Last week there was an urgent Parliamentary question tabled by the shadow health minister concerning CAMHS provision. You can watch the session for yourself as it lasts just over half an hour and is fairly interesting, for a few reasons.
The question was prompted by a few different events: last week NHS England issued guidance to all health areas that it was acceptable to admit children of 16 and 17 years of age to adult mental health wards, where specialist CAMHS provision was not available. That in itself was partly in response to the handling of a young patient in Devon last November who was held in police custody for two days because no specialist bed was available. Although unconnected to the urgent Parliamentary question, we also know that various other pressure exist on the issue of why there seems to be insufficient CAMHS provision. In case you’re not aware, the Government released extra funding of £7m to NHS England for use to commission extra bed provision during 2014 after previous problems.
All of the rhetoric we hear in connection with this issue when it spills over to the police makes me somewhat smile. It was part of the opening pitch by the shadow health secretary to draw attention to the ‘held in police custody’ issue. It was part of the answer that the Government were aware of the problem and addressing it through the Crisis Care Concordat. It is fair to say that the Government review of the operation of ss135/6 of the Mental Health Act 1983 has recommending legislating so that police custody cannot be used as a place of safety for children and the recent Home Affairs Select Committee report went further by suggesting that the words ‘police station’ should be removed from s135(6) of the Act and that the practice of using police custody as a Place of Safety for children should ‘immediately end’. We even know some police forces have written to their health partners and stipulated a date after which no child will be detained in custody under the MHA.
So this should bring these kinds of situation to an end, surely? Wrong, it won’t – let me tell you why.
Of all those people detained in police cells after being arrested – whether they be adults or children – most of them are there for legal reasons other than the Mental Health Act. It is quite difficult to be precise about numbers because research is limited but if you examine custody records to count prevalence you will find anywhere between 10-15% of people arrested for crimes who are initially suspected to have some form of mental disorder and are assessed by a Doctor or nurse in custody. That is when the police have to make that initial judgement – if you have a Liaison and Diversion service with access to health records, you can expect that rate to double. Around half of those flagged by the police will be thought to need a Mental Health Act assessment and as the police in England and Wales arrest over a million people a year, indicating around 100,000 to 150,000 detainees who will be thought to have some kind of mental health problem; and between 50,000 and 75,000 assessments under the Act.
Compare that to around 23,500 uses of section 136 MHA and you start to get a sense of scale.
When we recall the case of that young girl in Devon from last December where an application under the MHA was required but couldn’t be made for the want of a relevant bed, we immediately get drawn into these ‘police stations are not an appropriate Place of Safety’ debates which entirely ignore the fact that she wasn’t detained by the police under the Mental Health Act, but in order to prevent a (further) Breach of the Peace. That incident was nothing whatsoever to do with ‘Places of Safety’ because s136 wasn’t instigated. And this is very far from uncommon.
I am aware of several similar cases during January which did not make national news headlines because I have been contacted for advice in relation to some of them. In one example, a young woman was under arrest for common assault, not detained under the Mental Health Act. In another, a young man had been arrested for theft. In fact, it is some while since one of these ‘needs admission but we can’t find a bed’ cases actually did involve section 136 MHA. So if we’re going to legislate to alter the Mental Health Act – whether that be for everyone or just for children – we will only impact on a minority of these stories. Children will still be able to be held in police custody after arrests for offences and we will still have the legal problems that arise from an inability to secure access to appropriate beds.
If we want to ensure that children are literally never held in police cells then we have stop putting any of them in custody. As soon as you accept that this is potentially unrealistic, then you are back to a discussion about the real problem.
Why are AMHPs ever left in the position where they want to make applications for admission to hospital of vulnerable adults and children and cannot do so because there are no beds available? Whether increased numbers of inpatients beds is the answer, who knows. Community services to support people outside of hospital have never been adequate and have been particular eroded over the last fifteen years or so. Only this week I learned of a CrisisTeam operating out of hours who will not undertake any face to face work unless it is in an A&E department or in police custody. It should therefore come as no suprise that they then deflect demand towards the police and the broader 999 emergency system which would be perfectly manageable with responsive crisis care.
The problems that sit underneath the various incidents we keep being appalled by are not straight-forward and we usually need to strip back four or five layers of problems to get to the real issues. It should therefore come as little surprise that straight-forward reactions that fail to take account of complexity will address them adequately.
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