Imagine two medical problems had occured involving two seperate people – an elderly lady suffering a serious asthma attack or chest pains and a young child who falls and hits his head and scrapes his hands after falling whilst playing. In terms of clinical assessment, any paramedics called to the scene may suggest A&E for the elderly asthma / chest pains patient and a local minor injuries unit for the minor wounds and scrapes injury because they probably require cleaning and dressing after a check over. Now help me think through a patient whose medical needs to have two dimensions: imagine our elderly patient fell whilst struggling to breathe and hit her head in the same way as the child. A member of the public sees her fall, notices the breathing problems and injury before calling for an ambulance.
DISPARITY OF ESTEEM
Where these two problems are combined in one patient, you would expect a one-stop shop, wouldn’t you? You would gravitate to A&E because of that more serious asthma / chest pains condition and expect them to clean and dress any minor wounds and scrapes whilst they’re at it. Surely you wouldn’t expect A&E staff to stick a crude bandage around the wound once the breathing / chest pains matter is sorted and send that person off to the minor injury unit to get their head fixed. Right?!
No – you go to the one place that can manage the more serious matters and assuming all things can be dealt with as an outpatient, Accident & Emergency would deal with the lot. Of course, if any medical assessment indicated that person needed further treatment and care as an inpatient, it may be decided that a journey to the appropriate hospital would be needed. But basic assessment of need would all occur in one place and where possible, immediate treatment would occur in one place.
So why does mental health differ in this regard? Why would a physically injured person who is also in crisis or distress be forwarded on to a second location purely because their additional issue is a mental, not physical, condition? Well, actually, not all such patients are forwarded on – it’s usually only those in the custody of the police who suffer this indignity. Apart from referring patients to their own GP or community mental health team, A&E have no further place to discharge someone with outstanding, yet-to-be-assessed mental health problems. So they turn to existing Crisis Teams and / or to the hospital’s psychiatric liaison service if there is one but those patients in the custody of the police can be forwarded to a second location: either to a health-based place of safety if detained under s136 of the Mental Health Act, or to police custody if there’s nowhere else. Another example of clinical decisions becoming predicated upon non-clinical criteria and whether or not someone is in contact with the criminal justice system.
Imagine if it were suggested that the manner, the timing and the location of medical treatment you could receive for a medical condition or injury all hung upon whether the police had arrested or prosecuted you for something?
THE CRIMINALISATION CONTINGENCY
Imagine any kind of illness on a scale of 1-10 in terms of its seriousness and the need for urgent treatment. Level 1 is self-care, level 2 is pharmacy advice, level 3 is “Ring 111” etc., up to level 10 which is you need urgent A&E treatment. Imagine that following a medical emergency someone’s need for urgent, unscheduled care is floating up at around 8 or 9 and paramedics are called and imagine one part of several medical matters in play is a mental health condition. It could be someone who has taken an overdose and / or jumped from a height whilst in crisis and seriously hurt themselves. There is a pathway that results from the paramedics’ assessment of your presentation that gets you straight into A&E and you jump most of the queue because of the seriousness of your condition. Your two or three distinct but related medical matters are assessed and stabilised in A&E before they determine in conjunction with specialists where you go next and the mental health dimension to your unmet needs benefits from the involvement with the liaison psychiatry team. Imagine that after triage in A&E the overdose turns out not to be serious and there will be no lasting consequences in terms of internal damage or injury from the fall. All of that is fairly quickly assessed and treated and you await the arrival of the psychiatric liaison team
Now repeat that story and replace the word ‘paramedic’ with ‘police officer’ after we imagine a situation where there was no available ambulance to assist in initial assessment of need – this is an increasing reality, according to some. Overdose plus injury will still result in A&E, but we can start to anticipate the pathways will differ once we learn that the overdose is non-lethal and the injuries are treated. We can start to anticipate suggestion that the person be moved from A&E – especially if they were detained under s136.
But why?! – what is clinically different about this person or the situation? The only difference here is the nature of the uniform that brought the person to A&E.
I’ve often joked that to solve some of the problems we see in urgent, unscheduled care for mental health related demands, we would go a long way to solving the problem by having green overalls and clipboards in all police cars. If the officers just swapped into a paramedic’s uniform prior to arrival in A&E it would result in a greater healthcare focus on that patient as a patient – it would remove the criminalisation contingency and reduce all decisions to clinical ones. But this is a ridiculous idea and whilst it always gets a laugh during presentations I give, it says a lot about the experience of trying to ensure a health focus on health issues when – as a police officer – you have assisted someone in need or when you have detained them under the Mental Health Act. Somehow, your involvement is a game-changer for clinical care.
GLASS HOUSES AND STONE THROWING
Of course, some NHS reaction to police removal of vulnerable people to A&E under s136 occurs because of police overuse of section 136 and because of the all-too-keen instinct of police officers not to have to sit around for hours in A&E departments or places of safety. We’re already only part way through a journey to see more use of NHS based places of safety that our NHS is busy rising to that challenge. Figures published recently week show that we have now reduced the use of police cells to just over 6,000 times a year. Those who have followed the street triage debate over the last couple of years will have noticed a lot of NHS areas are seizing upon the initiative as a method by which to reduce the number of section 136 detentions they have to assess, by ensuring methods by which the police can bring people into faster contact with a mental health professional, without the need to legally detain them.
It needs to be recognised – the impact upon our NHS in having to handle assessment after assessment where the grounds for detention were not really thought through. I have written elsewhere about this, but it is essentially the speculation that behaviours thought by the police to be suicidal or non-normal (whatever that means) when people are intoxicated are attributable to a mental disorder. This is a really difficult call. Police officers have often asked whether someone stating they want to hurt or hill themselves whilst drunk should be taken as a sign of a mental health problem? This is question which a future blog will address. My summary answer is: if intoxication has reached the level of someone being ‘drunk’, then we should be very wary of making this leap. Unless the officers also have objective, independent or third-party evidence of someone’s mental health issues, we should deal in the first instance with the drunkenness, public order or other offences in front of us. If there are still concerns after someone sobers up, then mental health assessment can still be effected in police custody – and all of this whilst remembering the potential that whilst intoxicated, risks remain elevated that the alcohol is masking a medical condition. A&E teach doctors not to attribute anyone’s presentation to alcohol until everything else is ruled out.
Commissioners and senior officers who should be sitting down together just about now to discuss how they are going to draft the local crisis care declarations; a requirement of the Crisis Care Concordat – they have to be done by December 31st, folks!
They should all be thinking about why the blockages arise and what they can do about them –
- Proper training in the police application of section 136.
- Effective diversion arrangements to avoid the need for section 136.
- Proper arrangements in section 136 PoS facilities.
Unless you start putting all of these together, you’ll keep having a system that is not built to absorb the nature and variety of demand to which section 136 of the Act gives rise. And it’s when the system can’t absorb the demand that you start to see particular parts of the system pressuring the others – this is what links us back to the original point about two-stop, mental health shops which are never, if ever, patient focussed.
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