of course it is abuse and family related but there are many tragic cases and the police should be sympathetic because they do not know what has caused someone to behave in that manner and how the drugs are affecting that person. The best thing the police can do is also to read these books I have mentioned because these drugs should not be allowed and the way the patients are treated in hospital I have heard some beg to go to prison where it is better. I would like to see Alternative care centres set up with proper assessments and I am going to challenge everything having seen multiple diagnosis and after the shocking way my daughter has been treated. I want the assessment by Dr Walsh and only then will I be happy with any diagnosis and then I want holistic care and treatment and open dialogue approach like in Finland. Everything is working perfectly there because they offer humane care unlike in the UK. The Police are having to deal with more and more cases because the “care” is not working both in hospital and in the community but mainly becasue of the new line of drugs that lead to psychosis even if you are taking them as directed.
Who holds psychiatrists to account for the decisions they make (involving detention, forced medication and making persons bear stigma who might not otherwise have to)? Persons can of course appeal against being sectioned at a Mental Health Tribunal, but how often has a consultant psychiatrist been genuinely thwarted by such a tribunal? And if there have been cases, were the psychiatrists held to account for incompetence or worse?