Even when I started writing this blog just under two years ago, policing and mental health received nothing like the coverage it now gets and there are various formal and informal ways of seeing this. We’ve seen prime time television coverage devoted to it in last week’s Panorama, we’ve seen newly elected Police and Crime Commissioners getting interested in it, including Matthew ELLIS in Staffordshire who has hired a “mental health expert” to work for him on the issue; we’ve seen senior officers like Chief Superintendent Irene CURTIS giving the issues high-profile when she took on the job as President of the Police Superintendents’ Association. We’ve seen the Home Secretary talking about it and her speech at the Police Superintendents’ Association Conference in 2013 including two updates on all the issues I’ve covered in almost 350 posts: “We’re talking to the Department of Health about this” and “We’re rolling out Street Triage.” Chief Supt CURTIS called very specifically for things which stand a chance of helping: ammendment of the Mental Health Act and end to the use of police cells as a place of safety.
RISKING THE WRONG REACTION
This post argues that others risk over-simplifying complex problems and therefore we risk having the wrong reaction to them by introducing simplistic solutions and making simplistic statements. For example, In the debate about the use of police cells, I have repeatedly heard the phrase “cells are no place for the mentally ill.” What, ever?!
We all know what this statement probably means, it’s probably a call for the end of the use of police cells as a place of safety under the Mental Health Act. But why over-simplify and call for an end, full-stop? What should we do with someone with mental health problems who has murdered someone else? It strikes me that police custody is exactly where they should be whilst that is properly investigated, with supporting mental health assessment and care whilst detained, obviously. Indeed, if someone has been accused of an offence, taking them to police custody may be absolutely vital in terms of detention there triggering legal rights for police officers to seize evidence, take forensic samples, search premises and draw inferences from silence to questions. So where else would we ever go?
Well, some mental health presentations are so serious that people should be removed to Accident & Emergency departments after detention by the police under s136 or for offences and if that is the case after an arrest, then so be it. The person can be transferred to police custody after the immediate medical issues are stabilised or assessed. This is no different to if the police had arrested someone for a serious offence who injured themselves trying to escape the officers: prioritise the urgent medical issues in play at the time of arrest, custody as soon as you can once done. Parity of esteem has to work both ways.
The reality is that about ten times as many people are arrested for criminal offences whilst mentally distressed as those detained under s136. In the majority of those cases, their mental health disorders are not so serious as to make any difference to the criminal justice process that should subsequently follow an allegation of crime against that individual. The outcome may or may not be different in light of any assessment or input that is undertaken by mental health services. And again, think about parity of esteem: the police service detain plenty of people for offences who have asthma or diabetes, cancer or heart problems – why should a person living with a mental health problem not be detained in police custody if an allegation of crime has been made against and they were lawfully arrested? Unless their medical condition is so serious as to render this dangerous and assuming their rights and appropriate safeguards are put in place, it could be very necessary step to achieving justice for victims. It is a complex balancing act that comes with the territory.
If this is not what was meant by “police cells are not an appropriate place for the mentally ill” (whoever they are), then we need to raise the sophistication of our public debate.
But this goes further —– if we are now having debate on the issues of policing and mental health, either because we want to see better integration of services, improved access to NHS services or less police time / money spent, then we need to see responses to the issues highlighted which also don’t over simplify. It probably comes as no shock to anyone who regularly reads this blog, that I will immediately hone in on “Street Triage”. It is a solution-version of the over-simplification in this arena: officers dealing too frequently or too ineffectively with mental health related demand, so let’s give them a psychiatric nurse to improve things. No doubt it does improve things – 40% reduction in s136 usage; improved access to MHA assessment pathways, etc.. Who wouldn’t welcome this?
Most of the section 136 processes that I have ever seen – and I get emails from various forces asking me to check over new policies and proposed revisions to current policies – massively over-simplify the complexity of the issues that people detained under this section of the Act actually have. We still see NHS organisations calling for “violent and / or intoxicated people to the cells” in a place of safety process. We see this even though officers have been prosecuted amidst suggestions of neglect that this approach placed people at risk. We’ve seen HM Coroners criticising the failures to see through a fog of aggression and intoxication to recognise a legitimate medical emergency and we’ve seen clinicians agreeing that the police are right to think of some aggressive, intoxicated presentations as representing medical emergencies. You need only look at the recent Royal College of Psychiatrists publication on the “Prevention and Management of Violence” to see this. But because putting drunk, violent people in cells is intuitive to some, including to some psychiatrists and senior NHS managers, it represents an orthodoxy even though it could be clinically outrageous to do so for that vulnerable person at that time. So how do we know what’s what? Well we certainly don’t do it by over-simplifying the process.
These things are the solution or process equivalent of “police cells are no place for the mentally ill”. Street Triage leaves almost totally unanswered the issue of immediate needs in private premises of some vulnerable people and triaging of need by mental health nurses leaves the question of whether they are equipped to identify what could (also) be physically unwell people. And if we know that psychiatrists can miss underlying physical health care issues, are we confident mental health nurses will be better? Or will we still see police officers calling ambulances? I know I still would.
Directing aggressive, intoxicated patients to cells to contain them, leaves totally unanswered the potential of head injuries or brain tumours, diabetes or excited delirium to have brought about someone’s disturbed and / or confused state.
STATES OF COMPLEXITY
The reality is the reality: and it is complex. We are policing in the twenty-first century, a deinstitutionalised model of mental health care which still hasn’t reached a consensus of what causes mental distress and how best to approach it by using drugs or talking therapies which were barely conceived when the laws governing police interaction were written in the 1950s.
We then give very little training to officers, watch them get it wrong and decide that the solution to this is a range of over-simplistic notions that fail to take (full) account of the complexity we haven’t yet fully understood because no-one is researching it properly.
So this doesn’t mean we can look at the equation on the left and explain anything by showing off our nine-times tables.
The police are doing what they do, whilst under-trained, alongside an entirely fragmented health system, still wrestling with the provenance and aetiology of mental health disorders and we are doing this in an era of cuts to public services and other financial cuts affecting individuals and increasing the mental health burden of disease in the UK – we see this in the rising suicide rate. The laws we have don’t even allow our public services to keep people safe in their own homes without criminalising them and there seems little appetite to change that or do anything else to solve the issue, at the moment.
To think this is simple stuff that will benefit from simple solutions is quite naive but I will go further: to push for simple solutions amidst that naivety is to create further problems that compound the likelihood of adverse outcomes for vulnerable people. We know that things go wrong in policing because the mental health system we operate in the UK, implicitly wants the police to do the wrong thing because it isn’t set up to work with the police in doing the right thing. There is just some potential for simplistic solutions to make this even more likely than it ever was before whilst superficially making it look better. And this is why we need more proper research by world-class academics and far less over-simplification by people who choose to put their two-penneth into the public domain on issues they either don’t understand or have massively over-simplified.
Winner of the Mind Digital Media Award.