More debate this week about Street Triage in light of yesterday’s announcement that the scheme is being extended to five new police force areas. As such, Minister of State, Norman LAMB went out on patrol on Monday evening with a triage car in Leicestershire whose scheme is leading the way in many respects. But yet again, my expressing just some reservations about the scheme have been interpreted as being “against” it; or me thinking it is “bad”.
I can’t say this any other way: I welcome the scheme .. I really do!
I welcome the scheme both for what it is and for what it’s worth and I have consistently said so. My concerns are about what the scheme is not – it is not an answer to the crisis events examined by Lord Adebowale. I will henceforth refer to Street Triage, as well as other policing-and-mental-health arrangements, as having “an Adebowale deficit“. << This is the ‘gap’ between that which exists and that which is required to consistently, professional and legally respond to ALL of the mental health emergencies facing us in order to provide effective emergency mental health responses across the policing, health and social care agencies.
So Street Triage is welcome, but it’s not the answer to everything.
It’s exactly the same debate about Street Triage as we get when we are talking to the NHS about providing section 136 services – they also usually have “an Adebowale deficit”. Indeed, several commentators focus upon the ability of Street Triage to provide alternatives to s136, thus meaning the police don’t have to make those detentions and then sit around in places of safety for hours on end. Of course, the police shouldn’t be sitting in Places of Safety for hours on end anyway because the multi-agency agreement, published by the Royal College of Psychiatry in their “Standards on s136“, states that the police should be able to deliver s136 detainees in to the care of the NHS and leave. So in that sense Street Triage, in part, is a solution to a problem that shouldn’t exist in the first place.
The police need to remember, though: one reason services don’t exist as they should, is because the police over-use s136 in some parts of the UK and some officers misuse it. We need to acknowledge that.
Of course, even with the best s136 arrangements in the country, there will still be incidents where the police encounter individuals in the street and Street Triage provides the potential for them to be diverted away from detention. << You’ll remember, historically, that s136 was introduced into the Mental Health Act 1959 as a method to divert people from being arrested for minor criminal offences and to consolidate various 19th century ‘vagrancy’ and ‘lunatic’ laws. So street triage is trying to divert people from diversion, as General MELCHETT nearly said. “What? Divert him from diversion as we continue to define diversion? – yes! Why not? … sounds rather fun!”
And when it comes to the inability of Street Triage to provide an alternative – on occasion, some vulnerable people are always going to need detention – we then hit “the Adebowale deficit”. What happens when the person encountered is intoxicated or resistant? What happens if they’re encountered in a private premises? … what happens in one of the more difficult incidents where patients who are floridly unwell is being restrained by multiple police officers and resisting detention to a massive degree? For some of these cases, you may still need the pre-hospital clinical skills possessed by paramedics. Street Triage doesn’t address this and although some mental health nurses have balked at the idea that they may not be appropriately skilled in pre-hospital care, there are many more mental health and general nurses as well as doctors who have agreed with me.
When these difficult cases were discussed as our s136 processes were put together in the West Midlands a few years ago, an awful lot of health professionals said, “Well, if someone is being restrained by six police officers, they’ll have to be taken to the cells.” And the idea that anything else would happen genuinely seemed to be an affront to common sense. Of course, one answer to this remark is to say, “Michael POWELL” or “Sean RIGG.” The fifth anniversary memorial for Sean RIGG will be held at Brixton Police Station this evening; and the tenth anniversary memorial for Michael POWELL will be held outside West Midlands Police headquarters on 07th September this year.
There are other names that could have been given, and I mean no disrespect to their memory that I didn’t list them all.
POLICY AND GUIDELINES
Of course, in these difficult cases there has followed various kinds of legal investigation and activity that has lasted very many years, without really providing the clarity or reassurance that anyone needs. But statutory inspections around police responses and healthcare provided tend to look at law and relevant guidelines.
When you do this for s136 you end up reading the NICE Guidelines on:
You also look at –
- Royal College Standards on s136
- Code of Practice to the MHA
- Code of Practice to PACE
- MS v UK
- Academy of Medical Royal Colleges
- And of course – the Adebowale Report
Again, this list could keep going on and on – how many more vulnerable people have to die and suffer untoward indignity; how many more reports do we need before we look at our nation’s emergency mental health care arrangements and realise the extent of “the Adebowale deficit”? Parity of esteem?! – when we lock up people in police custody for being ill, failing to recognising some mental health crisis as the medical emergency it is?
COMMISSIONERS AND PROVIDERS
We hear that the Care Quality Commission are undertaking a review of Emergency Mental Health Care, at least in part to Lord Adebowale’s Report. We should rejoice at the notion that maybe something will come from this. Maybe it will, but I admit I’m doubtful for reasons beyond the CQCs control.
The CQC are a statutory body regulating providers of NHS services, essentially to check the quality of their provision. They don’t inspect the “commissioning” of those services. If you’re reading this from a non-NHS background, you may not appreciate the distinction. I wrote about NHS organisation recently, but basically Clinical Commissioning Groups decide what health care is needed for their area and “commission” those services from “any qualified provider.” The CQC then regulates those providers. So what if the CCG is not commissioning correctly … or at all? That’s up to NHS England so I look forward to learning where they will feature in this review, by examining commissioning gaps for specialist offender-health services.
The Adebowale Deficit has one further dimension: about legalities. Having been praised for the triage car initiative with Leicestershire Police, the Leicestershire Partnership Trust today published a press release. Keen to show the benefits it brings – I repeat: I don’t doubt them! – the press release wanted to contrast the skills a police officer and a mental health nurse brings to the situation and claimed that the CPN could undertake a “Mental Health Act assessment”, which of course they can’t. By law, Approved Mental Health Professionals undertake statutory MHAAs with DRs and mental health nurses play little or not part in it, except potentially to gatekeep the need. It is an AMHPs decision whether or not someone is subject to an application for their admission to hospital. Nurses have no legal authorities at all whilst deployed in a triage car which means a triage response to mental health crisis in private places is legally powerless: just like the police already were.
So here’s the Adebowale Gap in practice: the triage car turns up to support other officers dealing with a volatile situation involving a vulnerable person. There is little or no option but to detain under s136 MHA and this occurs in an area where the local PoS is not fully developed to RCPsych standards and is not properly staffed. A&E persist with the myth that they are “not a place of safety” and have always maintained that s136 detentions cannot be removed to their environment unless there are physical healthcare problems. The detention occurs and the patient, frightened for their life whilst suffering a terrifying psychosis, resists. Handcuffs, leg restraints are used after attempts to de-escalate have been tried and failed. An ambulance is called and it may or may not come to a s136 intervention depending on where in the country you live)
The patient is now contained, although still resistant and we need to expedite their onward movement to a more appropriate location than a street. Where are we going now? Who decides? I have asked this question of people directly involved or party to Street Triage schemes. The answer I’ve had to that scenario is depressingly predictable: the cells. And I’ve heard doctors and nurses as well as AMHPs and police officers say this.
The only answer that thinking after all the rationalisation has been tried and failed, and on today of all days: “Sean RIGG, Michael POWELL, James HERBERT.”
Vulnerable people detained by the state deserve far, Far, FAR better, regardless of how hard it is perceived to be. This is “The Adebowale Deficit”.
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