We’ve now seen a couple of case of Ebola in the United Kingdom, each of them healthcare professionals from the UK who volunteered to travel to west Africa to assist with the looming disaster there. I couldn’t be prouder of those nurses for their work and nothing that follows is about the healthcare that they will now be receiving. Indeed, my admiration for the first British Ebola victim, William POOLEY is immense following his decision to return to Sierra Leone to continue his volunteer work. Quite simply, inspirational stuff – and so this post is not to argue that anything we’re doing on Ebola is unnecessary or over the top. It is absolutely what you would expect to see happen and very obviously necessary.
Prior to Mr POOLEY returning from Africa having contracted the condition, I remember watching the evening news and seeing a BBC report about what would happen if and when the UK did find someone with confirmed Ebola within our shores. You may remember, airports including Heathrow as an international hub, implemented various screening measures for passengers travelling from affected countries and we were able to see the special isolation areas at the Royal Free Hospital in Hampstead, London where patients would be taken. News this morning confirms that Pauline CAFFERKEY, a nurse from Lanarkshire, has been taken there after returning from a month of working in the ‘red zone’ in Freetown, Sierra Leone – the most dangerous area to work. You can read more about their stories, Ebola and the various responses to this international problem by choosing the links in either of their names, above.
I was struck by an entirely new thought – were you? Why do we know – in detail, with infrastructure in place – the potential response we might need to have to a patient who may never emerge for a condition that we haven’t seen for decades? Meanwhile, we don’t know what will happen this afternoon with the next s136 detainee who is intoxicated whilst mentally unwell. The likelihood of an Ebola patient emerging is raised far above the ambient threat level we’ve known over the last few decades because of the scale of this Ebola particular outbreak compared to others. The management of any potential Ebola patient was always going to occur within the Royal Free Hospital’s infectious diseases unit and the RFH is home to the UK’s only High Level Isolation Unit. Hence all UK patients are transferred there, even from Glasgow. They are not specifically focussed upon Ebola but would care for any patients alongside others admitted for other conditions that would also require them to be isolated.
But I could help but keep contrast this to preparedness for certain ‘everyday’ mental health emergencies, including where risks to others exist, including to professionals providing care or support. You could make the same comparison to rare forms of cancer: oncology services still provide the infrastructure and there are specialist facilities and NHS staff for particularly rare forms of cancer. The comparisons could go on in paediatric services or orthopaedics.
Over this Christmas and New Year period, the National Institute for Health and Clinical Excellence (NICE) are consulting upon new guidelines on the management of violence and aggression, updating previous guidelines from 2005. I’m busy reading the full 80 page document during the Christmas / New Year lull where I have few meetings to attend but doing so also made me mentally link back to my above thought: that NHS services acknowledge the reality that on some occasions, psychiatric patients present in various states of distress that include resistant behaviours but we aren’t necessarily. So why aren’t we prepared for this in the sense of having clear pathways to care, in sufficiently safe environments? We know that the multi-agency agreement, published in the form of Standards on s136 by the Royal College of Psychiatrists, requires areas to commission services which can receive patients “even when the patient is disturbed” (p8). We have seen report after report following deaths in police custody that calls for greater access to urgent healthcare pathways for patients detained by the police under s136 where alcohol and / or aggression are relevant to the initial handling of someone at risk.
Every day in England, section 136 of the Mental Health Act 1983 is used 65 times on average. We know that some of these patients will be known to mental health services, with established histories. We know from the IPCC that 2 people a year die whilst detained under s136 MHA and that resistance to detention, especially whilst intoxicated, are particular risk factors – especially when we remember that people living with severe and enduring mental illnesses are likely to have far poorer physical health than the norm for population as a whole. Alcohol and aggression can mask the ability to tell whether there could be other, co-morbid medical issues in play and incline us to want to push people off to the cells.
We saw only this week that the President of the College of Emergency Medicine calling for those who are drunk and disorderly to be removed to custody and it was interesting to see the extent to which other doctors waded in to that debate on social media, pushing back against his idea. They were counselling against precipitate clinical decision-making which could leave doctors open to allegations that they had missed underlying problems – some of them were sharing the things they’d missed in their clinical careers by such hasty judgement. This remains true, if not more likely, where a patient is ‘drunk’ and ‘disorderly’ because they have self-medicated to stop auditory hallucinations or delusions and / or injured themselves. If you apply the historically difficult exclusion criteria to that 65 a day, it could be as many as 30 or more who would be excluded from the NHS on the grounds that their presentation involved intoxication or aggression, all dependent on how they select and apply their particular criteria. So what is the plan, given that we know many of those 30 are at greater risk if detained in police cells, away from clinical supervision?
I repeat a standard caveat that I’ve mentioned many times: the police in some areas over-use s136 MHA and some officers are too quick to opt for this power when others should be chosen. It has been my view for some years that use of s136 could be lowered if we just took the time and trouble to provide proper, detailed training on its application, on less restrictive pathways, and this should including specific guidance on what ‘mental disorder’ means; and on how ‘immediate need’ and ‘care or control’ should be interpreted. If we did this – as we do for stop / search, domestic violence and child protection, then officers would be likely to make better informed decisions.
Nevertheless, it comes back to this: we know the healthcare infrastructures by which we will manage a condition that had not been seen in the UK for decades until August this year and which is yet to kill anyone in this country – indeed the cabinet committee COBRA met yesterday under the chairmanship of the Health Secretary and then, the Prime Minister. Such is the prominence of this issue. Meanwhile in other (unreported) news, we don’t know where this evening’s s136 detainees will be taken so that they are safe, if they present in distress to police officers or paramedics whilst aggressive, intoxicated or both. Why not? Such patients have no less right to care than either of the inspirational nurses mentioned above and first presentations of those of us who experience mental health emergencies can also involve, occasionally, wider risks to the public and to the professionals in the police and NHS systems who are responsible for providing safety and care. We will probably see way more than two of these incidents before tonight’s celebrations in Trafalgar Square.
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