Emergency Mental Health Care

Last month it was announced that a newly invigorated Care Quality Commission will undertake a review of emergency mental health care.  This follows on from several things and is much broader than the issues arising from the Adebowale Report – recently, this independent Commission into policing and mental health in London which has national implications.  The Adebowale Report made 28 recommendations, two-thirds of which relate to health and social care and so it was well said that “The Metropolitan Police can’t do this alone”.  It was (partly) in response to those issues that the CQC announced their review.

What else could be done? – well, most operational police officers could list a range of things from our experience and if anyone thinks I’ve missed any points here, you should feel free to let me know or add a comment to the blog below.  I’m going to make sure via Twitter that members of the CQC involved in this, hear the views that are expressed to inform their inquiry.  In the link above, the CQC list four areas likely to be covered and although they were not intending to limit or be prescriptive, there are many, many more issues –

I have nine things to say, restricting myself to a couple of paragraphs on each when in reality each issue is a big piece of work where we need to properly research and understand the dynamics at play:

1. CrisisTeams – clear and consistent terms of reference are needed and greater public understanding of what they are for.  Do they have sufficient staff to meet the demand which exists; do we actually understand what that demand is?  In some areas, CrisisTeam work becomes 999 work for police and / or ambulance services, but I’m not sure we understand the extent of this or why it happens.  Do we keep records in CrisisTeams of how many times their work is deflected and do 999 services keep records that could allow us to know the amount of emergency mental health work that is “failure demand?”

We then have to link this to issues around staffing and duties – I often absorb demand that initially went to the CrisisTeam because of issues around staffing and terms of reference around deployment.  If CrisisTeams have two members of staff at certain times of the day, it means that they can do one thing at a time if it is a job unsuitable for a lone-worker and if they are doing two things at a time, they cannot undertake those more demanding or risky tasks.  We also know from response times to police custody or A&E that CrisisTeams are understaffed for the demand which exists.  If you do not resource your service to absorb fully the nature and variety of demand which exists, you generate “failure demand” which is inherently problematic to deal with and has all manner of impact upon your mainstream service.  I am absolutely convinced that in some cases, an unresponsive, non-integrated emergency healthcare system means that the criminal justice system becomes obliged to criminalise people who would have benefitted earlier from a health or social care led intervention

The CQC should also bear in mind, that if you are a 999 worker stood in a private dwelling with a known secondary care patient and you ring the CrisisTeam after your attendance in a private home, the notion that you could get from that position to any necessary Mental Health Act assessment in fewer than four hours is fantasy.  The implications of the “Sessey” judgement should be strongly considered when thinking about what a CrisisTeam may have to undertake.

2. Out of hours AMHP coverage – this links to some of the issues for CrisisTeams.  In many areas, the duty AMHP is a social worker also carrying generic social work responsibilities including child protection responsibility, etc., etc..  The CQC need to consider the feedback freely available on various social media platforms that AMHPs themselves feel under-resourced and unable to deliver a proper service for emergency mental health issues.  This means AMHP availability for s136 assessments in a place of safety (wherever that may be) as well as the co-ordination of MHA assessments, either in private premises which may need a s135(1) warrant or in police custody or A&E; AMHPs also have other statutory functions and it is certainly my experience that few AMHPs feel they work in an area where they have sufficient resilience to be able to provide a proper response to these issues.

For example, we all know that the Royal College of Psychiatry standards talk about a 3hr response by an AMHP after being notified of a s136 assessment – in many areas, it is frequently double this timescale and often triple or more.  I have personal experience of it taking in excess of fifty – yes, 50! – hours for a s136 detainee to be seen by an AMHP.

3. Section 136 provision – we still read, in the joint 2013 report by HMIC / CQC that health provision of place of safety services remains patchy and that we’re still far from achieving a national position where most people avoid being taken to custody.  We also know that in many force areas they are doing very well at this, AND reducing use of s136 through better training of the police and / or street triage schemes.

My point about emergency mental health care is different: we don’t seem to properly use the information generated by s136 usage, to identify other issues within the system.  How many s136 detainees are current secondary care patients? – in some areas this number is 50%.  How many s136 detainees are arrested out-of-area and known to their home mental health trust? – again we know that in some areas this is around 25%.  How many s136 detainees are repeat detainees? – we know that in some areas there are people who’ve been detained many times.  We could do with understanding these things so that we can think about the implications for care plans, so that in some cases we can ask why s136 became necessary or kept getting used.

We also need to think about the quality of emergency mental health care and I re-submit my view that no matter the difficulties, emergency mental health care provision will never have parity with emergency healthcare provision unless and until our response does NOT involve incarcerating people in cells whilst ill.  I personally feel that none of the arguments about use of the cells stand up to full legal and medical scrutiny and I call for an end to their use in any circumstances.  We build the NHS to have the capacity and capability to respond to complex, challenging medical issues: why not for those that are oriented around mental health disorders and that means emergency responses even where people may be intoxicated by drugs or alcohol or may be aggressive.

4. Liaison and Diversion Services? could there be more of a crisis than for someone who is mentally unwell to be arrested by the police for an offence and taken to custody?  We know that some versions of these services have not been put together to respond to demand in custody, but to operate at times which are bureaucratically convenient: there is little point operating 8-4 Monday to Friday because most people who get arrested whilst unwell, get arrested 5pm – 3am all days of the week with a greater emphasis on Thursday to Sunday.

Where people do get detained, it often falls to the CrisisTeam to respond to custody if and only if mental health assessment with a view to admission is necessary.  Liaison and Diversion services would need to be able to manage predictable unpredictably:  I know we don’t know when people will get arrested, but we know it will cover all parts of the 24/7 clock and that the focus will be on evenings and weekends.  Therefore, we need services that can respond to this.  I’m also interested in urgent mental health care recognising the value of having an input into the detention of those arrested even if formal admission to hospital is not indicated.  To give just one recent example: if someone is stealing food whilst ill, but not acutely ill enough to warrant compulsory admission, there could still be value in supporting people.  Are their social care issues at play which if addressed could mitigate further offending?  Who knows unless we get involved.

A previous post I wrote covered this on Liaison and Diversion, as well as posing a decision-making model for the police to guide all agencies through.  It all hangs on how the NHS could get involved and I want to see a process as outlined in that blog which is about helping to identify more people coming through the system – because we know the police will only identify a third to a half of those who may need support / assessment – as well as providing formal MHA assessment where indicated.

If we don’t get this right: we see acutely unwell people not being properly supported and / or public protection insufficiently considered in police decision-making; we also see moderately unwell people unnecessarily criminalised which is equally tragic.

5. A&E Liaison psychiatry services – we know that award-winning liaison services (like the RAID system in Birmingham) can add loads of value to A&E.  Research has showed that mental health is a decent bulk of A&E demand: 1 in 6 people entering A&E have a mental health problem, 1 in 3 of those are there just because of their mental health problem.  So it’s 5% pure mental health demand; up to 15% medical and mental health demand (for example, self-harming or overdosing whilst ill.)  So the NHS developed liaison psychiatry services: mental health professionals working for the mental health trust but who work in acute settings, supporting the mental health related demand on wards an in A&E.

I’ve often wondered why these services do not extend themselves to people who go to A&E in contact with or detained by the police?  Surely clinical need is clinical need and I’ve never understood why healthcare available to others is denied because the patient is under arrest?  Even in areas where there are no place of safety services available and where liaison psychiatry services exists, people can be denied access to them because of being in custody.

6. Out of hours CAMHS / LD provision – it would be remiss of me not to make a self-justifying statement about out of hours provision for children and people with learning disabilities.  The number of times normal processes in emergency mental health care are brought to a grinding halt because there is no out-of-hours provision in these specialist areas.

7. The Role of the Ambulance Service – the Adebowale Report talked about the importance of emergencies in mental health care being given parity by the ambulance service with other medical emergencies.  Most ambulance services have work to do on this.  We have seen in some areas like the West Midlands, that ambulance services can bring clinical skills to emergency mental health care in terms of a de-escalating presence; they have also successfully identified where someone mental health patients are at raised risk because of additional physical healthcare complications.

Of course, the ambulance service already deal with many frontline mental health emergencies, but it surprised me in my journey into this part of policing to learn that the ambulance service get comparatively little mental health training.  Some paramedics of years standing have a day’s training in mental health.  It also stunned me to find that many ambulance services are unable to access care pathways, CrisisTeams and many do not have access to very much patient information, to any established trigger plans for patients at risk or to GP information for primary care patients.  That I once heard a senior mental health manager (not in my force area) shouting at the ambulance service when they asked for an ability to access information and 24/7 CrisisTeams sums up where many areas are with integrating the NHS services which face this kind of demand.

8. Bluelight 999 Support – we need to fully face the idea that mental health emergencies are going to come to the attention of 999 services and that we need to train, prepare and deploy our officers and paramedics to face this demand.  It’s not enough that they have access to other services, they also need to have professionally relevant training in how to manage vulnerable people, legal complexity and medical uncertainty.  Our 999 professionals also deserve a clear plan B to initiate when we find that ideal plans about how mental health emergency should be managed do not survive contact with high levels of demand, individual professionals and so on. << This is not to denigrate anyone: it is to prepare for reality.

We also need to contemplate the potential of combining police and paramedic skills into fast-response cars.  I know that the current fashion in “street triage” is to pair a police officer with a CPN and whilst I’ve welcomed that to a point, I also point out it is not a panacea.  The answer to some mental health emergencies is a paramedic opening the care pathway into Accident & Emergency and providing clinical care from the first point of contact into the emergency system.  We need to find a way of brigading all of this into quick, effective 999 response which can “access all areas” and manage uncertainty.

9. Availability of Beds – we know that in some areas of the UK, acute mental health beds have been cut by a third – twice.  That means they have been cut by more than a half.  All of this against a budget which has risen 59% in the last ten years (in real terms).  We have seen amidst this, the introduction of Community Treatment Orders which are far more prevalent than originally contemplated with suggestion in recent research that they may not bring about the intended consequences of helping to stop a revolving door of admission > rehabilitation > discharge > relapse > crisis to re-admission.

We are at a stage where we see AMHPs on social media platforms, highlighting the intractable situations into which they are being drawn because having undertaken Mental Health Act assessments, they have no beds by to which they may make applications.  Naturally, problems are particular marked when AMHPs are searching for psychiatric intensive care unit beds (PICU) and other specialist or secure services.  We have seen debates – frankly I’ve been pushing at a lot of them – about the potential problems and illegalities arise and we know that the CQC themselves are now publishing reports which criticise from the statutory inspectorate perspective about areas having de-commissioned too many beds.

Surely this is the definition of emergency mental health care: having a patient in need of admission to hospital because the pose a risk to themselves (or others) and being unable to do so for the want of resources.  There is human rights law on these issues, both regarding the denial of Convention rights on the grounds of economics and on the issue of protracted detention in police custody whilst these issues are sorted out.  It is against some of the things we now frequently see.

That should keep them busy at the CQC for a bit – and I stop writing conscious that this skirts over the nine issues and is just a policeman’s perspective.  I’m aware that there are other issues that service users and carers would wish to raise and that each of these topics requires greater depth, research and they are inter-related ideas within the broader area of inspection.

IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.



7 thoughts on “Emergency Mental Health Care

  1. More important points Mental Health Cop. I hope CQC hear them loud and clear.

    I have myself repeatedly been held under Section 136 and yes I feel terrible that the police have been landed with dealing with my issues. But as you say the crisis teams are not man enough for the job. When I have rung them in distress to get told to ‘make a cup of tea’ and to be told that the earliest you can get a visit is 2/3 days time. What do you do then? When you feel overwhelmed and desperate and know that you need to be in hospital what then because I am too scared to ask for an admission (apart from the fact that I was attacked on my last psych admission) because it is l likely there will not be a bed. Again what then do I do? I just go with the distress and suicidal thoughts and then here comes the police.

  2. I can totally endorse every point you make with bells on, but if a fully integrated mental health service that can not only respond to crisis but help prevent it happening in the first place seems like a pipe dream, here’s a little flashback to the early 1990’s. Ideas from the dim and distant past which, given a little backing, minimal resources and some imagination, could very well be happening now.

    I was a Forensic CPN at a teaching trust in South London. It was a newly created specialist post and meant to be a little more proactive than the ‘mobile depot clinic’ still very much the norm circa 1990.

    Court Diversion was the ‘next big thing’ back then, and as a service we dabbled with it. But Court Diversion needed beds to accommodate those it diverted, and guess what? Then, as now, we usually didn’t have any. So I looked at ways of getting involved with high risk people before they ended up in court or detained under the Mental Health Act.

    I ended up doing regular sessions with the probation service and a generic community mental health team. I say ‘ended up’ as it was never a very formal arrangement. I sort of blagged my way in until it became apparent this was actually a very valuable and sought after service. And although it never developed quite as far as I would have liked, I also spent quite a few sessions in police stations working with custody staff to assess vulnerable prisoners. We even got as far as an on-call system using a thing called a pager.

    Much of my liaison work involved grabbing a free coffee in someone’s office while out and about on my patch doing other things. “Here’s the custard creams Connor, and oh, while you’re here I’ve just had this referral …” But it was often those impromptu meetings that prompted some of the best preventative work we did.

    I knew my patch. I knew most of the more vulnerable and high risk people living there. They knew me. I knew a fair bit about assessing and managing risk. I had good working relationships with in-patient staff which meant that if I really, really, really needed a bed and could make a reasonable argument based on clinical need and/or risk, provisions could and would be made.

    If we did this now it would no doubt be called a ‘model’. Skilled, experienced and knowledgeable mental health professionals working across (and being on first name terms with) key services identifying the most vulnerable and high risk individuals within a defined geographical area. But to me at the time it was merely common sense. A joining up of the dots.

    Unfortunately my bosses weren’t particularly keen on what I was doing. Sharing resources was criminal. Sharing resources with non-NHS services? Whoa! A whole-life tariff right there. Much of this ‘model’ never stood a chance of becoming formalised let alone audited or researched. And it could and should have been possible to do a lot more work with the ‘blue light’ services who then, as now, were having first contact with a hefty proportion of the trusts clientele long before anyone had even heard of a ‘blog’ let alone Mental Health Cop!

    Would it be naive to think we could tear up the rule book of mental health services and start again? Perhaps this time we could remember the word ‘HEALTH’ in mental health. We could recognise paramedics and police officers as the ‘psychiatric professionals by default’ they truly are. We could do more than pay lip service to those that have been in crisis and ended up in the back of the ambulance. And unlike my managers of the time, we could even have services learning to share their sweets with the other kids in the playground.

    I very much hope the CQC reviewers read this evidence and take note. Their evidence will no doubt bring into focus an emergency mental health service looking more and more like the smoking rubble of an apocalypse, But with decades of underfunding and neglect of mental health, I won’t be holdin my breath while waiting for change.

  3. Hit the nail on the head with all those issues! I’ve been having intrusive memories and thoughts about the many times I have been 136’d and being criminalised for want of mental health care (with devastating results on the rest of my life, I feel it is my vocation to help people yet these careers are cut off to me now). Glad someone with more influence than I is noticing these things!
    Also, I imagine information (open ended kind of questions) from current and former service users, AND those who’ve been 136’d repeatedly but unable to access services, would be very revealing and useful.

    Sadly I feel the majority of political weight is against us. You hit on it slightly when you mentioned people being criminalised “who would have benefitted earlier from a health or social care led intervention”. I think, with the complexities of the mind and brain, and the knowledge we have so far on the role of trauma and deveopmental environment, there is actually a massive blur between what is “mentally ill” and what is “sane” (and thus responsible). At this point it veers off into a philosophical debate about free will and nature vs nurture, but there is a serious point. We KNOW that poverty and poor mental health go hand in hand. We KNOW that stress, working long hours, or growing up in adverse circumstances affects mental health (even if sub-diagnostic threshold). We KNOW that the greater the wealth inequality in a society, the greater the levels of mental ill health (and many other social and criminal issues).
    The politicians, and anyone interested in maintaining the status quo, do NOT want us to join up the dots!
    Incidentally, if I meet you at a protest, can we shake hands across the riot shields?…

  4. A comment on point 2. There is a contradiction between the rush to have people assessed as quickly as possible when they are on a section 136 (where ever they are held) and the need to do a full and proper assessment. The laws allows for 72 hours for a person to be assessed and in certain circumstances i don’t have a problem in using as much of that time as required. I would rather do that (and in practice i think i have only ever assessed somebody on a 136 who has been detained for over 24 hours maybe twice in 8 years) and not detain somebody then rush in and detain somebody who doesn’t need to be. Certainly this doesn’t mean the person should be left in a police cell for all that time but unless more hospital PoS beds and staff are made available it is inevitable that cells will be used, possibly for lengthy periods of time.

    Point 3. repeat detainees. There is a desperate need for senior AMHP’s and police officers to have a forum (or just a good relationship) to discuss those people who for whatever reason put themselves in situations where they are being continually detained under section 136. It is frustrating for the EDT and duty AMHP’s to assess the same person maybe several times in a week when that person has been established as not having a mental illness and not being detainable under the MHA. Often the circumstances are almost identical. I understand that for the officers dealing with the situation they must think to themselves why should they take the risk of not detaining this person threatening self harm/suicide I agree that alternative options may seem limited or unsatisfactory. But when the cells and 136 suites are full and there aren’t enough AMHP’s to assess in what some call a reasonable time it is the AMHP’s who get criticised.
    I was once told by a very angry Custody Officer that ‘we’re not here to baby sit your patients’. I pointed out that it wasn’t me who had filled every county PoS bed as well as three cells with drunk people none of whom who needed admission or any sort of treatment when sober. It is not unusual for all our PoS beds and cells to be full with section 136 detainees but usually at least some are genuinely in need of treatment.

    Mostly I find AMHP’s and the police work well together knowing we are all facing our own pressures. However this is not the same as collaborative working, sharing risks and making joint care plans often at short notice. These forums exist in many other areas of ensuring community safety but are normally monthly meetings and can’t be used for the type of emergency or crisis (especially out of hours) that leads to a section 136 or community MHA assessment.

    In order to have parity with physical health all NHS trusts should publish the waiting times for mental health assessments (particularly where a police presence is required). As far as I have been able to ascertain such assessments used to be achieved within 5 days going back a few years. Apologies if incorrect but it may be that the cuts have made police/NHS work on a system of minor ,medium and major risk (which I have seen through this excellent site is called RAVE) I would suggest that 5 days for all is the only safe approach,(ie to prevent crime and look after the patient/client/service user.(which i’ll just call user)
    I don’t know how many London Trusts have published this info already, but I do know that that Camden & Islington Mental Health Trust have done so yesterday in their Mental Health Law Annual Report 2012/2013 following a meeting yesterday.I do hope all mental health trusts follow suit. Publishing them will allow debate about what services and public think times should be. These figures show that of 152 requests in Camden where police presence was required 33 were cancelled , 48 were responded to in 7 days, 35 in 8-10 days, 20 within 14 days , and 16 over 14 days.(of these 16 several were where more than one visit was required)
    The figures for Islington are also published
    (its hard to see this info on their website at present but hopefully it will be easier soon)

    This may already have happened for all I know but certainly my experience a few years ago was that it was not.
    Also I don’t know if police still use PACE but I was told at that time that police could have called for a second opinion given that they correctly thought the FME had got it wrong.

    Mental Health Teams are normally 9-5 Monday to Fridays . That leaves a lot of hours uncovered (128 !)Are all service users and relatives aware what to do in an out of hours crisis and are all computers accessible for relevant information in situations where the person contacted does not know the user.?

    3a) How aware are relatives about the right to request a mental health assessment and even where they are aware would they automatically defer to the care co-ordinator ? Who knows what an AMHP is ?

    In some potentially serious arising situations it may be necessary to get medication supplied quickly. Is this provided for by all trusts ?. Although it is rightfully regarded as healthy that users pick up their medication with a walk to a GP in a deteriorating situation it may be necessary to fax a prescription to a close pharmacy or hand deliver medication to the user.I do know of a case where a user got to his mental health centre. Because they are not allowed to keep medication on the premises he was given a prescription to take to a pharmacy in a local hospital. He was too ill to do that and I went for him. The pharmacy was located off a busy hospital corridor with hospital staff having priority in the queue. It took 45 minutes. I am sure that if I had been moderately mentally unwell I would not have been able to wait that long .

    Thank you and hope some of this is relevant and useful

  6. Just a quick question/thought about 136 PoS….
    I’ve only seen one (@ St Nicholas hospital, Newcastle) but it didn’t seem any better than a police cell. The ‘day’ room was ok (minus toilet facilities), but the overnight room was identical to a police cell (except for being about twice the size), complete with blue plastic mattress on the floor, and toilet with no door, no paper, and nowhere to wash your hands after using it. I was forced to use this unhygenic toilet when being held under 136 in the ‘day’ room.
    I was accompanied by cops, not MH professionals, and was told I’d probably be in overnight, which terrified me as the implication was the cops would go and I’d be left alone, locked in the awful cell-like room.

    I preferred being in police cells, they treated me nicer there and even sometimes left the door open with a cop sat there. They’d bring me tea and blankets. NHS MH staff are crueller than police.

    I think it’s utterly wrong to praise 136 ‘suites’ if they are merely a cell, in all but name. Anyone locked in there is going to go a bit mad – we are making ill people iller by constantly traumatising them!

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