NamibDesert

Inappropriate Detentions

I’m amongst the first to admit that police officers lack the necessary training to ensure that they get s136 detention decisions consistently correct.  I’ve written about this before, offering my view as to how the dilemma should be approached.  I’ve also acknowledged the point made by some mental health professionals: that police officers occasionally use s136 where it is blatantly illegal – for example, in private premises – or where other powers of detention should be preferred.

What I’m also clear about – and it seems fair to mention this when I’m prepared to accept problems in some officers’ usage of s136! – is that many detentions are only necessary at all because patients cannot directly access the NHS services they need or in a timescale that suits them.  That’s where the police often find themselves involved in taking detention decisions and I want to amplify this point yet further – some s136 detentions follow decisions taken by the NHS to seek the detention of patients or to refer incidents to the police which they ideally wouldn’t.  Some patients try and then fail to access their CrisisTeam or their community mental health team and end up coming to police attention when they have “one foot off the bridge” (to use a phrase from the Mind Report on Crisis Mental Health Care.)  Other patients are actively deflected to the 999 system by our mental health system.  Indeed there is some emerging suggestion that existing community and crisis teams are now more included to deflect demand to the police where they know the police have access to street triage service.

INAPPROPRIATE DETENTIONS

Two mental health trusts in the last month have used social media to broadcast their street triage schemes and have specifically stated that they are going to be working with their police services “to reduce inappropriate detentions”.  I will admit to smarting a bit at the very idea of this!  Whilst accepting that forces use section 136 in very different ways and that this includes usage which may be questionable, there are many forces using s136 quite lawfully and appropriately.

There are two types of detention that seem to get labelled inappropriate -

  1. Those detentions which are straight-forwardly illegal and those which should have been made under other laws.
  2. We also see an emerging narrative that suggests because street triage has reduced use of s136 by a certain percentage figure, that number represents the total number of interventions that were inappropriate.

I can accept point one: I will argue vigorously about point two! 

We should remember that the threshold to be satisfied for detention is actually remarkably low in the United Kingdom – far lower than in certain other countries where equivalent powers require the police to apprehend violence or harm.  Mental Health Act provisions in the United Kingdom merely require the officer to be satisfied that someone immediately needs care in their own interests, a much lower threshold.  As such, a greater number of circumstances can be legally justified as requiring or allowing detention.

We should also remember that far too many people who talk about section 136 MHA think that the only important measure of its effective use is the number of people who are subsequently admitted to hospital as inpatients.  I’ve dispute this for many years: how can we argue that section 136 was inappropriate if someone in immediately need of care was kept safe from harm until assessed only for the assessment to conclude that they weren’t known to the mental health trust but needed referral to the CMHT or various forms of social support?  Or a patient who is already known and s136 reveals that their care plan wasn’t working for them and this can be rectified?

RE-WRITING HISTORY

This alludes towards a narrative that alters how some people, including me, think we’ve ended up with a mental health care system consumed with criminalising vulnerable people and ensuring the justice system plays a key role in gatekeeping healthcare in a way that wouldn’t be tolerated in any other arena of illness.

I’ve tried over the last decade to understand how I ended up – as a police officer – frequently gatekeeping this entry to our mental health system?  Why did someone want the wellbeing of patients so acutely unwell that no junior doctor would go near them without bleeping the on-call registrar or consultant to be left in the hands of response officers and custody sergeants?!

I can’t avoid concluding something along these lines -

  • We (quite rightly) started mass de-institutionalisation of mental health care in the 1960s.
  • This followed on from the discovery in the 1950s of the first generation of anti-psychotic medications.
  • As the decades rolled through the 70s, 80s and 90s, we reduced the inpatient population of our mental health system by over 80%.
  • We subsequently failed to invest adequately in our community mental health care system – CMHTs, CrisisTeams, etc..
  • As a consequence of non-investment, the criminal justice system is drawn in to fill the vacuum that exists —
  • So we see the prisons providing ‘inpatient’ mental health services for thousands of vulnerable people who arguably need hospital care;
  • And we see the police providing ‘community’ crisis responses to thousands of people who arguably need accessible community care.
  • We also see probation drawing together social provision for offenders after sentencing of all kinds.

Of course, this crude summary that misses various important medical, social and political issues but it at least suggests how we have ended up with the police playing such a prominent role in our emergency mental health care system and why that demand has been growing in most major jurisdictions over the last two decades.

The police never prepared for this, of course: promises of sufficient investment in community care were repeatedly made to suggest there was no need to worry about reduction in the inpatient estate.  In fact, you’ll notice that these are the messages that have been put out over the last few years as the NHS has decommissioned approximately 10% of its inpatient estate since 2010.  And meanwhile, police contact with vulnerable people has been rising, use of section 136 has been rising and the number of people criminalised after being arrested under other provisions whilst unwell, has been rising.

SO WHAT DOES INAPPROPRIATE MEAN?

So back to the original point: I think the trusts concerned believe ‘inappropriate’ to mean the police using section 136 where a mental health nurse may not have recommended or requested it.  Of course this doesn’t actually mean that police officers actions were inappropriate!! … back to the two bullet points above, what does inappropriate’ mean unless it is illegal detention, or detention that should have occured under other law?

But an officer acting lawfully and properly where they may not have needed to do so, if only the patient could be referred to mental health services more or less immediately is not ‘inappropriate’.  It’s like debating a mental health nurse defending themselves by the use of force; the fact that when a police officers turns up it won’t be necessary because the officer will protect the person, use force and arrest the offender, doesn’t mean that the nurse is acting inappropriately by defending themselves lawfully.  But they would be acting inappropriately by defending themselves unlawfully – through excessive force, for example.

Of course it’s really easy to construct a narrative about how the poor police keep stuffing things up in mental health: we can point to the deaths in custody, the various IPCC inquiries and other complaints and legal cases.  Even the MS v UK case (2012) was presented by the media as being the police treating people appallingly when in fact, it was a legal action against the Mental Health trust for not expediting the admission of acutely ill psychiatric patient.  We have seen deaths in custody where the NHS have effectively wiped their hands of some patients who were at that time in their care – including where various statutory guidelines have been breached – and then had to watch as the police officers who were left with it gripped the rail in a criminal court.

So is whilst I’m pleased that someone is attempting to articulate what street triage is actually for – I’ve previously complained that no-one has articulated a particular vision or aim – I’m concerned that the narrative re-writes a significant part of the problem:  mental health services are insufficiently accessible and flexible to those in need, especially those already known to secondary care services.  As a consequence of this, many vulnerable people and mental health related demands drift not only to the police, but also to the ambulance service, and we then see that outcomes are not consistently what mental health services would hope them to be.

Is anyone actually shocked at this?! – that if you place a police officer in the position of a mental health professional and give them almost no background information about the person they’re dealing with, that they will be risk averse about the situation by comparison?  It seems perfectly predictable to me.  But if we had an NHS system that was accessible to those who want it, largely on the patient’s terms, then we often wouldn’t have to put police officers in that position in the first place.

This is what street triage is teaching us as the results start to emerge: that if you simply get a mental health nurse to interact with the person in a timely way, that largely does the trick.  So why don’t we just make mental health nurses and their services accessible – able to call on police support when needed and vice versa?

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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
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8 thoughts on “Inappropriate Detentions

  1. Dear Mentalhealthcop
    I believe you have given an excellent review of the need for mental health nurses to accompany police and vice versa for police to assist mental health teams.

    A word of caution though – how will we ensure that there are enough fully trained psychiatric nurses to go around? It would appear that there is a gap in provision between the “need” and the actual “provision”.

    And what about an area where there may be many languages in use how do you communicate with people who do not have a native tongue?

    These issues were largely ignored when the UK was basically a society with English as their mother tongue [pace the Irish, Welsh and Scots having their own indigenous tongues]. People coming from the Empire and Commonwealth usually had English as a common language and so had no language barrier.

    Now, however, it is different and we have many people who have come to the UK who do not have English as a mother tongue or maybe have a smattering of English. How do the police and essential services help in these situations?

    It is a pressing issue if a barrier exists between essential services of the Welfare State and those people who are assisted by them.

    What are your views please?

    Best wishes

    Rosemary

    Rosemary Cantwell

  2. Great post. I don’t think ‘call the police’ should ever be in a crisis plan. It doesn’t mean it won’t ever be necessary – but surely it should never be part of a plan. The reality is that in the absence of an out of hours service or any sort of emergency service / short term crisis care/ properly funded and resourced long term care from mental health services it may be the only plan………….

  3. It would be great to make mental health services more accessible. 2 O’Clock in the morning and a man goes into crisis. He calls his local Mental Health Trust crisis line. They advise him that they are unable to assist due to no service provision at that time of the night. They advise him to call 999 and ask for the police.

    True story that happened only weeks ago.

    A relative thanked the police for always being there even though they are not specifically trained to deal with mental ill health.

    Mental Health is 24/7. We need appropriate services to respond. If we had fully accessible MH services, would we still need a street triage service?

    Great blogg!

  4. Earlier this year I called the Crisis service, who for reasons neither the police or I understand, called the police, who took me to the hospital, where the crisis service refused to offer support, so the police took me to the cells for nearly 20hours. No crime was committed, but I sustained significant injury (requiring hospital treatment) due to self harm in the cells, partly contributed to due to distress and confusion at being locked in a cell. The senior police I’ve been in contact with following this have shown insight and sensitivity, we’ve talked about intersectionality and the complexities of non medically qualified staff having to take on risk from another service with no background knowledge, but fundamentally they cannot assure me it won’t happen again the next time I am unwell with the current resourcing in my area. It’s really frightening.

  5. The other key change,little understood,in the last 20 -30 years has been the escalating numbers presenting with self harm, or threats of,often with substances on board. I’ll confidently predict that the vast vast majority of ‘crisis’ cases are not people with severe mental illness, in particular psychosis.Arguably the result of the breakdown of anchors in our society eg.Family,church,community; there is often no available treatment for these ‘crisis’ presentation and In fact a medical response will often aggravate the situation ,unnecessarily medicalising behaviours and encouraging an escalation of said behaviours in future.(look at research which explores the poor outcomes for those with personality disorders admitted to inpatient wards as an example).

    My great fear is that while intending to divert “ill” people into healthcare we are unwittingly medicalising human distress ,giving the impression that ‘if only a nurse can have a chat and impart some secret knowledge and/or medicate then all will be well ie.the individual doesn’t have to ‘own’ their behaviour and response. In my particular inner London borough it is virtually unheard of for crisis teams to work with someone detained s136( I would acknowledge that Inner London has very different demographics to elsewhere in the country with police officers very used to seeing disturbed odd behaviours on the street every time they’re in work so probably only using 136 for very unusual behaviours). In broad terms, the person will either be acutely psychotic and disturbed requiring admission ,or is not mentally unwell rather has a combination of intoxication, bad behaviour including aggression etc. A back covering referral to the cmht may well be made (who wouldn’t) but our research suggests little in the way of active treatment tends to follow.

    So by all means let’s take pressure off frontline police officers by having mental health professionals more available to screen/assess but beware of the hyperbole which suggests there are legions of people presenting in ‘crisis’ who will benefit from treatment. There aren’t and actually – and we should be in no doubt about this – many will be harmed by medicalising their problems,encouraging repeat episodes and escalating behaviours as their perceived ‘needs’ are not met.

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