Working in Partnership

I have been thinking a lot recently about the phrase “working in partnership” given the extent to which we hear it said and the extent to which we see it written into the interface of policing and mental health.  The Stevens Report from the Independent Police Commission wrote about this in Monday of this week.  Of course, superficially, it’s quite right: police officers have skills and legal authorities that mental health professionals often lack and vice versa, why wouldn’t we want to work in partnership where all of those skills and experience brought together help to keep vulnerable people safe and potentially get them faster access to necessary support and services?  The street triage pilots are perhaps a great example of this, superficially.

Mental health law being written as it is, there are various things within it that professionals could do to support each other in difficult circumstances, but which the law stops short of saying they must do and this is one area where working in partnership becomes very difficult.  For example, after someone arrives in a place of safety, having been detained under s136 MHA, there is nothing in law that prevents the police from staying to support that person and our stretched NHS colleagues – doing so would help them out considerably.  Section 136 suites are usually not sufficiently staffed to deliver the reality of the Royal College Standards on s136 – the receipt of those detained and release of the police within 30 minutes, even where the person brought in is exhibiting disturbed behaviour.  Surely, officer, it would be best if we worked in partnership to keep everyone safe?  Of course, there is no legal duty to do so – but local protocols are often written in such a way as to make it clear that unless the police surrender that legal position at the threshold of the building and agree to do as they’re told, “no access for you, officer!”  (Or the detainee / patient, which is actually far more important!)

I want to put forward some examples which show that the expectation is upon the police to “do as they could”, when this is often not reciprocated.  It is often not a two-way street and this has the effect of impacting upon the welfare and criminalisation of patients, as well as upon police resources and individual legal liabilities for police officers.  It is also at the heart of the erosion and the corrosion of much-needed trust between the police and NHS on the frontline.

A TWO WAY STREET?

We know that if an AMHP has undertaken a Mental Health Act assessment in someone’s house and made an application for admission under the Act to a hospital, they will often seek police support to detain and convey any patients that are resistant – including, resistant to any degree at all.  So we understand this when adult men have barricaded themselves into a room armed with a knife and have a significant risk history of hurting people, but we have seen examples of very elderly, frail dementia patients.  People with other physical health problems, mobility problems and so on, that have been subject to requests that the police use personal safety techniques designed for resistant young men who burgle, in order to compel them from their homes, to hospital.  Well, we could do it, if we’ve exhausted all the other possible options; but strictly speaking, there is no duty upon the police to coerce passively resistant patients who are not committing offences or breaching the peace.  Surely there’s a better way involving nurses with appropriate training?!  Come on – let’s work in partnership!

We have seen those other examples of police officers being asked to stay at places of safety where there is no legal duty to do so and no real policing purpose served – it may even be a cause of fear for the person concerned.  We see officers asked to attend MHA assessments in order to convey patients to hospital, because no ambulance is available or because it has been thought faster to ask the police to do it.  In one area, over 75% of all post-MHA conveyance is done by the police.  Around 10% by the ambulance service even though they are commissioned to do it.  There are other examples, not least on the subject of being asked, directed or pressurised to detain people in police custody where it would be medically dangerous to do so or even illegal on the basis of established human rights law.  And yet it keeps happening and it has already happened this week despite there their being two post-s136 deaths in police custody so far this month.  Difficult to work in partnership when the police are having to resist incredible pressure from medical professionals to do things that would get those cops suspended and criminally investigated if it went awry and there is little, if any, support for that predicament.  So why don’t we have officers just stay in your health-setting with you, keeping you and other people safe from any potentially disruptive behaviour and you can do “health things”, everyone confident in the knowledge that if someone does collapse under restraint they are not in a cell block a good half-hour from medical intervention.  I’m sure I read that somewhere, so come on – let’s work in partnership!!

I could go on.

Now there are a number of reverse situations: those where the police legitimately need to ask for health and social care support or action and where it is declined either because there is no strict, explicit duty upon health to do something that Parliament clearly inferred they should be able to do; or where decisions that frontline teams are under-resourced, lead to the deflection of demands to the police or ambulance service, despite a complete inability on the part of those professionals to actually cope with the incident sent their way.  We know in the current bed-crisis where patients are being sent hundreds of miles to access beds, that police services are being asked to illegally detain people in cells without any lawful authority whatsoever to do it, because we should “work in partnership” and put the needs of the patient first.  What about the patient’s rights, not to be illegally held by the police?!

We see this in “safe and well” checks – I can’t possibly tell you whether a mental health patient superficially exhibiting suicidal ideation is safe and well, not least because I will never be afforded any sense of their history.  Turn up to confirm that the person is alive, breathing and conscious and then report the potential for ongoing vulnerabilities that mental health services will have to sort for themselves and it may well be “we haven’t got enough staff” or concerted attempts to pressurize police officers into stating, “yes, safe and well” when it should be perfectly obvious they can’t.  Come on – let’s work in partnership!

We see this in the difficulties that the police have in accessing medical support for people who must be considered, initially ar least, to be experiencing a medical emergency.  Only this week, I am aware of an incident where someone presenting in a highly paranoid, psychotic state (this assessment was vindicated by him being subsequently sectioned by psychiatrists and an AMHP) was physically injured and highly resistant to detention, necessitating ongoing restraint.  You may remember two deaths in custody following the use of section 136 during this month alone

I could go on.

REAL PARTNERSHIP

It is too easy to point out when health professionals are busy expecting the police to work in partnership by either doing illegal things or by spending resources on NHS business.  You know what?  I don’t actually think I mind mucking in a bit with stuff that, strictly speaking, I don’t have to do, as long as I see that reciprocated.  I know that in rural areas where AMHPs and police and others are few, that they report more blurring of the boundaries, but that is on all sides.  Where people can help, they often will.

But the concern I have in busy areas of high demand, based upon many emails and phone calls in the last few months, is the one-way street approach, where police officers are expected, literally, to do as they are told even if they know it may be foolhardy or even illegal, but they cannot see many examples of support coming the other way.  The biggest “blag” of all in recent times are the health professionals who ask for police support to deal with a person who has a history of being resistant or aggressive and when the police arrive and find no sign of the other agency, ring to enquire after them, only then learn that “something else came in” and could the police just deal?  With a healthcare issue?!  Come on – let’s work in partnership!

If we to legitimately build capacity in the public sector against a background of services being rationalised, we need to decide whether we’re retreating into our trenches to throw things at each other.   we have to release front-line staff to support each other, in a genuine arrangement that reflects roles and responsibilities, but allows them to improvise and work in partnership.  We know that the NHS is over-functionalised into disparate silos anyway; adding the police into this system is not just adding another silo, but another operating culture entirely.  This could be turned to the advantage of everyone if we thought properly about how to integrate and jointly operate the services, but we don’t.  We have insufficient consideration of the role of law, too much focus on insular concerns around resourcing and remits; too little thought about the needs of the person at the centre of decision-making.

If we did put people at the centre of decision-making, frontline professionals, operating within the law, would see that many small things could be achieved that would improve the world, if just marginally.  It would reduce the burden on all professionals and allow us to serve the public, both individual and collective – now there’s a thought!  But to achieve this, we are going to need individual professionals to ask themselves “What can I do to help this other professional who broadly speaking, has the same objective as me?”  Usually, people ask what others can do to suppor them and this is wrong direction of travel.  It requires that managers in all organisations allow their staff to think about overall partnerships, not silos, bureacracy and what we call “our core business” – whatever that is.

We need to get out of the trenches and play football* in no-man’s land – then we might start to know and understand each other – and then avoid the mistake of retreating back to the trenches to carry on as before.

* Rugby.


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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10 thoughts on “Working in Partnership

  1. The problem is that Policing was massively resourced during the last Government, (see: http://www.policyexchange.org.uk/images/publications/cost%20of%20the%20cops%20-%20sep%2011.pdf) but amongst the massive cuts in services enacted by the current government Police resources have been the last to be cut.

    Local Parternship working had been ongoing and as NHS changes and cuts took hold mental health services developed an unhealthy dependence on Police and other agencies taking on an increased burden and my perception is that this has become and increasing problem operationally as policing resources were stretched and then further damaged by cuts a re prioritsation.

    Then we reach the stage now where the focus becomes whose duty and legal responsibility it is in managing various aspects of difficult situations with people with mental health problems and the entrenching that has resulted. Mental Health services have become dependent on misusing other resources and managing crises in a hands off way.

    It’s difficult to see this being resourced and changing without a number of high profile incidents as has happened in the past. Troubling that activists and individuals like yourself will be able to say ‘I told you so’ but this will provide litttle comfort fro those involved in these incidents.

    It remains important to speak out and ensure our own practice is above reproach.

    1. Have to say, none of this – for me at least – is about money or resourcing. I was banging a drum about these issues long before the last Election and the so-called financial crisis. I also struggle to buy the argument that the financial position we are in with mental health arises for any reason other than the choices that DH and individual trusts / CCGs make.

      The high profile incidents are happening – two section 136 deaths in custody in this month alone. But yet again, the police did not act in a way that ensures scrutiny of the NHS will form part of the investigation, so it will not put any pressure on health bosses: it will all be down to the police “doing the wrong thing.” Again.

      Plan A in this business is everything working properly, as it should.
      Plan B is making sure that when I’m pressed to do the wrong thing, for reasons that are mainly connected to NHS bureacracy, I’m able to take my audit trail with me to the Coroner’s or criminal court that shows I did everything possible to discharge my duty of care.

  2. Again interesting if giving only one perspective – the police one & I understand why. Last week I was on training & we idendified a tag line of “mind the gap” i.e. look after & care for the gap between services. I would also simply point out that the above – ” they will often seek police support ” could equally be “they often don’t seek police support.” & in difficult & challenging & risky situations muddle through.

    BTW I am out of the trench, but its very muddy in no-mans-land. Indeed the mud is very deep.

    1. Necessarily one perspective – I don’t have any others. But in the spirit of proper, open debate and taking of feedback: do we have examples of MH professionals wanting the police to do something that officers could do, that MH professionals want them to do because they don’t want to do for themselves and which would lead to a straight-forward acceptance if the police say, “No – we’re not obliged so we’re choosing not to do so”?

      If the mud is deep, it’s probably even more important that we play rugby, not football? 😉

      1. I try to understand several perspectives & I like rugby.

        Rugby is a very good game & analogy – the pretty boy backs & coaches need robust forwards to secure the ball & then it gets more complicated by being selected for an invitation team & wearing the same shirt but your club socks.

        I am aware of several examples of your colleagues saying no & have even been know to do my own safe & well checks. I am equally aware of police officers doing more than they are required or should do & am always impressed by that..

        There is a gap in services & everyday AMHPs & poloce officers are expected to plug it.

      2. My point wasn’t whether the police said “no”, it was whether it was taken very straight-forwardly as correct that they did so. Why shouldn’t you do your own safe and well checks? You have specific training in the management of people with mental health problems. If you’d asked my officers to do safe and well checks I would have intervened to point out that they couldn’t possibly do so, no matter how hard they tried and how much they wanted to help.

        All the police can do is confirm that someone is Alive, Breathing and Conscious. Whether they are safe and well is quite another thing and not for the police to decide. So your use of the word “even” seems to suggest my thesis is correct(!) or would you not agree?! 😉

  3. really interesting agree with the need for partnership working and said so on many occasions. In Hertfordshire I worked on joint training involving the police. I worked with Prison College to input mental health awareness inyo training. Would love to do same for police. But be helpful to get police input to M H nurse educ also
    That way better understanding by all of the issues you write of.
    all the best

    1. Agree with all of that – I do inputs at three local universities for final year nurse students and agree it’s really positive to emphasise to nurses the importance of a somewhat legal approach to professionals practice, congisent of the many pitfalls. I’ve often said that what the police may lack in terms of “clinical” awareness, MH profs sometimes lack in the “legal awareness” area – so I totally agree with you.

    2. I certainly took it in a very staright forward way & left the 3 police forces, the ambulance service & 2 Mental Health Trusts to sort it out amongst themselves, I left my number – the custody stg face was a picture & I think he was contempting wrongful arrest/false imprisonment. I didn’t get passed the front desk before working in partnership was actually working.

      Like other AMHPs I do have lots of training & experience but am a social worker & have no medical training & limited first aid skills, so like you & your colleagues I can confirm the basics as you describe them – often thats a good start because like you I trade on my ability to engage with indivduals, even when they are unwell or distressed.

      Neither do I or other AMHPs have any control & restraint trainning or wihout a warrant & the company of your good self & a Sec12 Approved medic powers of entry to a property. Thankfully we usually dont need them, nor do we have the equipment, mates & radios etc just our diaries, mobile phones & on occasion our Jones.

      My use of “even” was immature. I merely point out that we often do these safe & well visits & visit vulnerable & not so vulnerable people everyday.

      I agree with & understand quite a bit of what you say & really want partnership working to mean just that – but there are lots of gaps & I see them everyday.& spend lots of my time trying to fill them.

      I have enjoyed the exchange but this is complex issue & best discussed in person – some where some time 🙂

  4. Great post the issues we experience here are that it’s getting the MH Trust ambulance service police and LA to work together. Most of the time until a patient is an inpatient the Trust don’t want to know so the idea of staff to assist an AMHP with a reluctant patient doesn’t even register on their radar so the AMHP left after medics have got their fee forms, call for the police and yes as resources for all are stretched further i see more and more incidents occurring. On the positive side i do see signs that the powers that be are starting to accept that changes have to be made.

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