A Factor of Ten

Today is the Opposition Day debate in the House of Commons and I type this as I watch it on my iPad.  Firstly, it was amazing to see that as Luciana BERGER, the shadow minister for mental health, introduced the debate, the first interjection from another MP was to highlight the pressure on policing, arising from the amount of demand they face connected to mental health.  This was not the last mention of policing: frequent reference was made to the unacceptable reliance upon police cells as a Place of Safety and the Secretary of State for Health, Jeremy HUNT, reference the progress that was made in reducing the use of police cells but that it was still unacceptably high at over 4,000 people a year.

Whilst this figure is right, it is also wrong!  And where it is wrong, it is wrong by at least a factor of ten.  Yes, a factor of ten! … at least. Let me explain –

Whenever discussion is made about the use of police cells in connection with those in mental health crisis, the figures are normally those relating to the use of section 136 of the Mental Health Act 1983. The Health & Social Care Information Centre tells us that around 24,000 people a year are detained by the police under this power and that 25% of them are detained in police custody as a Place of Safety.  Clearly we must do more about this to reduce that number even further.  But this is just about the use of the Mental Health Act – what about all the other legal situations?

ARRESTS FOR OFFENCES

The very first comprehensive piece of work I did on mental health in policing, was an examination of what we do in connection with people are not detained under the Act, but arrested for substantive offences – things like assault or robbery, criminal damage or burglary, right the way up to sexual offences, attempted murder or firearms offences.  What I found from that work and what other research tells us, is that around 15% of everyone arrested is identified by the police as having a potential mental health problem. I was pleased to find that in every case, medical assessment and advice had been sought to determine what needed to happen. 5% of all people arrested were recommended for assessment under the Mental Health Act and almost all of those were found to have mental health problems: many of them serious.

Now, the police in England and Wales arrested around 1.2m people last year. Working on these snap-shot figures, 5% is well over 50,000 people who are arrested and then assessed under the Mental Health Act.  And of course, that only counts people thought to be so acutely unwell as to need admission under the Act. We know that some people are living with a mental illness but are not acutely unwell – we don’t know what those numbers are. Then, you still have to count the thousands of people who are detained under the Mental Health Act and where the cells are used as Place of Safety, as highlighted in the Commons today! … so the problem is actual much, much worse than the common headline figures that are based on the more obvious MHA figures.

Just in case anyone is thinking, “Well, if there’s an offence involved, that is quite different and custody is less of a concern” – there are two things to say to this –

  • We know that mental health crisis incidents to which the police are called occur mainly in private premises where section 136 cannot be lawfully used – so officers who feel obliged to safeguard someone by making a detention, will have to choose another legal justification for doing so, hence we hear about arrests to prevent a Breach of the Peace; or arrests for what is mostly minor crime.
  • We also know that whatever the clinical issues for individuals, they are not going to be improved by the feeling of being criminalised by incarceration; and it does not mean that you get access to the clinical care that you need.

AND WE’RE STILL NOT DONE

But this is still not enough to fully understand the depth of the problem! – everything I’ve covered so far is based on the police recognition of people coming through the system and perhaps unsurprisingly, police officers don’t spot everyone because they are not experts and do not have routine access to NHS records. Not much work has been done, that I am aware of, to cross reference police arrest records with NHS patient records – but in one case where it was done in the south of England I’m aware they were stunned to find that 50% of everyone arrested was currently or previously known to the local NHS mental health trust.  So the police are potentially only spotting one in three of those vulnerable coming through the system.  (Important to bear in mind from a suspect’s point of view, that if you tell the police you have a mental health problem, you are immediately doubling or tripling the time you will spend in custody because of the practical implications of the safeguards upon which we rightly insist. Reality is, some people would prefer to get out quickly than benefit from the safeguards – they’ve told me so in custody, quite directly on occasion!)

So the number of us detained in custody whilst in crisis and potentially acutely unwell is potentially ten times the size of our normal public narrative, and certainly ten times the size of the problem referred to in the House of Commons today.  However, if you also then examine those of us with mental health problems who are not acutely unwell but nonetheless living with a mental health condition and you think about the impact of detention in custody: what do we think that could do to some? What emotions would you feel, what distress would you feel if the police locked you up in a concrete room than made you think about your predicament for hours whilst they sorted the situation? Whatever the reason and however justified that action may have legally been, it’s not going to improve your mental health and bearing in mind that two-thirds of people who end their lives after contact with the police are thought to have had mental health problems, it shows that detention in custody is serious business that should be undertaken somberly and only where necessary.

The problem is at least ten and potentially twenty times the size of the problem we all too often think we’re dealing with and we’ve known for years, if not for decades, that the solution is timely, available and accessible mental health services for those who want them. What we also know is, that if you don’t provide them, you’ll end paying even more anyway in criminal justice costs so whichever way you look at this, you’re going to pay for it: the question is whether you’d like to pay less for appropriate support to vulnerable people or pay more for outrageous injustices that degrade is all?  Norman LAMB summed up the debate for me today, “We spend £105bn on the failures in mental health – it is a moral injustice and economically stupid!”


IMG_0053IMG_0052Winner of the President’s Medal from
he Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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10 thoughts on “A Factor of Ten

  1. My apologies, above reply uploaded before completion!
    This issue is clearly difficult. A significant improvement in some local areas involves the attachment of qualified mental health professionals to custody suites. This is currently occurring in some areas on a 7 day week 12 hour day basis. Whilst managerial and resource management improvements can change ways of working, resource availability is a significant issue. My NHS Trust area has a population in excess of 1.5m. My understanding is that it has 6 custody suites and 6 single bedded s.136 suites. With current pressures of not detaining s.136 clients in custody my guess is that the number of arrests for trivial crimes are increasing along with admissions to A & E. One public purse with limitted budget does not make for any easy or quick solutions

  2. Interesting and thought provoking piece – however I think the debate risks being somewhat blurred by mixing issues here. Mental illness and crime are not mutually exclusive and just because someone has a mental disorder does not prevent them from comitting a crime. Clearly in cases where a causal relationship exists between a disorder and a crime then treatment is highly appropriate and Part 3 of the Act exists for this, but advocating that the criminal justice system shouldn’t deal with those with a mental disorder appears too simplistic a view for me.

    1. I’m not sure that’s what I was arguing for, in all fairness! – there are many other posts on this BLOG which show that’s not the way I think we need to go. This post merely attacks the over-simplicity of political focus on “getting mentally ill people out of cells” by focussing on the 4,000 who are detained there under s136 without appearing to acknowledge the 40,000+ who are there for other legal reasons.

  3. OK, I may have missed the point, But what I heard was…
    Lots of focus on s136 & ongoing misunderstanding about what the statistics mean & whether reducing this ENDLESSLY is actually a really stupid target (my opinion – sometimes it IS the right thing to do)
    A lot of people becoming involved in CJS with pre-existing MH issues that they themselves do not seek support for/refuse services – or that fail to get identified for lengthy periods or are excluded/ rejected from MH services.
    If you don’t believe in the moral & legal argument for improved processes to respect human rights & dignity – then we all agree on the financial benefits of doing it right don’t we? Clearly not.
    My personal view – statutory NHS & Local Authority services are under-resourced & have been for some time. BUT Commissioners & Snr managers have also chosen to inappropriately & possible illegally “gate-keep” services to no-one’s ( or no services’) benefit.
    I believe the police DO have a role (which in my experience they manage better in a crisis than many MH professionals)- a legal one under MHA, amongst others, but have often recently been given one of “last & only resort” and that is not acceptable.
    There will always be a section of the population that come into contact with CJS that also have MH issues & there will always be some with complex circumstances. We should be able to deal with these cases & would do so more effectively if they were not smothered in all the thousands that should not be there in the first place if there was an appropriate and effective MH provision.
    THE message that govt ( current & past) seem to want hidden isn’t that the police need to better/less restrictive/different but that MH service provision should be there FIRST!

    Oh – and people suffer less, we protect our future generations ( that means our kids) and IT COSTS LESS.

  4. I’ve been a background reader of your blog for a while now and your post made me furious.
    Firstly there is mixing up mentally ill and mentally disordered. These are aren’t the same thing at all, many behavioural problems get ridiculous labels, like for example oppositional defiant disorder or antisocial personality disorder which mean little more than they don’t behave In a way that ‘normal’ society wants and these labels don’t come attached with any meaningful treatment.
    GPs will tell you about the massive mental health problems they have to work with but they prescribe antidepressants and other medications for things which we should accept are part of normal life and cause unhappiness like bereavement, workplace stress and bullying, marital problems, abuse. The solutions to these lie with practical measures not throwing labels or tablets around,
    Depending on where you are in the country between 50 and 85% of referrals by GPs to secondary mental health services get turned away as there is no evidence of mental illness.
    So ‘previously know to mental health services’ means nothing particularly when you add the fact that substance use services are often provided by mental health trusts.
    Your back of an envelop figures are a dangerous and dishonest representation of the situation.

    It is very rare that a mental illness is of a degree and nature that it reduces capacity to an extent that the individual is not responsible for their actions. To suggest anything else merely adds to the stigma attached to mental health and means that service users as a whole are seen as some form of burden or worse a dangerous element in society.
    Shame on you.

    1. Terry.
      I can see what you are saying and to some extent I think we often over estimate the extent to which a mental illness removes the responsibility for criminal behaviour but I’m not sure where you get your figures from regarding GP referrals to secondary mental health services. Patients may not meet the threshold for a secondary mental health service but I doubt services would be so bold as to say there was no mental il was at all.
      I don’t always agree with Mental Health Cop about everything but his input is extremely valuable as he is one of the few voices from policing that is prepared to give a considered thoughtful response.
      Shame on you Terry

      1. Thank you – that means all the more precisely because we don’t always agree. Happy to have respectful disagreement and I hope arising from it, you occasionally learn something as I know I certainly have. But that someone who has never met should accuse me of dishonesty is offensive. Grateful for the supportive words.

  5. I’ll be honest: I got as far as ‘dishonest’ and then rapidly lost interest in trying to take this seriously. You can say plenty of things about me – broad shoulders and all that – and I’d work actively to take the feedback. I’ve been known to correct BLOGS and to write further ones acknowledging I’d learned things: but you can’t throw ‘dishonest’ at me without making yourself look silly. And to think I over-looked the inherent meanginlessness of your distinction between ‘mental illness’ and ‘mental disorder’ to get as far as ‘dishonest’ … the irony isn’t lost on me.

    The post is about political over-simplification of the “people with mental illness shouldn’t be in the cells” buffoonery and it says nothing one way or the other about the balance of prosecution versus diversion. (Incidentally, ‘capacity’ is a redundant legal concept when investigating criminal liability – it’s a proxy term usually used when people don’t understand criminal law but it’s too often then confused with the 2005 kind of ‘capacity’ issues we debate elsewhere.) The post is open and transparent about the dip-sampling basis of the ‘tens of thousands’ claim and since being forced to think about my dishonesty this morning, I’ve done something that perhaps I should have done before writing this BLOG –

    What I’ve learned takes away slightly from what I’ve said, but not much – it certainly still supports the ‘tens of thousands’ claim by suggesting 2% of all people arrested are admitted or referred to secondary care MH services after MHAA followin arrest by the police. My original estimate was simply many but by no means all of 5% – so not that far away. And all of this still leaves the under-identification issue in the hands of the police. I haven’t got a problem with tens of thousands of people who have allegedly offended being in custody: nothing in the above is an advert one way or the other for prosecution or diversion – it was simply a nudge against the political over-simplification we heard in the Commons.

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