One Hundred and Thirty Five Percent

The NHS publish figures each year about the use of the Mental Health Act 1983.  Apart from sounding the standard warnings about official statistics, they are worthy of further analysis as they suggest a rise in the use of s136 Mental Health Act of around 135% over the last six years.  This blog post arises from a query and a blog post by social work lecturer Dr Martin Webber from the Institute of Psychiatry.  (For those on Twitter, Martin is well worth a follow for a range of social work / mental health tweets from an academic point of view and someone with practice experience.)

The NHS reports that in 2006/7 there were 6004 detentions and that in 2010/11 there were 14,111.

So let’s start here >>> I know that these figures are ridiculously way off.  I have personally counted s136 detentions in my own force for every calendar and financial year since 2004.  These numbers for West Midlands Police were publicly released several times because of Freedom of Information requests – that was originally the reason I had to go and count them.  West Midlands Police have historically detained between 950 and 1050 people per year for the whole period since 2004.  It cannot be the case that one force alone accounts for 15% of national use.  When you remember that Greater Manchester Police use the power to broadly the same extent (similar sized forces and populations) and that the Metropolitan Police detain around one-quarter of all s136, you start to release these numbers are way out.  So there’s the first problem with offical data.

We know that the Independent Police Complaints Commission did research published in 2008, using data gathered during 2005/06.  They found that of 18,500 detentions that they could establish, around 11,500 were detentions in police cells.

You should read Martin’s post for yourself not least because he links to proper research which is highly welcome given the anecdote I’m putting out on this policeman’s blog:  he examines possible reasons behind a believed rise in the reported use of s136 Mental Health Act.  I think there is every reason to believe that we are counting the numbers more accurately and that there has been a rise.  I recently heard a senior officer explaining that there are around 25,000 detentions per year!  We clearly need to know more about this, but s136 MHA is one of the few parts of the MHA that does not, by law need to be recorded.  It is also true that the Care Quality Commission, whilst commenting on s136, do not drive the accuracy of the data requirement.  I suspect strongly, that the numbers gathered within the NHS report reflect health data, or predominately health data.  I know from work done whilst working for ACPO on MH that when one properly understands the s136 demands that are being generated for police custody alone, it is the majority of the demand in most areas.

Martin’s perfectly sensible explanations, in summary, include:

  • Increased mental health awareness and training of police officers – better identification of MH problems leading to greater use of the power.
  • Better recording systems – in the NHS and in the police and jointly.
  • Corresponding decline in the number of available psychiatric beds over the same period – and presumably, of shorter periods of detention as an inpatient because we know that average length of stay has declined.

To this, I would add:

  • The introduction of Supervised Community Treatment – we know that some patients who would previously have remained detained in hospital now can be released because there is the potential for a legal mechanism to recall them without waiting for another “crisis – admission – release – relapse” cycle.  We know that some of those have been detained by the police under s136.
  • The battle against exclusion criteria is being won, slowly but surely – many PoS providers are being obliged to acknowledge that previous reasons for excluding service users from assessment are not valid, often because they are not safe.  This is linking, in my view, to altered police behaviour around the use of s136.

I would like to make one point about disposal from s136 detention.  What happened to those detained.  Martin cites articles examining disposal pathways and notes that most people who are detained s136 are not subsequently admitted to hospital.  I once found this fact thrown at me as a reason to suggest that West Midlands Police needed to “sort itself out” regarding the way that the power was used because ‘only’ 40% of people detained in one of our boroughs were admitted as inpatients – to be honest, I’ve never known of ANY area where most s136 detentions lead to admission.  That 60% of people in that borough were not admitted at all was evidence, apparently, of misuse of the power.

I asked the question, “How many of that 60% were signposted to their GP, the Community Mental Heath Team or another healthcare professional?”  It turns out that the answer was “Two thirds” but it took a fair bit of getting that out of them.  In other words, of those detained s136:  40% were admitted to hospital; 40% were referred to a healthcare professional and 20% were released without further action.

So four out of five people had an unmet healthcare need.

So there is much to do on s136, not least around achieving accurate recording procedures which consistently combine police custody and health service data.  We also then need a realisation that if you record the demand correctly, you can design a system and a service to meet that demand.  Currently, we’ve got no idea what is going on because we know that the data and the activity is insufficiently understood.  But for this remark at the end of his post, I could quite happily track down Martin Webber and hug him:  “Mental health services should either accept police officers in their ranks as allied mental health professionals and provide them with full support and training, or provide mental health crisis services which genuinely meet the needs of their local population.”

Something about “Street Corner Psychiatry”? – Hear, hear!

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5 thoughts on “One Hundred and Thirty Five Percent

  1. I’d be very happy for you to track me down and give me a big hug. After all, isn’t that what us social worker-types are good at? (Giving hugs, not tracking people down – that’s your job!)

    I think you make some excellent points here which deserve further exploration.

    Firstly, I agree about the under-reporting of s136 detentions in the official statistics. These figures do seem far too low to be believable. Perhaps they are the ones which come to the attention of the NHS? Possibly they reflect an increase in s.136 suites or places of safety located on NHS premises in latter years so that more are officially recorded. I do seriously doubt if they include use of custody suites. Whatever is going on, this merits further exploration to ensure that planning can be based on accurate figures.

    Secondly, from the discussion my post provoked on twitter and previous experience, I think that it is wrong to describe an instance when someone is discharged from a s.136 with no admission to hospital or need for subsequent mental health care as an ‘inappropriate’ use of s.136. Quite frequently mental health crises can be short-lived and 72 hours are often sufficient for the worst to be over so that the person can return home and sort out the mess they were escaping from. If someone is distressed and in a public place, something needs to be done then and there to support that individual. If police powers are required for that person’s safety, or someone else’s, and if there is an appropriate place of safety, s.136 can be an appropriate means of providing that immediate care.

    That brings me on to the point I made in my post which you highlight in yours. I think it is time to realise that the police are providing emergency mental health care and should receive proper training and support from the NHS to undertake this role. You may not be administering drugs or providing psychological interventions, but you are providing a crisis intervention nonetheless. This needs to be properly respected and supported by mental health professionals. There are studies indicating that people find being detained under s.136 a frightening experience. I can well imagine that. Being taken into custody whilst in a mental health crisis criminalises distress and is certain not to be received well.

    Perhaps it is time for some joined up thinking to find ways to respond to crises more effectively and without the NHS washing its hands of them (see my twitter feed for some examples provided to me in the last couple of days). Crisis teams are not set up to work with the kinds of crises which result in the use of s.136. They require referrals and the people often need to be known to mental health services already. The police are effectively providing a crisis mental health service as crisis teams are not able to respond with the same immediacy. If specialist police officers were able to work as ex-officio members of crisis teams (in a similar way to police child protection officers working with social workers in children’s services), they would be able to access training and lead on mental health issues within their local force. A bit like you are doing, I think, except without the NHS connection!

    A number of years ago I trained to be a Samaritan. I gave up after a short while because of other commitments, but that period of voluntary work opened my eyes to the role of the police in mental health care. When I arrived for one of my first shifts after I had completed the training, I was ushered upstairs to help a suicidal young woman who was hanging from the window ledge of a second floor window. Police officers were also there holding her arms and trying to pull her back through the window. I relieved one of the officers and helped to haul her back in through the window. We had saved her life (or certainly saved her from some broken limbs). I don’t know what happened to her after that – or whether she was successful with a subsequent suicide attempt – but we had intervened at the moment to prevent her from harming herself. This is the bread and butter of community policing, but it is not recognised as emergency mental health care.

    Since I qualified as a social worker, I have come across countless situations when mental health professionals have said “it’s a matter for the police” in the case of some mental health emergencies. Mental health services are just not set up to deal with the real crises – that is left to the police. I know that many NHS Trusts have excellent working relationships with the police, but isn’t it time to take this a step further and assist the police in their provision of emergency care (even if that is only containment and control)?

    I appreciate that we are a couple of bloggers airing our opinions and could be dismissed as such. However, I think your excellent blog highlights the important role that police play in mental health care and that a more holistic approach is required which encompasses a multi-agency approach involving the NHS, local authorities, police, housing associations and so on. With community mental health teams becoming less integrated – with social workers being pulled out to focus on ‘core’ social work tasks such as personalisation and safeguarding – and the Age of Austerity tightening eligibility criteria, I sense a greater demand for crisis services is just around the corner. I’m not certain that the leaner public services we will have over the next few years has the capacity to meet it. But that’s another issue…

    I’ll be happy to further engage in this discussion on Twitter (@mgoat73) or via my blog (martinwebber.net).

  2. In an effort to get in on the group hug I thought I would join this discussion. I am the force mental health lead for Thames Valley Police, one of the largest non metropolitan forces covering the Counties of Berkshire, Oxfordshire and Buckinghamshire including the Independent State of Milton Keynes! We currently detain on average 2.6 persons per day on a S136 which I believe is a consistent number over the 4 years since I took up this post. Certainly there is not a statistically significant increase. I put this down to improved joint working, training and access to information for our Officers and partners particularly when it comes to not using S136 on very intoxicated individuals but actually arresting for offences instead.

    What there is definitely not is an increase in access to emergency care for people in crisis. The difficulty is that there is no emergency service for mental crisis unless in a public place. Crisis Services and CMHT are not primary care services and so will always require a referral from a health professional. Emergency Departments at hospitals robustly resist taking in persons who “only” have a mental health problem. Many health professionals including CMHT, crisis services and GPs (particularly Out Of Hours services) assume that when someone is in mental crisis then the police should be the first service to call. I am aware of a number of incidents where OOH GP has asked a Police Officer to “pop someone along to the surgery” to avoid them having to come out and Officers sitting with patients in Dr waiting rooms to make sure they don’t run off.

    In what parallel universe does this make any sense? Clearly if there is a real and immediate need for a person to be restrained under the Mental Capacity Act or to prevent a Breach of the Peace. How do services know this in advance unless they are there as well? Not only that but the number of requests we get to do a “safe and well” check on a person who professionals believe may have deteriorating mental health is increasing exponentially. Typically these calls come in at 4.30pm on a Friday – take from that what you will!!

    Why on earth is this a Police responsibility? Can you imagine the effect on someone who is already feeling very unwell of having a Police Officer turn up unannounced at their front door, sometimes in the middle of the night, just to ask them how they are? Personally I believe this is a violation of Human Rights Article 8 – A right to a private and family life. Worst case scenario they end up with acute stress trauma on top of their existing condition believing the Police have arrived for some other reason.

    My point here is that while it is important for Police Officers to have a broad understanding of mental health issues and legislation, I would really oppose a “Super Cop” who has specialist training in mental health. We do not need significantly better trained cops; we need better access to acute services for mental health crisis so the cops won’t be needed. We need to commission and train the ambulance service in a different way so they are able to deal with this type of health crisis. The hospital A&E departments need to start taking responsibility for the “whole person”. Crisis services need to be just that and become a primary care service. This is not going to get any better. There is a recognised deterioration in society’s mental health – there are not going to be any more Police Officers out there, quite the opposite and according to the Home Secretary our job is to “Cut crime, no more, no less”.

    Stop using the Police to deal with health and social care matters. Thank you for listening!

    1. Brilliant comment. Almost total agreement here. The thing I think we do not need better training on, which I would advocate being focussed on a few officers, is law training. Better understanding of the legal frameworks around mental health in order to assist officers in doing the right thing where there IS a legitimate need for the police; and better understanding to allow officers to better articulate and defend decisions that they may prefer to take that would allow them to decline inappropriate steps whilst focussing the responsibility back upon agencies who bear it. This could include OOH GPs or CMHTs, etc..

      I’ve said all my service and not just on MH: we need to know more law.

      1. Yep agree and I catagorise this under an overall awareness of MHA and MCA legislation and protocol. A few subject matter experts is handy without them being “super cops”!!

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