When I start an EARLY shift at 7am, the cell block is usually quite full. There will be prisoners there who have been arrested but not yet charged, who await investigation and those who have been arrested, charged and denied bail who are waiting for the truck to take them off to see the Magistrates. Once that morning truck run is done, the cells are obviously emptier. We then spend the rest of the day filling them up again, whilst kicking out a few who have their investigations finished and released without further action, released on bail for further enquiries or charged and bailed to appear before the courts on a future date.
In the background of daily comings and goings we also have bail management – those offenders arrested last week and last month who were released on bail pending further enquiries who will answer their bail today. Some of them will be re-detained for interview and further investigation, some will be detained to be charged with an offence, some may just attend to have their bail varied if enquiries necessitate a further period of investigation beyond the initial bail hearing. Usually, custody systems allow one person to answer bail each hour, on the hour, so there is no rush of people arriving at once. Especially important as no-one could know last week and last month how busy or otherwise custody may be today.
Finally, there will be some detainees in custody who may be there for some while, comparative to your average shoplifter or burglar. You get immigration service prisoners: if relevant processes are completed to deport someone, it can take a few days to organise. We obviously detain some people under s136 of the Mental Health Act 1983 who can be there for two or three days and some prisoners under arrest for serious offences, can spend up to 96hrs in police custody, subject to court oversight.
Why am I boring you with all of this custody stuff? I want to make some comparisons with bed management.
There is evidence if you look for it, that some managers think having greater use of capacity is inherently efficient. So if you have X number of beds and you use them 95% of the time, this is “better” than using them just 90% of the time. It’s common sense, isn’t it? Having empty beds only 5% of the time is better than having them empty 10% of the time, not least because you have to pay staff to provide for 100% occupancy, so the fewer prisoners / patients they have in, the less work there is to do, surely?! Maybe – but let’s do some maths!
If you have 100 beds and you have an average 90% occupancy rate, there will be occasions where you have admitted fewer than ninety patients and times when you’ve admitted more. So on occasion, you may have 96% occupancy of beds and on other occasions 84%. We know, for example, that MHA detentions and vary across times of the week and at certain times of the year. The extent of the fluctuation should determine where you try and “run your average” rate because you need to leave room for peaks of demand. Unless of course, you have effective contingency arrangements.
This is not different in custody. My initial description, above, talks of custody on a typical day but a typical week would look different again. For example, courts don’t sit on Saturday afternoons or Sundays so prisoners who are charged and denied bail after about 10am on Saturday morning cannot go to court until Monday morning – they spend that time in a cell that now can’t be used for any other purpose. So when you analyse a week’s cell occupancy, you will see a squeeze on capacity that starts to build around Saturday lunchtime and reaches a peak on Sunday evening and overnight until a lot of people are sent to court on Monday morning. And Sunday LATE shifts and Sunday NIGHTS shifts, see higher than average rates of fresh arrests, just to help!
I’m not an NHS bed manager, but I’ve heard it repeatedly said, that MHA admissions over weekends, bank holiday and especially over Christmas, puts a real pressure on supply to match demand. And of course where “beds” you refer are specialist in nature – CAMHS, forensic beds in medium secure units of female PICU beds, this problem is more acute because actual numbers of beds are low to start with a percentage point either way is a good slice of the overall resource.
So you remember those 100 beds and cells? What happens when you have to detain the 101st patient or the 101st prisoner? You’ll remember that quiet Tuesday when you (briefly!) had 79% occupancy, well this is the point where your peak of demand hits you, although your average is still 90%. And you start improvising through external processes: the NHS will look at out-of-area beds or even private provision. If Birmingham doesn’t have the right kind of MH bed, we wonder whether Coventry or Wolverhampton has one spare? Of course, that then eats into their 100 beds and increases the likelihood that they will also reach capacity and we look farther afield, like Manchester or London. So it becomes more important to understand how often we breach that upper limit of demand to avoid expensive contingencies that don’t do much good for patients and their families either.
But let’s imagine the Chief Constable and the local NHS commissioners reduce capacity by shutting a cell block and a mental health ward. Let’s say that we now have 90 beds. Let’s further imagine that reducing arrest rates and quicker discharge of some patients means that with 90 beds / cells we are now averaging 95% occupancy. This is not more efficient than before, even though it probably costs less on paper – you will still have peaks and troughs of demand and it will be now be harder still to manage the peaks, meaning you will probably have to do it more often. It doesn’t matter how low your troughs are to bring down the average, if you’ve got 92 human beings who need admission or detention and only 90 beds, you now have two out-of-area problems and they cost real money to sort. And the more of these instances you have, the more it pressurises both your system and the back-ups into which you tap when you’re pushed.
The difference I notice between the police management of cells and the NHS management of beds simply this: the police are far more relaxed about empty cells than the NHS are about empty beds. I doubt that cell occupancy is anything near 90% or 95% on average. NHS staff have told me directly, that because of the way services are commissioned, NHS hospitals must average 90% bed occupancy to break-even financially – even though peaks and troughs of demand show that demand can vary as much as 20% from the mean. This financial structure and the consequential planning for averages pushes the possibility that supply will not be available when demand comes along. That will create failure demand, which is infinitely more expensive than doing it properly. This is why we are seeing lots of media, currently, about how much is being spent on private provision by our NHS. It’s probably just cheaper to do it properly.
I once took part in a series of exercises with NHS colleagues to test reactions to a major incident. How would NHS staff handle a major fire in a medium secure mental health unit if the building needed to be evacuated?
All three 999 services were there in order that NHS managers could bounce requests / questions off us, as undoubtedly all three would have a significant role if a medium secure unit were ablaze. Somewhere in the exercise, I remember asking, “Where are your contingency places for medium secure care?” Blank faces, so I followed up with “Surely all medium secure MH units run let’s say, 90% occupancy rates, so that you have contingency for things like this? – unexpectedly high levels of demand, fires and other major incidents?” I admit that I knew the reality was that they didn’t but I posed the question so I was able to say this: “If a police station with a cell block were taken out of play right now, we could either spread those prisoners around existing capacity in other operational custody areas OR, if we really needed to, we could select one or more of over half a dozen “mothballed” custody blocks that can be activated.” We simply put the staff from the evacuated building into the mothballed building, turns on the lights and computers and off we go.
The next question was: “Could we put patients into your cell blocks if we also put our staff in there?!” It was a serious question. But I think we’re missing the point!
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.”