Sunset

Learning From History

Here are two ways of saying exactly the same thing —

  • “Most people who are violent need a policeman, not a doctor!”
  • “Some people who are violent need a doctor, not a policeman!”

I raise this because the first quote comes from a medical handbook I once picked up in a book shop – probably one of those Oxford University Press handbooks with very thin paper pages that you see junior doctors carrying around the place and stuffed into the lower pockets of white clinical jackets.  It was part of a section on responding to violent or disturbed patients in A&E and I’ve left uncorrected the author’s gendered stereotyping of my profession!

IN TWO MINDS

I’ve now told the story A LOT of the poor guy who was extremely resistant (and probably quite frightened) having been detained under the Mental Health Act by some police officers who were then told to remove him from A&E because his violent attempts to self-harm.  Ongoing restraint by the police had been the only way to stop him hitting his head (which was already cut) and they were all too aware of the dangers of prolonged restraint.  In terms of the effect on other people in A&E, there was certainly audible disruption but little else because the officers were ensuring that his behaviour did not physically compromise the safety of others.  Nevertheless, A&E staff asked the officers to leave without any clinical examination occurring as to what could have been causing or underlying his presentation.

Three days later, the same police response team took a drug dealer into the same A&E after he’d been hit about the head with a metal bar during a dispute about money that ended badly for him.  He took a serious knock to the head and had to be manhandled (under the Mental Capacity Act) to A&E because paramedics were very fearful of what may have occured internally.  His violent resistance was significantly greater than the first man’s and although still largely contained by the police, it was impacting beyond the audible and he had managed to kick an A&E nurse whilst thrashing out.  No request for him to leave – each could have been suffering from a life threatening condition and / or could have suffered from the impact of restraint.  The NHS have guidelines on these issues – showing that it is something that needs more than a visual inspection of how resistant someone is.

That’s why I juxtapose my own, second bullet point and ask this: where there is doubt about whether a person who is violent needs a “doctor or a policeman [sic]“, is it the job of the officer to determine which category someone is in, or that of the doctor?  In easy in the straight-forward cases: it will be the officer – we often make judgements that someone is just angry and there are few medical risks from restraint beyond handcuffed marks to the wrists.  But where restraint feels qualitiatively different – mainly where the need for it is ongoing – it starts to suggest that other things could be in play and that’s where the NHS needs to kick in with paramedics and from time to time, an A&E doctor.

AN EMERGING NARRATIVE

This post is not going to be much longer, because I’ve said all this before but in the last twelve months we see an emerging narrative that is pushing more and more for police stations to used to contain violent detainees with considerable ambiguity about how that decision has been reached.  We saw in 2013 a joint inspection report from Her Majesty’s Inspectorate of Constabulary, the Care Quality Commission and the Health Inspectorate for Wales, A Criminal Use of Police Cells which stated (p 18) “A police station should only be used where it is absolutely necessary to provide containment for someone whose violent behaviour would pose an unmanageably high risk to others.” (My bold emphasis.)  Last week we saw the CQC Report A Safer Place To Be which states (p29) “Police stations should only be used in exceptional cases of seriously disturbed and aggressive behaviour.”

Of course, we can argue about what “violent behaviour” actually means and what “seriously disturbed and aggressive behaviour” is – the fact is that none of these phrases is used in the Mental Health Act itself, or the Code of Practice – and on what basis are we going to identify these (fairly obvious) presentations but distinguish them in accordance with the two bullet points at the top of this piece?  My point is, that neither HMIC, the CQC or anyone else tries to do so – not at all.  As such, we don’t have a public discourse about these difficult issues and the reason why they are difficult, is because we know that such presentations have been the stuff of death in custody inquiries for decades.  There are currently several UK police officers being criminally investigated by the Independent Police Complaints Commission for alleged manslaughter and wilful neglect arising from incidents where it turns out that they basically did what our UK inspectorates think they should be doing.

At last week’s Summit in London, the Home Secretary spoke on these issues and the need to improve.  Not just the need for the police to improve – Lord ADEBOWALE is out front of us all pointing out that the police cannot do this alone.  We also need the NHS to improve, which is why we are now seeing various events to develop actions plans for the Crisis Care Concordat; and we also need our inspectorates to improve.  We cannot, surely, continue to push out very generalised statements like this without qualifying what we mean, by introducing extra-legal considerations to our legal framework and in effect suggesting that we keep doing what we’ve always been doing.  Various indicators suggest that mental health demands for the police are rising – suicide is rising, use of s136 MHA is rising (by 35% in the Metropolitan Police area in just the last year).  As such, the very small percentage of incidents that are as unpredictable and tragic as those we’ve seen in history are more likely to feature in our demand.

And we’re running out of excuses – if we haven’t already – for why we keep bring simplistic (policing) solutions to complex (medical) problems.

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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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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.

Sunset

Ten Minute Rule Motion

A few weeks ago – and all of a sudden – a Member of Parliament laid down a ten minute rule motion in the House of Commons, aiming to amend section 136 of the Mental Health Act 1983. After accompanying Metropolitan police officers on a patrol one evening, Sir Paul BERESFORD MP witnessed the handling of a mental health crisis in private premises. A young woman was found stood on the window sill of the 14th floor of tower block in Wandsworth and an officer managed to talk her down from it. Whilst still in the premises and beyond the reach of section 136 of the Mental Health Act, the young woman refused all offers to voluntarily access assessment, presumably by going to A&E.

Concerns for the young woman’s welfare were so serious that the officers called upon local mental health services and to be fair, were joined at the address by a mental health professional.  Whether this was a mental health nurse, an Approved Mental Health Professional or any other kind, is not clear, but we do know that they believed the young woman needed to be detained for a full mental health assessment as she again refused offers of help. Although the precise legal mechanisms by which Sir Paul witnessed the woman being removed from the premises remain vague, he reported that he was stunned to learn a similar incident in a public place would have led to immediate police action to safeguard the woman, but that in private premises it was beyond the legal authority of the police.

There is a now a page on the Parliament website to track the progress of the Mental Health Act (Amendment) Bill 2014, if you wish to obtain email updates about progress.

LEGAL FRAMEWORK IN PRIVATE PREMISES

  1. You can arrest people for any offences they are committing or attempting – she wasn’t.
  2. You can arrest to prevent or apprehend a breach of the peace – there wasn’t one.
  3. You can defend your intervention under the Mental Capacity Act, if it is in relation to a deprivation of liberty for life-threatening situation – once she was down from the ledge, it was no longer that serious.

If any one else is familiar with another legal method of allowing unilateral police intervention, I’d love to learn it!

So this rehashes a very well-worn debate – we’ve been here so very many times before. We’ve seen the Metropolitan Police sued successfully for handling a very similar incident and attempting to defend actions with reference to the Mental Capacity Act – the case of Sessay v SLAM and the Metropolitan Police Commissioner. We’ve seen South Wales Police sued for using breach of the peace in the premises and then changing over to the Mental Health Act 1983 once outside – the challenge of Seal v Chief Constable of South Wales failed on a legal technicality about section 139 MHA but Lady Justice HALE remarked in passing that what the officers did was probably unlawful.

We know from other, real examples that where criminal offences are committed amidst a mental health crisis, police officers will resort to those powers of arrest if they have no other choice, somewhat criminalising people in the process. The case of Webley v St George’s and the Metropolitan Police Commissioner all began after a very obvious crisis incident in private – because the very unwell and probably very frightened Mr WEBLEY threatened officers with violence before attempting to jump from a first floor window, he was arrested for the threats to keep him safe. I wonder whether one day a barrister will challenge arrests for offences which are in all reality, proxy powers of detention under the Mental Health Act.  I also wonder what they would have done if a Mental Health Act power were available to them?

We should ask ourselves why this issue keeps coming up? – the Government is conducting a full review of the legislation in sections 135 and 136 of the Act. Why are they doing this? – because we keep seeing examples of officers who feel somehow forced into a decision to act, whether or not they realise they are acting unlawfully and not to act is to leave someone at obvious risk. Why would you risk the consequences of this when so many stated cases have said it is unlawful? – well the view is sometimes put that it’s preferable to risking the consequences of not acting. Either way, it’s about selecting the least worst option from a range of utterly rubbish, frustrating options that you could be justifying to inquiries and / or courts for years.

The most ridiculous thing about such an outrageous point, is that it absolutely is NOT restricted to police decision-making! It is a human instinct to want to safeguard people at risk and public sector employees are often in the jobs they are because they want to keep people safe, help them and protect them from harm.

MENTAL HEALTH PROFESSIONALS

So with the police looking as if they can’t stop themselves acting illegally, what should they do to get it right?! Well, in the Sessay judgment, it was remarked that the Mental Health Act 1983 affords a full suite of options to intervene, including urgently. The judge reminded us all that the police can call upon mental health services in order to ask for an Approved Mental Health Professional (AMHP) and a section 12 Doctor to attend the location and conduct an urgent assessment under s4 of the MHA.

I will admit, upon reading the judgment, I laughed at it – out loud. The idea that an AMHP would respond to a police request without first wanting a mental health nurse to screen the need for it, was fairly hilarious. Even if they would respond, by the time they’ve found a section 12 doctor and possibly having travelled via a Magistrates Court for any warrant they may require under s135(1) MHA, I’m not anticipating any support for at least four hours. There are simply insufficient AMHPs to ensure a 999-style response to calls for urgent assessments. Many would argue that this is not what AMHPs are for. Certainly most local authorities or mental health trusts don’t staff their AMHP rotas to deliver this kind of service and since section 114 of the Mental Health Act 1983 was amended to remove the need for local authorities to ensure sufficient AMHPs to meet expected demand, there is no statutory basis for police forces or anyone else to argue that AMHPs should be available in this way.

In a seventeen year career, fourteen of which has been operational frontline policing (and three on mental health!) I have been in the position witnessed by Sir Paul BERESFORD on dozens of occasions. I had hoped that since the Sessay judgment that things would change – given the legal imperative that this case nearly represents, remembering that it is not an Appeal Court ruling and bearing in mind how many protests AMHPs and Place of Safety nurses have made over the years about these kinds of actions.  I couldn’t have been more surprised – instead, I found that CPNs and AMHPs are actually inclined thesmelves to suggest the very thing that we are told the police should be trying to avoid.

“Can’t you just get him outside and 136 him?!” Incidentally, if this is not phrased correctly, it could be construed as inciting the criminal false imprisonment of the person concerned! That aside, I’ve also seen written advice about this kind of predicament that advises misuse of the Mental Capacity Act. It turns out, that when you place mental health professionals in this position, you sometimes end up with similar instincts – to keep people safe, first and foremost.

So Sir Paul’s incident is not just about the police and we shouldn’t forget that it appeared to end with two police officers and one mental health professional as well as two paramedics (and an MP!) removing a person from their dwelling whilst they were objecting. Not one of these professionals or all of them taken together has authority to do this and so the action taken appears on the face of it to be unlawful!  The lawful route to MHA assessment is for an AMHP and a s12 Doctor to do a s4 Mental Health Assessment at the house, or get a s135(1) warrant to remove the young lady to a place of safety.  The only lawful thing the Metropolitan Police could have done in these kinds of jobs is to inform mental health services and walk away.

I wonder what families, Coroners and the IPCC would think if that was the action the officers had taken and then there was an untoward outcome? Do we imagine that the sound of police officers arguing technicalities as to why they could do little more would lead to everyone nodding and saying, “Fair enough”?  No, neither do I.

SO WHAT DO I REALLY THINK?

I think this ten minute rule bill will fail. At the second reading on 07th November, it will be pointed out that the Government is undertaking a full, formal review of sections 135 and 136 of the Act and that this review will fully report in 2015.  The Home Office is convening a particular discussion in early November about this very situation to determine what recommendations should be made to ministers.

I think that changing the law by extending police powers is a very poor, third-best option of how to solve what I must insist is a real problem. Option One: you have to wonder whether or not mental health professionals could be made sufficiently accessible and flexible to be able to respond?  In my experience some mental health professionals agree that an increased focus on ‘emergency psychiatry’ is required given the model of care we operate and maybe this is something that Crisis Care Concordats could address? Option Two: could legislation or statutory guidance towards mental health services be amended to ensure a response in support of the police or instead of them? Well, even before s114 was amended, removing a statutory need for sufficient AMHP provision, there were never sufficient AMHPs in all areas to know that one of them could drop everything else and come running. Even in some areas where they could, they may have problems with s12 doctors and / or s135(1) warrants. It’s only after using history to evidence why Options One and Two won’t or don’t happen, that you reach the point where the police could do things differently – Option Three. If they ever will, it will require a change of law that no-one really welcomes as the ideal solution.

Of course, there are many objections to changing the law and I do understand them – it would erode our civil liberties, some argue it may impede upon our fundamental human rights —

Be let’s be clear about one thing: the United Kingdom in the twenty-first century currently cannot ensure the basic safety of vulnerable people because it’s mental health services are either under-resourced and / or inefficiently deployed – or because its police service is under-empowered, depending on your point of view.  To avoid doubt: if that young woman did not want to leave her address and wasn’t allowed to exercise her own decision to remain, then her removal was illegal - because no mental health professional can unilaterally make the decision to authorise it any more than a police officer can.

So it turns out that our civil liberties and human rights are at risk anyway!  I truly hope someone can come up with a realistic and workable way to convince us all that options One or Two can translate into the real world.  It’s only because no-one has convinced me so far that I’ve resorted to Option Three in my head but I do remain willing to be convinced.  Someone just has to say something convincing!

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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.