High Hanging Fruit

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.

PERCEPTION

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.

THOUGHT THINGS

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.


IMG_0053IMG_0052Awarded the President’sMedal by
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


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20 thoughts on “High Hanging Fruit

  1. All good points, particularly around police being involved in “planned” restraint which you highlight. There are a few points though that, while not attempting to excuse poor planning, do qualify a few things.
    * Cutbacks have left hugely depleted numbers in mental health services. This year my trust has to find several millions of pounds worth of savings, that results in recruitment freezes or jobs losses. 6 nurses in my area are at risk of redundancy, sounds small but has a real impact.
    * 1-2 years ago the government seriously restricted what the NHS could use in restraint, ostensibly the older techniques were too restrictive but it was felt to be political point scoring. As a result violent incidents are significantly harder to contain.
    * Equipment wise, any form of restraint equipment/protective clothing is heavily frowned on. When I worked in medium security we had handcuffs and body belts etc but they were mainly for transfers, to be fair we did well to use them rarely. Can you imagine the excoriation NHS trusts would get if they started equipping staff in other areas with such tools? I remember a police officer being genuinely shocked when we told him we didn’t have riot gear to deal with a patient who’d barricaded, like the special hospitals do.

    You’re right about the difficult discussions, hopefully we can move forward on them one day.

    1. I do understand that, I really do. Those points often get brought up in the meetings I attend on these topics. My replies on your three points tend to be –

      1. From the turn of the century, your service had a 59% increase in real terms funding followed by the last six years in which budgets have been cut by 8%. In policing, the increase from the turn of the century was 31% since which time, there has been a cut of 20% with way more to come. I deliberately stay clear of the cuts argument, because there’s case law that it actually doesn’t matter a tupenny damn to everyone’s overall legal responsibilities, especially under Human Rights law.

      2. Very aware of Positive & Safe: it was the police exclusion from that agenda that mainly leads to the work the College of Policing are currently leading. In broad terms, unless the police are exercising their legal powers for policing and criminal justice purposes, it would be folly if the police were to rock up in mental health wards and choose to undertake tactics for MHA purposes which are precisely those tactics which the NHS have decided are inappropriate. If it’s not right to restrain in the prone position or to use mechanical restraints, then it’s not right whether it is a police officer or a nurse who is doing it.

      3. This links to answer two: I think it’s almost worse to say we’re not able to do something for ethical or for safety reasons and to then call on other organisations you can’t control with their inappropriate training to do what you’re not prepared or able to do for yourself. I just find that too weird.

  2. Dan, whilst I respect that your budgets are ever decreasing the same is true with the police. My force has lost over 100 staff last month with more due to go soon. Teams have been disbanded and entire departments dissolved to backfill the main frontline response to ensure we can cover emergency calls.

    Time and time again I see victims of crime being made to play second fiddle due to mental health crisises, absonders from hospitals and places of safety and missing people from care homes and nursing homes. It is time these institutions pulled their weight and dealt with the issues. If the staff or funding isn’t there then push back. If managers won’t listen go higher. If they still won’t listen go public.

    The police can not carry on being the go-to body of the NHS when anything spontaneous happens. These incidents are foreseeable, reasonable and preventable.

    As the old saying goes “A lack of planning on your part does not constitute an emergency on my part”

  3. Is this the same for spontaneous incidents in a bar?. It’s foreseeable that consumption of alcohol will lead to an increase in the potential for violence and reasonable to expect some form of alcohol related violence that is preventable by a bar employing sufficient security staff to stop such incidents or not serving alcohol. Would it be right for the police not to attend an incident in a pub where members of the public’s safety was jeopardised as the management had not employed enough staff. Same could be said of violence at football matches.

    1. It’s not the same, I’m afraid – for various reasons. By way of background, another professional specialism of mine has been public order policing, including command of Premier League football matches. I’ve obviously policed nightime economy areas operationally throughout my service and have been what we would now know as neighbourhood policing inspector of an area with a concentrated night-time economy.

      Firstly, people attending bars and football matches are not detained at those locations against their will by the bar manager or football club – different responsibilities attend the responsibility, by definition. Secondly, it is a requirement of licensing of pubs and bars and of football club safety certificates that they have sufficient door staff and stewards on duty. If the police are called to something that has already happened and believe that it is due to shortages of staff that are required under those frameworks, the police have the immediate authority to have the duty inspector shut down the bar and to refer the matter to a licensing committee. and in each of these examples, the police do also take the view that gatekeeping of entry and oversight of problems is a matter for the licensed premises and the football club, not the police. The police become involved in both where offences have been committed or the nature of the problem is legitimately and unexpectedly beyond the capability of those businesses to cope.

      Just my view, obviously.

      1. Regarding your first point the majority of people admitted to a mental health facility are not detained under the mental health act but are there voluntarily.
        Secondly I am sure that there is some legal framework around minimum staffing levels in a hospital but this seems to be well below what is necessary to maintain a safe environment. As someone who has spent too long in mental hospitals I am always shocked by the small number of staff expected to manage violent situations and the lack of equipment at their disposal.
        I still don’t see why the police feel they shouldn’t respond to dangerous situations within a mental hospital and why they begrudge doing this. We are all members of the public who pay tax and should be entitled to the same services as those not in a hospital detained or otherwise.

    2. I’d also add, that the post makes clear: if a spontaneous incident occurred and help were sought, the police can be involved in the response and it may need an attendance by the police to make the assessment of what is possible or necessary. Where they have attended and restored any control that had been lost, the normal duties then attend the NHS to restrain or transfer patients for NHS purposes. I’m not at all clear what section of the MHA allows the police to restrain someone on the floor for the purposes of nurses medicating them and this remains true even where a criminal offence is committed because powers available to the police under criminal law are absolutely for use in connection with criminal justice purposes of investigation and prosecution. By contrast, I’m very clear about the duty I have under the Licensing Act to evict people from bars when requested to do so by the DPS; or to arrest people for public order or football offences at large scale sporting events.

  4. As ever, an excellent and thought provoking article.

    In your example, I wonder what would happen if, for example, another partner rang up expecting the police to turn out to use force on their behalf? What if the prison service rang up saying they wanted police to assist in a relocating a violent prisoner to another cell? I am pretty sure they would be told to crack on and stop writing cheques on the police’s behalf. I believe that the prison service have their own equipment and specially trained teams to undertake these sorts of activities – and that seems quite right and sensible. I just wonder why mental health trusts / hospitals can’t train and equip their staff to deal with what are entirely foreseeable incidents ( in terms of likelihood as opposed to exact timing).

    My honest view is that it is as much a mindset as a resourcing issue. My view is that a lot of staff working in mental health settings see their role as therapeutic and getting ‘hands on’ with a patient goes against this as well as undermining any relationship that they may have built up. Much better to call in the big nasty policeman and subsequently deflect any blame from the patient to the interlopers.

    This is in no way meant to denigrate those who work in mental health. I have, without exception, found those I have had professional contact with at practitioner level to be excellent. But as the CoP themselves pointed out a huge amount of time, money and effort is being spent by police filling the gaps in this area and this will increasingly become unsustainable as budgets continue to shrink.

  5. In my experience services users (I use that term lightly cos often there is no service to use) are tired of empty words re mental health “care”. The reality for many is not “services working well together” but one service (the police) having to pick up and step in where there is no alternative “care” provided thus often criminalising people who are ill !

  6. Great piece. In my view as a relative, understaffing on acute wards is permanent. As an example 3 members of staff(1 nurse 2 HCAs ) on a 19 bed acute ward at night.. and a maximum of 5 staff (possibly 2 nurses) during the day. They have to handle admissions too. It’s not even safe, never mind therapeutic.And n acute ward is where you will be if you need an admission at all. If services can’t recognise that it’s not safe then they shouldn’t be in business. Professionals need to have difficult conversatiosn all round. IAs Laura says above otherwise the police just end up providing it.

  7. Just out of curiosity is there data on how often police are called to wards? Is there a significant difference between public and private sectors? Are police called out to mainly acute wards?
    My experience is that neither the police or the ward staff know what its like to work in either area and the procedures that go along with that. Most people assume what others do.

  8. The case law argument only goes so far, if there ain’t the money, it ain’t gonna happen. Veering away from the cuts argument is unfair; much of the extra funding has gone to privatisation, an example being Care UK winning a multi million pound contract for prison healthcare in the north east despite the NHS trust outperforming them. With regards to Ed Fenris’ post, any attempts made to equip our staff in such a way outside of the special hospitals is blocked at national level. Southern cop, you aren’t being fair. We’ve spent six years fighting, even taking strike action, something the police often criticise. The fact is we have a government bent on dismantling public services, something I know the police can’t comment on, but doesn’t make it less true.

  9. Dan, You mention in your post that your facility has been funded and structured by your management is such a way to deal with the patients in your charge , however I can see in your writing the anguish you feel about being faced with situations that your staffing levels and equipment are unable to deal with.
    Would I be right in saying that the fault line appears to show itself when staff are unable to cope with a situation within the hospital or facility. In such situations should the question then be asked what happens next and what is the plan in place for any escalation.

    What plans and agreed protocols does your facility have with other agencies such as the police to intervene and use force in such situations? What is the protocol you follow when you have an issue in your facility when staff are unable to cope? These are the Highly hung fruit which need to be agreed and in place prior to any such situation occurring.

    MHC has covered these “high hanging fruit” issues relating to what you have mentioned in previous MHC posts titled “Barricades, weapons and hostages” and “should we have to do this” where the question is asked what is in place to deal with these situations.

  10. Great read Michael.

    The ‘battle of the budgets’ (Police v NHS v Social Care) really is a ‘battle to the death’ with no winners.

    Ultimately, the solution is going to centre on accountability.

    So, do the UK Police have a legally enforceable duty to respond to calls for assistance from members of the public? As far as I am aware they don’t.

    1. The advice we’ve had is that there’s a legally enforceable duty to respond to situations that trigger obviously responsibilities like crimes in progress, crimes that have occurred, various other specific things around missing people, etc., etc.. But that duty needs to be seen against the background of other organisations duties. Clearly, A&E don’t have the same duties and obligations around patients as mental health providers. A&E aren’t detaining people against their will – MH trusts often are and doing so raises the obvious problems in the post.

      But even to the extent that the police haves duty to attend and prevent offended or further offences, that doesn’t necessarily extend to the various tasks that NHS trusts ask officers to undertake.

  11. OK, I have been detained under the mental health act in a “short stay unit” which is 4 beds within an A&E dept. I beleive that if you are “admitted” to this unit a medic is able to use the mental health act. In reality I was still sitting in A&E but if I was formally admitted on paper so the MHA could be used.

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