Map

Concordat Colours

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

This is what the colours mean -

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

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

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

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

More —

_________________________________________________________________________

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.

IMG_0015.JPG

Pavlov’s Dog

In the last few months, I’ve found myself in various rooms with professionals of all kinds, including police officers, finding myself saying the same thing over and over again that I was saying in 2004 when I first started working on this. Last week, I actually found that I was quite deeply boring myself witless when I realised that my mouth was on ‘transmit’ for some standard argument to reject a common misconception, whilst my brain was not fully engaged. I found cerebal space to remember that I have to get my car MOT’d in the next month or so and somewhere in my head I could hear my voice as if it were coming from elsewhere and my brain found space to say, “Oh, for God’s sake – do we gave to discuss this AGAIN?!”

Of course we do have to discuss it again – because we’ve still got so much progress to make and given how far we’ve come in the ten years I’ve been working on this, I’m already wondering whether this will get sorted before I retire in 2029.

For example, let’s think about the Crisis Care Concordat. The process means that local areas should meet to decide whether the signatory organisations agree in principle to work together. They don’t actually have to do anything – just agree to do so. Yet it’s still taken nine months or more! Why!!

PAVLOV’S DOG

If you were to tell me that A&E is “not a place of safety” then there’s a standard response to that. Tell me that extremely resistant or aggressive detainees have to go to police custody if they are detained unders 136 of the Mental Health Act and I have a few standard responses – some take longer than others! Tell me that you can only obtain a s135(1) warrant if we already know that access cannot be secured? – again, a standard response will emerge.

Ten years of banging on and On and ON; again and Again and AGAIN.

It’s amazing how pervasive certain myths are – and I’m casting my aspersions widely here, including within my own profession. I still keep hearing A&E colleagues talking about whether they are a ‘designated place of safety’, the implication being that unless somewhere is, the police cannot remove a person to that location under s136 of the Act. As soon as someone can tell me the legal reference for that concept, I’ll be right in the conversation! In reality it’s not even a ‘thing’ – the word ‘designated’ is in the Code of Practice to the Mental Health Act only twice and neither time, in relation to places of safety or section 136.

I keep finding that police officers, A&E staff as well as mental health nurses and, I’m afraid, even AMHPs keep tripping over themselves in conflation and / or confusion —

A police officer recently told me that if you find yourself in a private premises with someone who is in immediate need of care of control you can detain them to prevent a breach of the peace, as a proxy for the Mental Health Act, irrespective of whether you would want to place that person in court. Err, no … you can’t! The case of Hicks v Commissioner [2014] showed us this – you must have an intention in your mind when arresting to prevent a breach of the peace, to place that person before a Magistrate as soon as one becomes available.

So I’m worried that as areas are piling in to the issues they are going to tackle as part of their work on the Crisis Care Concordat, there will be more challenges than we could do with having to handle – yet handle them we must. We know that the Concordat did not arrive with a pile of money attached and that better partnership working must be achieved within existing financial envelopes, but we also find that we don’t fully understand the interface of our organisations, legally speaking. I’m still waiting for a convincing, detailed answer to the question, “When are liaising, when are we diverting; who is making this decision and how?”

FAILING TO LEARN LESSONS

Street Triage initiatives are exposing mental health nurses to some operational of the operational dilemmas that every frontline police officer knows all too well – and their reactions are proving to be the same as the ones the police have already been told off for! We know from the case of Sessay v SLAM and the Metropolitan Police Commissioner [2010] that you can’t use the Mental Capacity Act 2005 as a proxy for the Mental Health Act either. And yet that’s exactly what a street triage nurse was arguing to police colleagues earlier this month.

I’ve known Crisis Teams to ask, “Can’t you just get him outside and 136 him?!” Not without breaking laws, I can’t – so no. But a query I had from Professional Standards Departments indicates that some officers still think they can arrest someone to prevent a breach of the peace and then, once outside the premises, de-arrest and re-arrest under the Mental Health Act. It’s more than a decade since South Wales Police did that and were sued for it. Although something of a technicality meant that challenge wasn’t successful, the judge still made it abundantly clear they acted unlawfully.

If the Crisis Care Concordat means that we are going to get agencies together and do things properly for the first time since the evolution into a highly deinstitutionalised model of mental health care, it doesn’t just mean agreeing to work in partnership and help each other, but it means understanding the legal framework within which that has to sit. We’ve seen examples of services predicated upon disregard or ignorance of legal frameworks and oddly enough, they tend to be the backdrop to various kinds of disaster and difficulty.

Writing this particular post was a fairly boring half hour of my life that I’ll never get back, ameliorated only by also watching a very funny comedian whilst alluding again to those things I’ve said many times in BLOGS over the last three years. This post also marks the three year anniversary of my BLOG and I’ve now spent way over ten years working on this business, so you’ll have to bear with me as everyone is finally getting excited about policing and mental health because most of the problems we have could be sorted in a year or so – if there had been sufficient will. Ten years in and I sometimes wonder whether there is – and that’s why I wonder what things will look like when I retire in fifteen years’ time.

I hope the Crisis Care Concordat means we’ve reached some kind of critical mass but whether we have or not, we’re not going to get far unless everyone at this interface has appropriate legal education – from commissioners to senior managers on all sides, right down to frontline staff. Different amounts and kinds of education, varied by role. Maybe that’s a specific thing that all areas should have in their action plan?! Applied legal education in mental health and related criminal law, as well as health and safety and human rights law. I’m sure I heard that somewhere once!

_______________________________________________________

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

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.

____________________________________________________________________________

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.