I want to share with you some thoughts about the concept of ‘Failure Demand’, as it relates to policing and mental health. For those who have not previously heard of this term or are unfamiliar with the work of organisational psychologist Professor John Seddon and Vanguard, let me explain what this is by giving you John’s own definition:
“Demand generated from a failure to do something or a failure to do something right (for the customer).”
I have spent much of the last year reading about Vanguard’s work and considering it as it applies to policing and mental health – actually in relation to policing generally – and it has really caused me to pause for thought and start all over again. I’d encourage you to read Systems Thinking in the Public Sector (2008) as well as some other stuff I’ll mention as I go through.
In a previous blog called ‘Signals from Noise‘, I outlined some considerations that should be occurring to multi-agency groups who oversee ‘Place of Safety’ (Mental Health Act) operations. These would include asking questions about ‘repeats’ as well as about all detentions which occur in relation to any person who is already known to mental health services.
Before I write anything else in this piece, I need to be crystal clear about one point: not all mental health related demand for the police is ‘failure demand’; and not all of the ‘failure demand’ that I am referring to here is predictable and avoidable. << Please keep this at the forefront of your mind!
Somethings go awry despite everyone’s best efforts and for a wide variety of reasons. But some things that go wrong are as predictable in general terms as night following day and we have far more capacity to address this by looking at the system within which certain decisions work.
PREDICTABLE FAILURE DEMAND
How much of the demand that we face is demand which is ‘failure demand’? And how much of that ‘failure demand’ is predictable?
We probably don’t know, if the truth be known: we are not counting the things that would be relevant to our understanding of it. We often find that public sector organisations are counting quite arbitary things, convinced that they related to the public’s empirical understanding of how services work. What we can say, by way of example, is this: in one mental health trust –
- 50% of s136 detentions are known MH patients
- 30% of s136 detentions are people resident out-of-area, of which we know some will be MH patients in their home area’s mental health trust – shall we estimate this figure 33%?
- 10% of people detained under s136 have been repeatedly detained.
- Of course, not all of these detentions occur for predictable reasons. But some do, and I’m not sure we know how many.
- Of the 66% of 136 detentions, are we saying that all them were unavoidable?
Do these newly discovered numbers cause the system to be reviewed and revised to mitigate against the generation of such demands? If we reviewed these s136 detentions by the police OR if we reviewed offences committed by suspects with mental health problems who are known to the MH trusts, what would we learn about care planning? Would we learn that there were certainly predictable features – like failure to keep care community appointments, disengagement from medication, etc.? Almost certainly.
Policing exists in many respects to be able to provide a remedial, potentially crude intervention after other social structures have tried or failed to ensure the ‘right’ outcomes. This could be connected to failures in personal responsibility; in parental responsibility or in relation to other organisations’ capacity or capability to respond to demands which, ideally, would sit with them. So it is no surprise that some failure demand – predictable or otherwise – gravitates to the police. Some of it also gravitates to the ambulance service, Accident & Emergency and out of hours GPs. Do the dynamics and implications of all this? I’m not sure we do.
To make another important point: not all mental health-related police demand is ‘failure demand’. Recently, my area dealt with a lady under section 136 of the Mental Health Act who was very unwell and all information suggests she is someone who simply has never, ever come to police or mental health services’ attention before. So the ‘demand’ is not a result of any failure of any kind, but the ‘system’ is about having a ‘clean’ flow of work from the officers who came across her to the health and social services who will be key to ensuring she gets the right support in terms of unmet needs. But a ‘clean flow’ is what we often do not have, following the use of s136 and this lack of flow often means that the professionals who are seeking to survive in a system will improvise within the rules. Most of the blog posts I have written on s136 MHA are a testimony to the problems around the flow of cases not being ‘clean’ or straightforward.
MENTAL HEALTH PROVISION – AS A SYSTEM
To summarise Seddon’s work: you build an effective ‘system’ to manage demands by ensuring that the necessary expertise and capacity is within your ‘system’ at the point where the customer touches it. That way, the right professionals with the right skills, are available at the right time to respond to demand. It is through this simple-enough approach that the right expertise is on-hand to ensure that the work then flows cleanly through the system.
You can already see what’s happening can’t you? Mental health demands for the NHS or social care system can and do manifest themselves twenty-four hours a day and more than occasionally, issue manifest themselves amidst a cloud of drug or alcohol abuse. We know that it is not necessarily possible to access mental health care twenty-four hours a day, especially if you are intoxicated. << There is your first problem.
Your second and subsequent problems can often relate to actions which occur as result of the first problem. The person or relative who sought support from a crisis team with insufficient capacity to respond to predictable demand who is then told, “Ring the police.” or “Go to A&E”. << Failure demand. I have sometimes looked at some of the more controversial issues in policing involving the use of force or even deaths in custody and thought, “Failure demand.”
Sometimes, these demands arise because of system capacity; other times because of exclusion or access criteria. Our 999 services and A&E can then be sucked into the vacuum because the demand is still there, notwithstanding that the system isn’t. Arising from all of this work doesn’t flow cleanly, causing ‘failure demand’ of various kinds because we have the wrong people dealing with issues, or at the wrong time or in the wrong place.
There is a lifetime’s work there for someone who wants to research this, but we know that in public services generally – including the police – failure demand is very high. Perhaps as high as 80% in some police forces, according to Professor Seddon. I am really interested in failure demand across these agencies involved in this venn diagram of work and it is not just one-way traffic. Inappropriate police responses to incidents can cause “failure demands” for the NHS, which is why better training of officers and responsive mental health services are important. One of the repeat “s136 detentions” referred to above occured because the police were persisting with s136 when they should have been arresting and prosecuting someone. << Failure demand for the NHS.
Now – start this post over again whilst thinking about AWOL patients, criminal suspects with mental health problems and inpatient violence both by and against NHS staff: and remember to think of the whole NHS-police-Local Authority interface as one system. You wouldn’t design it like that if you were starting from scratch, would you?! << Therein lies the problem.
It might just be cheaper to do it properly …
Update on 01st April 2015 – since writing this article, a new Code of Practice has come into effect in England. It doesn’t substantially alter the post but certain reference numbers have changed. My summary post about the new Code of Practice (2015) is here, the new Reference Guide is here and the full document is here. The Code of Practice (Wales) remains unchanged.
The Mental Health Cop blog
– won 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
– 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.