All posts by mentalhealthcop

24/7 police inspector but blogging in a personal capacity. Interested in mental health issues and criminalisation but views do not represent those of any police force or police organisation.
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In At The Deep End

I couldn’t be more thrilled to have been given the chance to undertake a secondment to the College of Policing to coordinate their work on mental health. I’m still a West Midlands Police officer, but they’ve loaned me out to help with work that the College needs to do nationally. This is a total change for me, moving from a very frontline, operational police roll overseeing a 999 response team and back to an intense spell of being a Monday to Friday, office boy doing things around policy and procedure, training and guidelines.

I’ve worked on mental health issues twice before, so this being my third posting to this developing and important area of policing and my being hot off the back of such an intense operational posting, I’m keen to help make a difference to how my old team and others like them, can do the best possible for our public. The post at the College now exists at all because of the increased focus that this issue has achieved, in which we see individual forces investing more time and effort as well as the Home Secretary giving this prominence and attention. We are where we are on this stuff, vulnerable people are not being given the best and that means there is LOADS to do!

I started last Monday and in amidst all the boring stuff about finding out where you’re going and how some stuff works in a new organisation, I was straight into the deep end on day two, in London – some months ago I chose to put forward a written submission to the Home Affairs Select Committee inquiry into policing and mental health. A few weeks ago they asked if I would go to London and give oral evidence to the Committee. What an absolutely terrifying honour that was!

WILL I STILL BE BLOGGING?

Many people have asked whether I’ll still be blogging and tweeting?! Yes – without a doubt. It was something that was discussed in the first meeting I had with my new boss and the College recognises the impact that social media can have and I’ve been encouraged to continue. I will be thinking about how to approach it slightly differently – and for the record no-one has asked me to approach anything ANY differently. For the last three years I’ve been blogging in my own time, outside of work and in order to try and chip in and drive and agenda that, frankly, I wasn’t formally involved in. I’m now formally involved in it again as I was before I started using social media, so I may be doing more ‘newsletter’ type updates.

I’ve got to be honest about this job coming about at exactly the right time – because I’ve been running out of things to write about!! I’ve been posting less for the last three months and blog hits have fallen off a bit. I’m still on course to reach 1,000,000 hits by end of next year, but it’s fair to say that the approach probably doesn’t need to change if this is no longer me chipping with ideas or advice that I have to accept people can take or leave as they see fit.

In many ways, this merely reflects reality, doesn’t it?! – there is only so much talking we can actually do! Eventually, we’re going to have to decide what, if anything, we’re actually going to do and then commit to it 100% and crack on with it. A few retired officers who heard my HASC contribution this week contacted me afterwards to say they’d been working on s136 or other issues when they were serving over thirty years ago. We can’t let this happen again.

We CANNOT go on, as we are. And yet as I type this, there are at least three mental health providers in the process of shutting s136 Place of Safety services or have already done so. We need to grab this situation by the scruff of the neck and look at ourselves because there is no reason why the United Kingdom needs to be in the position it’s in – we’re a quite capable with what many people would argue are the best health and policing systems in the world of sorting this out. Right here, right now.

I wrote a few thoughts in a previous BLOG about what I thought the College needed to do for the service. This is now the broadest of outlines about how I’ll be spending my time over the next few months to understand how we can turn that into reality and how the College of Policing can help drive the police service as a whole to a better place.

I’ve asked already on Twitter for anyone, no matter what you’re background angle, to give any thoughts and ideas about what this will be in detail. If you want to, you should feel free to leave a comment on this BLOG post or email me, using the link on the toolbar, above.

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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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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
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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Personal Responsibility

I’m going to have to be careful about the tone of this one: it just mind end up sounding a bit like a lecture or a telling-off!  And I should be clear that this post is not just aimed at professionals in policing – what I am about to say is of applicability to anyone who has to deliver their profession within the constraints and opportunities of our mental health and capacity laws.

So whilst trying very hard not to sound too much like Mr GILBERT from the Inbetweeners, here goes —

If you are a professional reading this, you will have taken many decisions in your career which are, fundamentally, legal decisions.  Section 136 MHA detentions; decisions about whether to grant leave under the MHA and recall a patient from it; the application of the Mental Capacity Act or issues around the application for and execution of warrants.  There are countless other examples.  Of course, the origins of these decisions may well be based on practice judgements, health and safety considerations or the attempts to prevent harm but as soon as you get into this territory you will come up against legal considerations. So we need to know the law.

So here’s the rub: we actually have to know the law, which means we might have to study it. Here’s another rub: whether or not we have a training course on offer, we might still have to know the law, which means we might have to study it. Finally, here’s a real spoiler: whether or not we know the law and whether or not you have studied it, you’re still accountable to it. Ignorance is no excuse, etc., etc..

STANDARDS OF KNOWLEDGE

My personal view, is that the standard of legal knowledge across the professions is actually quite shocking.  I am prepared to be so blunt because I actually don’t think this is the fault of individual professionals.  I know that I had my views early in my career about police training, but I have subsequently come to think that legal training within various mental health professionals is far from great.  The only real exception I make to this generalisation is the training given to AMHPs, because they are legally warranted and professionally examined on the Mental Health Act.  It doesn’t prevent the occasional myth pervading that professional group, but their legal knowledge is usually spot on.

I’ve noted a few times on previous posts that I get loads of queries via social media or email about mental health law each week and and most of them are really quite basic. “What is a s37 patient?”; “Have I got a power of entry for this situation?”; “I had a job the other night, whose responsibility is to do this?”

Of course, some questions are more elementary for some professionals than others. A while ago medium secure unit in another area to mine reported a ‘voluntary’ patient missing and told us “The Secretary of State has issued an order for his return to this hospital.” This information is actually very confusing about the legal status of this patient and what, precisely the police are allowed to do if or when they find the man.  It seemed to me that there could be contradiction or confusion within the request.  Since the local police area were asking officers across the force area, including mine, to attend various addresses and search for the man, I asked the duty inspector for the hospital’s area to enquire of the reporting nurse, “We’re just trying to clarify police powers here: is this a conditionally discharged patient and is this ‘order’ you’re on about a warrant from the MoJ under s42(3) of the Act?”

Silence on the phone line.

Now this probably won’t mean much to your average response officer as conditionally discharged patients being recalled is so comparatively rare that most officers will go a whole career without encountering the situation – it’s only the fifth or sixth that I’d ever been connected to in the real world.  Nurses working on medium secure units will see this far more frequently and as they are an important link to ensure that the police are properly briefed on these situations, it’s important they understand their powers.  Most crucially, the word ‘voluntary’ should never have been used in this context: the police have no powers over voluntary patients, unless we encounter them in public places and feel that section 136 should be applied. So can you imagine if this man – who it turned out had been a serious sex offender leading up to his hospitalization – were found by the police in a private address (where they would have no powers) and left there because of confusion as to his precise legal status?  Imagine the horror if he offended after police contact with that opportunity to re-detain him having been missed?!  It’s too awful for words.

It turns out that our guess was correct: he had previously been in hospital as a restricted patient and then conditionally discharged under s42 MHA. For whatever reason to do with his care, he had been recalled to hospital and would again become a restricted patient.  So at last we understood what we could and couldn’t do.

This is not a knock at an individual nurse tasked with phoning the police: it is just the more potentially consequential tale from the last few months to highlight the point. There could have been the story of the woman who had been assessed under the MHA and an AMHP had applied for admission to hospital. She had not travelled to hospital on the night of the application and the following day, staff attended her home address to convey her to hospital and she refused to open the door. Could the police just force entry? …. not with a warrant we can’t, no.  There could have been the one about the police being asked to physically coerce the Community Treatment Order patient back to hospital before anyone had served a recall notice.  The list goes on.

The police are potentially worse: perhaps you’d expect that because although mental health is core police business we know that we’re not quite there yet with the provision of training.  This week alone, “What’s a s37 patient?”, “Can we force entry to re-detain a s3 patient?”, “Can’t we just use s17 of PACE instead of getting a warrant?”.

The list goes on – legal training all ’round.

PERSONAL RESPONSIBILITY

Here is a list of resources to help, but you might have to read and internalize them! —

  • What do all the sections mean? - each important section of the Act, summarised into one or two sentences.
  • Quick Guides – covering very common and some not-so-common scenarios under the MHA / MCA.
  • Knowledge Check - one post which summarises into around 500 words the most crucial information.
  • But you might have to actually read it and internalize it! – try doing it as an act of studying, rather than trying grab information at jobs when pressure is on.

I was remembering recently that the police legal syllabus doesn’t include very information on mental health. The Blackstone’s Manuals (2015) don’t include more than passing reference to the Mental Health Act.  They certainly don’t include detailed knowledge of the Mental Health or Mental Capacity Acts into the legal syllabus that is the basis of the first part of both the sergeants’ and inspectors’ promotion exams.  The examination is based upon surveys of operational supervisors as to what knowledge is needed and yet mental health doesn’t feature at all, despite it being daily business!  I would estimate I get several dozen queries a week about what different legal structures mean or what police powers are implied.  I can’t imagine how many officers with such queries don’t raise them.

The hope behind the above resources was that they would allow quick reference about the sections of the Act and what those sections mean officers can do.

We have seen that the police are only going to be as good as the information they are given. Most MHA related scenarios for the police are not instigated BY the police – the obvious exception being section 136 MHA which most officers understand pretty well. Otherwise, the police are almost always acting in support of or on behalf of mental health professionals who will need to ensure police officers are properly briefed to be able to act quickly, professionally and legally.

This is important stuff and it may well mean that each of us needs to spend at least a couple of hours (or more!) actually reading the law itself, taking personal responsibility for ensuring we are well positioned to discharge our responsibilities and to work in partnership with each other.

Over to you!

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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