All CLEAR?

Last Friday the Royal College of Emergency Medicine, in conjunction with the Royal College of Psychiatritsts, launched the ‘CLEAR’ campaign, concerning mental health emergencies – see the poster, above. It’s the last of the five points that has seen a bit of discussion on Twitter today and of course: that’s the one that affects the police –

  • Co-location of liaison services
  • Liaison services should be available 24/7 in ED
  • Education for ED staff
  • Adequate access for adolescents
  • Right person to the right Place of Safety

I’m not sure anyone would put forward an argument that emergency mental health care is entirely adequate. Indeed, the CQC published a specific report on this last year, touching upon patients’ experience of crisis services, A&E departments, the operation of s136 of the Mental Health Act, etc., etc.. So it has to be welcome that two medical Royal colleges want to do more and do better on emergency mental health care but we also know the rising pressure that ED is under at the moment as well as the rising pressure on MH services.

There are problems with ‘R’; and if you read the whole poster it goes on to say that Emergency Departments should not be the default option as a Place of Safety –

  • This implies the ‘right’ Place of Safety actually exists – we know this isn’t always true.
  • It implies that we actually know what the ‘right’ Place of Safety is for any given patient – we also know this isn’t true.
  • It says that an ED is not the default destination – is there actually any evidence that it ever was?!

The UK has detailed plans for various things in healthcare but one thing they’ve struggled with for decades is the question of where an intoxicated, suicidal mental health patient should be taken if they were detained under s136 by the police. We have no clear idea what would happen.

HISTORY

I’m one of those police officers guilty of having used an Emergency Department as a default option – in May 1998.  You see, they trained me on s136 MHA in Pleece Skool and told me that a ‘Place of Safety’ under the Mental Health Act 1983 was ‘a hopsital, a police station or anywhere else temporarily willing to receive to the patient’. Having detained a man I had concerns about on the Dudley Road in Birmingham, I was only 150 yards or so from the front door of A&E and not knowing of any other hospital in my area, we walked him up there. I’d already been in that Department various times, arresting drunks for threatening and assaulting staff and it seemed to be a place where people were keen to see the police. They often gave us a cuppa to keep us hanging about in the department when it was busy, it kept us acting as a deterrent against people causing problems in there.

But turn up with someone and say ‘section 136 of the Mental Health Act’ and it was a very different kettle of fish.

In 2008, the Independent Police Complaints Commission published one of the first truly national surveys of the use of this power. Based on 2007 data, it revealed that approximately 18,500 individuals were detained under this legal provision and that 11,500 of those were taken directly to custody. Of the remaining 7,000 people, many of them were taken to a Place of Safety in a mental health unit – London was more or less completely covered with PoS provision so that accounts for a further 3,500 of those. Of course, within the remaining 3,500 will be all those people who were presenting with conditions that made an Emergency Department the appropriate place: those patients who had potentially overdosed, who were physically injured by self-harm injuries or who had other medical problems. But this brings us to one problem: in what circumstances is ED the ‘right’ place? – even ED can’t agree about that.

The idea that ED was a default option most of the time is just not borne out by what we know about how this power has been used – that distinction is claimed by police custody and we do know that this has contributed to deaths in custody. Since 2008, other data have emerged and as the use of police stations has reduced, I’ve no doubt that ED has copped for a proportion of that demand. Whilst I understand ED frustrations about this for cases other than where ED is specifically clinically required, there are legal reasons why officers might be inclined to chance their arm there – and there is nothing unlawful about them asking the question! But by the time we get to the end of this post, I hope to convince you that all of this debate is a red-herring and that the real problem no-one discusses is – proper alternatives to detention for people in contact with the police; and sufficient services to which those who are detained can be removed where it can’t be avoided.

LEGAL PROBLEMS

There are further difficulties we cannot ignore: this initiative assumes that there is agreement about where various people detained by the power should go. Remember the case of Toni SPECK in York from 2011? – she died from serotonin syndrome according to the Coroner and her inquest led to various legal arguments, both during and subsequently, about whether there was a legal duty to provide a specific Place of Safety in a hospital that isn’t an ED. The High Court quite quickly dismissed an application for judicial review by stating that there was no such duty in law; and where police officers have immediate concerns about wellbeing, they could go to a hospital ED. Of course that Coroner’s jury also ruled it was not reasonable or fair to expect police officers to pick up all those potential medical problems with which patients detained under the provision may present and it also heard evidence that if she had been taken to ED her life may well have been saved.

The police cannot do this alone, as Lord ADEBOWALE told us – several years ago!

So if officers work in a place where there is no specific mental health unit Place of Safety; where that location is unstaffed by anyone who works for the NHS; or where the ambulance service either will not or do not respond to a request after detention – where do the authors of the poster want the police to go? … what is the ‘right’ PoS in that situation?

And what about those pesky things like statutory guidelines and caselaw? – it’s been a statutory guideline since at least 2008 that police stations should not be used as the automatic first or even second choice, but only as a last resort. Before giving in to that inevitability, officers should consider the alternatives – so is ED an alternative for someone who does not require it on clincial grounds, but where another health setting is unavailable? What about the police detaining an 87yr old woman with dementia and when you shout up to the control room, you learn the 136 suite is unavailable – do we lean towards police custody or ED – where do you want your elderly parent or grandparent taken? Does it matter if she’s not 87yrs old, but 57 … or 27?!

IN THE REAL WORLD

It’s all very well saying ED is not the default option, but that assumes we live in a world where the ‘right’ options are actually available to the officers who can then be expected to make the correct choice. What happens about acute behavioural disorder? – I refer you to another post for the ongoing debate about whether that’s a ‘thing’ or ‘not a thing’, but I can completely assure you, ED departments take a very different view about these issues. Only this week I had a conversation with a force mental health lead who was contrasting the attitudes of two ED departments in his force area towards the police when dealing with people in crisis. One of them even formally wrote to the police to tell them that they ‘weren’t a Place of Safety under the Mental Health Act’, helpfully quoting from the Act itself to emphasise their point. The only problem was they omitted the word ‘hospital’ when they were cutting and pasting section 135(6) MHA.

I’m sure it was just an error.

I’m curious as to what the poster authors recommend the detaining officers should say to the custody sergeant when they arrive in custody and the sergeant quite rightly asks, “What alternatives have you considered and tried before coming here to satisfy the obligation on us all under paragraph 16.38 of the Code of Practice to the Mental Health Act?” In case of doubt, the UK’s highest court ruled in 2005 that a Code of Practice is not mere advice, it is a statutory guideline “which should be followed unless there are cogent reasons for departure.” So read paragraph 16.38 and ask yourself what you would do as a police officer.

IT’S GOOD TO TALK

Bearing in mind the CLEAR campaign is collaborative initiative between professional colleges, it seems unusual that the College of Policing weren’t involved, bearing in mind that 20% of the headlines they’re hoping to raise awareness about are connected to the use of a police power. (I also wonder whether patients could have been involved, bearing in mind Twitter didn’t seem to have anyone popping up in discussion to say they thought it was a positive step.) It would be unlikely that a query to the College of this type wouldn’t end up with me and Friday was the first I’d heard of it. Of course, it’s not the first time the police (or patients!) have been left out of discussions on mental health that affect the police. It’s traditionally been seen as our role to do as we’re told and we quietly did that for many years, subcontracting our responsibilities for leadership and training to others.

But we’re now in a time where the police have had to learn some hard lessons and push back against a system that inadequately integrates the commissioning of ambulance, emergency and mental health services to allow the lawful discharge of the duty of care which is owed by the state to those who are detained in crisis. The frustration about this is evidence within the NHS itself, especially in ED – patients told the CQC last year that attitudes towards them are often poorest in ED.

I saw a tweet today during the debate about the above where a Consultant in Emergency Medicine and clinical lecturer at a University told the world that he was “happy for ED [to be used] as a PoS if guaranteed 1hr to see an AMHP and psychiatrist + immediate transfer if admission required.” No wonder service users were today wondering whether he makes similar protests to other medical specialists – that they MUST respond within a certain time and admit within a certain time, otherwise patients shouldn’t come in. Let’s be honest, that’s the inference of the tweet.

So on this basis, I’m really looking forward to going to the Royal College of Emergency Medicine mental health day in late February to see if I can stop us talking about red-herrings and see if we can focus on the real problem together!

– The RCEM and the RCPsych have issued a clarification statement on this very point, in respons to concerns. I’m not sure it helps me, but all credit to them for responding.


IMG_0053IMG_0052Awarded the President’s Medal by
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


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5 thoughts on “All CLEAR?

  1. I’m quite concerned about L – liaison. It appears to be written with almost no reference to reality.
    About 3 months before the crisis care concordat our CCGs cancelled the 24 hour liaison service because it was too expensive and under utilised.
    Now a solution using existing resources is being put in place to provide a OOH liaison service which I am embargoed from discussing publicly but 1 hour is completely unreasonable and isn’t met by the existing daytime service.
    As for A there is no CAMHS specific out of hours service at all.

    There is often talk about how poorly organised MH services are but GPs and CCGs are at the core of this as they decide exactly what is provided.

    I think the term place of safety itself, coming from times past, is now quite confusing for people as the reality is its a place of holding until an assessment can take place in most situations.

    As for this leaflet, once again reading between the lines and the fine words, in a time of extreme pressure on resources it would seem to be just another group of professionals setting out their stall as to why an aspect of Mental Health should not be their responsibility…

  2. Clarification around the ‘Right Place of Safety’:

    The recent CLEAR Campaign aimed at highlighting current challenges in the delivery of appropriate support for people in mental health crisis. The RCPsych and RCEM are delighted that it has been well received and promoted. However the final aspiration that EDs should no longer be regarded as default ‘places of safety’ has created controversy.

    Some have suggested that the campaign wishes to ‘turn people away’. In fact the campaign is predicated on the need to do better than current systems allow. Far from turning people away, the campaign aims to highlight the need for very close co-location of primary care, mental health and expert hospital services in safe and effective environments for delivering urgent and emergency care.

    RCEM strongly advocate the development of A&E services from unitary departments – ill-equipped to deal with every possible urgent problem – into ‘A&E hubs’. These hubs are characterised by closely co-located expert hospital services including urgent primary care, liaison psychiatry, community pharmacy and frailty services. Such co-location ensures clinical staff are able to safely and effectively care for patient emergencies.

    Few would argue that A&E departments are currently ideally configured to best attend to the needs of patients with mental health crises, yet it is commonplace for such patients to remain in A&E for more than 12 hrs whilst suitable help and/or premises are found.

    This is unacceptable and the term ‘health based place of safety’ in such circumstances is a disservice to the very people who are most in need. It is for this reason that ‘Right person – right place of safety’ is a key component of acute mental health care that is fit for purpose.

  3. It would be great if such services existed. At the moment in our area most peoples care plans read ins an emergency go to A&E or dial 999. Dialling 999 will mean the police, going to A&E is impossible anyway unless you drive, but will result in a very long wait before being either sent home or admitted.

  4. Me with MHC & Mathew on this & trying to figure out what the management speak from the RC of EM actually means?

    I work in a city where there r 5 big acute hospitals with Psych Liaison Teams that r provided by a MH Trust & paid for by a CCG. They r paid to concentrate on the 4hr A&E taget & no one is paying or planning or sorting how they might get an AMHP or Sec 12 medic there (in an hour) if required asap. I make the point that as an AMHP I have to park in the private for profit car park (if there is a space) & wander into the ED & that MHAAs r basically dependent on the availabilty of (well paid) volunteers = Sec 12 medics. Btw when called to a police station or when attending court for a 135(1) warrant or indeed a health based PoS I don’t get to park (in theory) either unless I pay the private for profit (PFI) provider. In contrast the ambo & police with their stripes & blue lights can park on any old yellow line or two.

    ED departments might not be ideal PoS – but I ask y not? Y can’t they b better at it? Y can’t they invest in something fit for purpose? They r certainty better than a police cell 99.9% of the time. Well 100% of the time if the CCG actually sorts/commissions an appropriate PoS & even then some peeps will need to go to the ED.

    Which brings me on to Sec 135(6) of the MHA & “willing” ! Check it out the PoS has to be willing to accept the person & as MHC has pointed out elsewhere there is no duty on any one to provide a “health based” PoS. U couldn’t make some of this stuff up!

    For the most part this is about the NHS & CCGs & commissioning. It is also increasingly about there not being enough AMHPs & that’s before we discuss beds & out of area stuff…..

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