Grey1

Partnership Working

SolutionNot for the first time, I was recently told during a discussion about the police / mental health interface that solutions to problems will be found in partnership working and that “we need to stop talking about what is your job and what is mine.”  I admit to having had a small cerebral dysfunction as my brain immediately condemned this kind of insight to the bin.  I tried really hard to reflect on my reaction and lift this feedback into the light so I could see it more clearly.

The more I thought about it, the further into the bin I wished to put it because it struck me as a very bland kind of patronising response to elicit more examples of a mental health system is guilty of creeping criminalisation and contingency, via policing.  I also immediately reflected that policing does this too, to our mental health system.  So as you read onwards, don’t think I’m just being criticial of mental health services!

Let me show you why I object —–

Scenario 1 – a patient in a mental health unit who has been exhibiting aggressive behaviours has improvised a pointed weapon by snapping the head off a disposable razor and has dragged a nurse into a side room, barricading the door with furniture whilst threatening to sexually or violently assault the nurse.  Imagine if as the local duty inspector I replied, “We need to work in partnership and stop talking about what is your job and what is mine.  Let me know when you’ve dealt with it, I hope everyone is OK at the end.”

The problem in these kinds of jobs is ensuring that the police don’t react by saying, “Haven’t you got security on” or asking, “Why can’t you deal with it?!”

Scenario 2 – a mental health ward is running understaffed overnight – it doesn’t really matter why.  Around 2am, a patient has become aggressive and staff believe he needs to be moved to a seclusion room and given medication against his will under Part IV MHA and they call the police for help.  Upon arrival at the unit, officers ask for a supply of the relevant drugs and some hypodermic needles so that once they’ve either talked or coerced the man into the seclusion room, they can give him his injection.

The problem here is NHS understaffing and / or a lack of contingency arrangements for the administration of medication without consent.

I hope by now you’re laughing at how ridiculous this is.  Scenario one, despite it being in a hospital, is a police responsibility.  Nurses and doctors don’t deal with weapons, hostages and barricades do they? — we can agree: that is my job.  But it’s no more frightening than the idea of police officers grabbing drugs and needles to inject people, is it? — again, we can agree: that is a role for properly trained medical staff.

We do, by nature of our professions, need to be talking about what is your job and what is mine at this difficult interface!

GREY AREAS

Grey1But not everything is so clear – there are many things at the interface that any number of professionals from various professional groups in policing or mental health could do.  Surely that’s what people mean by not talking about “what is my job and what is yours?” – the non-obvious stuff?  Surely, when there is ambiguity or ambivalence in laws or guidelines, it is important to work in partnership and not debate the rights and wrongs?

I suspect that is little more than the traditional expedience over principle argument -

Scenario 3 – a patient in their own home has been placed in legal custody following an application that they be admitted to hospital under the Mental Health Act.  The AMHP attended the incident only with the two DRs who made recommendations and they have now both left the house, the patient is refusing to move.  Because the NHS have historically never supplied staff to such assessments who can or will coerce other people, this must mean it’s a police job, surely?

Should we stop talking about what is my job and what is yours and work in partnership by the police just mucking in?

Scenario 4 – a patient who was given s17 leave from hospital over the recent weekend has failed to return to the ward at 10am on Monday morning.  A phone call by staff confirms via his family that he is still at home and has decided not to return because he feels OK.  Staff have now rung the police to report him AWOL and want officers to attend the address and make him return.

Should we stop talking about what is my job and what is yours, disregard para 22.13 of the MHA Code of Practice and just work in partnership by disregarding statutory guidelines?

We could go on and on couldn’t we?!  …..  I won’t.

Here’s the main point: as soon as you accept that it is an exclusively police responsibility to deal with armed hostage situations and a very bad idea for police officers to be injecting mental health patients with drugs, you are accepting the proposition that some things are my job and some are yours.  That any number of professionals are entitled to use physical force to coerce a vulnerable person, doesn’t mean that it always is a job for the police – Parliament gave those powers to AMHPs and nurses for a reason.  If we see a situation where mental health services have unilaterally decided to withdraw from undertaking functions that Parliament obviously intended them to consider at some stage, it is reasonable to ask, “So when is this my job and when is it yours?  It can’t always be mine just because you would prefer that it were when I have valid professionals concerns.”

FOR THE REMOVAL OF DOUBT

I could evidence that we have seen police officers and police forces massively criticised in courts for these kinds of things and I could give examples where these debates are linked to deaths in custody or following contact.  Incidents of the most sensitive and tragic kind which mean we need to debate this stuff far more:  some things are my job, some things are yours and solutions to problems in those areas will, ultimately, be unilateral.  No police officer can make more mental health beds exist and we know that some problems we’ve seen are connected to that.  No mental health professionals can ultimatately make police officers use s136 MHA in a proper fashion, so problems arising from that will only really be addressed by proper training and police leadership.

The debate is for those areas of ambivalence and ambiguity where we may find a conflict between the ideal world of NHS and statutory guidelines and the real world of rationalised services on all sides: and here we may make partnership working more effective without getting into the territory of one organisation feeling ‘left to it’ by the other.  For the avoidance of even yet more doubt, I am also thinking here of situations where the police fail to take their responsibilities seriously, too: leaving section 136 patients in A&E or an mental health unit Place of Safety; or by failing to properly investigate criminal offences which occur on inpatient wards.  We know that guidelines state the police shouldn’t be involved in the ongoing detention of a s136 detainee in hospital, but it still happens.  We also know that the police shouldn’t be pushing people into A&E and looking to leave automatically, treating it as if it were a fully set-up s136 suite, like we find in mental health units.

So this is not just about the police being disgruntled —– we do these things to each other!

But there are clues to look for in all of this.  The restraint of medically unwell elderly people may be better done by trained staff from older age mental health nursing because the restraint skills for these tasks is designed for the purpose and not, unlike police training, predicated on the deliberate application of pain.  There are NHS guidelines on this – what is the point of NHS restraint guidelines that say “no prone restraint” only to call the police and ask them to do it?  Other statutory guidelines exist for a reason: we shouldn’t just be tossing them aside because of expedience where the recovery of AWOL patients is concerned because the families of those who have died under restraint in such circumstances deserve to see improvements in our partnership working as a result of learning from their tragic experiences.

Some things are my job, some are yours and this will never change and it’s only fair and part of an ongoing debate to highlight this.  We each need to be influencing senior managers to deliver strategic arrangements that allow this to be reflected in practice.  Otherwise hand me the needles and a copy of the BNF – we’ll crack on as best we can.

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BadgeThe Mental Health Cop blog
– won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs
– was highlighted by the Independent Commission on Policing & Mental Health
– was highlighted in the UK Parliamentary debate on Policing & Mental Health

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5 thoughts on “Partnership Working

  1. It is complex & sometimes doifferent shades of grey etc & I am probably one of those that seeks better partnership working & understanding of roles & the interface etc.

    I am clear however that the idea of either of us “cracking on” with a needle & a copy of the BNF is not much of a plan & I suspect this demonstatres your both your humour & level of frustration – which i share. Though as you know the drugs might not work.

    As an AMHP I understand the gaps in the system & realise that I am at times asking the police to support me, when perhaps it should/would be possible to use alternative provision – if it was there, it is simply not – well it is sometimes, if having decided to make an application, the bed is 100s of miles away & I am allowed or can find someone to pay for private transport & muscle. But then again I do not want to be sending people & kids miles away from home etc.

    As an AMHP I often feel abandon & left between a very big rock & a very hard place – its seems that AMHPs have lots of duties & responsibilities, but no real power to instruct. I think parliament simply thought we would all get on with it, but then again it assumed we would have beds & it probably still believes that the drugs work.

    As I have said before – the MHA & the Code of Practice is the way forward. But holding people/organisations to account is much more challenging than it should be.

    Some things are my job, somethings are your job & sometimes it is our job – even when it should be someone elses job & we are allowed to say that out loud.

  2. Excellent challenging and thought provoking post.
    Whoever said that partnership working means ” we need to stop talking about what is your job and what is mine” clearly does not understand partnership working. Partnerships celebrate and build on the different skills and strengths partners bring in to the partnership, help each other deliver more than e sum of the individual parts by minimising impact of gaps and weaknesses and each partner is accountable for their contribution. What the person seems to be describing is homogeneity which bedevilled attempts to build multidisciplinary teams in mental health services. It inevitably leads to the lowest common denominator and blurring of accountability to point no one is willing to accept accountability. Successful teams and partnerships in all areas of life thrive on diversity but in working to a common purpose. A football team comprised of the best 11 goalkeepers in the world wouldn’t win much but nor would a team where all 11 players had identical skills. Same applies to orchestras or groups or business partnerships. There are still examples in mental health services of lowest common denominator homogeneity approaches described as team and partnership working but calling something by the wrong name doesn’t change what it is or isn’t.
    So all your examples are excellent examples of non partnership working! Partnership working and the newer jargon word co-production are based on equal respect between partners not equality of skills, powers or anything else but willingness to share those skills and use that power for the agreed common goal so partnerships can be simply for one task or for complex ongoing tasks.

  3. I am guilty of this but during crisis situations we all think we “know what is best”. Ultimately,this is informed by the law, our training, licenses, personal values, values of our profession, and our relationship with the client. This unfortunately can’t be entered into a computer and an answer be spit out. It is when law, licenses, and mandates conflict with personal values, the grey happens. Then you add two professional values (nurses v. social workers, police v. psychiatrist). Getting even greyer.
    I remembering disagreeing with a nurse about medication over objection. It was intense but the “spirited” discussion we had afterword made it clear where we stood in the future. It is hard in that moment but a quick assessment on the mandates versus the feelings in the situation may help. A healthy discussion or debriefing of these issues afterwards can also help to reduce problems in the future and add more color to the grey.

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