What Are We Trying To Fix?

We know that the use of police custody as a place of safety (PoS) shouldn’t be happening very often – only on an ‘exceptional’ basis according to the current and to the next Code of Practice to the Mental Health Act.  I was delighted to find out recently that since the work I did in 2009-11 has really settled in, we are now seeing single figures of detentions in police custody in a police force where over 1,000 people a year are detained under this provision.

Since ideas were turned into reality, West Midlands Police has seen more than 98% of people assessed in an NHS facility.  I will be dining out on that for the rest of my life – that’s thousands of people who have already been saved the indignity of detention in custody and numerous officers protected from legal liabilities that arise from having to ‘muddle through’.

Some other police forces are not yet as fortunate, for various reasons to do with capacity and because in some instances their NHS partners have not comprehended how it is possible for the NHS and police to work in the sort of partnership that Birmingham now expects in the management of detainees who are aggressive, resistant or under the influence of substances.  So in some cases we still see a majority of people taken to police custody.  It’s all just too hard to comprehend or deliver upon.  For some.

Meanwhile, and quite separately, street triage initiatives have sprung up around the country and depending on which area you examine you will find that between one-third and one-half of all previous s136 detentions are no longer happening, because the presence of a mental health nurse allows a less restrictive intervention that does not involve a place of safety, police cell or otherwise. What we have seen this morning in a BBC news article is the celebration of street triage as a method of reducing the use of police cells as a place of safety.  I want to spend the rest of this post outlining why this is faulty logic and why it doesn’t significantly reduce risks in forces where custody was still used routinely.

DO THE MATHS

* I can assure you these numbers are hypothetical, so no point trying to guess which force I’m referring to! I’m not referring to any in particular.

If you have a police area where around 1,500 people a year are being detained and to keep things easy, 50% are accessing NHS PoS care and 50% are still being incarcerated in custody, you could think of introducing a street triage scheme to reduce 136 demand and it may have the effect of reducing reliance upon cell space. Let’s imagine that the reason half of all detainees are still going to police stations is because the NHS still operate what I call ‘exclusion criteria‘ around those detainees who are under the influence of substances or who are – or have previously been – physically aggressive.

Let’s imagine, upon introduction of your street triage scheme you have reduction benefits like Leicestershire, of 40% overall.  You are now diverting 600 people away from any kind of place of safety and continuing to detain 900.  You might hope that these reductions would be split over the two kinds of Place of Safety being used so we end up without around 450 going to each place, rather than 750.

But this is not the way such things work in reality: re-examine the population groups going in either direction –

  • 750 non-intoxicated, non-aggressive patients going to the NHS, many of whom are wanting to access care but where it is proving difficult to do so
  • 750 people going to the cells who are intoxicated, aggressive or unfortunate enough to be detained during peaks of high demand when NHS PoS facilities are already in use and unable to receive them despite an absence of challenging behaviour.

Who do we think street triage is diverting away from s136?!

Well, in the main, it is the first group: those who would have been able to access an NHS PoS for help: patients who are potentially known to services and who are hoping to access support of some kind, where the CPN in the triage car can make arrangements for further follow-up the next day and where this satisfies everyone’s expectations and is consistent with managing risk.  Those who wouldn’t immediately benefit from triage, in the sense that section 136 may well still be necessary, are those where deferring intervention is not wise, where there is an immediate need to manage risks, including those posed by challenging behaviours whether or not aggravated by substance (ab)use.  Such individuals are those more likely to have been pushed towards the custody areas of our hypothetical police force.

Of course, each of these groups – the NHS group and the police group – will see a reduction in the use of s136.  From examples I’ve gleaned around the country, we can expect the NHS group to reduce significantly and the police group to reduce far less.  You might expect on these hypothetical figures that the NHS group to reduce by more than half and the police group by a quarter or less. Figures like 300 to the NHS and 550 to the cells.

NOT FIXING THE REAL PROBLEM

You see what’s happened now, though?!  Police custody is being used more often than the NHS because we didn’t address the section 136 management of those more difficult cases – vulnerable people with challenging behaviours and backgrounds.  If we look at street triage as a method of fixing the use of police custody, we will eventually realise that we were fixing a problem that shouldn’t have existed in the first place and which is fundamentally unaddressed in what we’ve done.

The health pathways for individuals who died in police custody are unaffected by fixing place of safety problems by the introduction of street triage in areas where police stations were being used on a more-than-exceptional basis.  Where police officers detain resistant, distressed individuals in an area where there is no clear clinical protocol in place, you still end up in stand-offs between A&E, MH PoS units and custody as to where should be used. Inevitably, the police get caught in the middle and told to take to custody.  It is for reasons like this that we are still seeing deaths in custody in the second decade of the 21st century which look and sound like those we were seeing over 30yrs ago and more.

Street triage and section 136 place of safety processes must be seen as *seperate* issues, notwithstanding the obvious overlaps.  Street triage is about providing less restrictive alternatives to detention, referral to existing community teams or back to GPs where required. Place of safety processes are about ensuring the existence of clinical care pathways for those who are detained – in all the wide range of presentational circumstances that vulnerable people become unwell. This includes those rare cases which are more likely than other mental health crisis incidents to generate calls to the police: resistant, aggressive crisis events where there is some potential risk to the public.

If your place of safety pathway doesn’t know how to deal with that today before you introduce your street triage scheme tomorrow, it won’t know how to deal with it tomorrow, either – and such vulnerable people are still likely to be detained section 136 despite the street triage scheme.  In some instances – but not my own force, I’m delighted to say! – I am worried that the existence of a street triage mental health nurse in the decision-making where areas PoS services are under-developed when compared to the Royal College of Psychiatry Standards (2011), is actually more likely to lead to calls of “violent patients” to the cells.  It is for this reason that I repeat my position that mental health / criminal justice interface training is urgently required across the police and NHS.

And to such simplistic clinical judgements, as “resistant patients to custody”, I say only this —

  • Faisal AL-ANI
  • Leon BRIGGS
  • Kinglsey BURRELL-BROWN
  • Rafal DELEZUCH
  • James HERBERT
  • Colin HOLT
  • Matthew LOVELL
  • Andrew JOHNSON
  • Olaseni LEWIS
  • Thomas ORCHARD
  • Michael POWELL
  • Terry SMITH
  • Toni Emma SPECK.

And that’s only this century – I’m sorry to say we could go back further but I think the point has been made.


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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16 thoughts on “What Are We Trying To Fix?

  1. In my area (Worcestershire) there is a dedicated 136 suite in a unit in the grounds of the hospital. I recently had the unfortunate experience of being detained there. Police stay until AMHP arrives and are then able to leave. The suite is somewhat more comfortable and less scary than police station. I think thoughit may only be able to hold one person at a time. Maybe this is an idea you could push a bit too?
    I can’t remember total website details but pretty sure it’s on the NHS website. Try googling elgar unit, Worcester

    1. I know the process as I’ve visited that unit – could never work out why the police stay until the AMHP arrives when national guidance says that things should be arranged so that the police should leave within 30 minutes?

      1. That maybe for some reason the assessment team won’t get involved until seen by paramedics (even when there is no obvious injury or query over self poisoning). Also in my experience our psychiatric assessment team don’t particularly act very fast. They are a real problem for the police I think. On that particular night Id spoken to the guy on the phone earlier. He told me he rang police and asked them to locate me and take me home. The phone call I’d made talk place on the slip road of the M5 and he seemed pissed off he’d had to come up to the Elgar Unit.

      2. Local Policy, agreed with the police, at that particular s136 suite is that when the AMHP arrives they immediately complete a joint assessment of risk which determines wether the police leave or remain. The target is for the AMHP to arrive within 90 minutes of being informed of the detention.

  2. Thank you for all that you are doing.

    It seems to me that at the moment Mental Health is being treated as a Cinderella service in many areas.

    Yours sincerely, Eileen

    _____

  3. People who know me know will understand this is a very burning issue. Having experienced the detention of a 14 year old ill child in a police cell for 26 hours as place of safety( due to lack young peoples mental health beds) the trauma this caused him and me still reverberates. Its a total disgrace that anyone ill but especially a child should be held in this way. I know many in the police and charities are fighting hard to get this changed but the hard fact is there are not enough child acute mental health beds in this country. If kids with physical illness were to be held in a police cell cos no hospital bed was available there would be a public outcry. 1 in 4 of our young people will experience mental health issues, thankfully not all need hospital admission but for those who do the service is very poor. I will continue to campaign as long as there are ill kids in this country who are in distress and end up in police cells. Detained not cos they committed a crime but cos there is no mental health placement available. As a parent ask your self how you would like your child who at there illest and most vulnerable would be taken alone to a police cell and locked up? It is barbaric and must stop. Thanks to pressure from service users, charities ,parents and bloggers like Insp Michael Brown I hope one day no police cell will be used as place of safety for a child.

  4. Having had some experience of the psychiatric inpatient system, I think maybe the wrong questions are being asked by the AMHPs in that there is such a thing as ‘leave beds’ which can be used in emergencies. The units are called and asked if they have any beds to which the reply is quite often ‘no’. However very often there are patients who have been given anything from overnight leave, to weekend leave, to a week’s leave. This means they are still on the books but aren’t actually using the beds.Very often when they are due back to the ward (certainly when on 5 days or more) they are reviewed and discharged. So in essence a bed has been left empty for a week and stays empty. However due to juggling of numbers and at some point contacting the patient on leave, hospital staff are reluctant to let go of their ‘leave beds’
    So really the PoS being a police cell doesn’t always need to be anywhere near the maximum stay.
    Perhaps a question should be asked by police when the AMPH says there are no beds ” Are there any leave beds available?”

    1. If only this was the case:-(

      I will gently remind u that that AMHPs don’t find beds. Strictly speaking i.e. The MHA & Code of Practice tell us that it’s the medics job. It’s now often/always delegated to bed managers ……

      I & colleagues always ask the right question & in many different ways, only to be left high & dry & disappointed 😦

      The question should be asked of commissioners & MH Trusts & then often & loudly of politicians etc….

      1. Sorry I don’t think I said that well. I know it’s not the AMHP’s that find beds, merely if the question was asked of the hospitalsthere would be more of a chance that the detained person might get to where theyre supposed to be quicker.

    2. I work in the area you are referring to. Leave beds are used on a very regular basis, Bed occupancy runs at an average of 106%, last time I read the figures, meaning that there are *always* leave beds being used whilst patients are on leave, despite the fact that increasing use of Home Treatment for early discharge reduces the availability of leave beds. We now send very few people out of area unless there is a specialist need. This has involved making difficult decisions such as placing voluntary patients in PICU or younger patients on older adult wards.

  5. No apology is really required – but thank you 😉

    The current bed crisis was described to me recently (again) as a “national scandal”………….. & people are ending up miles away fom home. That in itself causes so many difficulties in terms of co-ordinating the intially MHA Assessment & any subsequent request for a Tribunal or for a reassessment for Sec 3. I have colleagues travelling up & down the country & most days, when they should be here & again that has a knock on effect in terms of our ability to respond to requests for MHA Assessments locally. Add to this the personal family stories = great big fat mess, that serves no one well.

    take care & again thank u.

  6. Couple of points may be worth mentioning : I work for a CRHT who find allocate beds, should they be required when asking for bed status this includes leave bed status. Also in my experience a lot of 136 are picked up ‘ under the influence’ and once sober/free from are no longer in crisis . Also some ‘patients’ seek to get picked up on a 136 normally out of hours in the hope they will obtain a hospital bed.

  7. Hi, I’m a former Footballer having lost my career 18 years ago sending me into a spiral of depression so severe, I was self harming, over dosing, burning myself, drinking and planning my own death. I walked in utter silence for 18 years until last year. I got support from my GP & counselling. I wanted to provide support to Footballers experiencing what I did and founding FAD FC – Football’s Awareness of Depression Football Community was a move in the right direction.

    FAD FC have been working hard alongside our Patrons Lib Dem Cllrs Richard Shaw & Simon Clement-Jones recently to raise awareness of Mental Health and to encourage Footballers to speak out about their own Mental Health Issues. I know only too well how hard it is to open up about personal issues.. This is why FAD FC now provide a Counselling service as part of our 24-7 support service where should you not want Counselling but just want to have a chat, can email/phone myself!

    I’m urging Footballers (& Managers/Coaches) to speak out and not to walk in silence as I once did. Now I ”Speak Out… Speak Loud, Don’t suffer in silence”.

    All of our services are free of charge and as FAD FC are not connected to the FA or PFA, we NEVER share your details with them or your club.

    I have been campaigning to make Mental Health First Aid compulsory within the FA Level 1 Coaching Course Syllabus.

    Now, I also provide Football Initiatives for individuals experiencing Mental Health issues and run 3-4 Mental Health Football tournaments each year in Shheffield, as well as run the FAD FC Equality & Inclusion Football Academy.. Again, all of these services are free. All details can be found at http://www.fadfc.org.uk … You can also follow my updates on Twitter @FAD_FC and on Facebook https://www.facebook.com/footballsawareness?ref_type=bookmark ………. Please do follow us or like our page for daily updates on our work.

    If you do want to talk in confidence about your own issues, feel free to email me at talk@fadfc.org.uk .. Call or text me on 07880965609 or even chat on Facebook. Everything you say is confidential.

    If you want to get involved with FAD FC’s work and to expand what we do to reach more Individuals experiencing Mental Health issues, I am more than willing to chat about it to see how we can help each other and even to reduce numbers of crimes commited by using Football as an Initiative.

    Kindest regards
    Caroline Elwood-Stokes

  8. Good article. You are right about what Street Triage should be. In our experience (as a Triage Team) we always consider first and foremost what is the most appropriate pathway for an individual to gain help and support for whatever issues they have. As a side effect this usually means that s136 is not appropriate, in fact most of the time neither is an informal admission. We have drastically cut down on the use of s136 because we are working together Our Police force decide whether s136 is appropriate usually immediately as this is mostly a correct decision. i.e. they cannot wait a moment due to the risk of not detaining. Street Triage is not a service to remove a Police Officers autonomy, it is a resource and seems to be taken as an increasingly credible one that is proving effective and efficient. We also have a 136 suite which accepts those who are intoxicated.

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