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 —
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!
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.
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.
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