Remember a statistic I’ve pumped out a few times about the difference between the number of people suspected or identified in police custody as having a potential mental health problem in need of assessment and the actual number? For those who don’t – research suggests that the police will identify around 12-15% of people who are arrested as needing to be seen by the force doctor because of mental ill-health. This is to establish, legally speaking, whether they are fit to be detained and fit to be interviewed. Medically speaking, it is to determine whether they may need assessment under the Mental Health Act.
We know that the police do not always manage to identify people in custody – in some sampling by a police force in the south of England, they provided their arrest data to the mental health trust’s Criminal Justice team and found that fifty percent – yes, FIFTY! – were people that a) are known to the MH trust; b) were known previously; OR, c) need to be known by virtue of what has emerged from the arrest.
In fairness to the police, if someone’s condition is not manifested in obvious, overt behaviour and unless the person concerned or someone connected to the incident tells the police there may be a history of mental ill-health, then the only thing that may prompt questions is anything on police records, like PNC markers. That of course only works if someone has been if contact with the police or arrested before.
So how do we improve the rate of identification? Well, it could be easier than we think –
I’ve wondered aloud on numerous occasions over the last two or three years why we couldn’t just have a number within the mental health trust which the police ring 24hrs a day for everyone who is arrested. When they ring the police would simply say, “We’ve got Michael Brown with us” and give his date of birth and address before confirming whether the police doctor does or does not have concerns about his mental health or have indications of a history of mental ill-health. Then this next bit is key –
I wouldn’t want the Mental Health trust to tell me anything about Michael Brown – no need to breach his right to medical confidentiality at all. I would only need them to confirm to me whether or not they are coming to properly assess him in custody and to then decide, after a full appreciation of the legal and medical condition he is in, to decide whether disclosure of anything at all might enable a better decision by the police that balances his rights and entitlement with issues that arise, if any, for public protection.
This “assessment” would either be a generic MH assessment by a CrisisTeam nurse, OR a statutory MHA assessment by an AMHP and two DRs, depending on what the FME had indicated was needed. Of course, if the nurse arrived and felt a statutory assessment were required, the one could lead to the other.
CRISIS TEAM ASSESSMENT
I’ve written before on my idea of Liaison and Diversion. We’ve seen time and time again how patients can reach arrest after crisis without having sought help, irrespective of whether they are open to mental health services. We have seen that a timely sharing of information whilst we are still at the pre-charge stage could lead to better criminal justice decisions to don’t unnecessarily criminalise people, as long as the police have got diversionary mechanisms open to them. I have also argued that diversion should not just be something that “kicks in” when patients are so acutely ill that the need to be “sectioned” after an MHA assessment.
Bringing the CrisisTeam in at this stage, opens up all those potential benefits and whether or not the alleged offending in that particular case is attributable to that patient’s mental illness or not, could there be a more apposite point to intervene and re-consider what appropriate support could be than when a patient gets arrested by the police?
Just a point on confidentiality – you’ll notice that the opening telephone gambit involves the police disclosing information and the mental health trust disclosing none, at that point. This breaches no-one’s confidentiality, because the police have a duty when someone is under arrest to ensure appropriate clinical attention for detainees and to conduct thorough criminal investigations, which includes assessment of both the evidential test and of the public interest test. Disclosure at that stage of nominal details can be defended under the Data Protection Act against that background because the answers may well influence the police to do things differently.
The big question Mental Health Trusts will probably have is “what are the numbers?!” However desirable the idea may be, it will hit the brick wall of reality if the numbers are overwhelming. Well, the custody office area where I worked in the West Midlands, is usually around the third-busiest in a force, which is one of the largest in the United Kingdom. If it could be done there, I’d argue it could be done anywhere. There are around 24 adults a day arrested for offences, on average. Some days (far) more, some days less. But this clearly equates, on average, to one phone call per hour, to establish whether there is a potential to intervene to safeguard a vulnerable person and / or protect the public.
Is it beyond the wit of man for a police force and their local mental health trusts(s) to set up one telephone line that will be rung:
Sarge: “Morning, police station here. We’ve got Tom BROWN in, arrested for shoplifting – markers on PNC for self-harm and mental health. Doctor says he doesn’t need MHA assessment. What do you think?”
Nurse: [Rumbles computer keys]: “Yep – Assertive Outreach Team patient. We’ll send the CrisisTeam.”
Sarge: “Morning, police station here. We’ve got Joe BROWN in, arrested for assault – no markers on PNC for anything connected to mental health and Doctor says he’s good to go.”
Nurse: [Rumbles computer keys]; “Well, actually, he is a recent patient with the CMHT but discharged about three months ago. We’ll send the CrisisTeam.
Of course, not all detainees would need a response, nor do I envisage them getting one. This process is about having a sound basis on which to decide to “screen-out” some detainees. If the police have no markers on their systems, no concerns or any information from the detainee or people connected to the incident and the Mental Health trust have no history with that person as a patient, there would be no need to turn out or do anything differently. The MH trust response would only been potentially required if the police doctor was indicating MHA assessment was needed OR if the person was known to services and it was felt beneficial to be seen by the CrisisTeam for a generic assessment.
All of this links, in my mind’s eye, to the Liaison and Diversion model I previously outlined and for me, would significantly impact upon the number of detainees who receive inappropriately criminalising outcomes. To those who argue that it would increase the work of 24hrs CrisisTeam services: I would not disagree one bit and I know that this means NHS managers would have to work out how to do this against a background of budget restraint.
Maybe that’s true – but if we don’t provide the proper intervention at the right time, we’ll see the failure demand replicated in criminalising prosecutions of which only one or two need to become forensic cases coming out of the criminal courts to blow the budget argument sky-high. We know from some areas, that failure to provide Early Intervention services, which absolutely should include Crisis Intervention in police custody, will lead to prosecution of some patients into the secure NHS estate at massive cost. So even if you don’t get the human argument, above; the economic one is also there for those who prefer spreadsheets.
NB: on the budget restraint, did you know that the Department of Health has, for the second year running, returned money to the Treasury in what was described as “an underspend”? Here’s where some of that £2.2bn could have gone; or last year’s £1bn. Could have been used here, and also in the adequate staffing of all NHS Places of Safety. Both of these areas should be considered basic mental health services.
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