We’ve felt the temperature rising for some time. Mental health and crisis care have been creeping up the agenda and policing has often found itself front and centre, connected in various ways. Whilst we’ve seen a few areas of the country making different kinds of progress on issues that have dogged the police for years, there is a general acknowledgement that change is too slow and improvements too patchy. So some areas have more or less sorted Place of Safety provision; we’ve seen the emergence of initiatives like Street Triage which seem to have appeal for many in the areas where they operate; some of us have known for years that a few areas have always had good liaison and diversion provision that adds real value.
So what’s the point of a Crisis Care Concordat, given that we could argue we’ve heard it all before? Well, before we go any further, please make sure you’ve read it for yourself, especially if you are employed in this field. It is not an overly long document and won’t take more than half an hour. There are then a few important things that we could then say about it.
Firstly – this is NOT a POLICE Crisis Concordat. The development of the document was not lead by the police, not was it intended just to address issues in crisis care that the police have historically sought to highlight, like section 136 MHA and Place of Safety provision. The document is endorsed by a large range of professional organisations across health and criminal justice including medicine, nursing and social care and the emergency services. Most importantly, the development of the document has had service user and third-sector involvement. So this is about far more than places of safety and street triage provision.
A lot of the poster issues for emergency mental health include the police as principle protagonists – deaths in custody, the kind of media coverage we’ve seen around over use of police cells and the inquiries we see into homicide and suicide events involving service users: all of these things tend to have a police dimension, for one reason or another. Yet this document is not police led: it is a Government reaction to the issues which have been around for decades. Some may say it is yet another document and we’ve seen this sort of thing before – we’ll see, said the Zen Master to the Little Boy.
Secondly – this is NOT just about piles of money that we know we don’t have. We know that the overall costs of doing certain things properly are less than the costs of doing them in an uncoordinated way, where agencies look out primarily for their own interests. To demonstrate points like this, I was recall the presentation I saw several years ago about investigating half a million pounds into a new liaison and diversion scheme. By the end of year 1, the service had successfully reduce the number of people per year who need to enter the secure mental health system by 3. At the time, medium and high secured beds would cost around £300,000 per annum, more than paying for the initial investment.
There are other benefits along the way which were about organisations educating each other. We know that some police forces are over-using section 136 MHA. Rectification of this doesn’t lie in money – it lies in senior officers choosing to prioritise proper training in mental health issues for frontline staff, so that they know when to use section 136 and when to choose or methods of legal detention and when not to detain at all. That takes about 2hrs, tops. We also know that some NHS organisations give insufficient training to their staff about how to react to police decisions – for example, every person answering a phone in a mental health trust to news that the police have detained someone under s136 MHA should know the reality of para 10,22 to the Code of Practice to the Mental Health Act 1983 if they are contemplating not accepting the person for assessment. This paragraph obliges consideration of alternatives to police custody, rather than a vulnerable person being condemned to the cells and the Concordat gets into this sort of detail. Again, this won’t be just about money.
Thirdly – this is NOT a document which identifies the solutions and dicates from the centre what they should be. In due course, all local areas should agree and publish a ‘Mental Health Crisis Declaration‘ – I’m not yet sure whether this is at the CCG or the police force level. We should then see what the local actions are and how those identified needs will be met.
Much of the Corcordat is reinforcing what should already be happening. We should already have four joint protocols in each local area, jointly agreed (not imposed) that discuss Places of Safety, Assessments in Private Premises, Conveyance and AWOL Patients. It doesn’t take huge amounts of money to get areas sitting around a table discussing these things and writing or improving local arrangements. We should already be thinking about training: what training do police officers need from mental health services – but please, please, please don’t forget that the opposite will also be true. This is not a one way street. The Concordat is about something else: putting strategic framework, at the level of Government, around these issues that have proved problematic for years, if not decades. It is therefore about providing a framework of expectations that areas get on with what they already know is needed.
PARITY OF ESTEEM
NHS England are doing a lot of work on the concept of ‘Parity of Esteem’ – the notion that mental health care should receive an equal priority in all aspects with physical healthcare. Whether you look at this from the point of view of funding, research or the ability to access emergency services in a crisis, it is acknowledged that there is much to do. Lord Victor ADEBOWALE is chairing the group for NHS England that is overseeing this. When one remembers what he has said publicly about emergency mental health care since publishing the report of the Independent Commission on Policing and Mental Health, there is every reason to be positive about that drive, especially as it is recently backed up by law in the Equalities Act 2010 and the Health and Social Care Act 2012.
On page 8 of the Concordat we see the section entitled “When I need urgent help …” and it attempts to list those features of emergency mental health care that people should reasonably expect to be met. It does very quickly touch on ALL the issues I have written about for the last two and half years without specification of the detailed answers: access to preventative emergency mental health services, through mental health crisis teams or similar; place of safety provision; commissioning of ambulance service to reflect parity of esteem and provide dignified suitable transportation services. It also gets very quickly into difficult issues around restraint and drug or alcohol use. All the issues that we know areas have struggled with, historically.
So it is those specifics in the Concordat around certain these difficult ‘parity’ issues where I have unanswered questions. Perhaps the answers will come in the local mental health crisis declarations in coming months, but there are certain things that beg questions —
1. We know that some areas have not commissioned or resourced their place of safety provision properly, because they cannot justify prioritising the necessary money to do so – if there is a locally identified need for new money, where is it coming from, given that last year the overall mental health budget was cut (by 2%), albeit on the back of a 59% rise over the preceding 10 years. I’ve suspect it would be cheaper overall, and in the spirit of proper early intervention to have proper section 136 services working roughly as the Royal College of Psychiatry Standards envisages; but I know that some people don’t agree with me about that.
2. We know that there is a direct tension between mental health services and acute providers about the provision of emergency mental health care – people are often deflected to police custody because those in need of emergency support have been unable to secure it from a mental health trust and ended up in the A&E system who, because of an inability to provide a safe service, have asked the police to step in.
3. We know that the Concordat itself is not necessarily listing very much that is new, but bring together under a high-level political banner those requirements and opportunities that are already listed in documents as wide-ranging as the Code of Practice to the Mental Health Act 1983, to the various guidances that the police and health / social care agencies have already published – so if a statutory Code of Practice, the importance of which was reinforced by the highest court in our land, has not led to compliance with those frameworks, will the Concordat realistically add to that? Well, it will depend how it’s ‘policed’.
JUST ANOTHER DOCUMENT?
So could this be just another document that sits on a shelf? Well, yes – in a sense it could. The Concordat manages to list a large number of high-level policy documents in it’s exposition of aims and commissioning intentions across local and strategic partnerships. I’ve got copies of these various reports printed off on a shelf that are current sitting nearly two foot high (yes, I’ve read them!) and they include Royal College Standards on s136, they include documents by the Academy of Medical Royal Colleges that commence by suggesting that the need for another overarching, cross-organisational document is a quite disgraceful indication of provision; they include No Health Without Mental Health and the Bradley Review as well as others.
We’ve seen police documents providing guidance on how these things should happen; we’ve seen inquiry reports, stated cases and other documents. What, if anything, makes the Concordat different?
Potentially, it’s profile and it’s plan for delivery – which includes full deployment of the statutory inspectorates from Her Majesty’s Inspector of Constabulary to the Care Quality Commission. We saw Minister of State, Normal LAMB, appearing on television with Frank BRUNO as well as Commander Christine JONES representing ACPO to launch the document and there is every chance that the intentions and the plan within the Concordat would survive any outcome in the 2015 General Election. It arguably arises from work begun by the last Labour government in the Bradley Review and continued by the current government. But this document is direct product of Her Majesty’s Government, instead of being put out by a police, health or umbrella organisation. It is signed off by senior representation in all the of the organisations which are listed on page 4.
So this stuff now lies in the hands of senior people driving it through their leadership – by giving time and space to existing staff across the partnership to develop the joint local approach under a coordinated Mental Health Crisis Declaration. It means that they should find it easier to hold each other to account and it gives them a greater ability to imply the need for various kinds of change. Like I’ve often noted in discussions on policing and mental health, we are taking about the ability to deliver strategic partnership arrangements that allow frontline professionals to consistently deliver safe, dignified outcomes for vulnerable people against a background of complex laws which are themselves under review. It will take great skills to negotiate partnerships that allow this to occur, whilst organisations trade off their own priorities and their financial realities. It will take leaders who get sufficiently into the detail of things, to know why certain initiatives that appear to mitigate risks, actually build them – so let’s hope they know how.
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