Where Did It All Go Wrong?

Dr Jenny HOLMES has blogged here before – and she has an open invitation to post whatever she wants whenever she wants as far as I’m concerned.  An experienced police custody doctor and an NHS psychiatrist – she’s a medical professional who sees the interface of policing, mental health and criminal justice very keenly from two different perspectives. 

As such, she’s worth listening to and passionate about properly supporting those vulnerable people who find themselves in police custody or contact — this one is worth reading!


I am writing this blog as I believe many of the current problems with Policing and Mental Health are due to decisions Police Forces made to dispense with their experienced workforce of Police Surgeons (now known as Forensic Medical Examiners or FMEs). Many MH professionals have also raised serious concerns with me about the expertise of the healthcare staff available in Police Custody Suites.

Fourteen years ago when I was appointed as a Police Surgeon it was a sought after job and the Police had their pick of the best local doctors. It is absolutely true to say that this was partly due to the remuneration which was commensurate with GPs earnings and indeed most of the doctors were GPs. However all were on ‘item per service’ fee structures meaning you got paid per case you saw. In a busy night in the City Centre Suite you could earn at a rate of approximately £70 per hour in around 2006. In quieter areas it could be more like £35 per hour. Earnings were self-employed and came with no pension, holidays/ maternity pay etc. Well paid nonetheless and the skills and expertise of the doctors reflected this

Doctors from various backgrounds did this job but most were GPs having achieved the postgraduate Membership of the Royal College of Practitioners Examination and passed a specialist training scheme. Most were also s12 approved under the Mental Health Act as having specialist experience in the assessment and treatment of mental disorder and when I joined we were all expected to attain the Diploma of Medical Jurisprudence (DMJ) within five years. This was a specialist examination in forensic medicine in two parts: each with a written examination and viva and the preparation of a detailed case book with literature review that took me a year to complete. Failure to attain this led to the Force dispensing with your services

I’m not a GP, at the time I was appointed I worked in General Medicine, I have since retrained in Psychiatry. There are other relevant backgrounds for Forensic Medicine, Psychiatry, Accident and Emergency being other examples. There are also many postgraduate qualifications doctors could hold to demonstrate seniority and expertise as well as a forensic medicine one. I for example hold the Membership of the Royal College of Psychiatrists, am dual qualified in Law and hold the RCGP Certificate in Substance Misuse in addition to the DMJ.

The Faculty of Forensic and Legal Medicine was formed in 2005 and a postgraduate examination, the Membership of the FFLM was started which superseded the DMJ. This is equivalent to other Royal College examinations and those doctors who held the DMJ had this converted to MFFLM. The FFLM was set up to promote excellence in forensic medicine and holding the MFFLM proves expertise.

LOCAL KNOWLEDGE

My Force used to have five doctors available to them at any one time.  Local GPs who knew many of the patients, knew local NHS pathways and could solve problems easily. Senior enough to manage the complexity and risk of the workload. Referrals to Accident and Emergency were rare and inappropriate Mental Health Act Assessments almost unheard of. In fact it was rare for mental health services to be asked for assistance at all unless it was an entirely appropriate request for admission/Crisis Team follow-up etc. Now they have one doctor and two general trained nurses on duty at any one time.

Things were not perfect and as General Practice changed to be a much busier job without natural breaks in the day between surgeries to call into the local nick the Police found there were often delays. Plus the number of arrests were rising and as the fee structure was item per service the Police could not accurately predict costs year to year which is important in a public service. So many Forces took the decision to move to a mixed workforce including nurses.

This decision was a reasonable one, initially motivated by a desire to save money and have predictable costs by having salaried employees. Subsequent studies have shown the savings are minimal, if any, and in some cases cost more. Employees cost more than just their wages when sickness etc is taken into account

However the NHS was moving towards a workforce where nurses took on many of the traditional roles of doctors and there was no reason why Police Custody should not be the same. I have worked with nurses for six years now in my area and can report success: the Force now receives a service free of delays and the Custody staff like having the visible presence of a nurse. Nurses can manage a large proportion of the less complex cases extremely well. However hospital referrals do have a tendency to creep up in my experience. With a senior experienced FME in the Clinical Lead role, responsible for training, as a point of reference and to quality assure the nursing service the nurses can provide high standards of care.  However all services led by nurses should have access to experienced doctors 24/7, to deal with the cases that are complex, to share risk with and to support and guide them.  Any GP practice, walk in centre, Accident and Emergency Department runs like this.  So what is the problem in Police Custody?

Nurses are either general trained (nurses for physical health) in Adult or Childrens’ health.  Or they can be trained in Mental Health.  Sometimes they can be dual trained and some areas use paramedics but I have no direct experience of this.  My views are that general nurses are what we need in custody, ones who are confident with physical observations, assessing illness and injury.  Custody has a lot of risk in physical health of our detainees such as alcohol misuse (approximately 50% of Police Custody detainees are dependent drinkers).  Dependent drinkers can suffer epileptic seizures and life threatening bleeds from the stomach.  Cocaine users can have sudden heart attacks.  Many people have head and other injuries when they come in.  General nurses with Accident and Emergency, Prison, GP and walk in centre experience can manage these issues well.

However that leaves massive gaps in the assessment and management of mental health issues as general nurses are not trained in this. In some areas the NHS supports the Police well through Liaison and Diversion schemes but even in the best areas there remain massive gaps, particularly out of hours. NHS Mental Health Services are already under major strain without having to pick up work that would never be referred to them if the Police had the right skill mix in Custody.

FORENSIC CARE IN CUSTODY

There are also expert forensic aspects to the work in Police Custody which have serious implications for the public if they are not done expertly. Documentation and Interpretation of Injuries: eg are the injuries on this alleged assailant consistent with his account of having been assaulted himself and acting in self-defence? Bloods from drink drivers. Assisting the Police in the prosecution of alleged drug drivers. Assisting in the management of sudden unexpected deaths and providing expert opinion on possible causation to allow the scene to be managed appropriately. Some of this work can also be done by nurses: if expertly trained by a senior FME.

So to summarise, the Police have dispensed with local GPs, with postgraduate qualifications in forensic medicine and s12 approved as having expertise in mental disorder to back up their new nursing service which is made up of general nurses who aren’t trained in mental health. So what’s happening now? What are the problems and who are the FMEs?

When the Police dispensed with their old FMEs and brought in nurses they were left with a problem. Many turned to the private sector. The Police need doctors with local knowledge. Unfortunately in many areas the old FMEs were unwilling to engage with the private sector and could earn more elsewhere. The FFLM has set Quality Standards as to what experience FMEs should have but unfortunately these are not mandatory. Many of the new doctors hadn’t worked in substantive roles in the NHS and very few had postgraduate qualifications. It is important to point out that many areas retain doctors of excellent quality. My own area has a very good service with some old FMEs returning and we have recruited some quality candidates. Other areas however are really struggling and mental health services in particular are feeling the strain.

Many Police Forces have written into their contracts that the FMEs should hold MFFLM and be s12 approved but few are and most Forces seem unable to enforce this.  Many of the new FMEs I know really struggle with the complex mental health issues that arise in Police Custody (unless they have psychiatric experience). GPs did not struggle.  I also see this lack of confidence manifest itself in the inability to take a decision and passing fairly trivial issues to outside agencies to resolve.

I am an examiner for MFFLM and as a Faculty we are really worried. Few doctors (single figures) are presenting themselves for the examination and we have incredibly low pass rates of those that do. We are working with the GMC to attempt to get our area of practice recognised for the Speciality it is. That would prevent forensic medicine being one of the few areas of medical practice in the UK that a doctor can work in, almost entirely unsupervised, without relevant postgraduate qualifications or training

What’s the answer? Hopefully the NHS which takes over commissioning custody healthcare services in 2015.  I desperately hope they will reverse the decline in standards in Forensic Medical Examiners as I am extremely proud to be an FME.  I regard it as a highly complex, skilled job working with some of the most vulnerable people in society as well as serving the public.  I hope the role can be valued again.


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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4 thoughts on “Where Did It All Go Wrong?

  1. When politicians.committees,policy forums are making decisions on ‘how to move forward’ these are the experienced voices that need to be heard

    .Poor quality (or complete lack of ) MH assessment, support, care for those in custody suites is unsafe and costly on every single level.Ask anyone who has been detained while in mental distress – the experience is extremely traumatic and this stays – making any future contact with emergency services much more difficult to deal with.

    What is the point of inexperienced and unqualified FME’s attending to someone with mental health problems? Apart from a tick box exercise.From the detainees position it is yet another encounter where they are expected to endure an assessment only for the less than qualified professional to realise they are out of their depth and refer out.

    The police have immediate issues to deal with in respect of trying to manage the situation and have said long and hard that it is barley manageable.But what seldom gets considered is the impact the fragmented and frankly inhumane crisis system in MH has on people.

    Once you have had an experience with the police each and every crisis, each and every future encounter is then experienced as threatening when you are vulnerable – even a simple welfare check, a ‘hello’ from the officer in the street, the sound of a siren. That is the reality. The officer attending someone’s home could be the kindest, most compassionate person in the force but the mess the crisis system is in will have caused enough damage to at least engage many hours of resources and at worse full escalation.

    One person we tracked in crisis was detained out of area by the police. From first point of contact to final discharge from a local crisis unit she had 83 contacts with different people through that crisis journey.From emergency services, in the cells, through to general A&E staff, through to MH professionals. And on most of those encounters she was assessed in some way. She has never committed a crime in her life,

    So instead of listening to this excellent Dr the wheel has to be reinvented each time and another layer or fragment added to the crisis picture making the situation more complex, more stressful, more unsafe and more expensive.

  2. Would have to agree with the thrust of this post. We used to have excellent police doctors that qwere all from local GP Practices, now we have FMEs who seem to lack experince and any confidence in their own decisions.

  3. The FME service in my part of the world is now contracted out to a private sector company – v glossy & polished brochure & interweb pages etc & probably making a profit.

    However all is not what it seems & I have certainly observed an increase in referrals for inappropriate mha assessments.

    Their initial assessment appears to be almost by numbers & tick box & often they are there for one night only via some agency & lack any understanding of how the dysfunctional MH system can be made to work. They often scribble something unintelligible in the FME book & instruct the police that a mha assessment is required & head off into the night. Leaving the rest of us to sort something out.

    Through rose tinted glasses, the old gp based FME system seemed much more user friendly all round. I knew one or two of local ones reasonabley well & although it was not perfect we all knew where we stood & it was a shared thing & local knowledge & contacts sometimes just help find a solution. Of course they were getting paid much more than any of the rest of us – but then there is no change there. One of the old once bought me a beer once, which was a nice touch 🙂

  4. I’ve watched my force move from the old GPs to the private contractor and the only thing I want to highlight here is the assessment of “fitness to detain”. I’ve had this debate with many people, many times. How do we assess the basis of someone’s medical fitness to be detained if the only real issue to consider is their mental health? Clearly, subjecting someone to police custody if mentally unwell could be traumatising and we would all prefer to avoid it. That said, if someone has been arrested by police officers for a crime, it may be necessary to hold people there, even if it is just for MHA assessment and admission.

    How do Doctors reach this view – because I’ve had numerous experiences of inpatients offending, all relevant staff there saying no medical reason why the person can’t be held in custody or prosecuted, only for the FME to walk in and declare “not fit to be detained or interviewed.”

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