Reforming the Narrative

Yesterday, the Reform think tank published a (very modestly titled) report on policing “How To Run A Country: Crime and Policing”. It is one of various briefings they will be publishing ahead of the comprehensive spending review in autumn 2015 relating to various areas of public service.

This blog relates to just one brief section of the document on policing and mental health. To save you opening the file and finding the particular paragraphs, I have copied and pasted them here, from pages 9 and 10 —

FOUR POINT TWO POINT TWO

“4.2.2 – Particular attention needs to be given to addressing the current inadequacies in dealing with people with mental health issues. As discussed above, the police service is increasingly responding to mental health related incidents as the service of last resort. This is placing unacceptable strain on police resources, but more importantly is damaging for those individuals suffering from mental health problems. As HMIC’s report stated, the lack of alternative is leading to “vulnerable adults and children…being criminalised unnecessarily”.

The Department of Health is currently funding pilots using mental health street triage vehicles as a way of tackling this. Whilst it is early days for the scheme, initial evaluations have been promising, with a 40 per cent reduction in the use of Section 136 of the Mental Health Act by some forces.

Encouragingly there are examples of innovation in this area, with many PCCs piloting new ways of working. In Northamptonshire, following the initial success of a triage pilot, PCC Adam Simmonds has just extended the use of triage cars to 4pm – 2am at the weekend. He believes the additional time will enable more vulnerable people to be reached out of hours and reduce the demand on traditional services on Friday and Saturday nights. In Norfolk, PCC Stephen Bett has introduced a Mental Health specialist within the Norfolk Police Command and Control Room. This allows ‘real time’ support to be provided to vulnerable individuals and for the most appropriate services to be engaged reducing unnecessary police involvement.

However at the system level criminal justice services and health remain entirely separate, regardless of the considerable crossover. Despite multiple crime-related indicators in the Public Health Outcomes Framework, neither PCCs nor police chiefs are mandated to sit on Health and Wellbeing Boards, leaving it up to Boards whether to include them. This needs addressing.”

How To Run A Country: Crime and Policing – Reform, London, June 2015.

ISSUES TO NOTE

  • Agency of last resort – I actually think the problem is that the police are the agency of first resort.  I’ve said so for years and I think, if anything, street triage is making this even more true. I remember many years ago reading the website of the world-renowned Institute of Psychiatry in London and looking at the page they used to have for those who may need help and support. First on the list was ‘call the police’ – world experts in psychiatric and mental health research thought that the police, should be or were the first resort. They even went on to incorrectly claim that ‘the police have powers to remove people to a place of safety’. Of course, this is only partly true – they have no powers in private premises which is actually where most police demand connected to mental health actually occurs! We know that mental health services have often deflected demand to policing, purely because it’s more convenient to do so and street triage sees this continuing and extending – examples are available on request, but I did enjoy the story of the GP in Northampton whose patient rang for an out of hours, unscheduled appointment for ongoing mental health problems and was told to ‘ring the police, they’ve got mental health nurses now.’
  • Unnecessarily criminalised – this is an interesting remark, isn’t it? I know that it came from HMIC, but Reform have picked it up and used it. It very much depends on what you mean by unnecessary criminalisation as to whether this proposition stands true. It has been argued by some policing academics (Egon BITTNER, Meslissa MORABITO) that the reverse is true: that the police ‘criminalise’ vulnerable people with mental health problems to a lesser degree than the population as whole. So if we want to argue about whether someone was ‘criminalised’ are we simply asking whether they had contact with the police or justice system and ‘treated like a criminal’; or whether they were treated more or less favourably to someone else in the same situation who did not have a mental health problem. If someone in crisis stole food and was arrested, taken to police custody and then diverted from justice, were they criminalised? Yes, because they were arrested; no because their mental health problem meant a different outcome was achieved in recognition of their vulnerability – it depends on your values!
  • Initial evaluations (of street triage) – I do wonder whether the initial evaluations have been read. Now I’m not an academic, as you know, but I wonder how some of the evaluations I’ve read would do if they were subject to proper academic rigour. We know that street triage mostly occurs in private premises, largely in people’s own homes. Yet most evaluations focus on reduction in the use of s136 of the Mental Health Act 1983, which can only occur in public places and therefore, in a minority of street triage encounters. So initial evaluations, it could be said, are actually an evaluation of between one-third and a half of street triage – the remainder seems untouched by critical examination as if we’re just assuming it must be making things better to a similar extent. The fact is, most areas are not collecting data about the majority of their interventions so who knows what we can say about it? We need far more data and analysis of these (often expensive) initiatives, not least because there are various operating models in play, some more resource intensive for the police than others.
  • 40 percent reduction – this is presented automatically as a good thing; and I wonder why? Of course, if the police encounter someone in a position where s136 could be used, being able to render support to that individual without legally detaining them is, on the face of it, a good thing. But this is only one aspect of an encounter – what about those situations where there is also a crime within the incident: what do we know about how officers make their decisions? Very little, is the answer to that and if someone suggested that officers sometimes use criminal powers of arrest to immediately safeguard someone they suspect to be mentally ill rather than resort to the Mental Health Act, we couldn’t rebut that assertion with real data. We know that officers’ decisions are affected by issues of expedience and given that use of s136 MHA is a decision to take two officers off the street for hours on end, in breach of various agreed national guidelines, we know that officers will avail themselves of other lawful options. The Deputy President of the Supreme Court, Baroness HALE, therefore wondered whether s136 is actually very under-used?
  • Reduced demand on policing – this needs very careful examination and hard data. Tediously detailed data that can be properly analysed. Street triage analysis tends to go like this: “We used to have 600 detentions under s136 each year and each of those involved two officers for four hours on average remaining in a Place of Safety pending assessment. We now have just 350 detentions which means we’ve saved 2000 hours of police time and that equates to a full-time equivalent police officer.” I’ve heard this kind of thing a lot – we need to remember that in order to achieve these savings, some areas have constructed triage teams with between four and seven police officers, who work between 8,000 and 14,000hrs each year, in order to make those kinds of savings. And, we also need to remember that each of those 250 avoided-detentions s till took time to deal with and those hours needed to be deducted from the initial appearance of ‘savings’. Of course, the private premises dimension needs to be factored into time costs and benefits but we don’t have data on that so few areas can do so.
  • Unnecessary police involvement – if we want to reduce unnecessary police involvement, why don’t we just build accessible, flexible health services in both primary and secondary care? I spoke to a mental health nurse recently who told me that the number of nurses available in their trust’s CrisisTeam is currently 25% of the number of nurses available approximately ten years ago. We know that inpatient mental health beds have never been at lower levels in the modern era and that the number of times the Mental Health Act is used to hospitalise someone has never been higher: more admissions, for shorter periods and all against a background of mental health community care failing to keep pace with demand because some Community Mental Health Teams have seen their caseloads rise 100% in the last twelve months alone. No-one is going convince me that this is all entirely unconnected to why we see the police experiencing ever-greater levels of demand connected to mental health. If NHS structures don’t exist or are ineffective, the consequential policing impact is hardly unnecessary where people are perceived to be at risk or very obviously are.

THE ESTABLISHED NARRATIVE

This is all based on a narrative that has been quietly building – the police, untrained as they are, have been drawn further and further into managing mental health demand and arising from that, they have been unwittingly or unavoidably criminalising people, being connected to untoward outcomes, consuming lots of time and effort only to subject vulnerable people to traumatising experiences — therefore what we need to do, is provide expertise from mental health services to help the police get their response right by providing alternative options to those blunt tools they currently have and wrestle the decision-making back to the experts, in nurse-led teams, both the community (street triage) and in custody (liaison and diversion).

You’ll notice how this is still a conversation about improving police responses, not about withdrawing it from the landscape to the maximum possible degree and wondering about how we created the situation we currently have. There will always be a role for police involvement because not all crisis predictable and preventable; but assuming that all demand is just work to be done, rather than failure demand arising from a mental health system that MPs, inspectorates and others have branded inadequate or falling short, is to miss most of the point. Creating better police responses probably has, in some areas, meant that the police are now expending even more resources than they ever were before, in a way that encourages even more demand to be deflected by the health and social care system. There are reasons to think this arising from the data we see in the very evaluations relied upon in the Reform document as evidence of efficacy against the assumptions that underpin this reaction: that s136 is overused, the police unnecessarily criminalise vulnerable people as the agency of last resort.

What if that’s all wrong? – what if s136 is underused, that the police demonstrably criminalise those of us with mental health problems to a lesser degree than those of us without and are often an agency of first resort because increased capacity and focus to handle mental health calls (even without a core police component like a crime or immediate threat to life) is having predictable, if unintended, consequences?

In some areas, the inevitable conversations have begun about what further crisis mental health work could be taken on by triage teams during ‘downtime’. I know this because I have witnessed some of them. Certainly it seems that some CrisisTeams, out of hours GPs and others think there is a now a new, flexible resource on the block and that they should be making creative use of it. It is for this reason that we need to look far wider than policing and police responses: if the resources expended on street triage and liaison and diversion had been spent on the acknowledged inadequacies of mental health and crisis care, I do wonder about the extent to which these initiatives would be necessary at all. And if you were to nail me down and ask what I thought was the crucial, critical success factors of street triage, which it must be acknowledged is achieving positive incident resolution for many, it would be the ability of police services and mental health services to communicate with each other and share information to influence police  options and decision-making. There are a large number of ways of achieving that objective.

This BLOG post is already over average length and I could go on …. I’ll save that for another day and let you enjoy what’s left of yours.


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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9 thoughts on “Reforming the Narrative

  1. I know that you have raised many of these issues before and again my response is the same.
    Why are the police buying into this nonsense that it is their job to be better/ more creative at doing Health & Social care and managing MH crises? Yes it is the last blue light service that actually offers a ruddy response – and let’s face it as has been much reported is delivering this already much better than commissioned services – but just because the police are doing it DOES NOT mean that they should.
    I could not agree more with the criticism about the ridiculous ways that meaningless statistics are being used to rationalise irrational decision making and random outcomes are recruited to support erroneous conclusions. The lawmakers won’t make clear what they think should be done, Health & Social Care staff don’t bother to learn the law, Service Commissioners don’t want to meet their statutory obligations – but that still doesn’t make it a problem for police to solve – except in that they incur the financial and personnel costs of responding to the failures of other services.

    Resources should be invested in the MH services and facilities in order to reduce need for police to be involved in the first place, and then minimise the time taken when they are involved to get an individual to an appropriate environment.
    How many more times / more years before those that have the real power to resolve this start not just listening but bloody doing something? Not holding my breath.

    Keep up the good work!

  2. The other weekend, just trying to get some meds that hadn’t been sent home and trying to avoid a long drive, I said to the Crisis Team/ Home Treatment team, btw do you ever provide support for people when they are home on leave from hospital. Answer was no, because you shouldn’t be home on leave unless you are well enough to not need home support……..Yet I’ve seen crisis plans for people not in hospital that say ‘if in crisis call the police’

  3. I understand, I think, your concerns but this seems to come back to the same issue which is resources.
    If agencies expend their energy on blaming other agencies rather than publicly addressing the fact that services are under resourced, then they add to the problem and offer the Government an opportunity to cut further.
    In essence, wether it’s police, health, social care or the voluntary sector that end up dealing with the sharp end of a situation they need to be adequately resourced to do so. Street Triage appears to be a way of sharing resources to facilitate a good outcome for the person. Maybe that’s what should be being measured?

    1. But it’s not though! *That* – right there – is the very narrative that needs challenging. It has the effect of ensuring of ensuring in most cases, that the police expend even more resources in managing the same demand that they previously did. In some cases, it involves more the triple the resources whilst simultaneously ensuring they are drawn in to situations that are, quite simply, nothing to do with them whatsoever.

      Just to be extra clear here: I’m not referring to spontaneous mental health crisis where someone is ‘at risk’ (whatever that means). I’m referring to situations

      We shouldn’t pretend that agencies don’t have access criteria for the services they apply: mental health teams are amongst the worst for this, as the artificial division between street triage nurses and liaison and diversion nurses shows. If someone rang the police to say they’d broken their leg, then the call would be diverted to the ambulance service after suitable questioning to establish whether the fact of them calling the police indicated that there was some extra dimension that meant an ambulance only response was inadequate (like a need to force entry somewhere, for example).

      I’m really not at all sure why the police would be prevented from reminding people that we are constituted and resourced for a certain set of issues and that most of what comes to street triage is actually just crisis team work involving known service users. All the while a PC is driving a street nurse to crisis team work, they are not doing what the public tell us they want to see the police doing – visibly patrolling their area, proactively dealing with crime and disorder issues and responding to incidents.

      From time to time, MH crisis work and policing functions will overlap for various reasons: we need to be able to come together in a hurry to cooperate, just as the police do with all manner of other agencies.

      1. The parity with physical health agenda is misguided and dishonest in these situations.

        The fundamental difference between a person phoning emergency services about a broken leg and some once calling about a mental health crisis is the level of complexity.
        If someone has a broken leg, well I’m not a doctor but, we all agree that it will need immobilisation, perhaps dressing, transport to hospital, an x-Ray and either surgery or setting in a cast. There are some possible medical complications but a member of the public, a police officer, a 999 call handler, common sense all roughly agree what the outcome of that medical emergency is. Even if it is actually not a broken leg the pathway is remarkably similar.

        What then would be an equivalent mental health crisis where everyone would agree on a simple pathway and an agreed outcome? Given the number of times where following a MH assessment, with or without consideration of the mental health act, someone has been sent home, or left at home, but the individual, or the police, or the relatives who know that person best feel totally convinced that the individual NEEDS hospital, we can say these are not equivalent situations.

        You might call it an access criteria, I would call it an definition of clinical need. One of the major issues I have with measuring crisis response by a user satisfaction survey is that there is a significant difference between what an individual wants and what they ‘need’. Wether you frame mental health professionals as paternalistic arbiters of need, or gatekeepers of a scarce and precious resource or skilled practitioners of positive risk taking, the outcome is that at times when people want something ‘done’ just as you would argue the police shouldn’t always be the ones left worrying what to do neither should MH services be strong armed into taking measures which we know, despite appearances, may have poor clinical outcomes and ex average the situation long term.

      2. I’m not sure that’s connected to the point I’m trying to make – and your statement about complexity makes my original point even more apposite. If someone rings the police, in effect saying, “I’m; mentally ill”, then it seems to be that this is a matter for primary care health or secondary care mental health services or those in green who provide their emergency health service. It is not, without other factors, a matter for the police – at all. Of course historically, because of the distance and exclusion (or access) criteria that have been developed over time, the police have been looked at more and more to fulfil a role that others have declined to provide.

        My point is simply this: we’ve seen dialogue since the Crisis Care Concordat that has changed from ‘police are being drawn into stuff they shouldn’t be touching, how do we get them out’ (which was the original conversation between Norman LAMB and Christine JONES which led to the CCC) to ‘the poor police don’t know what they’re doing so let’s provide them expert help whilst at the same time costing them even more resources than were ever being expended previously.’

        If this stuff is oh-so very complicated then please feel free to configure health services appropriately, train NHS staff across all health services to provide effective responses and crack on. When you get stuff that is something looking roughly like a police responsibility, by all means seek police support. I don’t buy the argument that it’s about under resourcing because health haven’t spent their budget fully for years, they’ve returned billions to the Treasury and they’ve wasted billions most years for as long as I can remember. Examples available on request.

  4. If my house has just been burgled and I have called 999 I want the police to attend. I may be upset and distressed – perhaps they should send a street triage team. The PC can address the crime issues. The paramedic can determine whether I’m having a cardiac arrest or a panic attack by using ECG and experience. The CPN can assess whether I might need referring to MH services for counselling or show me how to use breathing techniques to manage hyperventilation. Really? No I mean REALLY?
    If I made a 999 call to request an ambulance &/or Crisis team response in this situation I would fully expect to be told (unless there were very specific reasons why it might be appropriate) why this was a waste of even the call handlers time. People might rightly state that paramedics and CPNs are a limited overstretched resource and shouldn’t be routinely used in such a cavalier manner.
    If we would challenge these agencies/services as to why they would consider entertaining this approach why would anyone not support some very sensible Qs about this use of police resources?
    I am not taking the issues of individuals in MH crisis lightly, but some of the arguments used in this debate about what more the police should be doing have become, in my opinion, seriously skewed.

    BTW in my experience in this situation if police – with considerable experience themselves – thought other agencies were required they would make the request – WHEN NECESSARY.

    And of course most folks would have the equivalent of a lottery win if they managed to get a Crisis Team visit or a prompt response to any MH referral not because those working in these services but because they are ridiculously under-resourced.

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