Crisis Care Concordat

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.


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’.


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.

IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


10 thoughts on “Crisis Care Concordat

  1. I have carefully read through the concordat and in a way it’s a bit like my own personal wish list of how as a service user I would like things to happen. Yes I’ve been in a police cell on Section 136 because of inadequate local mental health provision. I’ve spoken to MP’s about my experience of crisis care at a Mind event. I really really agree with you that much of this could be done without too much expense or indeed may be cost effective.

    In my case crisis care has often ended up in the laps of the police – deflected from an overstretched crisis service. It’s often the little things that matter and can avert a full blown crisis. Just over a week ago I knew that my mental health was heading towards crisis point and in fact I did finally end up in hospital. Now to be told by the crisis team person when I rang in that I knew more than him about managing how I was feeling and to deal with it myself rather than listening was not helpful. None of the nursing staff asked how I was feeling. I was ignored as they were too busy. I was not seen by psychiatric liaison while in hospital nor did I get any contact from the mental health service for over a week. A one minute phone call to ask if I was ok would have been enough. How much would that have cost? The night I left hospital the police were called by the hospital and then subsequently told it had been a mistake but they still carried on looking for me. A waste of their time which could have been avoided. But at least they cared.

    You may or may not recall I tweeted my experience to yourself recently where I found myself in the situation of 2 nights running I had the police searching for me (being a perceived risk) with a mental health assessment in the middle deciding that I did not need any help. I was being promised by the officers on the first night that ‘don’t worry love we’ll get you some help’, section 136, no help bounce back out, off in distress again with the crisis team calling the police again having spoken to me literally a couple of hours after being assessed. How many others end up going around in the same circles? Goodness knows what the police thought was going on.

    The Mind report on crisis care about what service users really wanted showed that people’s needs were quite basic. They didn’t expect much and a little bit of humanity went a long way. I truly hope that we can get to the point where the whole system is proactive rather than reactive to a mental health crisis as in the quote from the concordat below. Especially the ‘take me seriously’ phrase.

    “When I need urgent help to avert a crisis
    I, and people close to me, know who to
    contact at any time, 24 hours a day, seven
    days a week. People take me seriously and
    trust my judgement when I say I am close to
    crisis, and I get fast access to people who
    help me get better.”

    Training of all those likely to meet someone in a mental health crisis as you say is important. To recognize and not judge, to learn how to listen and not belittle that person’s feelings will reap huge dividends in cost savings eventually. When I think how much in my own case my crises have cost the emergency services and hospitals when I’ve asked for help and got none or that none has been available (no beds) I want to scream. I’m aware that a bit like the M42 bridge person recently I’m opening myself up to lack of understanding (you’re selfish, surely you can stop behaving this way) but anyway it’s written now.

    Final quote

    “The case for change

    There is growing evidence that it makes
    sense, both for the health of the population
    and in terms of economics, to intervene early
    when people may have an issue with their
    mental health, in order to reduce the chances
    of them going on to develop more serious
    and enduring mental health problems which
    are worse for the individual and harder and
    more expensive for the NHS to treat.”

    Yes yes totally agree. I have harder to treat enduring m h problems now and it’s hell being me.

    1. Hi J,
      I was really interested to read your response as I have been advocating for a very vulnerable neighbour for 4 years now and she has been left in so many dreadful situations that I have been sickened by the lack of humanity in MHS. Obviously, I won’t go into the details except to say that much of what you say mirrors her experiences. I have been trying to get her the care she needs and deserves all this time and am shocked by the response of the MHS. Not one to take things lying down I am refusing to go away and will continue to get answers/resolution until I am satisfied that lessons have been learned (to quote one of their much used phrases).

      The Concordat does look promising in many ways. Again it mirrors so much of what I have been saying (very loudly to anyone who will listen) for 4 years because so much of it is so obvious. It’s just a shame that MHS haven’t recognised all this themselves as it would save people with MH problems a massive amount of trauma.
      The more I delve into the MH care my neighbour has received (or the lack of it) the less I like it, but I am very determined that it changes, whatever it takes. On the upside (and there is only one upside) I have been lucky where I live as the police and ambulance service have been phenomenal – but as you know early intervention in a crisis would pre-empt the need for them to attend and, and, and…..!

      You may or may not know that the Care Quality Commission is doing a survey at the moment on people’s experiences of Crisis Care – sensibly you are able to fill it in for each incident you have experienced so if you have lots of different problems with the same MHS it is worth filling it in (I hope I’m not “teaching you suck eggs” if you already know about it). I have done 4 so far in relation to my neighbour and I haven’t finished yet. It will end up clearly identifying how many people contact MHS as the first port of call in a crisis, but which service/s end up responding first. I know in my neighbour’s case I have contacted MHS over and over again before she reaches absolutely critical crisis point and 9 times out of 10 the police and/or ambulance service have attended first.
      Anyway, I could go on and on but I don’t want to bore you with things you already know.

      So I will finish off by saying that hopefully things will improve for you, my neighbour and everyone experiencing problems with crisis care. I know that my neighbour will never get better, but she is entitled to a much better quality of life than she has now and that’s what we’re working towards.

      The changes can’t come soon enough, but until they do I wish you ALL the luck in the world. K. X

      1. Hi @creativecow

        I feel for your neighbour and sorry that it seems to always be such a battle to get any kind of help. She is lucky to have you on side. I find because I do speak up it has compromised my care – better that someone else does the shouting. I have filled in the CQC incidents for one episode but there are so many I don’t know where to start. It could take me all day!

        I have given up making official complaints because as you say the MHS doesn’t learn the lesson. How many times have they forgotten an appointment or a phone call and still don’t learn that it creates problems for me. If I had done my job when I worked like they do I wouldn’t have lasted long yet they carry on messing up when lives are at risk. The best I can do is get my experiences out in the public domain one way or another and that’s what keeps me going most of the time.

        At least I know from your comments that I’m not alone in experiencing difficulties because sometimes I get left thinking ‘why me?’

        Here’s to a better quality of life for everyone with mental health issues and that the concordat dream turns into reality in my lifetime.


  2. 23 February 2014

    Dear Mentalhealthcop

    I think that you are brilliant.

    You have brought to the public the knowledge that something must be done to effect an entire culture change, and very good luck to NHS England and Professor Sir Bruce Keogh and Lord Victor Adebowale.

    For “mental health” has for centuries been something feared as though people have “dark arts” and “witchcraft” whereas everyone is a human being with feelings and needs and no man is an island unto himself and as a caring society we must all be there to help one another in crisis, I believe.

    Good luck to you and well done for all you have done.

    Best wishes

    Rosemary Cantwell

  3. While hope springs eternal & I have taken the time to read it. Today & thus far this evening it’s seems that here at least there are no beds nor any available nationally ?………!

    So that’s the starting point…..not that beds are always the most important thing as highlighted above. But when one is required & it’s not there (anywhere) we really are left hoping.

  4. BBC keeping the debate alive with well researched programme on 5 live Investigates. Looks at responses or rather the lack of appropriate response to people in crisis. Includes case of police attendance to someone at home which while edited illustrates the point that when police called in can be there for hrs with no AMHP /CRT ever attending.

    And finally Crisis Team members, s12 Dr and MOST IMPORTANTLY AMHP’s finally saying it as it is. Think this stays on i player for 7 days only so catch it while u can . Worth publicising – better than any other programme on this subject I have heard

  5. Brilliant as ever Michael

    My one comment –

    Nick Clegg “We want to build a fairer society – one where mental health is as important as physical health”

    Yet your only aiming to reduce by half, so your happy for 4,500 people to be detained in police custody.

    Makes no sense to me.

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