This is really difficult post – and it’s necessary because I’ve often thought in policing and mental health we spend a lot of time avoiding the really difficult conversations and picking the low hanging fruit. I would argue that much of the time spent discussing Place of Safety provision, street triage schemes and liaison and diversion services: they are all examples of the low hanging fruit. I recently watched a person in a meeting have s moment of clarity that some fruit hangs higher and brings in to view a whole host of debates – I want to highlight some of them. The one I’m not going to mention here, because I intend to cover it soon, is that all those low hanging initiatives are ways of avoiding the discussion about how the will or capacity to intervene early has been lost and that this is measured most keenly in the extent to which people are criminalised. More on that next week.
I heard recently that one area has more or less abandoned its Crisis Care Concordat (CCC) plan, just over two years after the Concordat was published and made subject to an overview process via the mental health charity, Mind. We recently saw publication of the final evaluation report of the CCC, and I think it’s fair to describe it is ‘mixed’. I don’t think many people seriously doubt that the whole agenda has been a positive step in bringing together organisations who, in some areas, didn’t have an effective relationship. But getting together to chat about stuff and write it down, doesn’t make it happen and I think that summarises my view of the problem with it. My son has got a massive Christmas list on standby for December 2016 and we already know that no amount of careful handwriting is going to see him own those items come Christmas!
I remember asking police forces about the CCC when I first arrived at the College of Policing and received various emails saying, “They won’t talk to us – they’re not interested” and and so on. The number of those replies have dissipated over time but the police seem reassured that the lower hanging fruit is being gathered. I hear many mental health trusts and many forces highlighting what a good relationship they have and how important it is to work in partnership. Indeed, it has long since been my experience that where you start a conversation about the details of particular aspects of partnership work, in an effort to ensure that it works properly, you are often reminded of the importance of partnerships if the police part of that discussion is not willing to accept a status quo where they are committing more resources than they should be, because of NHS choices not to do what we all agreed they would.
I’m sure an example would help! –
POLICE POWERS AND DUTIES
Recent work on calls for police responses to inpatient mental health wards have led to discussions about staffing levels in the NHS – you may remember that NICE have stopped work that Government originally asked for on what constitutes safe staffing levels. Some mental health inpatient wards are occasionally not staffed in such a way as to ensure they could take care of those predictable aspects of being a mental health service provider. The RCN point out it is often not unusual to find 3 nurses during the day and 2 at night for a ward of 15 patients. (I do understand that not all available staff are nurses, there may be others available, too). But given that restraint can involve five staff, how do you do it? In some areas, anything that is known to be necessary occurs at shift change when double staff are available.
Accepting that not all wards involve similar levels of ‘therapeutic security’, these restrictive functions are usually understood to be –
- preventing people who are legally detained from leaving,
- being able to administer medication under Part IV of the Mental Health Act;
- secluding a patient or transferring them between wards and units.
It is an inherent risk of running an organisation that detains other people against their will and occasionally forces medication and location transfers upon them, that some patients will object and resist – I’m genuinely unable to see it any other way. I remember the occasion as a duty inspector running a 999 response team where we were contacted around 6pm to be asked if officers could attend a ward at 8pm to restrain a patient for medication because they were insufficient staff? The answer was, of course, the we couldn’t and the caller was advised to start ringing their managers to escalate any staffing problem they had. No current disorder or disturbance, no immediacy required – not something that needs to involve the police, assuming the organisation has the right plans in place around those functions listed above.
But this is really awkward isn’t it, as it starts to edge in to difficult ethical and legal territory? … in recent work, which has involved the College of Policing asking an independent QC to give legal advice on police powers and duties in these contexts, one question in particular arises about whether the NHS should be calling the police to wards to assist in preventing an assault if a patient is becoming disruptive; or is likely to be resistant and aggressive where staff must attempt to seclude, transfer or medicate a patient. It’s hard to resist the fallacious lure to answer the question that has been posed to me several times recently, “Does a nurse have to be assaulted before you’ll come, then?!” … it sounds like a relevant question, doesn’t it? If you say “Yes”, you’ll be slaughtered for appearing to countenance NHS staff being attacked during their work – which we all agree is an outrage – and if you say “No”, you open up the police to attending incidents that the NHS should be handling with sufficient staff who are trained and, if necessary, equipped. Obviously, I’m referring here to those functions that are obvious implications of the work these trusts do in circumstances where they have greater powers to handle the situation than the police (if the police have any at all).
It is slightly clearer where there has already been an unforseeable incident that involves significantly raised threats and / or an obvious criminal offence: if that patient were in possession of a weapon or something that could be used as one upon return from authorised leave, the risks are higher and it’s more obviously a police responsibility to become involved – that would be the case in any hospital or location. It is a challenge to draw any kind of distinction between what is a forseeable NHS responsibility and what could occur within a hospital that amounts to a police responsibility – but it can be done. It seems to be when we get in to the territory of attempting to define* these thing, we often hear that legend rolled out that we have to keep making sure we work in partnership, like the CCC says. I admit to feeling that this is often a euphemism for “can you please make sure you keep doing certain things that we know are not your responsibility?” I can’t help but wonder whether this is because of the cost of ensuring safe staffing levels – I admit I’d love to know why NICE stopped this work where it relates to mental health.
More than once I’ve known NHS managers describe their partnerships and relationships with the police as extremely positive: you only need to look around various social media platforms to see evidence of this. I admit to wondering on occasion, whether the closeness can create a blindness? One NHS manager recently told me that their relationship with their police force on s136 and Places of Safety was ‘perfect’ – they have meetings, they’re on first name terms, they have each other’s mobile numbers and can ring at any time to discuss problems and solutions to problems: it’s just perfect. That person looked stunned when I said that I doubted it.
I’m sure the relationship is courteous, good-humoured and professional and it can’t be a bad thing that there are open channels of communication between senior operational managers, but if the Chief Constable is still staffing unstaffed NHS Places of Safety and frontline officers are moaning about being bounced around the county looking for an PoS premises that will accept them and have to remain there with low risk patients for almost 24hrs (real example), it seems we need better insight in to what is going on. Things seem far from ‘perfect’. I do wonder whether there is a CCC plan that has moved an area forward on this particular issue, or on inpatient ward staffing levels to reduce calls on the police to coerce patients? Is there a CCC plan that means police officers or paramedics attending crisis incidents in private premises that can only be realistically solved by an AMHP pitching up rather quickly with a s135(1) warrant and a DR can access those people and those mechanisms in a timescale that isn’t edging towards the geological?
This is some of the high-hanging fruit which the CCC agenda may highlight or document, but which it often doesn’t address. If CCGs don’t commission services in a way which allows for sufficient NHS staffing to detain or restrain and medicate or transfer patients on wards, to what extent is it a role for the Chief Constable to undertake bearing in mind he or she will usually have no legal duty whatsoever to do so? The answer to the question “Do we have to wait until …” is that NHS organisations have legal responsibilities to patients, staff and anyone else who enter their premises (including to police officers and paramedics!) to ensure safety by mitigating forseeable risks. And ‘forseeable’ in this context doesn’t mean that the risks we’re talking about are only those which will be frequently occurring.
So here’s the challenge, in a thought experiment –
An incident occurs on a ward where an assault is threatened by a patient who is acutely unwell, unless staff allow him to leave. When this is refused during an attempt to de-escalate the situation, he attempts to force open the doors of the ward and leave. Staff manage to get him away from the door and ring 999 for the police. Upon arrival, they are not raising a criminal allegation around the man’s behaviour or conduct because it is recognised that he remains psychotic after a recent admission under the MHA. The unit is staffed by too few nurses to undertake these functions and in any event only one of them is trained in restraint to a level that is beyond their basic, ‘breakaway’ training (to maintain their own safety).
The request of the police could be to restrain the patient for medication or to help move him to another ward or unit where there is an available seclusion room. Either way –
The police arrive and contain the situation by surrounding the man on the ward, attempting to engage him in discussion thereby preventing any Breach of the Peace or criminal offence – order restored without any ongoing need to actively restrain him. The senior nurse or doctor makes the request (to restrain and / or transfer) and the senior officer declines to do so, arguing it is an NHS responsibility to administer the Mental Health Act but they will remain to prevent control being re-lost whilst NHS arrangements are made. The lead clinician states they do not have staff available to them and the police suggest contact with their on-call senior manager to make the necessary decisions around these responsibilities.
What is that police officer doing wrong, legally speaking, bearing in mind they don’t work for the NHS? It could be argued – and just to be clear, I am arguing it – that the police re-taking control of a situation and containing it whilst affording time for NHS arrangements to be marshalled is as far as legal duties upon the police extend. (Subject to any duty that arises to criminally investigate any alleged offence, which most usually will not necessitate an immediate arrest and which returns us to the main dilemma.) Any interruption of this principle should only be where the action is literally time-critical and cannot otherwise occur. In such situations, the police can refer the situation after the fact, including to the CQC who carry oversight responsibility for Health & Safety issues in the NHS. Happy to hear why I’m legally wrong, in the comments below.
Difficult stuff, isn’t it?! – that’s why proper partnerships need to be about the difficult discussions that I think we’re busy not really having and which are based on organisations’ legal responsibilities, not evolved custom and practice which we know has gone badly awry in the past, costing real lives.
* I was once accused by an AMHP of redefining policy on police attendance at MHA assessments with regard to situations where s135(1) warrants are required. Notwithstanding that my supposed views had been mis-represented, I made the point that this wasn’t an attempt to re-define a policy, but merely to create one in the first place. There were no national guidelines on MHA assessments and s135(1) warrants until 2010, the same is true of the topics covered in this post.
We’ve evolved our practice based on unagreed assumptions about roles and powers – enough people have been injured or worse to mean we now need to correct all conditions and that’s what I thought the CCC was all about.
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