The excellent Dr Jenny HOLMES remarked in her presentation to the Police Federation National Custody Forum conference this week, that she thinks the reduction in 136 needs to be health led. I don’t doubt for one moment that there are things the NHS could do differently which would impact upon numbers in section 136.
Very briefly, these could include improving the responsiveness of some out of hours services so that we didn’t see demand deliberately deflected to 999 services; improve monitoring of section 136 usage, so that repeat s136 detentions and the detentions of already-known MH patients is routinely reviewed to capture the learning that this offers. For example, in a sample of 1,000 section 136 detentions a few years ago, I saw over a dozen examples of multiple detentions (in a short period) and around 50% of those detained were current or recently discharged / disengaged patients from that trust. 30% of those detained were out-of-area patients, so presumably at least some of them were also repeats; and some of them were known patients, if these two features had been analysed over the borders.
POLICE LED REDUCTIONS
However, and whilst not disagreeing with Dr HOLMES, I also want to argue here that there is great potential to improve the police approach to section 136 in such ways that should lead to a reduction in usage across the country and to subsequently argue that this is probably necessary for Street Triage to succeed on any level, regardless of any arguments about the concept.
My police force detains around 1,000 people a year. Sometimes just over, sometimes just under – but always in the 950-1050 bandwidth and this was true before the introduction of health based places of safety that have seen 97% of people accessing the NHS. I could, but I won’t, name you several police forces which are roughly half the size of mine who use the power as much, or more than we do. One in particular, when allowance is made for population difference and number of officers, uses the power four times as often. One has to conclude that outcomes for section 136 are affected by usage when we learn that in some other areas, nowhere near 97% of detainees are accessing the NHS for assessment and when we look at outcomes.
If demand is too great for capacity, you either have to increase capacity or reduce demand or you will continue to have access problems. If NHS colleagues and managers are sitting in their world wondering why the Force they work in uses section 136 so often and doesn’t think about outcomes as (just one) indicator of appropriateness, you can imagine why they won’t resource extra places of safety and staff them properly. It’s spending money for somewhat perverse purposes.
OUTCOMES FROM SECTION 136
We’ve heard from some MH services that large percentages of detainees under s136 are released without follow-up. Professor Louis APPLEBY often remarks how approximately 20% of people detained are subsequently admitted to hospital. (These are based on national figures that I’m not convinced are counted correctly, but let’s run with it.) In the piece that he wrote for this blog, he remarks upon how use of s136 has risen since his time as a junior doctor when he was concerned that the police threshold for using section 136 was too high. Now I’m the first to keep pointing out that “admission rates to hospital” is just one part of assessing how section 136 is used. I remember being told years ago that an area in the West Midlands would not begin to look at provision of a place of safety within the NHS until we “sorted out the problem” that officers were detaining 150 people a year and “only” 60 were admitted. Apart from thinking this a good percentage(!) I asked “how many people who are not admitted get referred to community mental health teams or their GPs arising from the assessment?” He didn’t know.
I recently went to visit the Birmingham Place of Safety that I was part of establishing three years ago. Over a lovely cuppa – which they had to make me, because I took them biscuits – I enquired about updated figures on their outcomes and was astonished at what I heard, even though I knew they were good. They have an average of 45% admission rate, following use of s136. Yes: almost half those identified by the police require hospital admission. More importantly, in recent months there have been occasions where 100% of those detained by the police, received a health outcome — in August, 42% admitted, 38% referred to a community mental health team and 20% referred for mental health reasons to their GP. No-one was simply released without follow-up. << I submit this has to validate police use of the power and I did just wonder whether it may mean we’re actually slightly under-using it?
My good friend Richard CLARKE, the lead nurse for PoS in Birmingham agrees on this point: if this can be done in Birmingham, it can be done anywhere, given the will. Low use of s136 by the police, leading to high admission and referral rates by the NHS. It is no coincidence: before this service began, we made all significant professionals undergo a two-hour multi-agency training programme. Richard has spent many hours (of his own time!) flogging around police stations, delivering further inputs and Q&A opportunities to police response teams, who make the majority of these interventions. He also does the same for British Transport Police, who contribute to Birmingham’s figures because s136 is used at New Street railways station a notable amount. I have done likewise with mental health professionals and I’m looking forward to speaking (twice!) to the Royal College of Nursing next month so we can all come to understand each other.
GETTING IT RIGHT
When I’m asked to summarise what is involved in “getting it right”, I focus on two things —
- How officers approach the “arrest for an offence” or “detain under s136” quandary – you will remember the case of “Dave” from the Panorama episode. He punched someone in the street whilst hitting the criteria for section 136 so could have been brought in for either issue. Hampshire police chose the substantive offence in Dave’s case, which links on to my second point. Worthy of note that Dave subsequently pleaded guilty to assault. I think Hampshire got it right in that example.
- How to approach the question of “intoxication” where mental health questions form in an officer’s mind – we know that some argue that section 136 should literally never be used when intoxication is evident: how can an officer tell whether the presentation arises from drug / alcohol issues or from a mental health problem? My advice is to stay clear of section 136 unless you have objective information of a mental health background (police records, NHS information, third parties involved in the incident.)
So the guidance I normally give is that where officers have a “136 option” and another option involving arresting for an offence (including alcohol offences), you choose the offence, unless —
- It is a trivial offence, or actually a victimless offence.
- The victim is not ringing about the crime, but about mental health support for the person concerned.
- In all the circumstances, suspected mental health problems are the main issue in play.
- Remember: once you’ve started down the 136 route, you can subsequently revert to a criminal justice pathway, but not the other way ’round.
This means that section 136 is not used where mental illness leading to apparently “odd” behaviour is sheer speculation on the part of the police, it means that substantive victims are not ignored after being harmed by crime. It means section 136 is only used where there is very good reason to think mental illness is an issue and where there are few other options available, but to use it. This position then puts everything back in the hands of the NHS, to reduce section 136 yet further, as Dr HOLMES suggests; perhaps even via Street Triage.
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