A Foot In Both Camps

This post was first blogged on @NathanConstable’s blog – he had the wit to recognise @NorthWestDoc’s perspective on policing and mental health and ask her to write a guest blog.  Having it read it, I was struck by how important and impactive it is, and was keen to re-blog it to as wide an audience as possible.  Thankfully, both @NorthWestDoc and @NathanConstable agree and I’m grateful to them to be able to reproduce this here –


I’ve been a Forensic Medical Examiner for years.  Did my postgraduate exams in Forensic Medicine and Law.  Was asked to be the Lead FME for my Force.  Worked through the introduction of nurses, outsourcing and we are now working through the transfer to NHS Commissioning.

I’m lucky to work in a Force area which has excellent and established Criminal Justice Liaison Mental Health Teams and an experienced Force Lead in Mental Health.  The CJLTs are mainly 9 -5 but we do have some weekend on call cover and they have worked very hard to establish good links with Crisis Teams and Liaison Teams OOH for when FMEs and Custody Nurses become the first line opinion on mental health issues in Custody.  Our major gaps remain in CAMHS and Learning Disabilities but I don’t know of any Force area that’s well supported by those disciplines.

You will also be envious to hear that we only have hospital based places of safety for s136 detentions.  Mainly in our Emergency Departments.  And a Chief Superintendent who makes it clear to his Custody Sergeants that they never accept a s136 into Custody.  Yes our EDs struggle at times from delays in Psychiatrist and AMHP attendance but the detainees are safe and physical health issues are identified and dealt with.

The Force have recently had to implement a risk assessment policy to allow them to leave detainees in the care of the Place of Safety as their average wait was 9.5 hours.  However at a recent meeting we heard this has been largely supported by the Emergency Department Staff.

Yet still as the Duty FME Mental Health services were a mystery to me. And seemed to be an impenetrable brick wall when I asked for assistance.  So four years ago I decided to re-enter NHS training as a Psychiatrist and also work part-time as an FME.  So far I’ve worked across inpatient and community settings. Acute care, Early Intervention, Old Age, Learning Disabilities and CAMHS. Done emergency psychiatry assessments in Emergency Departments of Acute Trusts. Worked closely with Liaison and Crisis Team Colleagues.

SO WHAT HAVE I LEARNED?

Well firstly I was amazed to find out how utterly reliant Mental Health Services are on the Police.  There barely seems a day where Police cars are not parked outside our Emergency Department or Psychiatric Hospital. Responding to our requests for help.

Detained patients who have absconded from wards. Voluntary patients who have left, as is their right, but we are worried about their risk so we want the Police to find them. Reports being taken on patients who have assaulted staff or damaged hospital property.  Patients who the Police have been summoned to support their removal to hospital on CTOs or sections.  Phone calls to report a patient making vague threats to kill which we want the Police to take responsibility for.  Occasional calls for assistance where the ability to restrain and seclude aggressive patients is beyond the ability of our nursing team.

I then began to talk to my colleagues about how they saw the Police and was amazed at the range of attitudes.  A feeling that the Police sometimes ‘dumped their problems on us’; the concept that a person intoxicated and distressed in a public place was first and foremost a Police and not a health problem.  Yet these same colleagues lift the phone to the Police and expect an immediate response and a solution.

I then went off to a Forensic Psychiatry conference thinking therein must lie the professionals who would understand the interface between Policing and Mental Health.  Not so.  Although picking up the risky mentally unwell from the CJS they enter the frame at the Courts or Prison stage.  They felt very firmly that Police station psychiatry lay in the realm of general adult psychiatry but my experience of general adult psychiatrists did not find much interest or understanding within their ranks.

So back to work as an FME I tried an experiment.  I rang a Crisis Team about a case and identified myself as an FME.  The shutters went up.  I then told them I worked in the local Early Intervention Team. It was like the door to the Secret Garden had creaked open.  Suddenly I was in their world and they would help me.

I have been branching out nationally in recent months and what I find horrifies me and reinforces my view that MH services expect the Police to problem solve for them but don’t feel they should problem solve for the Police.  I came across Police bloggers on Twitter and find myself very much on ‘their side’ in this debate.

The current philosophy is that the Police need to improve their training around decision-making in mental health.  Training is always welcome but this is not the answer. If you look at the national s136 figures about 20% are detained under the MHA or admitted voluntarily.  A further 30% are offered follow-up by mental health services.  Well that’s a pretty good hit rate in my view.  Put me in a Police uniform and my hit rate for lawful arrests isn’t going to be that good.

Most Police Officers I know are instinctively very good at recognising those in mental health crisis and dealing with them sympathetically.  The problem is when the Police can’t go with that person to a health care facility. A small proportion of these people will have significant physical health complaints that can’t always be ruled out in a Custody Suite.  One death from a slow bleed in the brain of an alcoholic is too many.  Why do we expect these people to take chances just because they have ended up with a Police instead of an Ambulance response to their crisis?

In the same vein Street Triage, although welcome, may be flawed as mental health nurses will not be able to rule out physical illness. Whilst it will reduce s136 detentions the alternative may be ‘triage to cells’ which leaves the same problem of a person in crisis in a Police cell.  Add in the dangers of the restraint that often happens in these risky crises and I firmly believe that all these cases have to be managed in the NHS (supported by the Police if necessary).

So what works? Well it’s the liaison part of liaison and diversion.  The majority of mentally ill people do not need diverting from the criminal justice pathway if they have entered it because they have committed a crime instead of in a crisis.  A very small proportion (less than 10% in my experience) require diversion at the point of arrest as they have offended in a relapse of their mental illness and the pragmatic view is taken that prosecution should not be progressed.

However many people with mental illness offend in the same way as the non-mentally ill and have the ability to take responsibility for their actions and be supported through the criminal justice system.  We have a new initiative of a ‘Mental Health Court’ locally where a judge has taken an interest and takes a multi agency approach to disposal, making compliance with treatment, housing and advocacy part of the package.

Criminal justice sanctions often support the psychiatric management of patients allowing us to maintain them in community placements where they have been accustomed to assaulting staff and facing no penalties as they have a mental health diagnosis.  Liaison is the key – if I have a known service user in Custody I get on the phone, put it in context and ask is this a deterioration that needs hospital admission?  Are they compliant with treatment? Does the Crisis Team need to get involved?  Do they need a visit from their care coordinator?  Or are they stable and do we just let the CJS take its course with support for the detainee?

Liaison has also allowed advance planning. ‘Health Risk Assessment Meetings’ are held where the Police support the NHS in care planning and risk management. We look at repeat s136 detentions and agree pathways for the next crisis.  We put markers on the PNC to say a MHA assessment needed if this person is arrested.  I have also applied some of the lessons to managing some repeat cases with high risk physical conditions and agreed with the Emergency Departments that on arrest that person should go straight there for review before coming to Police Custody.

Yes the pathways across the NHS are complex as evidenced in @MentalHealthCop’s latest blog.  But we must get a joined up pathway agreed by the new Offender Health Commissioning Groups for each Force area.

I don’t agree that all mental health crisis is predictable or preventable.  Nor that the Police should not be involved in the response.  Many people in crisis are not open to mental health services and do not have mental illnesses.  But to see the Police as the agency who need to fulfil the roles of Law Enforcement, Protection of the Public, Paramedic, Nurse, Doctor, Drugs Worker, Mental Health Worker, Relationship Counsellor, Debt Advisor, Housing Officer……. is madness in itself.

It’s time the NHS stepped up to the plate.


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

Winner of the Mind Digital Media Award.


 

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5 thoughts on “A Foot In Both Camps

  1. MH Services across the country are utterly reliant on the police. Unfortunately, MH training and support for the police is extremely limited, and most definitely insufficient for the relative frequency of MH related calls.

  2. Totally agree about the 50% hit rate meaning MH training is not required for Police. I wouldn’t want this training in the same way I wouldn’t want midwifery or brain surgery training !

    Yes I might come accross that sort of scenario and I will deal with it via common sense. To expect me to have an in depth knowledge is just an admission that the current NHS system fails

    Once all the non- Police involvement is reduced/ removed, the MH Teams will find the Police very willing to assist in genuine cases

  3. quite agree. we already read in Adebowale recently the absurd situation where London Ambulance Service do not attend an MH scenario if police in attendance, because they feel police are better qualified in MH.
    yes but this post was really about an FME who recognised that she didn’t know enough about Mental Health services and thus set out to gain valuable insight into police/NHS interaction in MH. My own experience shows me that the police can have far more clue as to a person’s mental health status than an FME if the FME is not qualified in MH.
    I hope things have changed but 10 years ago my relative A was taken from home to a police station, neighbours and police thinking it obvious that A was suffering severe mental health problems.The Police said he’d be off to hospital for assessment in minutes The FME (a well respected GP in the local area) surprised everyone by saying if A had smoked cannabis he couldn’t be mentally ill.Jaws dropped, and the police regarding A as vulnerable suggested he be bailed to the home address and I to stay with friends. The police were sure MH workers would sort it out within a couple of days.Initially however MH team refused to be involved on the grounds that an FME had already made a decision. 3 weeks later they agreed to be involved but after assessment the Crisis Team decided to treat A at home.
    This went on for a couple of months I never slept there again and after three months exchanged the flat for a single flat for A. Meanwhile I had written to the police thanking them for their considerate action and also writing to the home office to say the law needed amending on FME’s apparent power. But the Home Office wrote back saying no new law was needed as police already had power of second opinion ( apologies if incorrect but under 1D and 1C of Pace on Appropriate Adults I think) and could have got in a mental health social worker.I did write to a chief inspector about it.I can’t remember exactly but I think he said everything is rosy in the garden.Such is life, but my point is that if doctors are not properly qualified in physical and mental health they should not be on an FME list, because it can cause a lot of problems.But hopefully all this is in the past and FMEs are now fit for the role.

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