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Concordatum

I experienced something last night that felt very surreal indeed – I was sat in my second rush-hour related nightmare of the day and bored. I hadn’t heard proper news for some while so flicked off the music and put the radio on. To be honest, the intention was to escape into other people’s reality but I immediately found myself listening to news about the NHS England commissioned report into learning disabilities care. For those who are not aware, in 2012 the ‘Winterbourne View Review: Concordat Programme of Action‘ was published in which a whole host of organisations, including ACPO on behalf of the police service, committed to a range of things around Learning Disabilities and the report yesterday basically said that those organisations had collectively failed to deliver any real change.

After the broadcast piece, there was an interview with Norman LAMB MP, Minister of State for Care and Support. He informed the listeners how disappointed he was that despite signatory agencies to the Concordat committing to change, none had happened. Of course, if you listened to the news yesterday you will also notice that the Prime Minister made pronouncements about how important it was for more care to delivered in homes and in people’s own communities, after highlighting instances of people being afforded care hundreds of miles away from their families.

I don’t want to gloss over the issue of learning disabilities or the disgusting crimes that ocurred in places like Winterbourne View – these are important matters and when one hears the campaigns like ‘Justice for LB‘ and others, we can see the clear importance of these issues – but my here is not about learning disabilities or institutional care: it is about Concordats. The irony of this report is that it was published on the day immediately prior to the National Crisis Care Concordat Summit in London – I’m writing this on the train on the way to the event where I get to speak for ten minutes about what the College of Policing are contributing to this work and running a workshop and training. But listening to Norman LAMB talking yesterday, I couldn’t help but think it was a somewhat surreal foreshadowing of what we might hear if we’re not careful in 2016 after two years of talk and action plans.

The word concordat comes from the Latin, concordatum or ‘something agreed upon’. Therein lies one of the problems: it probably remains true that whatever the signatories to the 2012 concordat agreed upon, they still agree upon it. Agreeing on something that needs to happen doesn’t mean that anything changes in the real world. It is against this background that Norman LAMB stated that there will be a green paper on institutionalised care for people with learning disabilities in 2015 and that it may be necessary to legislate. This is the point where my irony-meter hit critical levels: because suggestions that on some issues we should legislate to give effect to change have previously been rejected on issues under active examination in the Crisis Care Concordat. For example, we could legislate to remove the words ‘police station’ from s135(6) of the Mental Health Act 1983, thereby making it illegal to use such places as a place of safety. Indeed, this proposal was put forward to Parliament in 2013 in a back-bench motion involving Paul BURSTOW MP, Mr LAMB’s predecessor as Minister of State. Despite suggesting a lead in time of 2017 for that legislative amendment taking effect, the proposal was rejected, in part because other methods of achieving this were preferred. Yet we have thirty years of history to show how hard this has been and there are various reasons to suspect that a lot of this stuff is too difficult for many to properly contemplate.

In recent years, whilst overall use of police custody as a place of safety has fallen, in some areas it has risen as place of safety services have been closed for one reason or another. In Cornwall, although a service has not been permanently cut, the mental health trust has transferred all PoS detentions to police custody after a mental health unit was temporarily closed for fire safety reasons. So paragraph 10.22 of the Mental Health Act Code of Practice and the implications of the Civil Contingencies Act 2005 don’t seem to apply there. (For clarity, the CCA does not apply to mental health trusts, but NHS England has told them to act as if it does. So where is the contingency that avoids the need for deliberate violation of the Code of Practice for these vulnerable people?

There is no reason at all why the Mental Health Crisis Care Concordat cannot succeed as a vehicle for driving proper change, but we always new the risks around this and why it therefore needs to be properly led: you can ‘go green’ on the Concordat without actually doing anything and whilst developing a local action plan which is basically a wish list if our broader crisis system won the lottery. That’s why I’ve argued for another colour to be introduced to the map of England on the Mind CCC website: we need blue for ‘deliver our action plan’ and a deadline by which to ‘go blue’. So ahead of a National Summit at which we find ourselves ten months into a process that finds some areas unable to yet agree on the very hypothetical task of delivering on the principles of the Concordat which would mean they can ‘go yellow’, we should refocus and double our efforts because some people are worrying that this time next year, we will have areas struggling to ‘go green’ and by then we’ll be nearly two years into a process that has lasted as long as the 2012 Learning Disabilities Concordat. Just to focus everybody’s attention on the importance: history suggests that by the time of next year’s summit, two people will have died in police custody / contact following the use of section 136 MHA and a further half-dozen people in police custody after arrests for alleged offences. That we progress some of the most complex issues is, literally, a matter of life and death for some people to whom we ALL owe a duty of care.

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Call Me An Ambulance!

“CALL ME AN AMBULANCE!?”

“OK – you’re an ambulance!”, went the well worn joke.  One my favourites, to be honest!

This weekend’s Daily and Sunday Telegraphs carried two articles entitled —

If you haven’t read them, pause here and give them a blast, as they’re both relevant to what I’m about to say.

This post is only indirectly about mental health or cognitive issues: it follows the announcement of a review to be led by the Chief Constable of Leicestershire, Simon COLE, about police officers being used as ‘ambulance drivers‘.  A few of my views on this issue don’t seem to go down well with my colleagues and even in the last twenty-hours I’ve been told these things are “easy to say as an inspector!” … presumably because inspectors don’t go anywhere near the streets and never support their officers by taking on some of the tougher decisions.  That queue of officers at my desk coming in every few minutes for advice must have been a figment …… all the Airwave radio calls must have been something I imagined.

As I understand it from the articles, we are going to see an inquiry into instances of where the ambulance service are asking the police service to attend a location instead of them because they are short staffed and of delays where officers call for ambulances to attend to ill or injured people that the police encounter when responding to crimes and other incidents.

BACKGROUND

It’s important to understand why the ambulance service seems to be struggling.  From the conversations I’ve had there are various complex, contributory reasons in the wider health service, including far longer handover times at Accident & Emergency.  A&E themselves are experiencing rising demand, which is again attributable of other service alteration in GP, minor injury and walk-in centre services – one consequence of this is that paramedics are no longer able to handover patients and leave again within the nationally agreed 30-minute target.  Some paramedics have spoken of twelve hours shifts where they left their base late (because the crew using the vehicle they were due to have were delayed at A&E!) only to go to one job and remove a patient to A&E where they remained until the end of their shift waiting to hand over.  Nine or ten hour handover delays! Add onto all of that, 24hr drinking, ageing population and and an increasing burden from chronic illnesses and you see how things are piling up against them. NHS England are currently doing a massive review into Urgent and Unscheduled Care, led by their Medical Director, Professor Sir Bruce KEOGH. It’s a complex set of stuff to balance!

So whilst everyone’s waiting in a queue outside A&E, 999 calls continue to come in and where they’ve fully expended all the first responders, bikes and big yellow trucks, the situation can emerge where thoughts turn to ‘other options’ which can include the police.  Some officers may not be aware of the world of stuff going on in ambulance control rooms to mitigate against the need to do this. But where it is thought necessary, surely better to have one emergency service there with its first-aid trained staff, than no-one at all?  Better that people who are ill or injured and who may need Accident and Emergency services are taken there by police officers than not taken there at all?! … or family are corralled by the police into assisting where possible.

Firstly, this has always gone on, even in the so-called ‘good times’ of public sector expansion.  And secondly, this issue seems to open two avenues of conversation.  As these articles did the rounds on social media, various cops were getting into it, often on the basis of first hand experience of attending a job where someone was injured and calling an ambulance to find a serious delay or an hour or more.  On the basis of that wait having no end in sigh – even with officers dealing with things like arterial bleeds – they’ve taken the decision to transport someone to hospital.  Other examples included the police being requested by the ambulance to force entry to a house on behalf of paramedics only to find that no crew were there, but in light of the information given to the police, they felt duty bound to force entry and try to help.  Final examples included instances of where the ambulance service knew they had no-one to send and felt obliged to send the police to ‘do something’.

“Policing is what happens when something’s happening that ought not to be happening about which somebody ought to do something now!” –- Egon BITTNER.

PARA-POLICING

Might I suggest there are two things going on here – the jobs where the ambulance service ask for police support and can’t attend along with the officers and the jobs where the police call an ambulance and then feel obliged to act after a delay.  I  want to focus on the second one, notwithstanding that I’m actually more interested in the first!

The thing I’ve often wondered which seems to cause disquiet amongst my colleagues in the police, is whether the police are calling ambulances too frequently?  This kind of heresy seems to go down especially badly with some frontline officers.  Unless the person concerned is vulnerable or lacks capacity, medical decisions are for people to take for themselves, so the only relevant issue is whether a person the officers have encountered has capacity to take their own decisions.  There are numerous ways to access what the NHS call ‘unscheduled care’ and these include 111, minor injury units, walk-in centres, GPs (who do offer some urgent appointments) as well as A&E. (I particularly like the leaflet from NHS Direct Wales, which is the picture at the top of this page.)  A 999 ambulance is not the only means of transport to A&E – many areas have buses, trams, taxis and pavements by which to make one’s way to these other locations!  Some people even have friends or family who might be able to help.  Indeed, where the police have encountered someone who is a victim of crime, nothing prevents officers assisting people to A&E if that were the place they chose to go.

When these articles started circulating on social media, some of my paramedics friends understandably bristled at the articles and pushed back against this.  “Stop calling us just to ‘check someone over’ at minor RTCs and fights, then!”  I’m sorry to say, I do know what they mean!  Remember what a 999 ambulance is: it is for medical emergencies and some trusts estimate that only 10% of the 999 calls they received are for genuine emergencies. There are any number of other methods by which someone who wants to get ‘checked over’ can do so – and by which the police can encourage them to do so, if they feel the need to reinforce that point.  Accepting that there will always be some situations in which there are ambiguous symptoms compounded by issues like shock or alcohol, etc.. So it’s important you understand what I am saying and what I’m not saying here! — if you feel calling an ambulance is justifiable and you feel you bear a duty of care to an individual, then it’s a decision you’re obviously free to make. Just remember what 999 ambulances are actually for, in the way that we hope to remind others what the police are actually for!

I’ve covered assessment of capacity (including for non-mental health incidents) elsewhere – here I just want to remind everyone that you must presume people to have capacity to take their own decisions, this includes parents and guardians having the capacity to take decisions on behalf of their children.  If you decide that someone lacks capacity, then it’s a whole different ball game because the police can often walk into a situation where they then win a duty of care.  Imagine forcing entry to someone’s home where a crew had not yet arrived and finding an apparently unconscious person?  Clearly, a lack of capacity; clearly a duty of care – officers must act in that persons best interest, whether that is starting first-aid / CPR or whether that is taking a decision that the best thing to do is get that person in a police vehicle and get them to A&E.  Very difficult stuff, either way – and very far from ideal!

SPECIAL RELATIONSHIP

I’ve always thought the police and ambulance services have something of a special relationship – so much of their work overlaps and at many incidents they appear to be opposite sides of the same coin. Many emergencies involve both clinical and security risks to some people and often, the incident is beyond the competence of any individual police officer OR paramedic. It is sometimes necessary to operate hand in glove. This is something to be valued and cherished at all costs, in my view. However, each service seems to have a niggling complaint about the other! Some may suggest that this is typical in many close relationships – why would it be different between two organisations with closely related but distinct roles?

The police deal with security risks, in the main – but we have first aid certificates to tolerate a certain amount of clinical risk, pending the arrival of the ambulance service and (should!) have the requisite amount of common sense to be a police officer, so they should be aware that a 999 ambulance to A&E is not the only way a person who is ill or injured can receive (what the NHS call) unscheduled care. There are walk-in centres, minor injury units, GPs (who offer emergency appointments) as well as A&E departments who don’t only grant access to people ferried there by the ambulance service. Equally, the ambulance service do go about their clinical business in circumstances of some security risks. They don’t always demand a police escort to issues where people are drunk or shouting, or even aggressive, but there is a problem of perception between the two sets of frontline staff.

At the risk of caricature, the police often wonder why the ambulance service information about previously encountered risks means that they need an escort to an address where there were last known to be problems many years ago. It nearly tempting to lapse into pejorative banter by saying “problems in 1973!” Clearly things aren’t that bad. But it is true to say, that data that influences calls from green to blue sometimes are out of date and lead to inappropriate demands for back up. Equally, police officers are often thought by paramedics to call upon the emergency section of the NHS too quickly in some cases. Minor injury accidents where people ‘just need checking over’. Is it the role of a mobile intensive care unit to give people a once over? The advertisements on the side of ambulances often remind us that it is for life-threatening situations. Why not advice such motorists to seek attention from appropriate medical professionals in due course?

ADULTS WITH CAPACITY

We should remember that all adults should be presumed to have capacity for their own decisions. Any suggestion to the contrary needs to be based upon some kind of assessment, as I’ve written about in posts on the Mental Capacity Act. So this is where the very general point about police officers calling ambulances for ill or injured people at incidents links back to broader points about mental capacity. If you attend a car crash and find the driver of a vehicle has hit a brick wall, wrecked his vehicle and is unconscious at the wheel, then it shouldn’t take very long to work out that he lacks capacity and that officers can start taking decisions in his best interests. If that drive had merely dented the front of his vehicle at low speed and suffered a seat belt injury and a bit of whiplash it may well be a different matter. If the police are first on the scene and they find the driver walking, talking and starting to sort out his details for the owner of the garden wall, why would we want to try and take control of his medical decisions? He seems a sentient intelligence sort of human being, not drunk or otherwise vulnerable, it is up to him to sort out his medical care, so advice him to do so and sort the collision issues. It is certainly not for the police to be calling him a 999 ambulance, unless he requests it with some sort of reason for needing it. Maybe the man could even call it himself, if he is a fully functioning adult who feels entitled to call one in circumstances where officers are unconvinced. What is clear, is that whatever legal duty of care the police have towards this accident victim will vary depending upon whether it’s the unconscious driver situation or the walking whiplash man.

Things change when we start talking about vulnerabilities – the duty of care shifts in its nature. If the police come across injured children, unaccompanied by responsible adults, then it is clearly different – the officers are temporarily in some form of loco parentis until parents become involved. The police also come across people where mental capacity, is not obviously present at the material time: drunk people can lack capacity, as well as those of us living with mental health problems and various other conditions. Where one of these vulnerabilities or temporary impairments is in play, then clearly officers win a duty of care which in some circumstances is only going to be discharged by calling for support from one of our colleagues in green. We also need to remember that the nature of some clinical risks may seem serious or ambiguous to the cop with a first-aid certificate, but clear-cut and less concerning to a paramedic. This is no different to paramedics feeling that a risk history at an address demands police support and when the police turn up in their paramilitary kit with handcuffs, stab vest and taser, nothing untoward seems to be going on.

The police service and the ambulance service each do security risks AND clinical risks – we can manage a bit of each other’s business, but that’s all. Many incidents involve both. It is important that in decisions police officers make around calling upon 999 ambulances that they understand the NHS principles of ‘Choose Well‘ – this is the NHS initiative to encourage people to access the right kind of service for their respective health condition. It is equally important that paramedics and ambulance managers understand how the police are sometimes inappropriately drawn into health situations that should be resolved by better dialogue between NHS providers. I’d also love to see the risk based information updated to we don’t get called to a house just because someone shouted at a paramedic in 1973. Ooops! – I see what I did there. ;-)

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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.

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HASC Inquiry

On 26th March 2014, the Home Affairs Select Committee announced a new Inquiry into Policing and Mental Health, under its chairman, the Rt Hon Keith VAZ, MP. This page simply collates all the various links to written and oral evidence and I will update it with the final written report once published.  It could be completed by the end of 2014, but watch this space!

They invited written submissions from individuals and organisations and published this on the 14th May ahead of taking oral evidence in various sessions over the remainder of the year.  I submitted written and oral evidence to the Inquiry.

You can click the date of the session listed below to see the oral evidence on video.  Links to the written transcripts are also given because the video streaming technology used by HASC does not play on all devices, in particular I can’t get it to work on iPhones or iPads!

There have been five sessions so far —

  • 1st JulyMatilda MacATTRAM, Director of Black Mental Health UK; Dominic WILLIAMSON, Chief Executive of Revolving Doors, Deborah COLES, Director of Inquest; Tony HERBERT and Barbara MONTGOMERY, parents of James HERBERT. (Written transcript of this session.)
  • 2nd SeptemberInspector Michael BROWN, College of Policing.  (Written transcript.)
  • 21st OctoberLord ADEBOWALE, Chair of the Independent Commission on Policing and Mental Health; Dr MJ TACCHI, Lead on Crisis Care, Royal College of Psychiatrists and David DAVIES, College of Paramedics. (Written transcript.)
  • 28th October – Custody sergeants from Devon and Cornwall Police and Essex Police; Chief Constable Simon COLE, Leicestershire Police and Ch Supt Mark SMITH, British Transport Police. (Written transcript.)
  • 11th November – Rt Hon Normal LAMB MP, Ministers of State for Care and Support; and Rt Hon Mike PENNING MP, Minister of State for Policing. (Written transcript.)

 

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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.