Failure Demand

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

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.

Advertisements

6 thoughts on “Failure Demand

  1. failure demand……….a simple example if i may. A CMHT client with serious drug and alcohol and MH problems was rehoused by local Authority Housing Dept into a flat next door to a notorious Drug dealing pub.. By a most unusual and happy coincidence, the local CMHT lead was at a meeting that included a Housing Officer. The CMHT lead raised the problem and now the two agencies work in a cooperative manner to try to ensure that this doesn’t happen again. So, result! Cheap and cheerful Partnership Working sorted it. could this approach reduce failure demand in other scenarios?

  2. In an ideal world we could start from a blank sheet of paper … but so many services, and the resourcing of these, are developed according to politics rather than evidence-based policies. Our prisons are full of examples of failure demand …

  3. I’m an example of failure demand. I’ve been repeatedly on section136’s, I’m known to mental health services, get told to tell them when I’m going downhill but they do nothing when I tell them. What can they do – often there is not a hospital bed available, the home treatment team give very short term support and I have complex long term needs. Often the crisis line is engaged or I speak to the call centre style team to someone who doesn’t know me and doesn’t know what to say. Yes they do fob me off and tell me to go to A&E or call the police but I only end up going round in circles with these. The police are sympathetic and frustrated with the local services.

    To make matters worse I’ve now been discharged from the mental health team because they cannot give me long term support due to service restraints (resources and finance) and there has been no measurable improvement recently, even though classed as a high risk patient. They can do that and I have no right to insist on support. Locally there’s nothing else suitable to turn to. The police have already had to pick up the pieces 3 times since discharge. As an example a few weeks ago I went missing, I can become so distressed I don’t remember anything. This resulted in a long search using dogs and helicopter finally finding me several hours later on a freezing night. An ambulance was called but the mental health team refused to come out so I was taken to A&E. The psychiatric person there was grumpy and dismissive, I was tired and unable to express myself much so he opened the door and let me leave. I had no money or phone and was miles from home. It could so easily have resulted in tragedy.

    Night before last I was sitting in my car in a car park upset after going to a meeting and up come the local police. Recognising my car they inquired after my welfare. In the end they insisted that I was followed home. Seems like the police are now in loco of mental health services.

    1. With respect, I think this post highlights the realities of people commenting on MH services. Usually,in over 90 per cent of cases people with mental health issues means people with personality disorder. Untreatable in the vast majority of cases. In any case for any chance of success the person with the disorder must have a level of intelligence,motivation,ability to reflect and ability to limit substance use for any chance of progress. All therapeutic work is aimed at the individual taking responsibility for their own life and behaviour,that is where the idea of mental staff charging around in emergencies doesn’t match the realities of clinical work. Specialist clinicians for instance when called by a client who had self.harmed wouldn’t go running but would encourage emergency medical Intervention if necessary then confirm a scheduled appt in maybe a weeks time. This is obviously the opposite of what 999 colleagues would do but emphasises the need for separation between the two deSpite understandable
      Calls for the alternative.

      1. THoughtful comment … I’m absoutely certain that it will have me thinking for weeks ahead, so thanks for that. All I’d say in immediate return, for example where the police are called to mental health related issues in people’s private dwellings where s136 can’t apply and where the Sessey / SLAM case reminds of us of how MH-type emergencies should be responded to, is that in my force area, the number of people identified as suitable for detention under s136 in public who are subsequently admitted to hospital under the MHA is around 50% of those detained. The vast majority of the remainder – 60% – are given the follow up referal you suggest. I have three points to make about that, whilst acknowledging that these numbers are not necessarily replicated in all police forces:

        1. Police judgement about whether someone needs an intervention which involves compulsory admission to hospital is about right, half the time. It would be fair to think that on other occasions they’re close to the mark and that on other occasions, admissions were not made because the increasing issues around bed access.
        2. If we want a model of community care which reflects the clincial reality, then we need clinical colleagues who are accessible enough to press for the alternative: standing in a room only yesterday with nurses who respond to calls from secondary care patients, they admitted they are being told by managers to encourage patients to ring the police. Perpetutates the possibility of the wrong response.
        3. It’s not the role of the police to make the assessment about what kind of MH situation or emergency will wait a week and which won’t, especially if someone is self-harming or expressing suicdal ideas: those are clinical decisions. You only have to look at the multitude of situations where responses have been argued with 20/20 hindsight to have been indequate to see the pressures on a fullsome response.

  4. Mike

    Re your response to my post – I’m assuming that you are a mental health professional but I am saddened by your attitude. It is a very typical one towards those patients with personality disorder. I might l would like to point out that my experiences come from someone who has a diagnosis of post traumatic disorder punctuated with episodes of dissociation co morbid with other issues. Personality disorder can be treated or improved and yes you are correct about the responsibility taking requirements of someone with that disorder perhaps when undergoing dialectical behaviour therapy (DBT) but nonetheless they can be at considerable risk at times from themselves and the police will probably be the service that ends up dealing with it because the mental health professionals can be very dismissive if a patients has that label.

    Mental health cop

    I was not surprised that you found out m h crisis services are being encouraged to ‘pass the buck’ to the police as in reality there is little they can do as I pointed out in my post.

    Yes you are so right the police are not qualified to determine whether the person they have in front of them is yet another ‘time wasting, attention seeking’ personality disordered person who should be taking responsibility for themselves. The police have to take the safest option or they would be in great trouble if that person ended up harming themselves. In fact a person with personality disorder is incredibly sensitive to abandonment/rejection and would be more likely to harm themselves if the police walked off – a sad but true fact.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s