Surviving In A System

I came across a New Statesman article by Alan White a few weeks ago.  It sought to address certain problems around society’s response to complex and demanding characters and it contained this:

“There’s a doctor – my friend – and he works on an A&E ward somewhere in the north of England. One night a man comes in – he’s psychotic, and he’s drunk.  My friend phones the hospital’s mental health team, and describes the patient to them. And here’s what they tell him to do. They tell him to dare the man to threaten someone in the street. That way, he’d most likely end up being the police’s responsibility rather than theirs. They couldn’t take any more patients and this guy was just your classic fuck up – mentally ill and self medicating with drink (or perhaps the other way round – there’s usually a chicken and egg thing) rather than a potential serial killer or whatever.

Now I didn’t believe this at first. But he swore it was true. Then I talked to a psychiatrist in another town, and she told me she totally believed it, and that she had a problem with the police bringing guys in to be sectioned even though they were just drunk and angry, because the cells were full.”

This alludes to various things that are daily experience for a lot of front line professionals.  Principally within it is the notion of what some police officers call “batting”.  Such officers are often good at mimicking a forward cover drive to the boundary to symbolise hitting the problem away where it is supposed to become someone else’s.  I often wonder why those who use the term forget to remember that the ‘problem’ is always recovered from over the boundary and thrown at you again until they take your wicket?  Anyway …

The article also alludes to the ownership issue.  We know that some people who abuse drugs and alcohol are ‘captured’ – whether deliberately or otherwise – within s136 detentions.  I’ve previously mentioned the West Midlands man who decided to give up smoking and took over-the-counter medication for nicotine withdrawal.  Failing to read the instructions he drank two bottles of red wine at a family meal and woke up three days later in a psychiatric ward, having been detained under s136 by the police and then under s2 of the Mental Health Act by psychiatrists and an AMHP.  Then there are the various people who have been detained after appearing psychotic and disturbed who are suffering an episode induced entirely through drugs like cannabis, crack cocaine and / or others.

Operational Difficulties

Some of the responses to this sort of detention are suggested by Alan White, above: something of a tactical struggle about whose responsibility someone is.  We know of stories of police officers appearing at A&E departments because someone “we think he’s taken something” or because “we think he passed out in the van”.  Go and prove me wrong?  Of course, once through the door we can get into the discussion about whether or not the police remain there.  “No, he wasn’t detained s136 but we did tell him we might have to do so unless he voluntarily agreed to come to A&E so it doesn’t matter whether you’re a place of safety because he’s not detained.  So we don’t have to remain here, either – bye!”  <<< I’ve heard stories like this from the NHS so many times in so many places.  Are they all wrong?  Of course not.

I’m not suggesting the NHS are any better, as the above alarming story suggests: “He threatened me and we have zero tolerance approach to violence so I want him removed from here and taken to the cells.” or  “We’re not a place of safety [because we’ve chosen to opt out of UK law]” or “We can’t assess someone who is under the influence of alcohol, take him to the cells.”  Turgid buffoonery, all of it.

The solution?  To look at the police involvement in mental health processes as a part of a system.  So first thing:  get knowledge about the system.  My last blog was about statistics around s136 following a blog by Dr Martin Webber.  The fact is we don’t know what on earth is going on.  Not even vaguely.  We also regard the police and the mental health system as two different things, often with oppositional targets.  However, the law makes the s136 pathway one system: started by the police, ended by the NHS with no clear point where responsibility moves from one organisation to the other.  It would be easy to think of it as two culturally different organisations but we know that there is no ‘NHS’ – it any area, there could be as few as three but as many as six parts of the NHS that may be necessary to a s136 pathway including the ambulance trust, the acute trust for Accident & Emergency as well as the mental health trust.  In some areas, Child and Adolescent Mental Health Services and / or learning disabilities services are different ‘providers’ to the NHS trust.

Is it any wonder, with such functionalisation of provision where we’ve all been set up with our own targets and legal responsibilities that at the organisational level and at the frontline level, it doesn’t work?  Why aren’t we looking at this from the patient’s point of view?

The Only Important Question

How many times in an area does someone get picked up by the police, transferred to ONE location by the ambulance service and arresting officers; where health and social care needs are assessed, identified and met in a non-police station environment; with police support to that assessment process only where this is needed; and within three hours unless delayed for medical reasons or for reasons connected to intoxication?

I want numbers / percentages.  I want to understand why this does not occur in cases where there are problems.  So I want to know –

  • How many times can we not get an ambulance?
  • How many times do receiving Places of Safety (whether A&E or psychiatric) bounce or attempt to bounce the patient?
  • How many times do the police play games with the legal frameworks of whether someone is / isn’t detained?
  • How many times have people been detained s136 who SHOULD have been arrested for a substantive offence?
  • How many times do medical problems and / or intoxication hold up an assessment?
  • How many times do we say that medical problems and / or intoxication hold up an assessment?
  • How many times do people need to be transferred from one place of safety to another, which is inherently wasteful?
  • How many times do we struggle to get an AMHP and (s12?) DR within three hours?

If we understood this, we could start working out how to improve the system as a whole, cutting across the police and the many health and social care organisations that need to be involved.

And obviously it will cost loads more to do this, won’t it?  Probably not … if we’re looking at the immediate cost to the NHS only of providing a place of safety services, it may cost more in day-to-day operating costs to the mental health provider and the PCT to do it properly.  But by doing it properly, it will be the case the ‘failure costs’ reduce massively.  No more or fewer inquiries into a death in police custody, some of which have cost over £10m; lower overall legal costs for the NHS being sued for human rights violations, etc..

Total Costs

There was another s136 contact death this month and another independent investigation by the IPCC is now ongoing.  This is in addition to investigations into last year’s s136 incidents in York and Birmingham.  The costs of these inquiries, irrespective of whether there is alleged to be specific wrongdoing by the police officers involved, are a part of the cost of the s136 pathway.  The legal bills and court fees from all of the challenges against the NHS in various courts which relate to the challenge of MS v UK are part of the cost of s136.  I wonder how much time and effort is spent within each organisation investigating internal complaints arising from s136?

Overall, it is cheaper to do it properly.  In the meanwhile, police officers, nurses, doctors and organisations are trying to deliver against their non-integrated and arbitrary targets within which there is nothing about s136 specifically.  As such, they use their human ingenuity to survive in that system.

A&E is a poor environment for handling mental health crisis – for that matter, so is a police station.  Neither are commissioned to provide care for aggressive and disturbed people with unmet health needs and we know that A&E professionals are the second most frequently assaulted group of NHS professionals (after mental health professionals, incidentally).  So am I surprised to hear a suggestion that mental health teams are encouraging A&E doctors to wind people up until they make threats and force the matter on the police?  No – appalled, but not surprised.  Am I surprised to hear that police officers don’t want to sit around in NHS buildings doing ‘security’ for compliant mental health patients for 12hrs whilst their colleagues are running from 999 call to 999 call and that they blag the legalities so they can find an argument that allows them to leave?  No – appalled, but not surprised.

So what is to be done? – understand the nature and variety of demand, commission it properly, design it properly against demand and think of the service from the patient’s point of view.  Not hard to do, but apparently hard to understand.

____________________________________________________________________
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.

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