Have you ever had an unexpected knock on your door from the police? I haven’t, thankfully – and long may it remain to be so. I’ve actually been the unexpected knock on the door from the police on more occasions that I’m comfortable with and I’m not sure you ever forget the first one – I certainly haven’t. We were asked to attend an address on my area in Winson Green in Birmingham to inform a woman who her elderly mother had unexpectedly died in hospital – and this task fell to me on the morning of Mother’s Day. I could still take you to the address now, almost eighteen years after this responsibility and I’ll never forget the look in her eyes when she first opened the door. That was actually worse than her reaction when I said the words, at least for me – it bordered on terror.
Far more frequently and more recently, I’ve had a different version of a similar thing – being an unexpected presence on the door step on a mental health service user. This has been in a few situations over the years: being asked by mental health professionals to accompany them to a Mental Health Act assessment because it is claimed that there are inherent risks that will require police support; being asked by mental health services or out-of-hours GPs to undertake an urgent welfare check on a patient, because of concerns – and both of those without the patient or service user having an idea at all that the police are being brought or sent. More recently, there is a third variation on a theme – street triage (ST). In a similar way that I could take you to that first address, I could take you to another where the police were told a service user was suicidal. The look on that young woman’s face when she opened the door was, again, one of sheer terror. It’s always been my experience that sending the police to an address is not without an emotional impact on those who are there, regardless of the reason. Let’s remember what the police do: they often break terrible news; investigate criminal offences, occasionally by arresting people; and they are a ‘just in case’ service where it is predicted that risks may emerge that require the police to manage them in ways that only the police can: by the threat or the use of coercion, for example under the Mental Health Act. Officers, of course, try their best to be decent and humane and proportionate, but we all know the mere impact a uniform can have when it is unexpectedly introduced into our reality.
Of course, some service users have stated that they have good experiences of the police responding to a mental health crisis, either on their own or as part of a MHA assessment or street triage intervention. So this post, whilst aiming to prompt a discussion about whether the unexpected involvement of the police in a mental health related incident is an entirely benign thing, is not assuming that we can reach a simplistic answer. Some people observe paradoxically that unnecessary policing is stigmatising but that they’d rather deal with officers when they’re in crisis than mental health professionals – others vehemently disagree. Maybe we could do with proper research on service users properly about their experiences, not just about police attitudes; but about their involvement at all. And these questions have to sit within the overall public and political debate about what we want the police to spend their time doing – Chief Constables could choose to offer themselves up for all manner of tasks: the question is whether they should and what factors they should consider in reaching those decisions. This is about whether unnecessary involvement of the police in the provision of mental health care is entirely without impact on those in contact with mental health services.
Earlier this week I took two police officers and a paramedic from a West Midlands Police street triage scheme to the South London and Maudsley NHS Trust to go through some training simulations on mental health. It’s was a testing ground to see whether NHS simulation training for mental health professionals can useful apply to 999 emergency services. We were joined in that trial by the London Ambulance Service and the Metropolitan Police. The idea was that two members of the course were given a small background briefing on a situation and they then walk in to a room where a professional actor with relevant professional MH experience acted through a situation, responding to the professionals attempts to manage a situation. The first situation involved a man calling 999 for the ambulance service after he had a taken five paracetamol tablets whilst drinking and whilst becoming mentally unwell. His flatmate had called the police about the situation also and we end up with one paramedic and one officer at the same location. As soon as the officer walked in to the room, which represented the patient’s flat, he said, “What are the police doing here? I haven’t done anything wrong! They shouldn’t be here.” and he become verbally agitated for a while.
In the debrief of the incident, we got in to the discussion about what the police were doing there. Obviously, they were called by the flatmate and it was unclear whether the police knew that paramedics were also at the scene or on the way – this mimics reality all too often. But on arrival, the officer found a paramedic already dealing with a patient and no-one has flagged any aspect of the incident involving anything that you would immediately think of as a police responsibility – no imminent or immediate threat to life; no crime by or against this member of the public; and no Breach of the Queen’s Peace. I wondered why the police wouldn’t just make sure the paramedic was aware we were there, but remain outside the incident until asked to do something that required the police to prevent the possibility that the officer’s mere presence aggravated an already difficult situation? Obviously, if the police had arrived at the incident first, this wouldn’t have been possible – officers would have had to start establishing what was going on until the ambulance service had arrived. Mental health first aid, if you like.
This phrase parity of esteem is used a lot, to argue for equity in mental health care, comparable to that seen in physical health. If this situation had involved an accident or physical injury, we could expect the police to lead, only until such time as an ambulance arrived and then to take a back seat, or even leave the incident. If officers arrived and found the paramedics dealing, they would check whether or not there was anything in the incident requiring police support and if not, standby back or leave the incident. We also have to remember this reality about mental health care in particular: the police are possessed of coercive powers of arrest and detention under the Mental Health Act – the dynamics in play are just not the same as officers providing first aid to someone who has fallen and broken their arm.
A paramedic at the simulation training offered the view, based on her own experience, that police officers – more often than not – were professional at incidents where she had found herself dealing with mental health crisis incidents. However, on balance, she argued that the introduction of police officers without an obvious purpose was usually an aggravating factor, despite an officer’s best efforts. I have heard similar things said by service users: that they don’t want routine involvement of the police in their healthcare and this is often for a variety of reasons. There have been previous concerns that incident records end up influencing things like DBS checks for future employment; concern is often voiced that it makes people feel stigmatised or criminalised for have a mental, as opposed to a physical, condition; and finally, that it does affect the ability of the police to prioritise against their broader obligations.
Street triage schemes often turn up to support at incidents where the police were the agency called and they often make a better fist of things when they do. However, we are starting to see they are also sent to patients who merely require from by a mental health nurse what the NHS would call ‘unscheduled care’. This is the case because CrisisTeams, community mental health teams and out of hours GPs often lack the capacity to provide this kind of response and have realised that triage exists so we see triage asked to undertake unscheduled visits to service users in their homes. (The reduced capacity of CrisisTeams and CMHTs of various sorts to provide unscheduled care; and their increasingly frequent policy of only seeing patients out of hours in A&E is probably another BLOG altogether but suffice to say here, that in the last decade, the number of patients requiring secondary (ie, specialist) mental health care has risen by 60% according to the Royal College of Psychiatrists, and outpatient crisis care has reduce in many areas to a third of its previous level. Arguably, it’s no wonder that demand upon our emergency system – police, ambulance and A&E – has risen and we have seen a development in support by mental health trusts to those processes. We now see MH nurses in ambulance control rooms, in A&E departments as part of psychiatric liaison services; and in policing – control rooms, custody and triage.)
I would like to see this examined more thoroughly in proper research, not just with reference to triage but evaluations of such schemes do seem one obvious place to consider this and it’s often unmentioned (in the ones I’ve seen). How to service-users perceive the routine involvement of the police in their healthcare pathways where that is unconnected to statutory duties under the Mental Health Act or broader police responsibilities around crime, disorder and safety? Mental health is core police business and officers need to be better at it: I suspect this may also mean better at recognising when not to get involved as well as better at understanding how to get involved when it is appropriate.
Perhaps we should start simply: by asking each time the police are deployed on an unexpected basis, “What do you expect to be the reaction here? – have you considered this request in terms of its unintended but inevitable impact?”
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