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Evidence Based Policing

The creation of a professional college for policing – part of the professionalisation agenda – is an opportunity to work towards becoming evidence based. This is something that has been made clear to me over the last two months and something I’ve been arguing for years, incidentally! We can look around and see that the College and individual police forces are trying to engage academics to bring research skills into policing and actively build that evidence base. West Midlands Police and the Metropolitan Police are just two forces hosting research fairs and inviting academics into their organisation with the aim of understanding what works in policing – and why?

Evidence is key to this – being the police, we should be concerned about the standard and quality of our evidence, shouldn’t we?! We are in criminal trials – why haven’t we been overly concerned with it terms of evaluating interventions? We see examples all around us where evidence is not being brought to bear on the claims we make – again and again, I see this in policing and mental health. For example, that the Centre for Mental Health, in writing various documents about liaison and diversion services, has said, “the evidence for liaison and diversion is just not there.” It doesn’t mean there is evidence of it not ‘working’ – whatever that means – it just means we haven’t (yet) gathered the data to show it works. Let me show you another example of where we’re not relying upon evidence.

I have repeatedly heard in the last two months that ‘street triage is saving officer time’ and other claims implying the same. You can see for yourself in the recent HMIC report ‘Core Business’ (2014, p116) – there is clear wording that the introduction of street triage has seen average assessment times for 136 fall ‘from eight hours to five’. We see the same report imply that street triage has reduced the time spent dealing with the consequences of section 136 detentions and an example is given of a force where over 13,000 hours of time was spent in 2013 waiting for assessments. (This amount of time has more than doubled in two years, incidentally – so we can all agree that the force concerned will want to do something about the ever-increasing tacit consumption of their resources by the mental health system.)

So does it actually save time? – and is that actually the point of it?!

THE EVIDENCE FRAMEWORK

Let me firstly suggest that the evidence you would want to gather around you concerning street triage will be highly dependent upon what you see as the point of it all. If you’re wondering about the time it saves you will need to know certain data; if there are other objectives, you’ll need other data. To test the proposition that it saves time, you would look to gather proper evidence about time spent on s136 and time spent undertaking new ‘street triage’ approaches.

  • Usage of section 136 prior to street triage
  • Usage of section 136 after the introduction of triage
  • Data about the average time spent by officers waiting for assessments
  • Data about the average time spent by officer assisting with detention and conveyance for those patients who are subsequently admitted to hospital after assessment
  • Data about time spent talking people home who were not admitted to hospital after the use of section 136.
  • Data about the time taken to deal with those incidents that previously would have involved use of section 136 MHA but will now be handled differently because of street triage – these jobs don’t go away, they are just handled differently and that takes time, too!
  • A clear understanding prior to the introduction of ‘triage’ of your areas s136 usage – how much of it is appropriate / inappropriate (you may have to define this yourself!);
    – how much of it represents ‘failure demand’ that could and should have been prevented from reaching the police in the first place;
    – how much of it represents ‘value demand’ which was perfectly proper, necessary use of the power which can now be handled differently because of the ability to engage the NHS far earlier.
  • If you’re really doing it properly, you may need to have a control area – where 136 usage and health funding or infrastructure is similar; where demographic and epidemiological data is similar; and where police training and resourcing are similar.

Then – and only then! – can you start to work out what impact street triage has had. The factors mentioned so far are only those you would need to start evaluating the impact on the police – and I’ve cut short the list of things you’d probably examine! I could go on and on if we start to think about the impact on health and social care. I repeat the point: you have to be asking yourself evaluation or research questions which address the issue “What are you trying to achieve by this scheme.” What is your objective or objectives?

WORDS AND DEEDS

This is really important to any evaluation: we need to be clear about what we’re actually trying to achieve because otherwise, how do you know whether you’ve succeeded? I heard recently that street triage is about ‘reducing the use of s136 – the end’. That’s fine – so if that’s what you’re trying to achieve, why are street triage schemes busy trying to do other things? Are they just over-resourced for their main purpose and kindly helping out with other extraneous ‘stuff’ or were they actually always there for a broader purpose? This question is really important and in no way flippant – because it affects the research and evaluation questions you ask yourself in relation to which you then draw on or seek out particular quantitative and / or qualitative data.

One other area told me “We’re trying to reduce the use of police cells.” Great – who could object to that? But please tell me why street triage is being done in areas that weren’t really using the cells anyway? It really must be about other, broader issues, otherwise areas like Birmingham wouldn’t be doing it at all – there was cell no usage to reduce! Reduction in the use of the power AND a reduction in reliance upon police cells? – still doesn’t explain why triage services then do things that achieve neither purpose and it doesn’t allow you to pose a proper research hypothesis that can be tested by proper inquiry.

If the activity of street triage schemes is undertaken somewhere other than in public streets, then it’s clear we must be trying to achieve something else – as well or instead. So what is it we are trying to do? That needs to be part of your evidence base as you assess these things. I admit that I personally have long since stopped judging schemes by what they say they are trying to do – I look instead at what they are actually spending their time doing.

Points about mental health street triage from various areas:, they are not responding in their multi-agency vehicle to most of the incidents they are contacted about; they are ‘dealing’ with incidents (often from afar) that are two-thirds of the time being hosted in people’s private homes; triage is seeking to avoid s136 usage but that was only ever a possibility in one-third of the incidents they attend and it seems to be occurring in areas regardless of whether the cells are being relied upon as a place of safety or not and irrespective of how that police force is perceived to be using the legislation in the first place.

So it’s about some else or something far broader, otherwise they wouldn’t be wasting their time on extraneous ‘stuff’. I’ll let you decide for yourself what you think it’s about!

SAVING TIME

What I do know is this: a police officer works for 2,080 hours a year (without working any overtime). So we can look at the various schemes and work out how many hours and pounds are being expended in providing it. (Let’s just stick with the police service, for now.) We can then look at the reductions in the use of the power and the use of the cells and work out the time and / or money saved. Let’s say, that a force with 1,000 detentions per year reduced s136 use by 40%, therefore avoiding 400 instances of two officers sitting in a place of safety pending assessment by an AMHP and a Doctor.

If the average wait was four hours per detainee after the half hour that the Royal College of Psychiatry standards suggest the police should spend handing over, we can then do the maths —

400 (avoided detentions) x 2 (police officers per detention) x 4 (hours spent waiting per detainee) = 3,200hrs saved. If your street triage scheme requires four full time equivalent police constables to deliver this, then you are expending 8,320 hours to achieve this. If you’re new improved arrangements also mean that you reduce the average wait from 4hrs to 3hrs, you can recalibrate that answer to suggest that 2,400hrs were saved, but that you also saved time for those detentions that still occured.

600 remaining detentions) x2 (police officers per detention) x 1 (hour saved by reduced waiting times) = 1,200hrs saved. So you can celebrate a total of 3,600hrs saved overall before moving on to ‘do the maths’ for the health and social care investment, versus saving and pose that back against your new operating model.

You could also work out the custody time saved if police cells were still being used. Where a street triage scheme brought about end of custody being used as a place of safety after previously having seen 250 detentions per year in the cells, averaging 10hrs each, you can calculate the implications and therefore the cost. Half an hour of a sergeant’s time saved per detainee booking them in, 5 minutes of a custody sergeant’s time for every subsequent hour in custody; one consultation by a police doctor; 5 minutes for every hour in custody for a detainee to be attended to by the custody assistants and 10hrs of someone undertaking level three or level four observations in custody. Forces model this time and cost different – for our purposes, I’m simply making the point that you could calculate it.

REDUCING 136 AND CELL USAGE

So if we’re trying to reduce s136 usage: Great, we’ve reduced it by 40% – job done. But we can’t claim in our hypothetical model that it has actually saved time. It is actually costing you time: because in order to save 3,600hrs overall, you are posting four FTE constables to the position and expending 8,320 hours of effort. This is a net loss totalling 4,720hrs – in other words it is more than two full time officers for the area where the scheme works. Well done.

Police time is FAR from being the only important thing in these issues, however – but the point I’m making is that we are claiming we need to be evidence based and claiming we save officer time when we actually seem to be spending it! But what price human dignity, less restrictive assessment options, faster responses to incidents of mental health crisis care by the health service? ……. ALL of these things are not easily measured in terms of hours and pounds so perhaps the emphasis should be on these positive outcomes and greater human dignity which is worth paying for (up to a point, given that budgets are finite).

I was talking to professionals today at a Crisis Care Concordat meeting asked them ‘How many people in your area ask for urgent help whilst in crisis?’ (accepting that ‘crisis’ isn’t defined.) No-one knew – it’s fair to say no-one knows in any area! But if we don’t know how many attempts are made to seek crisis support, how can we tell how many of these incidents were managed correctly, at the first time of asking? How can we evaluate whether crisis demand for the police today, is failure demand from attempts to access support via the CrisisTeam earlier today or yesterday. How many people who’ve attempted to access Accident & Emergency today, had attempted to access their GP or Community Mental Health Team before self-presenting?

No-one knows. So we probably need to take crisis care back even further and ask even more fundamental questions about what we’re trying to achieve before we can put street triage in it’s proper context and determine that it’s an answer to something – but only after it is properly evaluated and we have evidence, not anecdote!

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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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Erasing History

Do you know what I mean by a ‘vanilla’ tweet? – the phrase refers to something fairly inoffensive on Twitter, quite bland information that doesn’t tell us a huge amount but whilst purports to inform. Something like, “Great meeting with partners about mental health – loads of work going on to keep you safe” or similar. Well, I’m bumping into a fair few of them on the subject of the Crisis Care Concordat and I have a couple of concerns arising from it -

  • Vanilla tweets – of themselves – don’t tell us much and they never, ever have.  I can see, however, that they may be infrequently necessary.
  • Vanilla tweets on the subject of the CCC imply little difficulty in resolving the thirty to fifty year evolution of problems in policing and mental health.

It’s almost as if history has been somewhat erased and it makes me wonder why we ever had any problems in this arena because just one or two meetings and we seem to be sorting it all out without much difficulty! This also strikes me as highly unlikely. Take it from me, it took five years of my life (that I’ll never get back) just to sort out section 136 Mental Health Act Place of Safety provision in one area. That’s before the subject of Liaison and Diversion (whatever that means); patients who are absent without leave; and the multitude of other problems that all areas face to one degree or another.

Principle amongst the ‘other things’ should the creation of a system that avoids the need for as much crisis care as possible, because help is available before people have ‘one foot off the bridge’, to quote the Mind report on crisis care.

CRISIS CARE CONCORDAT

You can look at the Crisis Care Concordat website for yourself if you want to read more about it or see the local progress mapped out for us all by the mental health charity, Mind.  They will be chivvying people along for progress updates towards the end of the year.

One problem with the Concordat always was that it simply puts into one handy document with a checklist and a schedule of work, all the issues that we know have been problematic for decades, imperatives for which already exist. This, as Winnie the Pooh said, is “a good thing” – if you want it summarised and neatly presented and for those professionals in policing and health who are relatively new to this, it’s a great tool to help you start benchmarking where you are and working out how to plug the gaps. However, if you’re familiar with the field, it’s all very last century in some respects. Some commentators asked upon publication, this stuff is already written down in range of documents – why do it again?

So the Concordat asks us to address crisis care and in some areas this will mean that everyone works out there is overuse of section 136 by the police and, even allowing for the overuse, under-provision of health based places of safety by the NHS. The Concordat would say you get these things into the Action Plan that is submitted with your Crisis Care Declaration in November 2014 and look to improve this position over time. So you’d probably train your officers better on the use of the power, consider a phone or street triage approach so you reduce usage and look at expanding provision. Sounds easy doesn’t it?! Here’s the problem —

We’ve known that these things needed doing for at least twenty years and there are already various statutory imperatives to do so – what does the Concordat give us that laws and statutory regulations didn’t?! If we can ignore statutory guidance on the Mental Health Act, what is it about the Concordat and its implications that we won’t ignore?

Well, the idea is that this will be driven a lead in a way that wasn’t previously there – this is “a good thing”. And there is no doubt that areas are now talking whereas previously, they weren’t – this is “a good thing”. Arising from discussions, some areas have filed their local Crisis Care Declaration, implying that they now have a jointly agreed action plan to allow progress in 2015 and beyond – “a good thing”. However, there are many more areas that don’t seem to be fairing quite as well.

IT’S GOOD TO TALK

I’m assuming that in some areas, these joint CCC meetings have led to some of the discussions that I had when you have culturally diverse organisations coming together to discuss issues. You get doctors and NHS managers who know comparatively little about the law, getting together with police officers who know little better to discuss issues that are bedevilled by the received wisdom and inherited thinking of generations of professionals who’ve gone before them. And they are having to do it with fairly dreadful data sets about ‘stuff’, in many cases.

In some ares, no-one fully knows how many section 136 detentions take place, where they go or what the outcomes are. There are myths and personal opinion abounding about what percentage of those detentions is ‘appropriate – despite the fact that no-one seems to be offering a definition of what is appropriate. No-one looks at how many section 136 detentions are ‘repeat’ detainees or how many were already known to the MH, perhaps indicating a breakdown in the care plan. No-one knows the percentage of people arrested for offences who are known to the MH trust and no-one seems to be trying to define what ‘diversion’ means in terms of when the police push ahead with a prosecution decision for an offence when they know the offender is mentally unwell, as opposed to when they don’t.

Legal training in all the professions is parlous: I learned again this week having a child in an ‘adult’ place of safety is a safeguarding risk. What do we think is not a safeguarding risk about having a child in a police cell, not too far away from a masturbating drunk who is singing sex songs or threatening sexual violence to the custody officer? I can only imagine that in just some CCC discussions about certain issues, the myths and folklore are raging hard, with professionals of all kinds arguing they can’t do things they actually could do, that they shouldn’t be doing things that they’d prefer the other agency to do.

LET’S TALK ABOUT VULNERABLE PEOPLE

And nothing in this blog post so far is about vulnerable people is it? … their rights to effective police responses, accessible crisis care and dignity and respect for their human rights whilst in contact with the state? Those people who experience the indignity of being detained in the cells under s136 because they had the temerity to have a few drinks (or more) – to stop the voices in their head, or at least make them quieter. None of this includes references to the difficulties that some patients have in Accident & Emergency despite very obviously being there appropriately to access some kind of care that is otherwise unavailable and inaccessible. We’re not even talking about the ongoing extent to which our mental health care system is being increasingly criminalised by reliance upon the police and the justice system just to make extra sure that some face the extra stigma of having cops staring at them whilst the NHS do their thing with all that we know the feels like for some.

The Crisis Care Concordat will be examined next month for progress and as things stand just four areas out of 43 police forces and 57 mental health trusts have submitted a local declaration with an action plan. I’ve already heard that some areas feel they will be unable to submit anything by the November deadline. I’ve also heard that some relevant senior people have only not read the CCC, they hadn’t heard about it, as of a month or so ago. Quite remarkable, really. So we need to continue to raise awareness of its imperatives and remember, that most of them arise from existing laws and NHS guidelines anyway.

It’s what we should have been already doing – for some thirty years, actually!

If one or two CCC meetings is all it has taken to get complete agreement about what we need to do, then I’m thrilled. I’m also quite unconvinced.

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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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Something’s Not Quite Right

You may remember that in July the IPCC launched an inquiry into the death of a man in Sussex following an incident in Hayward’s Heath.  The family of the man who died following restraint have suggested he was tasered and subject to the use of pepper spray as officers appeared to disregard information that he suffered from epilepsy and a seizure was mistaken for violent behaviour.  Initial reports suggest he may also have suffered a heart attack either during restraint or once in the police vehicle.  Another tragedy for all involved, regardless of what the IPCC findings may be and I can only imagine what his family have been through.

Of course epilepsy is not traditionally viewed in medicine as a mental illness, despite the fact that for the purposes of nineteenth-century laws on insanity, it could be viewed as such.  So could diabetes, for that matter.  However, this incident links to concerns I have written about before for various reasons:  we know that epilepsy is one of those medical conditions flagged up, along with diabetes, Addison’s disease and others, as examples of non-mental health conditions where presentation could be interpreted by many people as indicators of a mental health problem.  We also know that some people who suffer seizures because of epilepsy occasionally exhibit quite marked, sometimes violent behaviours and it’s crucial officers know enough to stand the maximum chance of recognising this where it happens.

I’ve written many times on this blog about different opinions, incidents and anecdotes which show the difficulty in deconstructing behaviour at incidents into those inherently artificial categories of disease, distress or dissent.  And of course, nothing prevents those three things overlapping just to make the decision a harder one – about how those issues should be prioritised.  The story circulated on Twitter and amidst the expressions of regret at the human tragedy, commentators started to second-guess what the IPCC will discover during their inquiry – I would advise against such attempts given that no-one yet knows the full facts and already there are disputes about what occured.

Let the IPCC do their job, first!

So what remains of this blog is nothing whatsoever to do with the specific case, about which I know nothing beyond that reported in the media.  I want to address two broader issues -

  • The issue of particular awareness or training for particular medical conditions.
  • The issue of deconstructing behaviour into clear decisions about whether to this ‘this’, ‘that’ or ‘the other’.

AWARENESS TRAINING

We hear requests for more police awareness training on mental health and following this incident and others like it there have been calls for more epilepsy awareness training.  A couple of comments also emerged in the discussion about autism training.  Here is a list of the various conditions I’ve heard mentioned during my career amidst suggestions that police officers should have raised awareness of that particular issues, above others.  Not all of them are mental health conditions but the others are conditions that officers may often mistake for indications of mental distress —

  • Schizophrenia
  • Bipolar
  • Alzheimer’s
  • Dementia
  • Depression
  • Post-natal depression
  • Autism
  • Apserger’s
  • Learning Disabilities
  • Personality Disorder
  • Anxiety Disorder
  • Acquired Brain Injury
  • Epilepsy
  • Diabetes
  • Stroke
  • …… plus awareness of how drugs and alcohol can confuse and conflate all of the above.

Quite a syllabus isn’t it?  When one asks the charities who represent those in our society who are affected by the above problems how much training would be required, you tend to get answers of between two and four hours.   There are fourteen conditions listed above – even at 2hrs per input that amounts to a week of training and at the end of such a course we would still need inputs about mental health and mental capacity law as well as the operational implications for the police of all of it.

You can’t do that in just one day! … so we’d already be looking at a course lasting a week and a half, if not two.

I have a more controversial question, however – to what extent do the above conditions make a difference to the way something should be policed?  If there is an answer to that then I see the relevance of training it – I’ve argued before that I see the point of specific autism awareness training for police officers because we know that where officers deal with incidents involving someone with autism there could be considerations that wouldn’t necessarily apply to other situations, if they can be accommodated.  I’m not sure if that could be said of all of the above conditions, however.  Would it matter to the policing of an emergency mental health incident whether someone who appeared to be in distress was psychotic because of schizophrenia or because of bipolar or because of Addison’s disease?  Probably not.

If police officers are going about things properly, they would be calling upon paramedics to support their decision-making about what needed to happen next where they have concerns about someone’s medical welfare.  But even this is a difficult balance to strike because police officers are not going to call an ambulance for everyone who is violent or resistant just to rule out encephalopathy or anything else.  But there is a point where no police officer with a first-aid certificate and any amount of enhanced mental health training is going to be the right person to be making certain clinical calls.

So where is that line?

DECONSTRUCTING BEHAVIOUR

The reality is that not every police officer in the United Kingdom is going to get a two-week mental health training course – and I would ask the question whether every one of them actually needed such a course.  I would argue a few need whatever we eventually decide is the most comprehensive training on offer and that most need a diluted version of that.

For many policing incidents, of course, an approach which starts with understanding particular conditions looks at things the wrong way ’round – officers are only occasionally asked to attend an incident where a family member is giving full information about medical or psychiatric history.  More frequently, we meet people and have to figure it all out for ourselves from scratch.  We often don’t know the person’s name when we first meet them and paramedics are rarely better off.  We simply don’t attend vast numbers of jobs where we know in advance which medical box someone fits into and even where we do things become more complicated when you introduce issues like drugs, alcohol and obviously, restraint.

And perhaps less obviously, some police incidents are going to be policed in exactly the same way irrespective of a mental health issue because it sometimes makes no difference to a police response whether someone is mentally unwell or not, at least to very initial handling of an incident.  All cases on their merits – everyone is an individual in those particular circumstances, whatever they may be.

I would argue that the police can be expected to make the obvious calls; but the more subtle things become the less reason there is to think the police are the right people to be deconstructing behaviour into clinical or non-clinical paradigms.  Clinical support is important and it isn’t always there, frankly.  That’s why I argue for greater involvement with our colleagues in the ambulance service and I suspect more integrated ways of working across those 999 agencies could bring enormous benefits, not just in the arena of mental health, but also domestic violence, night-time economy policing and so on.  It’s fair enough for police officers to see someone with a gaping, bleeding head injury and allow them to make the judgement about whether someone needs to go to A&E or not.  I say this because we would all hope an officer in that situation would agree that they should!  But it is far less reasonable when a knock to the head didn’t lead to any visible injury or any other sign of distress.  Does that mean everyone with a knock to the head goes to A&E? – no.  It means we need a combination of paramedics, healthcare support in custody and A&E as suite of options with good training on how far things should be escalated.

UNREALISTIC EXPECTATIONS

The same principle holds true with diabetes or epilepsy: if a person has collapsed to the floor and appears to have slipped into a coma, we would expect officers to spot that and react, irrespective of whether they knew it was caused by diabetes or whether they were quite unsure.  But where someone is disoriented but conscious, slightly incoherent and confused, would we immediately say “suspect diabetes” when a similar presentation could arise from other conditions?  Probably not, unless given information from someone at the scene.  Some years ago, just after West Midlands Police started routinely calling ambulances to all detentions made under s136 of the Mental Health Act, there was an incident that showed how precarious this all gets -

A gentleman outside a pub brought to police attention because of concerns by a member of the public about him being in the “confused, disoriented” category.  He didn’t appear to be drunk and enquiries confirmed he hadn’t been in the pub and officers formed the view he may be suffering a mental health problem.  They detained him under s136 and called an ambulance – he promptly collapsed in the back of it and was rushed to A&E has his blood sugar levels had fallen through the floor.  He was entirely undiagnosed – he had absolutely no knowledge at all that he had diabetes and after not eating properly that day he found himself in some medical difficulty.

Of course, it must be said that the police have got a bit of form in some high-profile incidents for not making use of information and people available to them who could better help them to understand certain situations.  This was true in the so-called ‘ZH’ autism case in London.  In certain other cases, family and professionals have claimed to have given the police information that should have been seen as relevant and it was ignored or disregarded.  If true, this is quite damming and officers must bear in mind how useful information and advice is from people who know those were are interacting with.

However, on the main issue here of officers’ recognition of medical issues cutting across mental health and other conditions I have to wonder whether the best we might be able to hope for, is not something which approaches diagnosis or specialist awareness of particular conditions, but an ability to have a general sense that ‘something’s not quite right here’ with a set of standard approaches to keep people safe and engaging with clinical professionals of whatever kind, as soon as possible?

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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
ccawards2013 – won a World of Mentalists #TWIMAward for the best in mental health blogs

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.