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.
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