Earlier Intervention

There was a really interesting debate on Twitter last night between two mental health professionals who responded to one of those tweets I throw out to provoke debate and thought!

You can have as much Liaison and Diversion as you're prepared to pay for. And if none; you'll end up paying more for secure care. #stigma

— Michael Brown (@MentalHealthCop) March 3, 2012

In response to this, the following figures emerged:

• Community mental health care costs (on average) – £3,500pa
• Prison costs – £39,000pa
• Medium Secure mental health care costs – £190,000pa
• High secure mental health care costs – £300,000pa

A primary care trust once informed me that they are spending 55% of their total mental health budget on detaining 67 patients within medium and high secure hospitals, them having been convicted on an offence in circumstances where it was argued they posed “a serious risk of harm to the community”.  Most were detained under one of two types of mental health order:

• An order for compulsory treatment after conviction for an offence (s37 MHA);
• A direction to transfer a convicted person from prison to hospital because of mental ill health (s47 MHA);
• Each of these orders can be ‘restricted’ to prevent the person’s release until such time as the Ministry of Justice is safety that the person no longer poses a risk of serious harm to the public.

Forensic professionals last night observed that they often have to deal with people in the forensic mental health system – which is the medium / high secure hospital estate – purely because people have not been picked up or helped before their lives get to a point where they commit a serious offence.  Indeed they went further and argued that they often deal with people who have committed a serious offence in order to get the criminal justice system to enable access to the mental health system.  Access which has otherwise proved too difficult.

The PCT who are spending 55% of their budget of 67 people, serve a population in which c2,500 people need their services. This means 55% of the budget on 3% of the people.  The other 97% have 45% of resources to share between them and it is against this background that some forensic mental health professionals are arguing they are seeing people in circumstances where prevention may have been possible earlier.

Of course, this is not a new discovery: this has been part of the ‘Bradley’ debate since 2009 when Lord Bradley published his review of mental health problems or learning disabilities in the criminal justice system.  Lord Bradley himself was the latest in a line of notable people to lead such reviews after the Reed Review in the early 1990s and the Butler Review in the 1970s.  They are running at fifteen year intervals, currently.  Another one in the mid-20s perhaps?

Meanwhile, areas have given thought as to how they can approach liaison and diversion differently.  I recall hearing Craig HARRIS from NHS Manchester give a briefing at an event a few years ago where he explained that by investing £500,000 a year in proper liaison and diversion services, working with Greater Manchester Police and criminal justice agencies, they had reduced the number of people entering the criminal justice system who end up being sentenced to, or transferred into, secure care.  You only have to do this twice a year to save the need to spend £500,000.  Of course, it is not as simple as this, because you are still then providing other mental health services and there are various costs associated with criminal justice operations and so on. But it is fair to claim, as he did, that this approached significantly reduced costs.  Not only by by providers adding value earlier, or differently; but sometimes by providing healthcare at all.

So what form did this take?  I’ll do a longer post on this in due course, but it basically involved earlier and better liaison between police and mental health professionals at the point of arrest; the establishment and successful development of ‘mentally disorder offender panels’ who would meet to share information on those who were being investigated or who had been arrested, in order to determine whether prosecution was in the public interest and whether it was or not; what mental health or social care interventions may be needed.

This links to a point I’ve made before: if someone has been arrested, the practical variable which will determine whether they are diverted or not, is “whether they are sectionable under the Mental Health Act” on the day they are arrested.  If so, divert; if not, investigate / prosecute as normal based upon the evidence.

This has two problems for me:

• Premature CJ decision to take no action:
• If a person is ‘sectioned’, do they police immediately say, “no further action” (NFA) on the criminal offence or do they – as I strongly believe they should – release the person into mental health care under sectioning, whilst releasing them from arrest on bail, subject to a requirement to return to the police 30 days or so later.
• What if someone was released ‘NFA’ when sectioned and the s2 assessment concluded that they were not mentally disordered; or that their condition was in no way a barrier to a prosecution / caution / fixed penalty notice, etc.?

• Criminalisation of those who are not sectionable.
• The opposite scenario is one where a patient does not need to be detained in hospital because their mental health condition is not sufficiently acute, but where there is or has been an issue with access to healthcare (for whatever reason).
• What if enabling that access were to address substantive issues that led that person to offend?  To see this one through, why not complete the investigation in custody and again, bail the offender (possibly with conditions to meet MH services and / or engage in assessment of needs) for a brief period to allow fuller establishment of proper care arrangements?
• Decisions about prosecution could then be taken on the basis of engagement / outcome / public interest.

NONE OF THIS means that offenders should not be prosecuted, merely that greater care should be given to the decision and its impact.  Whether or not a discussion between an MHA assessment team and a custody officer can determine this properly at 2pm on a Sunday may be doubtful.  Of course if an offence were serious, if there were bail risks, inc. to the individual themselves or of harm or to the public – nothing prevents prosecution in such cases even if the person is ‘sectionable’.  That would happen then and there.  In such situations the police, via the CPS, can inform the court of the medical recommendations made by the DRs when assessed under the MHA and the courts have options under the mental health act to remand for assessment / treatment.  This then facilitates decision-making by the courts pre-trial and during trial.

This is not as complex as it can sound; it’s actually about getting back to what the legal frameworks actually are.  It’s about closer partnership working between health / social care and criminal justice agencies but as the pathway for this stuff is as many as eight organisations working together in flow; and this will require strong leadership at all levels.

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Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award

 

All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2012

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I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

Government legislation website – www.legislation.gov.uk