It is my massive pleasure to publish a guest blog from Dr Jenny HOLMES who is a psychiatrist, a police doctor and works with the Faculty of Forensic and Legal Medicine. That combination of background and experience should indicate that what you are about to read is an insightful, thoughtful contribution to the fallout from Monday night’s episode of Panorama. You can follow Dr HOLMES on Twitter – she is @NorthWestDoc and I’m grateful she has found time to write this piece for us all.
I had high hopes for this programme. It started well, a realistic portrayal of Custody: not an especially busy period, just regular shifts. The Police came across as human, empathic, doing the best they could with blunt tools. Equally their tired frustration as they tried to secure advice and assessment from Mental Health Services.
The programme lost its way a bit, tried to tell too many personal stories and there wasn’t enough time to do justice to everything. The debate between Irene Curtis and the Clinical Director of the Mental Health Trust was highly edited and became polarized with the disagreement between them of the practicalities of using A&E as a Place of Safety.
Equally the Street Triage segment came across as the Police providing a fast car for a crisis mental health response: s136 could not have been used in this instance as it was a private dwelling. The crisis could have been managed by dispatching an ambulance to bring the woman to Accident and Emergency for assessment by the Crisis Team and the Police Officer could have been sent to deal with core Police business. I don’t doubt the Street Triage model will help drive down s136s and I do believe such reductions need to be health driven. Good liaison between Health and the Police both in advance for repeat s136 cases and in real time as we see in Street Triage will reduce unnecessary detentions.
The response of fellow Mental Health Professionals on Twitter during the subsequent #mhpolchat discussion really surprised me. Many felt that the people portrayed were probably not mentally ill and would not hit the threshold for services hence were primarily a Police problem. If we look at points of entry in to health systems we don’t see these attitudes applied elsewhere. Accident and Emergency nurses don’t block the entry of ambulance patients with arbitrary exclusion criteria. Nor do General Practitioners: beyond a triage of urgency patients enjoy open access to a medical/nursing opinion as to whether they require investigations/referral onwards/admission etc.
The NHS Commissioners who are currently looking at Offender Health Pathways also see Police Custody as a potential point of entry into Health and it makes sense that if you treat health problems such as substance misuse and mental illness which have a strong link to criminality or the criminal justice system you can reduce re-offending and drive down demand and cost.
The “25%” that the Police talk about are a complex mix of mental health (both acute and coincidental), substance misuse, physical ill-health, social and emotional crisis etc. I find it pretty challenging as a doctor working out what’s what in these complex people so how on earth do we expect the Police to?
I also need to be clear that the Police are not asking Health to take on their problems. I’m never asked to make a quick arrest, interview witnesses or secure a scene when I’m the duty doctor in Custody. They are an organisation whose raison d’etre is crime: the Home Secretary repeatedly tells them that their job is “to reduce crime, nothing more, nothing less.” Whilst this may be a touch simplistic, it influences the mind-set of officers at all levels whose performance is often assessed against crime activity in their area and on the investigation of crime.
When they encounter someone on the street and there is a criminal offence they make judgements about whether to arrest for it or apply discretion. That’s what they are trained to do. To exercise s136 they need to suspect a mental disorder, broadly defined. An individual Officer will exercise his or her power of arrest many thousand times in a career and section 136 only a handful of times. Once a person is in custody under arrest all they want from Health is a timely opinion on the person’s needs and close partnership working to determine whether an individual and the public at large may benefit from them being diverted from the Criminal Justice pathway. In my experience that’s less than 10% of people at point of arrest who may also still need a plan of support around their health needs even if they are diverted.
PLACE OF SAFETY OPTIONS
What’s the big deal about not using Police cells as a place of Safety for s136? Let’s look at the arguments: Firstly it criminalises the mentally ill. Yes, from a purist perspective but someone taken to Accident and Emergency still appears to all intents and purposes to everyone else to be under arrest.
Secondly it can worsen the mental state. The Panorama programme certainly showed how difficult the environment is. But it also showed real compassion and care from Police Officers. I have seen Police staff bring in bags of clothes for the homeless. Feed them up. Provide extra blankets. So yes it might worsen the mental state and if the custody suite is busy it’s a noisy, scary place and the staff are pushed for time.
However there are three main reasons I believe we MUST have Health Based Places of Safety. Firstly a proportion of these people will have serious physical health concerns. Diabetes, Liver failure, Sepsis, Head injuries……there must be a safety net so we don’t miss these cases.
Secondly the dangers of restraint. There are too many deaths of mentally ill people after Police restraint. Health Guidelines emphasise the need for Immediate Life Support trained health staff to manage restraint in psychiatric facilities. That there must be a review of physical and mental health within two hours of restraint. Police restraint techniques rely on pain compliance and this does not work in the mentally ill but worsens the situation. Let’s get them to an appropriate health facility, by health transport and keep them safe.
Thirdly s136s contain a large proportion of people who have health needs who need health solutions. In my area the ‘hit rate’ for s136s is that 20% are admitted either detained under a s2 or 3 of the Mental Health Act or informally. Another 30% get some sort of mental health follow up. The rest usually have some recommendations made to attend their GP, access addiction services, third sector services etc. In areas where health have really focused on partnership working around s136s the percentages are even better with 80 % or more getting admission/follow up.
Its World Suicide Prevention Day today. David in the programme had lots of factors that made him high risk for completed suicide: male, living alone, estranged from child, alcohol misuse and previous self-harm. So finally I want to quote from the National Institute of Clinical Excellence’s Guidelines on Self Harm for Healthcare Professionals.
People who have self-harmed should be treated with the same compassion, dignity and respect as everyone else using healthcare services. Judgemental or negative staff attitudes towards those who have self-harmed can contribute to poor experiences of care, and may also lead to further self-harm. People who have self-harmed should have an initial assessment of physical health, mental state, social circumstances and risks of repetition or suicide. This can identify if a person is at immediate physical risk, so that steps can be taken to reduce this risk, including referral for more urgent care if needed
A comprehensive psychological assessment should be carried out each time a person presents with an episode of self-harm. This is aimed at identifying why it has happened. The assessment can also start a therapeutic relationship with the healthcare professional and be used to develop an effective management plan
Last night I saw distressed people who had self-harmed or had strong suicidal ideation, some of whom had called the Police themselves, in Police stations. If they had called an ambulance they may have got care in accordance with the NICE Guidelines. As a Psychiatrist part of my job is to advocate for some of them most vulnerable people in society. It’s not acceptable to me that there is such disparity of care just because a person has ended up with a Police response to their self-harming behaviour and distress.
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