Panorama

So last night’s BBC Panorama was always up against it – all of policing and mental health in less than 30 minutes. We saw very human stories and in keeping with the proportions I see at work, most of them involved people with serious mental health problems who were actually arrested for a criminal offence, not detained under the Mental Health Act.

Tyler’s case highlights everything perfectly – he called 999 from his home after being unable to access the mental health care that he recognised he needed. The police, having no legal authority under the MHA, detained him for the offence of threatening to kill someone and that guaranteed his detention in police custody. Detention in a MHA Place of Safety (PoS) does not occur after arrest for an offence and although there is no reason why it can’t, legally speaking, it’s just not the way they are set up to operate. Those of us working the frontline of policing know that if he’d been taken to A&E, as he would have been with a head injury that lead to equally disturbed behaviour, he would have been quickly checked out “physically” and then declared fit for custody. Why can’t he get checked out “mentally”, demonstrating a parity of esteem?

Dave’s story was also interesting: he was arrested for punching someone in the street, which means officers recognising his mental health issues, could have chosen to prioritise his mental health by detaining him under s136 MHA instead. In Hampshire, this may not have made much difference because he would have been removed to custody anyway, given his resistance and aggression. However, officers in Birmingham could have detained him MHA and accessed the Oleaster Mental Health Unit where they would have stayed with Dave supporting our NHS colleagues in managing his risky behaviour. Dependent upon the outcome of the assessment, which would have happened faster, he could still have been prosecuted for assault, if that had been felt appropriate.

Speaking to Dr Lesley STEVENS, the Clinical Manager for Southern Health NHS Trust who provide mental health services to Southampton – so many of the problems for vulnerable people in the care of the police is the commissioning of services and the funding given to the providers. I’m sure if the cheque book were opened and Place of Safety services fully established in proper accommodation, numbers detained in police custody would shrink – as they have in the West Midlands where around 97% of people detained do not go to police custody. And whilst Panorama hinted at it, I would have loved the point to be shouted far louder, that the number of patients detained for offences dwarves the use of section 136 MHA by a factor of TEN. Which means we need to see far, far better Liaison and Diversion services and I would have liked to hear that far more prominently.

But Panorama made a valient effort to raise awareness of the reality of custody and I agree it showed my working day very well. It seems the objective was awareness raising and I think it did that without telling us anything new. This comes at the inevitable cost of getting into the causes of the issues with some depth and moving beyond “Street Triage” as the solution to everything, because it really isn’t. In a one-hour version of this programme, I would have wanted more from the medical and social care professionals and I wanted to hear the word “Adebowale” and didn’t.

In particular, I would have loved to see an interview with the lead Commissioner for mental health services in Southampton’s CCG. I heard nothing of Approved Mental Health Professionals (many of whom were shouting at their televisions as the programme broadcast) – the role of social workers is always going to be key in a system that rightly looks to operate a least restrictive principle, detaining people in hospital only where other support is not appropriate. I also wanted to hear why ambulance services are often not fully involved in this area of healthcare.

There was a particular distraction to the show, caused by the reporting of a side debate – Chief Superintendent Irene CURTIS, President of the Police Superintendents’ Association was interviewed and – amongst other points made that weren’t used! – called for an end to the use of police cells. Having discussed this with her, I know she means an end to the use of cells as a Place of Safety under the Mental Health Act, calling instead for A&E to be used where mental health units are unable to accept. This would merely put the UK on a similar international footing as countries like Australia, Canada and South Africa who do not allow cells to be used. Dr STEVENS’s on-screen reaction was described as “Shock”, stating that A&E would not be suitable. However, this betrays an attitude the police custody probably is suitable despite it representing an argument for the ongoing breach of Para 10.22 of the Mental Health Act Code of Practice. To deny Ch Supt’s CURTIS view, is to argue for potential breaches of statutory guidelines and to increase the potential for patients to be held away from mental health care. And this debate is a red-herring: arguing about A&E or cells as the best back-up is like trying to decide which car you’d prefer to use if you were sailing to France. You obviously don’t want a car at all, you need a boat – and this means properly established MHA Places of Safety so that 500 people a year in Hampshire are not detained in custody at all.

NB: Having reflected further on this programme, I am going to do a follow up to this post focussing on how the tactical examples given did not serve the more strategic and political points being made.


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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16 thoughts on “Panorama

  1. Firstly let me say I adore your blog, thank you for the time and effort you put into it. As someone who has been detained on a 136 and placed in a Police cell as a PoS, it brought back many bad memories which I was fully aware it may. I recall getting very frustrated with the Police as I was put me in the cell as I hadn’t “commited” a crime, at the time it felt my only crime was to have a “mental health disorder”. Once I was assessed and allowed home I spent at least an hour in the bath at 4am trying to “cleanse” myself of the experience. Not good. Our local commissioners have recently re-commisioned the local CAMHS service. there was a provider that would have been able to provide appropriate 136 mental health suite in the bidding process, who did they choose? A provider.who will put our children in the Police cells! You are so right to highlight the role of commissioners I believe the lack of accountability for some of their decisions is appalling.

  2. I was disappointed as I felt it was potentially misleading. It gave the impression that a shortage of beds in hospitals resulted in peopel being held in custody, didn’t clarify the different issues for people held under a s136 and people being held for a crime who also had mental health issues amd was misleading about how long people can be held under s136.

    There was a depressing focus on cost, when are poeple wiith other illnesses ever endlesslyy told how much they coas the system.

    The episode with the ‘triage car’ was worrying. I would be very worried if I had to wait for a triage car to be sent from 20 miles away. I was also alarmedat the judgement that the opinion of a mental health nurse was given so much weight. And a s136 could never have been used anyway as the person as it was in a hopuse not in a public place……

  3. I work as an AMHP in a Crisis Team that has a s136 suite.

    I found the programme difficult viewing and feel it was poorly researched and sensationalised mental health problems – depicting people with ‘mental health problems’ as violent and uncontrollable which has the potential to undo many years of campaigns to destigmatise the label of mental health problems.

    Most of the people portrayed in the programme appeared to have a whole host of complex social problems which resulted in either substance misuse, violence, aggression and family discord. These are not mental health issues and should not be labelled as such.

    The s136 protocol that I follow states that a person detained on s136 MHA should only be taken to a police cell if they are violent and unmanageable in s136 suite or A&E or if they are so intoxicated they are not assessable. Those portrayed in the Panorama programme would not be suitable for a s136 suite place of safety for the above reasons.

    This team is about to trial a ‘Street Triage’. AMHPS have not been approached to partake in the trial – WHY?

    In principle Street Triage is a good idea but there are concerns – this Crisis Team does joint assessments. The practioner will be making a sole decision – compared to if someone is in the s136 suite then the AMHP does a joint assessment with a s12 Doctor and then has the privilege of an experienced team in the office to discuss other points with.

    The programme misrepresent the (acute) shortage of beds as a factor behind these issues. Lack of beds are a huge problem but if someone requires a bed then we will find one, even if it is at the other end of the country (as if often the case). Mental health services are not here to pick up and find solutions to the deep seated problems of society.

    It takes years for psychiatrists and AMHPS to train to carry out Mental Health Assessments and make the appropriate decisions regarding Mental Disorder and pathways, I was disappointed that no frontline mental health practitioners were interviewed. The Police are not qualified to make these sensitive decisions and often ‘misdagnose’ social problems and responses to them as ‘mental health problems’.

    1. Thanks Sara, I appreciate the comments and understand that point of view. Of course, on of the difficulties in them spending a week filming, is that the examples that came in are what came in. My main concern was that either all or most of them were actually people arrested for an offence so the s136 protocol would not have been of any particular application.

      Secondly, I’ve heard many times the suggestion that where the police have (rightly or wrongly) detained people under s136 and they present as violent or intoxicated they should be removed to thec cells. The problem with this approach, is it is usually one that is usually forced upon the police, not agreed by them and it is the subject of various IPCC enquiries and Coroner’s cases where restraint has led to untoward outcomes or intoxication has masked other problems. As a point of law, custody sergeants would be quite entitled to decline the detention of people in cells who have presented like that who are not triaged first (ambulance / A&E / PoS staff – take your pick.)

      Your point that AMHPs and psychiatrists are trained for years is precisely why the police should be discouraged from attempting to diagnose anything and the presentations that we saw last night would, to any lay person, be considered “mental health issues” and would be acceptable conclusions for officers to reach in terms of assessing what might be a “mental disorder” for the purposes of s136. The issue is whether the officer, properly trained and led (about which there are many questions nationally) has acted in good faith against the five criteria in s136.

      We know that forces vary in their use of the power – some include examples of misuse and abuse, so I’ve spent today telling a room of senior officers they need to lead staff better to use it more accurately. They approach I have just advocated led to health outcomes in Birmingham for 100% of those detained. We also know that Hampshire and West Midlands use the power around the same amount per year, despite West Midlands having significantly more officers and a significantly larger population.

      There is a load of stuff going on in all this: it needs carefully unpicking without the professionals involved regarding them as being on “one side” of a conflict. It is a joint operating problem, mis-understood on all sides and we need senior leaders to build a consensus.

    2. I’m watching it now on catch up and have lost count of the number of times ‘mental illness’, ‘unwell’ etc, unqualified opinions are being misrepresented as fact by the programme makers.

      I haven’t yet seen a single person here suffering an acute psychotic or severe affective disorder. MH services are resourced to deal with the +/- 1% of the population that exhibit these illnesses.

      Anyone requesting admission and ‘recognising’ their ‘mental illness’ is showing insight into their condition and therefore missing a major clinical marker for SMI relapse. Show me someone who believes there’s nothing wrong with him, that he’s being kidnapped and medicated against his will despite holding some very unusual beliefs that could point to a marked distortion of perception, or that is behaving in a way suggestive of severe mood elevation for example. None of these people will be angling for admission under MHA – why should they? Remember, in their minds there’s NOTHING wrong with them.

      I would gladly do frontline triage work as suggested was being piloted. It’s a change in emphasis given that our Crisis Teams are, despite the name, emphatically not a ‘blue light’ service. Unfortunately i suspect we would continue to turn away the gross majority of those being presented to us for consideration.

      1. Michael – good! I welcome your disagreement. I’m ready to be wrong, i’m ready to retract (maybe). But just remember the power that you hold before here you post and moderate accordingly.

        If, as in the past, i find my comments belittled and lambasted, or you show disparaging and dismissive attitudes towards the nursing profession en masse, i will simply vanish and you will lose another voice from a profession that is typically reticient to speak up.

        All yours.

      2. I sincerely hope I have never belittled or lambasted and would welcome feedback if you think I have ever shown disparaging or dismissive attitudes towards the nursing profession en masse, as you suggest I have in the past. Profound and serious disagreement does not inherently amount to disparaging or dismissing anything or anyone. We are allowed to disagree! Will comment fully later this evening.

      3. So who picks up the rest of the people who need help? The severly suicidally depressed who know they are depressed but can’t make themselves better? Or people with psychosis who have enough insight to stick with treatment? Or someone with psychosis who refuses treatment and manages to appear fine when they are seen by services? Have I misunderstood your comment?

      4. I’m not sure you have – I’m about to reply to it properly, but you’ve pretty much anticipated some of my responses. The need for an interface with the police about mental health is not just for those who have severe and enduring conditions and lack insight into their condition. My any standards: a person who has a history of bipolar disorder who punched someone and then spends several hours bouncing his head off a cell wall and door needs a mental health input in custody. This doesn’t presuppose that he will hit criteria for admission, but that’s not the only way to measure “success” in a referral or outcome.

        Ironically, it has been the police inability and / or unwillingness to try harder to identify this lower risk group with potentially complex and unmet needs that has previously attracted criticism. Now that a focus is being put on the whole breadth of conditions and co-existing personality disorders and / or substance abuse problems, the true extent of how disinegrated our mental health and health systems are is being revealed.

        The more I do this work: the more I realise that when you start to make in roads into the things that were previously criticised, you find the criticism alters because many professionals with comparatively little insight into the reality of policing didn’t realise what they’d find under the rocks when they picked them up and looked underneath. 😦

      5. Sorry for the delay, a manic week for me this week …. my main point of disagreement, is around the potential of the police to spot what you can see from your professional background. I have long since given up attempting to guess the outcome of an MHA assessment in police custody, because I’ve come to understand how ill-equipped I am to know whether patients hit the criteria. I’ve seen people who were “very obviously, severely ill” be released without any further follow-up because they actually weren’t, much to the amazement of me and my colleagues. I have also seen people who I never thought in a million years would be admitted or detained, receive exactly that outcome. This has included patients who indicate “insight” being admitted and those who don’t being released – sometimes with community follow up, sometimes not.

        So this is my main point: Some events (like MS v UK being the very best example of this) have included patients coming into custody with behavioural presentations like those we saw with Tyler and Dave – banished to the cells despite a s136 detention. Police officers (and police medical staff) have then spent over 48hrs or even over 72hrs attempting to care for them, whilst their own blood pressure rockets because of the sheer worry of being responsible for holding people away from healthcare whilst indirectly inflicting significant indignities upon them amidst concerns that they are ill.

        My main objection to the Panorama reaction by some mental health professionals has been firstly, not all mental health professionals agreed. Some where appalled at the “they’re not severaly mentally ill” and “they calmed down when sober” kinds of responses. See the Guest blog on here by Dr Jenny HOLMES to see but one example of that. So it was all very well AMHPs and others shouting at the television about substance induced behavioural problems amongst people who were not severely and enduringly mentally ill: my point is, there is absolutely NO WAY a police officer can be expected to tell the difference when the event commences with suicide threats, backgrounds known or supected to involve conditions like schizophrenia and bipolar disorder and others.

        Some of us have spent hours with the Tylers and Daves of this world from the first points of arrest, only to see them assessed as severaly mentally ill and admitted. But we have also seen them discharged and frankly, we have wondered why and we have wondered whether any community follow up or GP follow up will be successful enough to mean we’re not back to square one a week’s time with a similar event. I can respect the outcomes of assessments – what I admit I’m struggling with, is what I consider to be a too-casual attitude towards keeping people safe that fails to see the dangers (for some) in being held in police custody, under conditions of restraint. That most end up calming down whilst a minority who are severely ill usually end up OK, is not how I was taught to approach risk assessment when the stakes are often measure in legalities and fatalities.

        I repeat my main objection to the show: because I also have reservations about it — most of those people were arrested for offences, so they always were going to have to go to custody. There was only one s136 detention in the whole programme and she looked a fairly calm character on camera who I did wonder should have been in a s136 assessment suite. Otherwise, it was really a programme about how we get timely support for people under arrest for criminal offences who are suspected to have mental health problems of the broadest kinds, including PD, substance abuse and lower level disorders like depression, anxiety, etc., etc.. I get that. Just as MH hospitals keep telling in relation to patient-on-patient or patient-on-staff assaults should not lead to a police attitude that “justice stops at the hospital gate”; I also think the health system need to realise that “healthcare doesn’t stop at the police station gate” and this needs to mean, timely, relevant care. If some people think that’s what happened on Panorama, I simply reply that you are not speaking with one voice on this, because some of your number very profoundly disagree.

        Genuinely interested in your views on my reply.

  4. Reading some of the responses to the programme has left me feeling a little bit puzzled in all honesty.
    As far as I understand it a s136 can be used when a person appears to be mentally disturbed in a public place, so when police 136 someone they are not making a judgement on whether the person is mentally ill only that the person poses a risk to themselves or others. It’s then up to the MHAA team to decide what support that person needs.
    In my county, sussex, we have a high rate of 136 to a large extent due to Beachy Head. A large number of the people 136ed will not qualify as ‘mentally ill’ but that’s not to say that they are not suicidal and therefore need removing from immediate danger. My worry with the street triage is that in places like Beachy Head where police need to quickly assess risk and remove people from danger, the street triage will act as a hindrance and potentially increase risk. If someone has been up to Beachy head but willingly goes to A and E for assessment there is nothing to stop them leaving a and e and returning to Beachy Head, so it seems to me the best way of insuring that persons safety is using s136 and then allowing mental health professionals to decide what help they need.
    Having had personal experience of 136 detention in police custody I totally agree that it is not ideal, however unless other places of safety are available it’s the only place they can keep people safe, which is the whole point. I’m concerned that desire to reduce the number of 136s is more about lack of appropriate provision within the healthcare sector than a genuine decrease in need of them.

    1. Good points, well made – I think some forces could reduce their use of s136 without creating risks, because some forces over use the power by getting it wrong on scenarios that also involve criminal offences and those that involve intoxicated patients. I’ve already finished writing my next blog which will be published shortly on that very topic and would welcome your views.

      But the thrust of what you say above, is spot on, as far as I’m concerned.

  5. I really want to view this as Tyler is a very good close friend of mine! unfortunately I am unable to view it!!

  6. I know that this is an old post of yours, but I recently re -watched the Panorma programme on Youtube and having read the comments above, I can say there are some I find actively disturbing, more so because they are written by people who claim to have the interests of those suffering from mental illness at heart.

    Firstly, the claim that mental health services were created and continue to exist for the tiny minority of patients who are severely psychotic and lack insight does not make any sense. The majority of mental health services are geared towards supporting people in the community. Community support requires a degree of mutual co-operation between the service user and supporter. The majority of people in the community do have “insight” in that they recognise they have a MH condition and engage in some form of treatment and receive (or are seeking) community support. It is still possible for a person to have perceptual disturbances and be aware that there is a problem that needs addressing, and as someone else says, a person can be severely mentally distressed and in need of support whilst still retaining insight and their “higher mental faculties”.

    In any case, if a person is intoxicated (and therefore probably violent/aggressive) a 136 suite is unlikely to accept the person for assessment anyway… (And a lot of people detained on a 136 are intoxicated). I think there is a continual need for police cells if there are complicating factors in the persons situation that might otherwise make them difficult to manage in a hospital environment.

    I agree that the general uproar about too many people being detained under s136 is more to do with the lack of provision within the healthcare sector and their insecurities around being unable to create good support packages for people who reach crisis point, but are otherwise seen as being able to make a fully informed decision about whether they keep themselves safe or not (supposedly people who are “just” depressed can do this).

    As a final point, I think street triage is another way of discouraging people from using front line mental health resources that are primarily reserved for ensuring treatment compliance amongst those who are seen as highly unpredictable, violent, or a possible danger. A suicidal person is in need of care and attention, but sadly their misery doesn’t qualify as a mental health emergency as depression doesn’t set off alarm bells in professionals heads (Depressed people are generally seem as “harmless”).. Depression can be a very irrational affliction, I’d disagree that tarring every depressed person with the same brush and assuming they possess full insight and capability in caring for themselves is a stupid and harmful mantra to adhere by.

  7. And another thing I forgot to add is that social deprivation, substance abuse, and mental illness are inextricably linked, it presents a fairly glib/disheartening understanding of “unwellness” to presume that it exists totally independent of these aforementioned factors!

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