Putting Patients First

I had an absolutely horrible thought the other day – I had to wonder out loud whether it was really right to put patients first … the very public that the police are here to serve? I immediately felt very awkward indeed because even as my mouth was asking me the question I could tell my brain wanted to say, “Yes!” on principle AND say “No!” with reference to specific examples. And I must insist: I’m almost indignant with myself for asking the question and feeling that the answer occasionally may be in the negative. I know I’m going to get a slap for this post from a friend of mine who is a mental health lead in a police force, but she really got me thinking.

This all arises from a discussion about how the police should approach the issue of structuring partnership and a remark by a police officer that at the heart of everything the police decide, we should put patients first. Seems highly intuitive, doesn’t it? But I confess to wondering. It sounds like a question that doesn’t need asking or answering – would we put organisational issues ahead of public need? It may say that it would be outrageous to do so. Let’s see, with this thought experiment —

DEMAND MANAGEMENT

An AMHP has attended a private address with a psychiatrist and GP to undertake a Mental Health Act assessment on a patient. There is no need for the police to be present to manage any raised risks and once the MHAA is complete, it is decided that the patient will be admitted voluntarily to hospital – he is not resisting and happily watching TV. Demand on the ambulance service means it is not possible to secure transport from them and the AMHP has no other method to get the patient admitted after 4hrs of waiting and re-trying. Is this now a role for the police? Should we put patients first in literally, everything we do?

We could have used other examples – for example involving the recovery of AWOL patients or the completion of welfare checks. In fact, almost anything that is about the operation of the mental health system that does not involve allegations of criminal offending.

The question is abstract at this stage, isn’t it? If you were the duty inspector or sergeant in that area, you would have a computer screen full of jobs that your area is managing. Is the answer effected by whether or not you have a unit ‘free’? I should be clear about what ‘free’ means in policing. It means that the officer(s) in that vehicle are not currently assigned to a particular task like attending a burglary or a domestic incident, but they will have been given default tasks by their supervisors to undertake in between job assignments. Depending on the shift they’re working, those assignments could be “Check this list of current offenders to ensure we’re managing their conditions” – things like their compliance with bail conditions. It could be “Patrol the High Street, where the recent spate of street robberies have been” and the briefing would have contained details of locations, offender descriptions and victim profiles. There are countless others.

So how and when should that duty inspector make the decision that any request to convey has reached a stage where they should say, “Yes”?

1. Should the police literally put patients first and say Yes, when asked – bearing in mind that this must, by definition, mean that they stop doing something else. Is supporting the AMHPs request more important than patrolling the High Street or checking known offenders are complying with criminal justice restrictions? What if there are no units ‘free’? Is supporting the AMHP more important than the burglary job that came in at the same time?

2. Should the police set objective criteria for their involvement – it’s some while since I’ve written about or re-referred to this idea on my BLOG, but I came up with the concept of RAVE risks to suggest an approach: the involvement of the police in mental health system ‘jobs’ should be predicated upon Resistance, Aggression, Violence or Escape risks. You could come up with other criteria: these are just suggestive of the idea!

PROTRACTED DELAY

What about if things go on? Let’s imagine the duty inspector is a fan of the second approach and satisfied on the detail first given, that there is no urgency, the patient is happily watching TV and the control room have been told the politely decline the request, to continue to make other arrangements via the ambulance service or escalate the problem to the AMHP’s managers for another solution but to ring back if risks escalate. But now it’s 10hrs beyond the decision to admit and the ambulance service still cannot resource the job.

(10hrs is not an exaggeration, incidentally – several AMHPs have stated they’ve waited that long for support in conveying patients.)

Should any preferred principles of approach – whether you chose option 1 or option 2 – bend? Perhaps the police putting patients first stops when there are not in immediate need, or at risk and when there are 999 calls unanswered – I’m assuming most people would accept this? Perhaps we could set aside any criteria for police involvement if a vulnerable person has been waiting an outrageous period of time?

Difficult isn’t it? It brings us back to my too-often quoted remark from Egon BITTNER that “policing is what happens when something’s happening that ought not to be happening about which somebody ought to do something NOW.” He separately remarked that “There is nothing that could not legitimately become the proper business of the police.” Of course this doesn’t mean that everything IS the proper business of the police: it probably comes down to whether the ‘thing’ in issue needs to happen NOW.

URGENT EXPEDIENCY

Who knows how many robberies have been prevented because an officer who was targeted in their patrolling made an arrest that brought a crime wave to a halt? I know there have been days in my career as a PC and Sergeant where the only mission that really mattered was being in the right place to interrupt a local, mini crime-wave that was getting out of hand. Some of this stuff has meant that a lucky intervention of one kind or another has taken robbery levels in some districts from ten a day for the last week and half to one a week after the intervention.

It is these competing tensions, writ large, that are constantly juggled in policing – how would you hypothetically explain to do dozens of robbery victims that the reason you weren’t all over that time area like a rash was because officers we’re plugging other public service gaps? I’m a fan, for what it’s worth, that we don’t routinely consider the police a part of mental health care – our involvement should be exceptional and only when those gaps give rise to risks that require a quick or urgent intervention. I hope to achieve a position, quite frankly, where the police are as uninvolved in our wider mental health system as possible and only where it is connected to the safe management of incidents that we clearly understand as being a part of policing. It may not be popular to say so, but the expectations on policing as an adjunct to healthcare have grown exponentially in recent decades and not always after involving the police in how health paradigms develop. Some healthcare professionals think it is acceptable to ask the police to visit someone who failed to show up for a routine outpatient appointment, without having exhausted their own methods of following them up and without there being any indication that someone is at risk. Police forces are dealing with hundreds of thousands of requests for ‘welfare checks’ every month and estimates of the proportion of them that describe any kind of police responsibility in the initial phone call to the police vary between 4% and 25%. Whichever figure you pick, it’s clearly a minority figure.

This is not going to be popular: the NHS made certain choices about its budget management and its priorities that needn’t, strictly speaking, have been made. That’s how senior NHS managers chose to use the money they were given and actually, they chose not to use all of the money they were given. There has been a significant underspend in recent years. They have made these choices in an environment where their budgets have been far more protected than those of Chief Constables who are managing forces now with 20% less money than they had five years ago. It is an operational necessity that police forces prioritise what they do and that must mean looking at what we agree to do.

I’ve been a response duty inspector for most of the last three years and have made minute by minute decisions about what has to take priority: accepting that there is ambiguity in some situations, there are also other calls to the police for which the answer is “No – I’m afraid we can’t do that.”

Policing absolutely is about putting the public first in everything we do. Patients are the public and will often see their difficulties reflected in this thinking but they are not the totality of the public and it’s striking the right balance that is the role of Chief Constables and our operational duty inspectors, the country over. Remember what the police are for —

1. Prevent crime and bring offenders to justice.
2. Protect life and property.
3. Maintain the Queen’s Peace.

We have to accept that outside those responsibilities for our officers, there is a limit to how far vulnerable people should be further stigmatised and criminalised than they already are by the inappropriate involvement of the police. Wider responsibilities around health, risk and vulnerability sit with other organisations and with individuals themselves.


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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7 thoughts on “Putting Patients First

  1. “No” should be the answer in the scenario you describe. It’s a healthcare problem. If the patient is calm and compliant, why can’t the AMHP stick them in their car, then raise the issue of ambulance service delays with the appropriate people? It’s not conceivably a police issue in this situation.

    Regarding ambulance delays in these situations, someone in an ambulance control room will be making the exact same judgements. Do they send an ambulance to someone with no medical needs for the services of a frontline ambulance crew, potentially losing them for a long time with an out of area transfer, or do they send it to any number of outstanding potentially life threatening patients? Do they prioritise the patient sitting watching telly awaiting a medical taxi, or the elderly lady on the floor?

    1. Hi Jessica

      The NHS (Ambulance Trust) is commissioned to provide the service. In short it is paid by me & you do do the job.

      I can just imagine the parity of esteem people jumping up & down at your comments. If you break your leg they sent an ambo & they should do the same for Mental Health issues. The ambo trust here has a 4 hour target time to respond (they often fail) & I raise the matter with them & commissioners often. I accept that they are managing their demand.

      As for my car. I do sometimes if I think it appropriate & safe.

      But I am not supposed to, indeed my employer expressly instructs me not to.

      Remember it’s my car, it’s not provided to me & I might not be insured if something happens. It’s the same car I use to pick my kids up it etc. I also have colleagues who don’t actually drive. They use public transport.

      1. I agree the ambulance service is contracted to provide the service. I agree fully with parity of esteem. It is totally inappropriate to call the police in this scenario as there are no risks to anyone and parity of esteem means being taken away in a police car is completely wrong.

        However, the ambulance services are under huge pressure. Someone sitting safe and well at home who is in no immediate medical need nor in any immediate mental health need for treatment will inevitably be pushed down the priority order for an ambulance when there are multiple people waiting for ambulances for immediately life threatening problems – chest pains, difficulty in breathing, stroke etc. That is of course a sensible prioritisation. No one wants to leave you and the patient sitting there for so many hours, but when demand exceeds supply as it frequently does, that is inevitable.

        Someone safe at home watching telly awaiting a medical taxi will wait over and above the old lady laying on the floor – again, that’s a sensible prioritisation.

        The commisioning may well be wrong – a patient such as Michael describes does not need a frontline ambulance, they need a taxi, in exactly the same way that a person with a physical health problem not needing immediate paramedic intervention and able to walk will be increasingly invited to make their own way to hospital.

        The mental health trusts need to work with the commissioners and the ambulance service to provide a suitable vehicle which will be responsive to the mental health service needs. The obvious and really quite cheap solution to this is to have some pool cars so the AMHPs can get to appointments easily and conveniently and then convey suitable patients by car themselves.

  2. In the example given I cannot imagine that colleagues or I would call the police to fill the gap i.e. Convey the chap. Even if I did I would expect the answer to be no thank u mr AMHP & it’s your problem to solve.

    Of course one of the difficulties with being AMHP is that while in theory we have lots of power & can remove an individual’s liberty with a signature on a pink form & have lots of other duties & responsibilities, we have no power to instruct the NHS to provide a bed or to send an ambulance.

    I once found myself waiting 16 hours for a bed & then an ambo. I had been contacted by the police who where called to the house because of disturbed & threatening behaviour & drug misuse (cannabis). Having made the decision to detain a chap with the RAVE risks, I was left to it by the HTT, the police & the medics. After a number of hours I contacted my better half & again explained why I would be very late home & then my managers to discuss options.

    These options are always limited btw. I distinctly remember being asked what the risk management plan was should I leave? My response was “it appears to be a 16 stone man sitting in the front room, so I suggest send similar!”

    Can you really imagine what it is like to sit in someone else’s house for 16 hours with young kids present & a level of distress & aggression & threat? Remember without the bed an AMHP cannot make an application, never mind call & request the ambo. Eventually a bed was forth coming & by hook & by crook chap was taken to the ward – in my car. I could recount many tales, indeed I once half seriously gave some thought to putting pen to paper & writing the “Odd Job Man”.

    This week, not a million miles away from where you are sitting now I was contacted by the police & a GP. They had been called to this chaps house because of his disturbed behaviour. This 73 year old was seemly not v well & was living in squalor & sharing the filth with his neighbours.

    An AMHP was duly dispatched to undertake a MHA Assessment. Remember said AMHP has to secure the services of a Section 12 medic first & this itself is sometimes not always easy. The assessment was completed & the GP & the Sec 12 medic complete a joint Med Rec. The AMHP was willing to make the application, but there was no bed.

    BTW the chap was described to me as a very spirited & physically fit 73 & his language was it seems as filthy as his house. He was also very clear that he was not going to go to hospital of his own volition.

    In theory the doctor should have secured a bed, but both exited stage left, leaving the AMHP & the police in the house with the chap. At this point I will acknowledge that the police officers were excellent & stayed to support the AMHP & were definitely putting the patient first. At a push they probably could have arrested him in relation to the threats & behviour towards his neighbours & indeed the towards them & the mental health professionals present. But that was never really seriously considered. The man needed to be in hospital, that decision had been made, but there was no hospital to take him to.

    Add to this, that because he is an older adult there is no option of a HTT as such. What to do? Phone the NHS Bed Manager. No where in the MHA or Code of Practice or Reference Guide does it mention Bed Managers, but they now very important people. Usually nurses, usually v experienced & definitely under paid & over worked (mostly, & some of them are even human & friends of mine).

    The Med Rec for the Section 2 that the medics have completed does not have to indicate where the bed is. It is only the AMHP application that needs to have the where. It is different for Section 3 Med Rec, but even then the medics/NHS has come up with a (maybe) legal swizz, that leaves the AMHP high & dry.

    So now there is am impasse, because there is no bed. What next? Waiting. How long can we expect the AMHP & the police to wait?

    I am convinced that the MHA reflects a different era & was written with the expectation that there would be no waiting, that there would always be a bed. Maybe there always was in 1959.

    After an extended period of waiting & conformation from the Bed Manager that no bed was likely the police & the AMHP leave also. They agree a plan, not much of one, based on returning the next day if/when a bed is available. It seems that the same officers will be on shift & are willing to return. He even gives the police a key to his door to be kept safe overnight at the local station. I wonder if they will actually be able to return? The same AMHP will not. Being an AMHP is part of our roles & we are on AMHP duty for that day or couple of days. We have case loads & other jobs. The Bed Manager to be fair has managed to get the HTT to agree to look in on the chap.

    I wonder about how they will do this? But it looks like a plan on paper. I wonder about the key & how we will get back in, will we need a warrant,? Again this is not a straightforward activity. I wonder about the man & his neighbours, he has no family 😦

    If the bed had been available the AMHP & the police & an ambo would have gotten him there. But with no bed we will have to start again.

    A bed became available overnight. EDT are contacted & after a debate & legitimate questions about if & why this is now an emergence an other AMHP is tasked with trying to get the chap from home to hospital. The EDT manager will have pointed out that one AMHP had already been there for an extended period of time & that if the bed had been available, there would be no need for the second AMHP. The NHS will now point out that it is urgent because there is now a bed, that might be lost & that we need to put the patient first. It is urgent, but it was also urgent hours earlier when there was no bed! To be fair to EDT they have a very limited AMHP resource & have to manage demand.

    Anyway the 2nd AMHP goes with the HTT CPN, not the police, they are busy & the key it seems is safely locked away & the now off duty officers have the key. The Man robustly & angrily refuses entry or to engage in what is technically another MHA Assessment. What to do?

    Do nothing is sometimes the right answer. He says go away & comeback tomorrow, which is what had been agreed by the first AMHP & police. Man uses more colourful & industrial language & he is not to know about bed pressures!

    Will the bed still be there?

    Yes is the answer so yet another AMHP is dispatched. The police are unable/unwilling to return. Maybe a different inspector or sergeant, who takes a different view. Perhaps she/he thinks this is now clearly a health/NHS issue. But the AMHP is not part of the NHS & can’t instruct. The key is produced, the AMHP picked it up from the station.

    My colleague (the 3rd AMHP) supported by a CPN does a difficult job brilliantly. They use all there magically powers & skills to get man from A to B. Of course there is no magic, there is compassion & lots of phone calls & effort.

    I apologies for going on, but this is happening everyday & every where!

    Should we put the patient first? Yes

    Should it be this difficult? No

  3. No, but maybe – if it expedites that assessment team getting to my custody centre to stop the guy being in cell 15 for another 12 hours for his bizarre behaviour! He should not be there in the first place.

    Demand is huge upon the police and health service everywhere. Looking at the other screen in front of me today, I see 15 jobs for my cops to get to (it is 0900 so this is currently low) and 5 of those calls are concerns for welfare/MH connected. IF crime has gone down (stats are lies and more lies) then the demand is coming from all other quarters. We all know where………

    In your very well worded scenario Michael, I would say ‘send a PCSO if we have one’ . I often have 10 of those and unfortunately only about 5 real cops to play with.

    I like to think of an old leadership course I once went on, and it talked about a plane full of people in danger at only 5000 feet. ‘Just fly the plane’ was the rhetoric espoused. the pilot could have been doing 10 things, including panic, but he trusted his staff and did his core job astonishingly well – saving everyone from disaster.

  4. Jessica…. with respect if it were my loved one was “sitting watching TV” but deemed to be in need of inpatient care, I rate that as just as much a priority as anyone else in a physical emergency!!! Having experienced the trauma of having my loved one held by the police due to no bed available and having to be transferred to inpatient hospital by the police and all the trauma that involves I would say my suicidal/distressed loved one has every right to an ambulance as someone with a physical emergency even if he is calm and watching TV his need would be just as acute!

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