I’ve never known what the “frontline” of policing really is, but I was asked last year to give a presentation on policing and mental health from that perspective. Given that my main role in the police is that of a 999 response inspector, it is actually the viewpoint I take from my work and so working on the theory that “frontline” means uniformed policing and police custody, I try to summarise that view in this blog.
I start by highlighting one thing that pervades my view now that I’ve done a lot of work on the police side of the interface between policing and mental health. Worry. I worry each and every day about this stuff, because I am confident in the knowledge that during a tour of duty, I could well be asked to become legally responsible for individuals with clinical needs that no junior doctor would manage without seeking support from more senior medical colleagues. And I worry precisely because I could be asked to manage such needs in a vacuum, without necessarily being able to engage the health service of this country. I start each day worrying whether I’ll actually be able to see quickly as some of the more complex challenges present themselves and whether I will have the time and capacity as well as the strength and professionalism to consistently do what is required of me.
I worry about that, every single day I put on a uniform.
THE DILEMMA THAT IS NOT A DILEMMA AT ALL
It is my view from the frontline of policing that in order get through any working day that involves responding to mental health emergency incidents, I will be repeatedly required to choose between adhering to local policies and procedures; OR adhering to the law. I cannot always do both because the services that exist where I have worked are not set-up to deliver outcomes that are always consistent with the law. This is true of much of our country in many different aspects of the interface.
There is a constantly implicit expectation – it is very often made an explicit expectation – that I will put aside considerations made clear in law in order to deliver outcomes that suit the set-up of local services and procedures that are legally inadequate. It’s important I provide examples: we know that the humiliating and degrading condition into which the claimant from the MS v UK case deteriorated was a clear violation of his human rights, because the courts have ruled on it. And yet, where people are detained under mental health law by the police, there is often an expectation that vulnerable people in such a condition may be detained ad infinitum where beds don’t exist for them or where services exercise exclusion criteria on their “Place of Safety.” I have seen this and heard of it multiple times in 2013 and once had to threaten to take legal advice about the position in which the frontline police officers I was supervising were left.
I know that I have seen countless examples in both practice and policy of mental health professionals preferring that paragraphs 10.22 and 22.13 of the Code of Practice to the Mental Health Act didn’t exist – but they do exist and the Munjaz case heard in the House of Lords (now the Supreme Court) reinforces how important it is that we adhere to these frameworks. The Lords ruled that the Code of Practice is not binding instruction, but it is statutory guidance with which we should comply unless there are “cogent reasons for departure.” We know from other European case-law that not delivering upon someone’s Convention rights cannot be defended by arguing “no money” or “not enough money.”
If I do what the a local protocol says – if it exists at all, because joint protocols on required business have not been agreed everywhere that should have them – I may find myself in legal difficulty if untoward events occur; but if I try to give practical reality to the law as I’ve understood it, I may find myself in direct conflict with frontline professionals in other organisations whose managers have in effect assured them that the police will disregard the law for their convenience and their benefit.
So what will I do?!
Actually, this dilemma is not very hard at all because I’ve got a family to provide for and more importantly, I took an oath of office to uphold the law. So I would take on inter-agency conflict to the extent that it is necessary to show that I’ve done everything in my power to access healthcare for people who I think may be ill and in a sincere effort to deliver a lawful outcome. Whether or not I succeed, I then refer it to the appropriate managers to debate, resolve or ignore as they prefer.
DEFLECTED DEMANDS
It is my view from the frontline that mental health related demands placed upon both our mental health and broader health systems inappropriately deflect some of that demand to the police. This occurs even though the police would be quite unable to ensure such demand is adequately managed from either a clinical or legal point of view.
Too often assumptions are made about what police officers are capable of doing, both clinically and legally. I can’t possibly tell you whether suicidal ideation by a mental health patient represents a high risk vulnerable person who needs safeguarding immediately, or whether the risks arising from certain behaviours or utterances are less serious than that. I can’t do a mental state examination or a mini-mental state examination and even if I could do those things, mental health services sending me to such an event in a private home means I’m legally powerless to do anything anyway.
Parliament do not want me there, as things currently stand – they want AMHPs and doctors there and this is the reality of our mid-twentieth century law. The fact that we’ve revolutionised our mental health provision in the sixty or so years since it was written doesn’t alter the fact that someone in a private home experiencing a sub-criminal or non-criminal mental health crisis is not someone they envisaged the police would deal with.
It is my view from the frontline, that the playing field of partnership working is not equal. And I say this, notwithstanding that there are many known short-comings in policing where officers and organisations fail to identify the policing and risk issues inherent within certain mental health incidents and take the necessary interventions, as required. For example, I know that some officers don’t know how to approach the decision-making that is required when an incident involves a vulnerable person who could be arrested for a crime OR detained under the Mental Health Act. Which should they do? I’ve seen it many times that the police get this wrong and that means the view from the frontline is insufficiently influenced by proper training on mental health and associated legal issues.
My view from the frontline is entirely unclear about whether managers in all of the relevant organisations are spending enough time in rooms together. I know that in some areas of England, some or all of the four basic protocols required by the Code of Practice to the Mental Health Act don’t exist and some that do exist are quite hilarious in their bias and their illegality. I reviewed this week on behalf of a front-line police officer in the north of England who reads this blog and was simply stunned that a formal governance process in a mental health trust AND a police force approved it for signature, bearing in mind that trust and force solicitors will have been asked to approve it. So I have to conclude, from the frontline, that the people who have to put our partnership structures together don’t always fully understand what they’re doing.
ARE WE MAKING THINGS WORSE?
My final view-point from the frontline, is that I worry we’re just making things worse. It is not always clear to me that creating a situation where we call the police to psychiatric wards to restrain patients for medication makes things better. How does having place of safety arrangements in place that send very distressed people to custodial environments make things better? I’m still to be convinced that the models of liaison and diversion for suspects in police custody are thought through sufficiently to represent a sound model that appropriately balances wellbeing and public interest.
We are seeing the start of many initiatives and improvements in this area: I just hope that they are properly evaluated by people who know what they’re doing so we don’t throw good money after bad. The amount of project money spent on liaison and diversion services that just fall flat on their face despite warnings that we do exactly that is depressing beyond words. And meanwhile, we know that some people end up unnecessarily criminalised because of it or diverted into a contact with a mental health system where there are good grounds to raise concerns about whether, at the population level at least, it is actually doing more harm than good.
The view from the frontline: there is LOADS of work to be done and when we do it we need to be wary of the “Do something” instinct that convinces us “this is something, so let’s do this!”
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2014
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 
It is so complicated. If someone who was depressed and emotionally unstable had cut themselves many times with a razor blade, most people would think they needed to be kept somewhere safe, like in a hospital. Not necessarily, because that might increase their long term risk of serious self injury or even death, by reinforcing self injury as a coping behaviour that leads to hospital admissions and removal of stresses. It might also make that person more aggressive, when a previously reinforced behaviour is suddenly uninforced, such as sudden discharge.
(Only doctors can make these decisions.)
This denial of a place of safety may seem counterintuitive and look like professional indifference, but not really. Hospitalization can be dangerous. I have no medical training, just personal opinion.
I suspect some conflicts between police and mental health services revolve around this. It would be interesting to see whether this argument is advanced more frequently when there are less beds available, rather than when there are many (not now!)
I’m in my first year of a foundation degree in Police Studies at Portsmouth University, my essay I’ve just submitted was about frontline policing and mental health and comes to similar conclusions about the police lack of training and the buck passing from other agencies. Interestingly the report by Victor Adebowale also reaches the same conclusion but he concludes that dealing with persons with mental health problems is actually a core part of policing
Dave
He does – I spent two hours discussing this with him as I was privileged to be asked to give evidence to his report. He argues that it would be core police business even if we had the best, most well resourced health system that gave a proper focus to MH parity of esteem issues – he’s quite right to do so, in my opinion. Not all MH emergencies are preventable and many of them will involve threats and risks that only the police are equipped, trained or legall empowered to handle. As such, his argument is “core police business” and once you accept that fact, the next step is to train for the reality of having to deliver upon it – whether you police an area with good, bad or indifferent MH services. I think he’s right – in fact, he and I agreed about most things we discussed!
I read his report cover to cover for my essay and I agree, it was very well written and researched what was interesting was the view from the London Ambulance Service that again the police should be the primary emergency service responding to mental health issues within the community, I didn’t realise their staff hardly get any training at all in mental health. Like you say we just need more training in mental health than we currently receive.
Ideally ill people should not be in police cells – although some may require that level of security because of the individual circumstances of the case and or nature of offence. I accept that the police are often left to fill the gap, but that is exactly what it is, a gap. In terms of COP 10.22 often there is simply no where that is available & we have a POS in my area.
Often the circumstances preclude a relative or friend or family from helping & anyway they assume that the state (NHS/LA/MOJ/MOD/POLICE etc) will provide somewhere appropriate for someone in crisis/need. These palces simply do not exist & even when they did they where provide/commissioned in such away that “risk assessment” allowed them to say no thanks as the risks are too high to be safely managed! Residential Care homes again require a process to access them, usually including a financial assessment & one of need & then a budget application etc. Again not a straight forward process nor one that meets crisis. A couple of years ago I tried to access a LA residential care home using the NAA. The manager & staff of the home & some of my bosses could not comprehend the matter. Remeber sometimes others see the solution to a problem as a MHA Assessment, even when this is inappropriate. However I agree the police station should not be the first option – but there is no other option sometimes.
I would like to reassure you that in terms of COP 22.13 – often patients are returned without police assitance. i accept that it might not fell like that & I canm offer no figures. But I know it does happen & I have done it. However I suspect that all NHS MH Trusts have policies that mean they report missing patients to the police & they & relatives expect the police to look for & assist with returning the person. again it depends on th ecircumstances & gets a little more grey when the police have had recent contact with, or are involved with the missing/AWOL patient.
Its together that we need to fill the gaps & seek to deliver a service that can meet the demand. I would like to say that “I’m with Nick on this” – but as welcome as Nick’s words were yesterday, I see no real action or £s to improve things on the frontline, other than the continued efforts of individuals like mentalhealthcop. 🙂
Actually from a relatives and carers point of view it is as much a nightmare for them when NHS staff report a patient as missing as it is for the police . In fact more so. Because the police will contact the relative – often repeatedly night and day- to try and find the whereabouts of same said missing person. The relative often doesnt know and certainly doesnt have the resources to track.
And very often huge amounts of unnecessary anxiety is caused when patients are simply late back to a setting and NHS protocol kicks in without much thought. 10 mins late and so report to the police. Ward pts are threatened with this by staff with no thought as to what happen when police are called and the knock on effects.
The carers of someone I know – whose mother often goes ‘missing’ by the definition of MH services- have been called up to 18 times in a 36 hr period night and day to try find her. They are used to her disappearing and have never reported her as missing as this is normal behaviour for her, Buy apparently their intimate knowledge of these behaviours dont count for anything. They have got to the point of slamming the phone down on the police and accusing them of harassment as they now take the position that to notify them once is Ok but to contact them repeatedly solely to contain police and services anxieties is certainly not.
I am not sure it falls to me to defend NHS or Police colleagues & I don’t hear to many of them defending social workers/AMHPs – often quite the opposite. While I can see & understand your point of view, in the circumstances as you describe them. I suspect that when patients going missing, even for a short periods of time, the NHS & Police are damned if they do & damned they don’t follow policy & procedure, particularly when something untoward has occurred. Again it is a very imperfect system that struggles to cope with the needs & individual circumstances of users & their carers/families.