Earlier today a mental health professional engaged in research described many efforts to arrange and develop Liaison and Diversion services as “The Emperor’s New Clothes” because they too often rely upon models which do not operate when people find themselves arrested and which sometimes fail to ensure the public interest is met by engagement with the services to which people were ‘diverted’. All too often, the whole thing relies upon police officers to identify those potentially suffering from mental health problems and then has the potential to regress into an ineffective, half service which is more about the police than mental health.
Have I mentioned how I deplore the term ‘diversion’?!
Of course, we know that leaving identification to police assessments and / or to self-declaration is prone to problems – just like investigation of crime by nurses is prone to problems of competence. It’s not what they are trained or constituted for. I’ve always worked on the idea that around 12-15% of people arrested and brought into police custody are ‘thought’ to have a mental health problem. This would include: police suspicion based upon behaviour or information from police systems; self-declaration by individuals and / or information from third-parties at incidents.
This figure is mentioned in published research (JAMES, 2000; RIORDAN et al, 2000) as well as found by me when I did research for an MSc dissertation some years ago. However, we always thought that this would under-identify mental disorder, because some less obvious conditions; including non-psychotic conditions, some learning disabilities and / or autism. We know that sometimes such conditions are not identified by mental health professionals with time to examine people against a background of years of training. Not really surprising that the police miss things when some decision must, of necessity, be taken quickly without time to check, ask or refer.
I heard last year of a criminal justice mental health team in the south of England who used to get a daily fax from their local police listing names, dates of birth etc., of all people arrested by the police. They found that 50% of arrested people were currently known, previously known or should be known to and engaged with mental health services. So the police are potentially spotting less than a third of people coming through custody who should be considered for assessment, referral or diversion. One third.
So what does this mean for Liaison & Diversion Services, delivered to the vision of Lord BRADLEY?
Ideally, we’d hope to see mental health professionals deployed to screen everyone in police custody, with the benefit of access to health records systems like Epex. Of course, the police arrest people 24/7 all year round. In my force alone there are thirteen 24/7 custody offices and in my borough, we arrest about 750-800 a month. To have a professional available to see everyone, it’s quite possible you’d need psychiatric nurses or other appropriate mental health professionals working 24/7 covering two custody blocks. Regardless of which grade of nurse / professional used, it’s going to be expensive business and this is usually where the vision falls flat and thoughts turn to cheaper alternatives. This is where ‘The Emperor’s New Clothes’ comes in, because in reality diversion services often seek to turn 24/7 business into something that can be managed without face-to-face screening and on more of an ‘office hours’ basis and that’s where initial problems start to emerge.
How else would you do it?
- What about an L&D scheme operating 15hrs or 8hrs a day?
- What about attempting to use police bail to delay investigative decisions until a person has been ‘referred’ to an L&D type screening or triage service, operating office hours Monday to Friday?
- What about importing a screening tool developed by MH professionals, but administered by the custody sergeant or custody staff around MH?
- What about linking the development of police healthcare commissioning by the NHS to improved training for police custody nurses / doctors, to screen all patients for mental health and / or allow them access to medical records for secondary mental health care?
- Why can’t the police share information ‘fast-time’ with mental health services about people under arrest in the first couple of hours of their detention and then have an assessment response based upon that information sharing? For example: if the person is / has been known to MH services; OR is suspected by the police to be suffering mental ill-health, then a response is configured.
- Well, if you’re screening on a less-than-24/7 basis you risk missing something: clearly, the more hours covered, the less would be missed and you cannot hold someone in police custody just to screen them for mental ill-health when the professionals come back on duty in the morning.
- This is fine, as long as the person is not a ‘bail risk’ – is it a responsible CJ decision to bail someone, if they have a history of offending on bail, failing to surrender back to custody, etc., etc.. Some people cannot and should not be bailed before or after charge.
- Screening tools are being trialled and / or used around the UK for various reasons to identify various things – not just in the police station, but also in other parts of the CJ system, including prisons. Of course, some tools take 30mins per person to administer; some are better than others at identifying generic mental health concerns; others may be good for identifying certain problems, like learning disabilities. Of course, you couldn’t possibly have two screening tools to use as they aren’t enough hours in the day or in the ‘PACE clock’ (custody time limits).
- I think the NHS becoming responsible for commissioning healthcare in police custody has lots of opportunities, if it is done correctly, to improve the extent to which screening and mental health identification is then integrated into wider health provision. But we know there can be difficulties for experienced mental health professionals identifying the correct cohort, so generic medical / nursing staff may also reasonable be expected to miss some identifications.
- This fifth option does still leave a gap, but it risks missing people who are and never have been known to MH services and about whom there is no suspicion at all of mental ill-health. Maybe THAT is where you then apply a screening tool? Of course, best of luck persuading the NHS that it would be legal to share this information: which it would.
Whichever you may prefer, you still end up back at the heart of the dilemma for Liaison and Diversion: once you’ve identified someone with mental health problems – whether unmet need or not – what is the ‘right’ criminal justice decision and how do you ensure that diversion ‘worked’ before you surrender the possibility for prosecution of positive criminal justice action?
I know from my MSc research, that the practical determinant of whether someone is prosecuted for an offence whilst mentally ill is “whether they are sectionable under the Mental Health Act on the day they were arrested”. If you are sectionable, you will most likely be diverted; if you are not, then you probably won’t be. This discovery invites consideration of why people with enduring mental illness, who do not happen to be so acutely unwell upon arrest to require immediate admission, are not also considered for the potential to be ‘diverted’. It also invites consideration of why we are not seeing more serious offences prosecuted of those who are mentally ill. Insanity is a defence to be raised in court and “every man is presumed to be sane and responsible” according to law.
This comes back to the false dichotomy of the ‘mad / bad’ debate: we seem to have ingrained an approach which says you are either criminally responsible OR you are mentally ill. In fact, you could be both. Or neither and we more urgently need a criminal justice decision-making model which reflects this.
Finally, failure to get this right in police custody is not without cost. I’ve mentioned elsewhere that the costs of high-secure and medium-secure care for convicted offenders is considerable <<< understatement. A primary care trust once told me that they spend around 55% of their budget on 3% of the patients – those detained in secure care. However, a separate mental health trust once explained that an investment in proper Liaison and Diversion had paid for itself within two years, because of earlier identification of unmet mental health needs which subsequently reduced the number of people requiring secure care after prosecution for offences.
In other words, as I’ve said before, when you consider all of the costs, including the costs of failure demand and the obvious service-delivery costs across the health / justice systems: it’s cheaper to do it properly.