This is my written submission to the Home Affairs Select Committee Inquiry into Policing and Mental Health.
Advance warning: it is much longer than a normal post, written differently and posted here mainly for reference; but feel free to wade through it if you wish!
BACKGROUND AND SUMMARY
1.1 I am currently serving as a police inspector with West Midlands Police, with over sixteen years’ experience. During my service, I have been posted to uniformed police roles in Birmingham and the Black Country as well as having spent over three years in a specialist position dealing with policy and practice on policing and mental health. I have been seconded to work for the Association of Chief Police Officers and the former National Policing Improvement Agency during which time I have supported most police forces in England and Wales with development of their approach. I continue to support such work in addition to responsibilities as an operational police inspector on a 999 response team where I see the reality of this each day.
1.2 Between 2009-2011 I was responsible for establishing seven place of safety services for those members of the public detained under section 136 of the Mental Health Act. This included one service specifically for children and they were highlighted in 2010 by Her Majesty’s Inspectorate of Constabulary and the Care Quality Commission as national best practice and contribute to over 97% of those police referrals for assessment being undertaking in an NHS setting. Previously, 100% of assessments involved the use of police cells.
1.3 In 2011 I started using social media to raise awareness of the issues faced by the police at mental health incidents. In particular, blog has drawn attention having won the Digital Media Award in 2012 from our leading mental health charity, Mind. The intention behind this was to educate and inform police officers of the various legal and clinical difficulties into which they can inadvertently be drawn and encourage them to mitigate risks to the public and themselves by improving their legal knowledge and basic mental health awareness. For several years, I have been a visiting university lecturer – on the MSc in Forensic Mental Health at the University of Birmingham as well as on undergraduate training programmes for paramedics and mental health nurses.
1.4 This submission is my personal view and does not represent any organisation to which I am or have been in any way been connected.
1.5 I was specifically invited by the committee to disregard the word limit publicly indicated – accordingly, this is a 5,000 word report.
1.6 This submission will argue – there is a de facto mental health role for police officers; that initiatives we are currently seeing to better manage those responses are under-researched, unevaluated and done in the absence of proper training for officers to tackle such incidents. This submission will further suggest that there are other, potentially cheaper ways of achieving the same thing and without having to criminalise vulnerable people who are increasingly coming into contact with criminal justice services in order to access care or as a proxy for it.
POLICING AND MENTAL HEALTH
2.1 We know from the Adebowale Report (2013) that mental health issues are a contributing factor to 20% of police demand. We know from research by Victim Support (2013) that those of us with mental health problems are significantly over-represented in the profile of all victims, being at least three times more likely than the general population to experience crime – in the case of women with mental health problems likely to suffer from violent crime, this rises to as high as ten times as likely. Every year in England and Wales the police detain approximately 22,500 people under section 136 of the Mental Health Act 1983 and my own estimates as well as other limited research suggest that the number of people arrested for substantive offences who may be experiencing a serious mental health problem equates to between 25% and 40% of all those detained. The Independent Police Complaints Commission has consistently reported that mental health is a feature in many of the complaints they receive, including annual reports that just under half of the deaths in police custody and two-thirds of those following contact include individuals experiencing mental distress.
2.2 This is a significant contributor to overall police demand and amongst the most complex and sensitive areas of all the work undertaken by police officers. In my day-to-day role as a police emergency response inspector, my team deal with mental health crisis situations almost every shift, frequently many of them in a single day. It is a larger feature of my day-to-day work than robbery or burglary. More importantly, this work is crucial to public confidence in policing as a whole because it focusses upon the ability of government to ensure the basic safety and wellbeing of citizens.
TRAINING AND PREVALENCE
3.1 Most police officers receive between four and eight hours of mental health related training at the start of their careers and this must cover raising awareness of various types of mental disorder, legal frameworks and as well as the implications for operational policing, including crime investigation. There are many examples of localised training being delivered by mental health trusts to those police areas they cover. Nevertheless, overall, it is inadequate and we frequently hear of “a lack of mental health training” for police officers. Having witnessed local training provided by mental health trusts, I have also been alarmed at how wrong some of it is, legally speaking. If nothing else rings loudly from this submission, it should be the urgent need for validated, professional training for police officers at all levels.
3.2 The increased demand connected to mental health issues has been seen over the fifty or sixty years since mental health services began to move away from a heavy reliance upon institutionalised models of care. The introduction of antipsychotic medication in the mid-1950s and the unaffordability of our old county asylum structures in the post-war era forced us to look at new ways to provide care. Since then, police forces around the world have reported a steady increase in the demands they face which are connected to mental ill-health. Models of care have shifted, quite rightly, to a less restrictive, human rights oriented model of community care where possible. However, we have seen an increasing tendency to criminalise the behaviours which arise from mental health crisis and the inability of our NHS system to manage the implications of deinstitutionalisation is seen in the issues examined by your inquiry.
3.3 We know from research in police custody (JAMES / RIORDAN) that around 12%-15% of those arrested for offences are suspected of having a mental health problem and we can also infer that this represents an under-identification of individuals – it relies upon police officers screening those who are detained. We know that where police forces have engaged in better information sharing about those arrested, as many as 50% of individuals are known to mental health trusts, currently or previously, and would benefit from referral after arrest. The prevalence of suspects in custody who live with disorders and / or substance abuse problems has given rise over the last few decades to local initiatives in what we now call “Liaison and Diversion” – these have previously been ad hoc, uncoordinated programmes which ensure some screening in custody and referral if required. Even as recently as April 2014 when the Centre for Mental Health published a report Keys to Diversion, it has been the case that research and discussion in liaison and diversion is focussed primarily on health, with much less focus upon justice. The evidence base for Liaison and Diversion is not as robust as we might hope it is something the Centre for Mental Health acknowledges and little of it focussed on re-offending rates.
3.4 We know that police forces face significant challenges in implementing the implications of the Mental Health Act Code of Practice because in many specific instances, NHS services are not commissioned, not managed and not integrated in such a way as to give effect to it. For example, para 10.22 of the Code of Practice requires that officers who detain a person under s136 MHA should not choose police custody as a place of safety, other than as a last resort. They should consider alternatives available even if the primary identified location – presumably a mental health unit – is unavailable. One option, for certain kinds of patient, could be an Accident & Emergency unit and yet today, despite at least one former Strategic Health Authority writing to all Emergency Departments directing them to desist from the mantra that “A&E is not a place of safety”, it is still a widely perpetuated position statement. I fully understand why this is said because I recognise the unsuitability of those kinds of environments for certain kinds of patient with mental health problems. And yet separate developments in health are seeking to ensure that all A&Es have liaison psychiatry services. Denying access only to those in the custody of the police is likely to have a disproportionate impact upon BME communities and more complex patients.
3.5 If a uniformed police officer who has detained an elderly person with dementia or a 15yr old girl with depression and an inability to access a mental health unit as a place of safety emerges, they are left with the choice of somehow improvising a pathway or using police custody. In some situations A&E would be a preferable, if far from ideal location for some. Not all, just some. Far more importantly, if those patients had been in contact with the ambulance service and been referred to A&E because paramedics have few other pathways available to them, my experience shows there would have been few objections by A&E staff. There is a problem around equality and parity of access and esteem for those of us with mental health problems.
3.6 Paragraph 22.13 makes it the responsibility of mental health providers to lead the re-detention of AWOL patients whose location is known. I am yet to encounter an example of mental health nurses or other suitable professionals undertaking this. Every time in my operational work I draw this provision to the attention of a hospital who is reporting a patient missing where their location is already known, they will simply reply, “We don’t have the staff and if you don’t bring the patient back, it will be your responsibility.” As if that settles the matter definitively. This small example is at the heart of the problems that have emerged over the last decades: assumptions that it is acceptable for mental health services not to organise and structure themselves in such a way as to envisage how these responsibilities are discharged. I’m confident no Chief Constable would get away with organisational level disregard of PACE Codes of Practice, for example. This gives rise to questions for the Care Quality Commission and NHS England about the detail of inspections they undertake.
PLACE OF SAFETY SERVICES
4.1 Section 136 of the Mental Health Act and access to place of safety services has been the poster-issue within all of policing and mental health for decades. As recently as 2008, the Independent Police Complaints Commission published a study indicating only 33% of those detained were able to access the NHS. By 2013, the Care Quality Commission published in its annual report that this figure had risen to 66% – still some distance from the vision in the Code of Practice that police stations should only be used in exceptional circumstances.
4.2 Having been involved in discussions with partner organisations between 2005-2010 about the establishment of place of safety services, there are certain problems faced by NHS organisations in delivering the kind of services envisaged by the Royal College of Psychiatry Standards on Section 136 (2011). In particular, there are problems around the management of detainees who are under the influence of drugs and alcohol as well as those who are physically aggressive or resistant. Also, there are quite remarkable problems in achieving access to NHS services for children, who are often excluded from place of safety provision because of misguided concerns around safeguarding.
4.3 The issue around drugs, alcohol and resistant behaviours is worth emphasising – we know individuals who present in this way to officers can represent management difficulties and can pose a risk to the safety of others. We also know that alcohol and drugs can mask other; underlying medical problems and those resistant, aggressive or even very violent behaviours can be connected to medical problems. In the Royal College Standards there is specific mention of place of safety services being commissioned in such a way as to allow for this reality. Obviously, mental health services should also have in mind the Rocky Bennett Inquiry (2000). Mr BENNETT was a patient in Norwich who died following a restraint intervention by mental health nurses and the investigation that followed heard from experts in the medical implications of restraint. The Inquiry recommended that restraint of psychiatric patients should be treated “as a medical emergency” and that it should be undertake only by trained staff with access to drugs, defibrillators and the ability to call upon a doctor to arrive within 20 minutes (p55). The police service often deal with similar vulnerable people who face and pose similar risks but without officers having anything like as much knowledge of the individual, the only way to give effect to these kinds of recommendations is to advice an ambulance to every section 136 intervention and removal to A&E to allow them opportunity to consider the NICE Guidelines on the Short-Term Management of Acutely Disturbed Behaviour (2005).
4.4 We know that in various death in custody inquiries – Sean RIGG, Michael POWELL and James HERBERT – it was a feature of the criticism of officers that they did not treat the incident as a medical emergency and attempt to secure removal to an Accident & Emergency Department via ambulance. Yet it is my experience around England that when one attempts these discussions with partner agencies, many professionals in those areas of the NHS think this is blatantly preposterous. It was only last week that a senior professor of psychiatry stated public on Twitter that police station cells should still be used as a place of safety in exceptional circumstances “for those who are violent”. This statement was not further qualified and is an example of why it is difficult for police officers, unqualified and inexpert as they are in mental health issues, to undertake partnership work which delivers the realities that Royal College Standards, NICE Guidelines and the Code of Practice.
4.5 A final point on place of safety provision which I know is in the background of NHS concerns about ensuring effective provision. The police in some areas massively overuse and occasionally abuse, section 136 MHA. Nationally, the CQC will state that 17% of those detained by the police are further detained by NHS. Whilst accepting subsequent admission to hospital is not the only indicator of appropriate use, it does give a sense of it. When examined more locally areas vary enormously. In Birmingham, the Place of Safety service sees around 45% of people subsequently admitted. Many more are referred for mental health problems to community mental health teams or back to their GP. Only a minority of cases lead to no need for further follow-up and in most of those, nursing staff were mainly satisfied that officers had reasonable grounds to suspect a mental disorder.
4.6 By definition, these statistics mean that there will be other areas getting nowhere near the 17% average that we see nationally. I am aware from a police force in the north of England that fewer than 10% of section 136 detentions lead to admission and most lead to no further follow-up at all. This suggests very strongly that officers in that force are misapplying the power and need further direction and training. I know from mental health professionals in that area, that this is training the local force is not willing to give and they see few problems in their decision-making and this disregard is why street triage was conceived to be necessary. We need better training for officers, in my view. Otherwise, we are expecting the NHS mental health crisis system to operate as a dumping ground for problems the police wish to push elsewhere. There particular problems in the use of this power when the police encounter intoxicated people and those who have committed offences whilst unwell. I have written more about that on my blog.
5.1 Street Triage schemes, as they have become known in the United Kingdom, have come into operation around the world in various forms. In US and Canadian cities there are examples of police officers working together with mental health and / or social professionals. We have seen models involving literal partnership working, in the sense of an officer and mental health nurse patrolling and responding together as well as other models based upon the ability of officers to ring mental health professionals for information and advice, sometimes from nurses based in police control rooms.
5.2 The reception of these teams has been extremely positive and has been linked to significant reductions in the need for the use of section 136 MHA. In Leicestershire it has been associated with a 40% overall reduction in use and in Cleveland the reduction has been greater still (during the hours the scheme operates).
5.3 During the time that street triage schemes have operated, I have taken as much opportunity as I can to learn about how these schemes operate and discuss them with people involved. It is fair to say that most of those involved in the schemes are especially enthusiastic about what they deliver. Whilst I can fully see why they are, I have learned various things that alarm me about street triage, notwithstanding these acknowledged benefits.
5.4 In particular –
- I have repeatedly put the scenario to nurses and police officers involved in these schemes about how a situation should be handled if the police are called to someone who is floridly unwell and highly resistant and aggressive. Nurses and police officers have repeatedly stated that in such scenarios police custody is the only place that could safely contain such detainees. For reasons I have written about at length on my blog, such actions are the stuff of death in custody inquiries – Sean RIGG, James HERBERT and Michael POWELL amongst others. I have therefore been forced to conclude so far, that street triage schemes could potential raise the risks of such tragedies, not mitigate against them.
- I have had cause to raise concerns about the misapplication of the Mental Capacity Act by street triage schemes – for reasons outlined below; there are problems in bringing easy legal solutions to mental health crisis incidents in private places. The Metropolitan Police were successfully sued in 2010 for “using” the MCA to resolve such a situation – in the case of Sessey v South London and Maudsley and the Commissioner of Police for the Metropolis (2010).
- I have been contacted by police operational supervisors and force incident managers from three separate police forces for my advice in connection with situations that street triage schemes have attempted to resolve, concerned as they were at the legality of following the advice that was given or the action proposed. On all occasions, I have had to agree with their concerns.
- Finally, street triage schemes were introduced in some places because mental health services were extremely concerned about the overuse and indeed, the abuse, of section 136 by their local police force. One AMHP lead informed me that the trust worked out it would be easier and cheaper to deploy a nurse in support of the police “to stop them doing the wrong thing” than to process the high volume of drunk people who were being processed into their place of safety service when other legislation should have been used. I have no difficult in accepting their concerns given the published volumes of s136 in that force area.
- These schemes are not about improving the ability and knowledge of police officers to resolve situations appropriately – I am not aware of any validated training schemes for any of the professionals involved. They rely upon operating cultures in policing and health being shared. We must hope they were appropriate in the first place and we know in some areas, they were not.
5.5 Street triage schemes normally introduce a nurse into a situation where previously, only a police officer would have been. In some schemes there is also a paramedic involved. This is clearly of enormous benefit in assessing clinical risks and assists in identifying the appropriate pathway required. However, despite nomenclature, street triage does not just respond to situations in public spaces – they are often called to domestic addresses. If the person within the incident does not wish to engage with the nurse or paramedic concerned, then those health professionals bring no additional legal powers to those already enjoyed by the police officer. We are then back to a long-standing, complex problem: the safe resolution of mental health crisis in private premises when it is thought that immediate intervention is needed. This is why I have heard of incidents from colleagues that triage cars have encouraged illegal use of section 136 and of the Mental Capacity Act – just as some police officers did when previously acting alone.
5.6 That said – I wish to re-emphasise that these schemes are bringing obvious benefits when they encounter people in public places or those who wish to engage and most of the above concerns could be corrected by effective training for all involved. If set against evidence that they are actually cost-effective schemes to operate, then I would welcome their expansion. My own view is that if police officers were properly trained in mental health, including mental health law and if mental health services were sufficiently accessible to those in crisis or seeking help, then we would not need street triage and as long as we have capacity problems in inpatient units and amongst community teams, it raises the question of what street triage are referring people to. If we are not careful this could be the opposite of early intervention which is so cherished for its impact in other areas of mental health care.
LIAISON AND DIVERSION
6.1 In 2003, I completed a Master’s degree in Criminology at Cardiff University and undertook research on 10,000 police custody records, to examine the decisions made about offending for those who were suspected on arrival to custody to be mentally unwell. This research concluded one important thing which is almost entirely unmentioned in all of the research, material and reports I have read over the last ten years — in practice, the one thing that determines whether a person is divert from the justice system without prosecution is whether that suspect, on the day of arrest, is so potentially unwell as to need admission to hospital under the Mental Health Act: were they “sectioned”.
6.2 There are several problems with this observation –
- Firstly – whether or not a person meets criteria for MHA admission is nothing whatsoever to do with whether they can or should be held criminally liable for any offence committed. Examples exist of extremely unwell people who have been prosecuted for serious offences and been found fully responsible in court and convicted, despite meeting MHA admission criteria from the point arrest to the point of being sentenced.
- Secondly – most people (75%) who are ‘diverted’ under the MHA are admitted under section 2 of the Act. This provision allows for full assessment of someone’s condition and in many cases concludes that no significant mental health problem exists and a patient is discharged. If a person has released from police custody without further action, where does that leave the victim and notions of justice?
- Thirdly – on what basis is this decision made? Despite mental health professionals recommending MHA admission, it still remains open to police and prosecutors to commence criminal proceedings where Part III of the Mental Health Act (patients concerned in criminal proceedings) can ensure treatment, care and full information to the courts concerning someone’s mental health. Such information is normally not known or made known to police officers and prosecutors taking diversion decisions.
6.3 When are we liaising? When are we diverting?! – who is making the decision and how? I am concerned that a lack of clarity and research about this is stacking the deck in favour of expedient decisions to remove just some people from the criminal justice systems who would be far better cared for in the long-term, if they were within it or diverted from it later in the process. Diversion can occur at all four points of justice – police, courts, prison and probation – we need an overarching strategy for how this is determined. I am also concerned about the impact these decisions have on public protection because of their ability to contribute to a revolving door of crisis intervention – admission – discharge – relapse.
MENTAL HEALTH LAW
7.1 Those parts of the 1983 Mental Health Act which affect the police were carried over from the preceding 1959 Act and were unaffected by the 2007 amendments. As such, police officers are policing a 21st century, deinstitutionalised and diverse society which leans towards a human rights oriented model of community mental health care. In my sixteen years of experience, I have formed the view that I am ill-equipped legally to ensure a professional policing response which supports that approach because I lack the ability to safeguard vulnerable people who are at risk in their own homes. I am no better placed to do this if accompanied by paramedics or mental health nurses. I cannot rely upon legal safeguarding powers under the Mental Health Act without calling upon an Approved Mental Health Professional and a section 12 qualified Doctor – but nor are those partner organisations with whom I must work able or obliged to respond in timescales which would support me in mitigating risks to vulnerable people. In the several hundred times in my career when I have called upon an AMHP to assist in a crisis situation that had not been foreseen by them, I can only give one example of a response and it took in excess of four hours to achieve and frankly, it surprised me that it was so quick.
7.2 Instead, we see people arrested for offences or to prevent a breach of the peace to achieve assessment in police custody – the antithesis of what we should be aiming to see where the main concern is mental wellbeing and another example of our national system needing criminalise those who are mentally unwell.
7.3 I am aware of the current Government review into section 135 and 136 of the Act. If it were agreed there is an operational problem we could conceive responses which do not involve altering the law. If crisis services were structured in such a way to provide a nurse-led response – and where needed an AMHP / DR response – then the law would be fit for purpose. This is what the judge said in the Sessey case. However, such a view is contingent upon mental health services being willing and able to support 999 services asking for a crisis team type response or an urgent Mental Health Act assessment. Many do not agree they should provide their services in such a way and they do not do so.
7.4 So a health and social care response to mental health crisis in private would be welcome but we should also consider how to equip 999 services to safeguard vulnerable people without criminalising them unnecessarily where such a response cannot or does not occur. To ensure such provision would be consistent with many other nations from the Republic of Ireland, to South Africa and the states of Canada and Australia.
7.5 There are other difficulties with the Mental Health Act, which I suggest could be massively simplified in the interests of clarity to the police service – for example, there are in excess of twenty-five different timescales which apply to patients who absent themselves from admission under the MHA or fail to return from authorised leave. It is envisaged by the Code of Practice where patients are missing that officers be informed of the timescales by ward nursing staff. I estimate that in excess of 97% of the time they do not know – because legal training for mental health professionals is parlous, with the exception of Approved Mental Health Professionals.
8.1 Mental health is core police business and needs to have greater prominence in the strategic management of the overall workload. We need to see vastly improved training for operational as well as senior police officers. However, we need to ensure through proper partnership structures at national, regional and local level that this is done on the basis of recognising what our police service, and our emergency services as a whole, are actually for – and on the basis of far more research and improved legal training for all. We currently see significant disparity between the way resources are allocated in physical and mental health when in reality there is no proper distinction of that kind. We see a significant lack of legal knowledge amongst health and social care staff at all levels, as well as in police officers that contributes to the creation and perpetuation of myths and folklore about how the interface between mental health and criminal justice is managed.
8.2 Our mental health system as a whole is still wrestling with very basic questions about mental distress in terms of whether we should view people’s experiences and behaviours as disease, distress or dissent. We read unresolved debates about the efficacy of drug treatments and talking therapies, including claims that these approaches lack evidence to support the claims we frequently hear. We have also seen the efforts to which many professionals, charities and service users will go to put distance between the notion that those of us suffering from mental health issue of various kinds are violent or likely to commit crime.
8.3 And concepts like street triage and liaison and diversion, by their existence, are recognitions that we need different systems to those we would otherwise employ, in the effective response to those of us in crisis, in disorder and / or when accused of offending and we are contemplating them without a robust evidence base for their inherent claims. We need far, far more research. I am mainly concerned that the emergence of these schemes will have unintended consequences elsewhere in our mental health and social care systems – will it become even more normal that access to services is achieved through the criminal justice system and what impact will this have on the poorest and most disenfranchised in our society?
Winner of the Mind Digital Media Award.