For many years now, we’ve heard the repeated mantra of early intervention – both in terms of treatment of mental health problems and in terms of diversion from the criminal justice system for those who come into contact with the police or the courts. We’ve heard of and seen services explicitly branded with an Early Intervention label, for example in first-episode psychosis services.
Of course, early intervention of any kind poses a particular kind of problem, whether in mental health or in youth justice and child protection where we also see this kind of discussion. If we did nothing other than sanction children who were caught shoplifting, not all of them would begin an inevitable decline into drug taking, acquisitive crime and custodial sentences. It is far from inevitable that if someone experiencing their first episode of psychosis in their late teens or early twenties does not receive an appropriate early intervention service, they will end up detained for long periods as an inpatient and / or caught up in the criminal justice system.
So how do we identify those children, those first episode psychosis patients and those of us with mental health problems who come into contact with the criminal justice system after an offence that will go on to experience a life-altering decline of offending, substance misuse or mental distress? Difficult. But we know we have to find a way – the Centre for Mental Health will state that for every £1 spent on early intervention services, £8 is saved later in the mental health and / or criminal justice systems and £15 of savings for the overall economy. Of course, because budgets are in silos, that benefit is not usually felt by those who would have to spend, so it’s almost nothing more than a theoretical benefit and whilst we know this from research and we know we need to do something to give a reality to this kind of thinking, we are currently seeing something else happening instead.
We’ve seen in the last couple of years various attempts to rationalise mental health services: Community Care reported last year how the workload of CrisisTeams had risen by 16% at a time when budgets were cut by 2%. We frequently hear anecdote that the threshold for inpatient admissions has increased as the hospital beds in some areas have been cut by something like 33% or even as much as 50%. Consequently, community mental health teams have seen an increase in their workload. It has been a trend in mental health care for many years now that average time spent as an inpatient is decreasing as people are discharged earlier to more and more community care, in the hope that initiatives like Community Treatment Orders will end the cycle of “crisis > admission > recovery > discharge > relapse > crisis” etc., etc.. Except they don’t.
CRIMINALISING VULNERABLE PEOPLE
If you consider the complexity that is added whenever any of this stuff is done with people who are in contact with the criminal justice system, you start to comprehend what a difficult system we’ve evolved for ourselves – perhaps one that you wouldn’t ever design, if you built it from scratch.
But as we now see the emergence of particular initiatives in response to the lobbying that the police service has been engaged in for the last few years, we have to consider again the extent to which our evolved system is criminalising people. So for example, in many areas the remit of the community mental health teams and their out of hours CrisisTeam colleagues was to provide enough support to people to prevent hospitalisation. During the period of time that both of these kinds of team have reported their workloads increasing, their budgets decreaing and their remits narrowing, we have seen the introduction of Street Triage and Liaison and Diversion schemes. So where some patients have reported that their contact with some NHS services has led to that demand being deflected to the police, they can now expect in some areas that the police will turn up with a member of NHS staff, which may have been all they were trying to access to begin with. Equally, this could be pointed out for Liaison and Diversion services – will PoS services for 136 and other structures in the NHS be more likely to say, “take that victim to the cells” knowing that such a decision now puts people into direct contact with trained NHS staff from mental health services. We need to be mindful of unintended consequences.
Of course, there have always been some situations where it is quite unavoidable that some of us with mental health problems will end up in contact with the police and some of those will end up in custody, either detained under s136 of the Mental Health Act or for a criminal offence. Surely, street triage and liaison and diversion is a positive thing in those circumstances – providing screening, support and referral to those who need it and might not otherwise receive it in those particular circumstances. I’ve never disagreed with the general thrust of that kind of argument – however, what I have increasingly wondered, is the extent to which we’re cutting services in one area, whilst increasing them in other areas, the effect being that we increase the extent to which you have to be in contact with the police or criminal justice system to access certain levels of support? Another version of the criminalisation contingency?
If we’ve got money for extra mental health nurses to operate in street triage and liaison and diversion schemes, why don’t we put them into the teams where they could give reality to the concept of early intervention? Why better fund and better resource that part of the mental health system that we should be trying to minimise because it is so extraordinarily expensive as well as ineffective – the criminal justice interface? There is a real argument that we’re seeing Street Triage and Liaison and Diversion as increasingly necessary, because we’ve rationalised other mental health services to a point where it is difficult to access them in a timely way, if at all. We know that this process is ongoing as NHS England have recently committed to cutting mental health services by a greater extent than non-mental health service in forthcoming budgets. Disparity of esteem in action.
Of course the answer is and always was: that the financial benefits of funding proper early intervention and preventative services is not felt by those who would have to pay the bill for it. Which is why it doesn’t really matter to the right people – it badly matters to all the wrong people. So instead, we see the increased propensity to criminalise vulnerable people and focus on all the different ways in which we could do the wrong thing, righter – and ever later in the system.
Winner of the Mind Digital Media Award.