#CrisisTeamFail

I noticed a hashtag on Twitter last night that made me feel quite anxious but also intrigued – #CrisisTeamFail.  Whether or not you’ve signed up to Twitter, you can still go on it and see the content.  In short, various patients were tweeting their experiences of contacting mental health crisis teams and noting the replies that they received – it was revelatory in many respects, although I’m familiar with some of the responses people received because of what I’ve heard and seen as an operational police officer.

Before we get into this, I want to go out of my way to make one thing abundantly clear and please imagine me in a raised voice so there can be little or no doubt that I really mean this! —

  • We all know mental health teams are under-funded – this is acknowledged right up to the level of HM Government ministers.  We know that NHS England chooses to apply a differential funding arrangement to mental and physical healthcare, ensuring a recent 1.5% and 1.8% rise in funding allocations last year causing Department of Health Minister Norman LAMB MP to make his views very clear and he has continued to do so.
  • We know that when demand exceeds supply of staff – this means they have to make decisions about what to prioritise.  Like other public services with finite resources, this means that from time to time you will not deal with things that you would ideally like to deal with.  Or, you will not deal with them as quickly or as well as you would like.  The police do this too – as a duty inspector, I personally took certain decisions to that effect.

So, honestly – we do get it!  The system is underfunded and ineffective and this is not the fault of frontline Crisis Team staff.  We know this because we’ve seen the Crisis Care Concordat looking across the board from commissioning and commissioners to the detail of frontline provision across providers, to see what can be done better and a lot of that will be about joining up over-functionalised silos in which various kinds of healthcare provision sit.  So really – we understand that ‘the system’ accounts for a lot.

Until it’s sorted out, we understand that decisions may be taken about what staff will or will not do and that this means some demand may end deflected to the 999 services, whether deliberately or not.  As long as we’re not asked to do things that are illegal or asked to assume responsibility for decisions we cannot possible make, there’s a certain degree to which I don’t mind, however much I’d prefer it properly sorted by correctly constituted mental health teams.

But this hashtag went way beyond all of that for me.

RAPE INVESTIGATION

In 1983, a fly-on-the-wall documentary was made in the Thames Valley Police area.  It included an incident where a woman attended Reading police station to report a rape and the documentary makers were allowed to film the interview of that victim by a Detective Inspector and a Detective Sergeant.  So these were supervisory CID officers.  We then watched the most awful berating and disregard of that victim and it quite rightly generated public uproar, leading to disciplinary proceedings against both and to a total overhaul nationally of initial responses to rape.  I’m afraid to say that the unfolding of this hashtag made me think of that.

Even now in relation to the investigation of rape as well as other offences, there are indications or perceptions in just some cases that victims question whether or not the police believed them. Of course, the operating presumption should be that people who walk into police stations tell the truth, unless and until something indicates otherwise.  Prosecutions for wasting police time or perverting the course of justice for false reports of any kind of crime are comparatively very rare indeed, perhaps the most recently notorious of which was the prosecution being faced by Eleanor De FREITAS which led this young woman with bipolar disorder to take her own life.  Validation for victims is achieved by the police taking reports serious and treating them as true allegations for the purposes of conducting a thorough investigation.  In Ms De FREITAS’s, case her father stated that he understood that inconsistencies in her allegation rendered a prosecution very difficult and why the police did not seek to bring charges against her alleged attacker.  That man then brought a private prosecution against her for allegedly making a false allegation against him and the CPS decided to continue the case, despite objections from her solicitor and family.  Very, very difficult issues.  Guidance to the Metropolitan Police would have made it clear however: upon first receipt of her allegation of rape, she is to be believed, validated and the investigators go wherever the evidence takes them.

This is what concerned me about the stated responses, which we all must acknowledge were made known entirely without context on a social media platform.  I’m sure mental health professionals involved in those conversations would have their views about whether comments attributed to them were accurate, or whether context alters anything.  But regardless of all that, it seemed clear to me that those patients tweeting their experience didn’t feel validated.  They often felt patronised or dismissed.  One example included a female service user who was asked whether she had considered going for a walk – whilst on her own, late at night and whilst feeling vulnerable.  Oddly enough, she didn’t wish to consider this.

DISTRACTION TECHNIQUES

The suggestions about patients having a cup of tea, a hot bath or a long walk were frequently mentioned, by many.  A doctor – who it must be said, was one of only a couple of professionals brave enough to become involved – pointed out that such things can be valid distraction techniques for people in crisis.  It must be fair to observe, few people found this acceptable: many were beyond that stage themselves before ringing the CrisisTeam in the first place.  Others had specific objections to the advice – like the woman who did not wish to go out late at night on her own for a walk.  Or the person in crisis who didn’t want to have a bath and see a body they loathed as part of their principal mental health condition.

A few mental health professionals have then since made the point: there are far two few professionals in a crisis team to necessarily provide an effective response, that they are trying their best and that in some situations, all they can do is encourage forms of self-care or distraction that may get someone through the night or to the next day.  But that moves us on to various tweets that made reference to the police.  It was someone tweeting about being ‘threatened’ with the police that first drew my attention towards the #CrisisTeamFail hashtag.  Now I’ve been the police officer sent to a home on many an occasion and I’ve taken advice calls from PCs and sergeants hundreds of times about such incidents.  There is often a very stark difference between the 999 call made by the CrisisTeam and the response to officers from the patient.  Of course, this could be for any number of reasons: might I be bold enough to suggest that occasionally, the risk to a patient is occasionally exaggerated to ensure the police do respond and become responsible?  Might I also suggest that sometimes, patients are so surprised, intimidated or unwell that when cops with stab vests and tasers suddenly appear at the door, they quite naturally attempt to downplay their crisis for fear that they will be detained in custody to keep them safe?

Regardless of the explanation, I know this – the police can confirm whether someone is Alive, Breathing or Conscious and whether they are obviously Ill, Injured or Intoxicated.  They can even inform the CrisisTeam of these observations – ABC/III. Whether this means that a person is ‘safe and well’ is a totally different assessment and not one for the police to make, ever.  It does not ‘tick off’ a discharged duty of care that the Crisis Team called the police, except in the sense of mitigating an immediate threat to life.  If the officers pitch up and find someone in similar circumstances to which the principles of the Seal, Sessay or Hicks cases apply, then the officers have no legal powers to act whatsoever unless there is also a criminal offence being committed or attempted.  So the Crisis Team will still have to decide: “what are we now going to advise, if anything?”  They are effectively back to where they were before they called the police because mental health care in this country is the responsibility of mental health trusts and general practitioners, not the police.

This hashtag – for me at least – showed how important it is to have good communication skills, to have a response that doesn’t sound like people are being dismissed or even disbelieved and to validate people’s experiences even if you are on the way to providing a response that may not be what they had hoped would happen.  Some people reporting crimes as victims aren’t victims at all – no matter what their belief to the contrary; and some are actually telling lies.  Only a professional investigation will properly determine into which category someone falls and you’ll never get that in an initial phone call.  I can’t see how mental health care is any less complicated!

Maybe some patients aren’t in full-blown crisis when they think they are – some victims aren’t victims when they think they are – it sometimes takes more than a conversation on the phone, not only to make this clear but also to explain it and then further support someone.  This will be no different in those seeking crisis care responses – your perception is your reality and if we’re talking about a group of patients experiencing suicidal ideation or delusional ideas, however short that falls from whatever the definition of ‘crisis’ is, it is effectively denying the significance of that experience by providing a response that doesn’t work for the person, and is therefore no response at all.

But I repeat my original point: if this is about the capacity of CrisisTeams, then commissioners and managers need to look at that.  But this is also about how frontline staff communicate, which – of course – is an issue in the police too, especially when pressure is on professionals to deal with volumes.  Managing sensitive, high-complexity demand sometimes takes time that appears not to be there.  If this is about how vulnerable patients come to better understand how to support themselves in crisis, then who could object to that.  But if it is also about how we communicate with people.  The police are busy and being ‘rationalised’ too, but I was glad to read remarks in this hashtag that patients found that the police listened, cared and tried to help whenever they were involved.

So if all else fails we seem to ring the police – and I wonder if CrisisTeams do that more now many police forces have access to street triage?!  Various pieces of anecodatal evidence made known to me suggests that we are – but that’s another post altogether!

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The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
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

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.

MagistratesCourt

Witness Warnings

The Crisis Care Concordat is ensuring that a lot of discussions occur about the interface between the police and our mental health system, amongst other things.  We are quite predictably hearing a lot of the standard lines about “joint working”, “partnerships”, and cutting across silos and so on and so on.  It’s the lingua franca of these things that we have to work together, which I am unable to hear without recalling the Birmingham accent from that appalling Prudential advert “We wanna be together!”

I’ve thought hard these last few months about what kind of policing and mental health interface I think we should be trying to build – not least because I’m involved again in trying to build it!  What are we actually trying to achieve here?  We could use the police in any number of different ways and I’m sure that views vary about the extent of the role the police should play in administering our mental health care system.

This post is about my vision for this, in the context of hearing cries by various people who argue for a blurring of boundaries – and I will warn you now that it’s slightly longer than my average post, so pause and pop the kettle on before you continue!

THE ROLE OF THE POLICE

I keep coming back to this —

  • I want the police to be as uninvolved as possible in our mental health care system;
  • I want the police to be as involved as possible in the response to mentally disordered offenders.

I put these two things forward against the backdrop that we already know from my favourite criminological quip that “policing is what happens when something’s happening that ought not to be happening about which somebody ought to do something now” and that “there is nothing that could not become the legitimate business of the police.”  Of course it does not following that everything is the legitimate business of the police, who are something of a crude safety net and checking system – the police service (and the broader criminal justice system) is a secondary, not a principal lever of social justice.

There are ideas in both of my aspirations that need explanation —

MENTAL HEALTH CARE

Parity of esteem has to start with this, for me: we don’t routinely involve the police in the care and treatment of people with hip replacements or cancer.  Only in fairly weird and exceptional circumstances do the police pitch in with things connected to oncology or orthopaedics and that’s usually around preservation of life issues, which falls under their remit anyway.  So why would we want the police involved in our mental health care system any more than is absolutely necessary?  Notwithstanding my passionate interest in this issue, I am not and never will be a mental health professional: I am a police officer and I, like many of my colleagues, joined the service for certain reasons.  I have my views about the health system, I have my views about the mental health system – and believe it or not, many of them go unexpressed on this BLOG because they’re not relevant to the professional points I’m trying to make here.  That being the case, it’s fair enough for the police to remind everyone that we are here, constitutued for a certain set of purposes:

  • Prevent crime
  • Bring offenders to justice
  • Protect life and property
  • Maintain the Queen’s Peace.

But as Sir Robert PEEL made clear almost two hundreds years ago: it is not just the responsibility of the police to do these things.  The police are merely individuals paid to do on a full-time basis that which is every citizen’s responsibility – the police are the public and the public are the police.  This is why consent is so fundamental to British policing and over-involvement in the mental health care system means that for some of the most vulnerable, already marginalised members of our society, their involvement with the police service is not about consent, but about coercion: officers being called in by the mental health system in circumstances which are all too often connected with coercing them into systems which may or may not actually be effective.  We know for example, that Community Treatment Orders don’t work.  We also know that when those kinds of legal orders are imposed on those of us with mental health disorders and are then ‘recalled’ under the Mental Health Act, this coercive revolving door is making little different to anyone and it could even be making things worse.  Why should the police be involved in this, when there is absolutely no legal obligation to do so, in the majority of circumstances?  Mental health services can plan and prepare for the implications of their statutory activities if they want to – indeed the Health & Safety At Work Act 1974 rather expects them to!

But more importantly, what does the routine involvement of the police do for patient experience?  You want or are perceived to need a form of healthcare and a professional who pops along has a police officer metaphorically in their medical kit.  For what purpose?  What is it that the police do?  Well, they usually talk to people, enforce laws and apply lawful force to compel – but they are not the only ones who can do this.  So what is the message here?! >> “You’re having this, whether you want it or not – and I have come armed with the coercive apparatus of the state just in case the answer is ‘not’.  Can you see the taser, the handcuffs and the leg restraints? – now let’s talk about whether you think re-starting medication would be something you would like to consider.”  Remember, there are well over a million people in contact with secondary care mental health services in any given year, but only a small percentage of those are brought under the auspices of the Mental Health Act.  We know that most of the contacts that mental health services have with patients do not and never will involve the application of the Act, so why involve the police in those that won’t?

For all the times I’ve heard the argument about the presence of the police ‘promoting cooperation’, I’ve got examples where the presence of the police stigmatised and unnecessarily escalted the distress in a situation.  For all the patients who have told me that the police are often a welcome, reassuring safeguard there are others who feel involvement of the police further stigmatises and criminalises them – so police involvement in non-criminal aspects of our mental health system is something to be done very, very sparingly indeed and without presumption about what involvement of the police will achieve.  Patients are individuals with complex situations – one size doesn’t fit all.  This is (yet!) another reason why I have concerns about street triage: we already know that most interactions occur in places where legal ‘enforcement’ wasn’t going to happen anyway – so what the officer is achieving by being there is a subjective thing that hangs on any given point of view or background presumption.  But it does re-introduce the NHS mental health crisis system to some of its patients, which may be an end in itself.

CRIMINAL INVESTIGATION

Regardless of the reason for an offence being alleged, the police clearly have a role to play when incidents occur which involve offending behaviours or vulnerable victims.  I want the police to be better at this.  By better I mean, I want victims believed and supported where they are vulnerable – let’s just STOP assuming that someone with a mental health problem is inherently unreliable as a witness in court.  The CPS did this a few years ago in the cas of B v DPP [2009] and were successfully challenged under human rights legislation by a victim with schizophrenia who was probably far more reliable than some bankers, police officers or politicians!  Many things may render someone unreliable as a witness, but whether it does so will vary from witness to witness.  Anyway, does it really matter than a very unwell, victim who was attacked gave a statement to the police that seems unreliably inconsistent if the attack was also witness by two other people and captured on CCTV?  Let’s look to cooberate allegations with other evidence and deal with actual problems when they arise – not assume there will be problems before we’ve tried to secure justice for people.

I’ve written elsewhere on this blog: I want a more sophisticated approach to decision-making about mentally disordered offenders.  Liaison and diversion sounds great to me, but only if we start talking about things and addressing issues that I’ve heard little about as new schemes have started to be piloted.  I keep hearing about health interventions and health outcomes for mentally disordered suspects in police custody and at court: I keep hearing little about re-offending rates and crime prevention.  The Centre for Mental Health admits that there is little evidence that liaison and diversion works, so let’s gather proper evidence as we go and see what we learn in the future.  The evidence may emerge: but concluding that we’ve made offenders healthier is only one side of the coin.  We also need to know what happens to offending and re-offending rates.

And we need to make sure that whatever approach we take in Liaison and Diversion, we don’t just build risks into a system that we thought was mitigating them.  We know from the report into the treatment and care of Philip SIMELANE (who killed Christina EDKINS on a Birmingham bus in March 2013) that failing to take a longitudinal view of repeated arrests for a pattern of allegations that is increasing – in frequency, in seriousness or both – can lead to risks not being managed.  But where individual offenders are arrested and on that day reach the threshold for the criteria of compulsory detention under the Mental Health Act to be applied to them, how do police and prosecutors take sound decisions about whether or not this should bring a permanent or temporary halt to an investigation?  I’ve written about that elsewhere, but I submit that no-one is putting forward a comprehensive view of when acutely unwell offenders should be prosecuted notwithstanding how unwell they may be.  And yet we know, occasionally – from time to time – it will be necessasry and proper.  But we also know that NHS contributions to investigations through information sharing and professional opinion are not where they need to be, either – so we all need to get better at this, for the sake of ensuring humane, non-criminalising outcomes wherep possible and public protection where necessary.

WE WANNA BE TOGETHER

So back to what this means for partnership working – we know that the police exists for a certain set of purposes; that this includes a broader public safety remit rather than a narrow focus on crime and that we will see officers involved in supporting the administration of the Mental Health Act and our mental health system, from time to time.  But we know that there have to be limits to this – we don’t want cops routinely standing on psychiatric wards and restraining people who are having medication forced upon them by medical and nursing staff.  When the issue of ‘safe and well’ checks was being discussed on Twitter recently, there were some responses that indicated the police should just endlessly absorb requests for these things, partly because they always previously have.  Apart from the unsustainability of this, it has to be remarked that some of these welfare checks are perfectly legitimately directed to the police and others are just not their responsbility.  Agencies have a variety of means of checking up on the welfare and wellbeing of people who are not at immediate risk, who are not missing and who may benefit from checking.  The resources that police forces are now pouring into checks for which there is no (broadly defined) policing purpose and which could be done equally well by others needs addressing.

“But we haven’t got enough resources – we’re too stretched as it is!” came the reply.  If this means that things others are too busy to do because of high demand, under-resourcing or whatever other reason become police responsibilities, then we’ll also have start work on fixing potholes in roads, cleaning streets after the nighttime economy binge we see each weekend and doing various other things, too.  We know that the police don’t fix road surface problems, but where they come across potholes that suggest dangerousness, they block roads, cone things off and call the Highways Agency.  That they do this at all, doesn’t mean they fix potholes – they just mitigate risks around those that may render people unsafe.  But all of this begs a far more important question about ‘partnership working’ and ‘working together across agency boudaries and silos’ -

IS THIS A ONE WAY STREET?

For example, if the police are rammend busy on a Thursday night with a serious incident and high demand of 999 calls, could they ask the Crisis Team to visit addresses for late notice court warnings?  Obviously, each evening, the Courts Service sometimes have to re-jig Magistrates and Crown Court trials for various reasons.  This often leads to a request being made to the police that homes be visited to tell witnesses they are required at short-notice.  Maybe community mental health teams could do these things for us, if we’re too busy to attend?  After all, that’s within the skill base of almost any sentient, responsible adult isn’t it? – ‘safe and well checks’ on those of us with mental health problems, is actually not within the skill base and competence of a police officer!

Because remember: this is all about breaking down organisational boundaries isn’t it? Let’s stop working in silos, not erect exclusive criteria about whose job is what – just get yourself down to Mrs MIGGINS and let her know she’s needed up the Crown Court tomorrow morning without worrying about how you’ll manage your patient caseload and your mental health assessments.  The point I’m making here is not  subtle one! – if the police were to say about ‘police work’ the sorts of things that some health professionals are saying about ‘health work’, it wouldn’t move an inch in a partnership debate.  It would be (rightly) dismissed as ridiculous!

Your police force has finite resources, folks! – we can only one thing at a time for each of the officers we have and for all the reasons made above about mental health care, deflecting demand to the police and telling them not to worry about the resource this is costing or the fact that prevents them doing something else, is actually about the opposite of partnership working which should be built on mutual respect for the differences between organisations, as well as the overlaps between them.

Some jobs are ours; some jobs are yours and some could or should involve us all – the fact that on some issues there are overlaps does NOT mean that in all issues there are overlaps and that we all can or should be doing everything.

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The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
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

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.

Map

Concordat Colours

The Crisis Care Concordat has it’s National Summit in London next week – a gathering of all the signatory agencies in order to mark progress ahead of the first big deadline.  For those who follow me on Twitter, you’ll notice that I keep uploading a developing map of England, shaded in various colours, like this (as of November 19th 2014) —

This is what the colours mean -

  • Map2Red - no progress yet recorded.  Doesn’t mean nothing’s happening or that discussions aren’t occuring.  Just that they haven’t yet delivered the first outcome.
  • Yellow - the first outcome: this means that individual areas have agreed in principle to work together to deliver what the Concordat aims to do and that they are going into 2015 with the intention of delivering an area-specific action plan to work out what in particular needs doing locally.
  • Green - the second outcome: this means that areas have completed and jointly agreed their action plan with that commitment to deliver upon it.

The keen-eyed amongst you will obviously recognise that nothing needs to actually happen in the real world for an area to ‘go green’.  Your local services could, in theory, be completely and entirely unchanged and unaffected, despite going ‘green’.  For this reason, I want to put an argument for in introduction of another colour … or two!  Do we also need something that says “We’ve delivered our Action Plan”? … perhaps one colour for ‘delivered in part’ and another for ‘delivered in full’?!

This suggestion hits at the heart of certain frustrations that many have – and I’m not just referring to police officers here.   When are we going to stop talking about this and DO something?  Action plans are great – it doesn’t actually mean a damned thing has changed or been done, quite frankly!  Actually, whilst some areas are meeting to discuss their commitment and / or their action plans, some of them are also busy closing place of safety services and reducing hospital beds which will increase the pressure at the bottleneck of crisis care.  There are AMHPs, mental health nurses and doctors working in frontline mental health services who are just as weary anyone else having worked their whole 35 or 40 year careers with the same frustrations about the crisis care interface.  Difficulties in arranging the detention, conveyance and safety of vulnerable people have been ongoing for decades.

So whilst the Concordat is bringing people together and we are seeing chat, declaration and plans it’s vital that local leadership turns this into an operational reality on the ground because patients and victims live there, not in meeting rooms where concordats are discussed and plans are conceived.  And a final plea from me in this short post: something I’ve concluded all over again now that I’m back in the thick of this – Concordats need to have a detail for proper, applied legal education for all of the health, police and social care professionals who will be involved – and NOT just frontline staff.  No point managers conceiving how services will be built and run, unless those services are predicated on the legal frameworks that govern us all.  I still read and hear legal nonsense, most days as my last post highlighted.

More —

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The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
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

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.