Signals From Noise

It has often been said when discussing problems within the Criminal Justice System that in reality, it is not a ‘system’ at all.  It is a collection of separate organisations – police, Crown Prosecutors, Courts, Prisons, Probation – who are ‘managed’ by different parts of Government (Home Office and Ministry of Justice) and who have very necessary links to other apparatus of society including education and health.  It is not a single, controllable ‘system’.

These agencies have for a while been operating to different targets, standards and goals and are not and never have been a coordinated whole.  The farce of targets and functionalisation, costing money and lives.

Much the same could be said for the ‘mental health’ system.  Care is provided by different parts of the NHS – primary care (GPs) and secondary care (MH trusts) as well as specialist services, NHS Direct, A&E and so on.  Again, this is not necessarily as coordinated as PCT three-year strategic mental health plans may imply.

Consider the links that mental health must have to other apparatus of society:  this care continuum must be provided in contact with local authorities and a criminal justice system whose very raison d’être could be said to be diametrically opposed to that of mental health services (individual care / public safety).  Remember: you can only enter certain parts of the mental health system, via the criminal justice system: thus creating another larger ‘system’.  All clear so far?!

Information sharing is a problem when looking at the de facto system which has evolved.  The police gather so much information about mental health (from arrests, s136, AWOLs, etc..) which NHS services could use to look at ‘their’ system and some of it could be key to proper long-term thinking.

If shutting down mental health beds to save £100,000 on inpatient care means that over the next five years two patients will end up prosecuted for serious offences and placed in secure services at £250,000 a pop, then you’ve saved nothing at all, but you have created victims and criminalised patients along the way.  Brilliant.  Manchester NHS looked at this the other way around a few years back and chose to invest £500,000 on a comprehensive approach to ‘diversion’, thereby reducing the number of people entering secure care.  They’ve made the money back already and more besides, in avoided secure care costs.

I posted three questions on Twitter this morning, to provoke thought:

  • How many people in your area who are arrested under s136 are current or previous mental health patients?
  • How many AWOL patients in your area are repeat reports?
  • How many people arrested in your area are current or previous mental health patients?

In some areas the answer to all three of these questions is fifty percent. These figures in your area, may not be exactly the same, but you need to understand what they are because understanding these numbers will be a signal (from noise) about what may be right or wrong with your system.

Now some of this information sits with the police and sometimes with mental health services: some can only be established by sharing information into a joint pool.  The police need to tell mental health who got arrested, in order to allow them to establish if they are current or previous patients and therefore provide necessary follow-up to those who were not flagged in police custody as having a potential mental health problem.  Let’s remember, that the police usually spot 10-15% but sharing this information can identify up to 50%.  What does the figure for your area tell you, if anything, about mental health care or policing?  Maybe nothing, but probably loads.

Why not do it?!  It would not be prohibited by the Data Protection Act 1998.

What about s136 MHA (EW) / s297 MHA(S) / a130 MHO(NI)?  In some areas, as many as fifty percent of people detained under emergency police provision are current or previous patients.  In some cases, by studying the nature and variety of this demand and by treating it as a signal, you learn something about up-stream provision which may have prevented the s136 becoming necessary.  How many of your detentions are repeats?

  • One sample in one area of my force showed that just 1 person accounted for 3% of detentions; and had been arrested in other mental health trust areas of the force.
  • Proper evaluation of this demand made it clear: she was usually arrested s136 whilst committing victimless, quite low-level offences but it always emerged that she did not have a mental health problem of a nature or degree that warranted admission to hospital.
  • We found out later that MH professionals were busy asking, “Why don’t the police realise she’s not mentally ill and just prosecute her?!!!” but it emerged she’d never been arrested by the same officers twice.
  • So a strategy was formulated – via the ‘system'(!) – that she would be arrested and prosecuted like anyone else.
  • Result: reduction in s136-type demand, prosecution for offences, remand to prison (because of her previous history of absconding and offences on bail), conviction for the offence and a short-term period of imprisonment.
  • Upon release from prison, there have been no more similar offences 12 months after release and no more s136-type detentions.
  • Easy isn’t it?! … and not just about upstream interventions by mental health; this is an example where different police action is key.

By not identifying these signals an officer may end up arresting someone for a serious offence, rather than under mental health law and then it is quite possible that just some of those patients will end up in the criminal justice system and subsequently back in the mental health system via Part 3 of the MHA(EW) or Part 8 MHA(S).  By the time you then find health authorities paying £250,000+ a year for secure care instead of a fraction of this for effective community or occasional inpatient care, you realise the error of failing to examine signals from noise.

We properly understand the nature of the demands we face because we don’t study them.

5 thoughts on “Signals From Noise

  1. You do realise you have identified one of the most annoying problems the public do get to see ….That of a ‘criminal’ who somehow manages to hide under the wings of ‘menatl health’ when in reality ‘menatal health’ was just used as an excuse! I am not saying there are no genuine ‘mental health’ problematic persons BUT some ‘criminals’ have found yet another shelter to get away with basically Anti social type crimes. I have read many of your blogs and tweets and you have scared me with your compassion for ‘mental health’ issues where maybe that wasn’t the case, but someone just using the system to get away with whatever they want to ! I know it might be a fine line betweeen criminal and ‘mental’ but sometimes there is too much compassion not always in the right place ! What you have done via twittter and your blogs is to be applauded and i hope many take notice and many are helped BUT , are they all really ‘mental’ or just using the system! (p.s I know of a real case of someone who is doing exactly this claiming to be ‘mental’ when it suits to get away with all sorts)

    1. Of course there are some people who ‘play the mental health card’ and some are very good at it. Equally there are others who offend because of terrible situations in which they have found themselves. I do think you’ve fallen slightly into the ‘mad or bad’ (false) dichotomy. It is perfectly possible to have a mental illness and be criminally responsible for one’s actions.

      If you look at my blogs on prosecution, on s136 and on inpatient offences against MH staff, you’ll see that I do argue for greater consideration of prosecution and greater use of arrest (for crime) and full investigation, to ensure that conclusions reached are balanced and fair. Balanced and fair, in my own (strictly personal) view, would involve more arrests for offencs, fuller investigation, greater use of Part 3 of the MHA (patients concerned in criminal proceedings, because I believe we are currently ‘stacking the risk deck’ in our practice.

      More research required.

  2. What a conundrum eh! Risk seeing person as a manipulative criminal or is it a genuine case of a seriously ill person.? For every manipulative type, am sure there are quite a few “ordinary people who become ill and really dont want to be sent to part of services they have heard so much about…..and are frightened of maybe!
    These “ordinary” people could be someone you work with, sit next to in cinema or go to college with …..perfectly ordinary until illness strikes…often just like physical illness!
    Should mentally ill people have to run the “are you just a lying criminal”gauntlet or should Gov and DH be leading the way and showing an understanding of what serious illness can be like and train staff appropriately to deal with it.
    MHC made a great point re investigation and investigations carried out using Root Cause Analysis would find the reason why some mentally ill do what they do. But it seems if you identify a problem you have to fix it and its cheaper to just put that on shoulders of all the fragmented systems described in blog. IMO If someone has a manipulative character, they will use it to full advantage wherever they are, especially if easy to get away with it!
    Make mental health services a more professional service…lets stop accepting Cinderella and challenge system to do something real about it!

  3. You mention a case where an offender “did not have a mental health problem of a nature or degree that warranted admission to hospital”. Is hospital admission the only definitive way to ‘prove’ a mental health problem in these circumstances?
    I ask because I have a criminal record from a time in my life when suffering depression and under considerable stress – emotionally abusive and sometimes physically abusive boyfriend, homelessness, unemployment, all causing emotional instability which made things worse, as I desperately tried to keep going (I kept getting jobs and then getting fired when I tried to stop the tears streaming down my face at work).

    Meanwhile, appalling treatment from mental health professionals – such as being told in A&E (on a 136) that I was a waste of time, and generally a complete lack of any kind of service provision, meant my problems worsened. Still, I was told I would “never be admitted to hospital” and that they didn’t provide treatment for “people like [me]”. It was awful; I’d originally gone to the GP asking for counselling sessions and been very surprised and horrified at the complete lack of services and hostile way I was treated.
    Anyway, point is – I was clearly ‘not well’ to some degree or another – yet the failure of the mental health service to correctrly diagnose/treat/support meant I was not spared when it came to being charged. Ironically, the alleged offence(s) were basically when I had finally flipped at indifferent mental health staff after months of desperately trying to get help (non-violent).
    I was actually recommended to get mental health treatment by the court – unfortunately this obviously didn’t happen. Apparently they still didn’t class me as mentally unwell. (note: I pleaded guilty on bad legal advice, the judge was actually very kind even in the way she spoke to me).

    The result? – Several years later, due to my record, my hard-earned place to do nurse training was withdrawn; which I had felt was a calling from a young age – even now, people often comment that I should become a nurse. It’s heartbreaking.
    And secondly, for the past 18 months I’ve suffered severe depression and PTSD-like symptoms, having nightmares and flashbacks of that awful time, dissociating from reality at points.
    Due to this, I have been unemployed for some time.
    Apparently this time around I AM entitled to help (living in a different area) and the original PD diagnosis (sure you guessed!) has been realised to be inaccurate and it’s accepted that I was just showing extreme stress-type reactions to situations at the time!

    I truly resent the officers and MH professionals I encountered during that time, the appalling decisions they made and frankly cruel treatment at times that have devastated my life and hound me to this day.

    But I will never forget the few kind ones who brought magazines and blankets to the cell one time.

    I hope there’s hope… remember even those with emotionally unstable-type PD’s are in great inner pain and turmoil; many have been abused all thier lives.

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