I woke upon one day last week and whilst boiling the kettle checked Twitter to find an article entitled ‘police liaison’ in the British Journal of Psychiatry (no less) about street triage. Consumed with interest, I opened the PDF to find it granted free-access (I don’t subscribe) and I started reading. In paragraph one, I admit to putting the phone down on the kitchen surface and breathing deeply whilst I got the milk out of the fridge. I read on, caffeinated!
The article sets an evaluation of street triage against the background of section 136 usage – more on that premise, later – and tells us that “it requires [my emphasis] the input of an Approved Mental Health Profession (AMHP) and two doctors for the assessment.” Except that it doesn’t! …. it requires just one registered medical practitioner, which is made clear by subsection 2 of the section itself, which states, “A person removed to a place of safety under this section may be detained there for a period not exceeding 72 hours for the purpose of enabling him to be examined by a registered medical practitioner (RMP) and to be interviewed by an AMHP and of making any necessary arrangements for his treatment or care.” It doesn’t even demand that the RMP is ‘section 12 approved’, although this is highly recommended by the Mental Health Act Code of Practice.
So what occured to me after reading it –
- The whole article about police liaison is about usage of s136 – yet we know most street triage encounters occur in places where s136 can’t be used. There is therefore no analysis of the majority of its work!
- We also know that s136 is only a very small, and in some areas a relatively unimportant, part of ‘police liaison’.
- It is predicated on not fully understanding what s136 requires – although many MH trusts and AMHPs prefer to have two doctors for assessment, this does not arise from the law, but from local policy. It makes me wonder how we justify any greater, longer restriction whilst we look for that second, no doubt helpful but legally unnecessary doctor?
- It fails to ask some really obvious questions about the approach of triage to encounters, where reductions in s136 have been observed – how do you delay the instigation of powers that are, by their drafting and definition, immediately necessary whilst officers ‘phone a friend’?
- It starts from the premise that s136 is over-used, when we don’t know that it is – there are some commentators, including the Deputy President of the Supreme Court, who argue it’s probably under-used. In reality, forces use the thing so differently that it’s probably a bit of both and depends which area you’re looking at.
- None of the problems associated with non-use of s136 following triage contact are mentioned, at all – we know there are some issues with it, not least because there have been Coroner’s inquiries following contact with these schemes. Have these things happened in that area?
I want deal with the reaction on Twitter from a few nurses and AMHPs, that two doctors for assessment is ‘good practice’ and standard procedure in many areas. Fine: the law can set a minimum standard and areas can choose to exceed it, but we know that this will also not be without difficulties and consequences. As s136 is currently framed, detention can last for up to 72hrs. This does not mean that all of 72hrs can be taken just because it’s convenient – surely if the principle of ‘least restriction’ (which I remember reading about once upon a time) is to mean anything, it means we don’t detain people for longer than is necessary.
If the law demands one doctor and there is no particular and obvious reason to include a second doctor from the outset, any delay in their attendance would need to be justified as proportionate to the delay it caused. If an AMHP had one (s12) Doctor available 3hrs after somebody’s detention under s136 but a second doctor wasn’t available until 9hrs after that, how do we justify the extra 9hrs of detention when the law could have been complied with at 3hrs? Indeed, during this morning’s Twitter exchanges, more than one police officer was explaining that they’ve known cases of long delay to secure that second doctor so this is not hypothetical. I’ve also known it as recently as yesterday where a Mental Health Act assessment is requested for someone in custody (which would require two doctors) and the AMHP has turned up with just one, because they apparently pre-determined that the man’s history would preclude him being sectioned under section 2 of the Act because admission to an acute admission ward would be inappropriate; he would require prosecution for the alleged offence to be admitted to a medium secure unit. Fair enough: but these decisions were made without anyone knowing or asking whether there actually was sufficient evidence to charge the person!
And this ‘two doctors’ approach for section 136 doesn’t play the odds – most people detained are not subsequently admitted to hospital. Accepting some cases will be borderline, I’m not suggesting that none of those cases will always just need one doctor because an AMHP and the first doctor may know enough upon receipt of the referral to know a full MHA assessment is necessary; and the 72hrs is there to be used. I’m just imagining a situation where one of my family members is jailed in police custody as a Place of Safety for 3hrs when the first Doctor becomes available, but is then kept there for a further 9hrs for a second-opinion without any sense that it’s necessary and everyone pitches up at 12hrs to do what could have been done earlier and my relative is sent home. Indeed, if a common complaint about police decision-making, also voiced this morning, is that it’s “obvious” some people – or even many people – detained under s136 shouldn’t have been detained at all and that police officers are too risk averse in their approach. It makes a bit of a mockery of that feedback that we’re always using two doctors to do what one doctor could do in the vast majority (83%) of all cases and this approach has been normalised to such an extent that we’re publishing articles on the false premise of what the provision involves.
During discussion about potential research on things like s136 and street triage, it was mentioned this week on Twitter that ‘clinical’ people should be doing it. Conscious that this tends to mean doctors and nurses, I was most curious because a) look at the above; and b) there is an obvious role played by non-clinical professionals in a mental health crisis care: police officers, paramedics (who someone recently insisted to me are ‘healthcare’ not clinical staff!?) and – of course – AMHPs (usually mental health social workers). I do try really hard not to be too picky with this kind of stuff (believe it or not!) – but one reason I keep banging away via a BLOG is: if we’re happy to exclude the police from and others from research and discussion about a process that flows from a police decision and which requires ongoing police involvement then what else is being missed by professionals who often have too little legal training around the issues they purport to evaluate?! This is just one example: there is no ambiguity at all in s136(2) about what is required – it’s written in everyday English language and is hardly the most technical or complicated of our laws.
But that gets me to a wider point: I worry about the exclusion of the police from various discussions that are going on in this country about the police role in our wider mental health system. In the same way that many patients have rightly demanded, “Nothing about me, without me”, the same should be true across organisations and their partnerships. The College of Policing has worked for two years on Guidelines for situations where calls are received asking the police to undertake restrictive practices (ie, restraint) in mental health or learning disabilities settings. It took this long purely because of the large number of health, NHS, third sector and other organisations who needed to be involved and consulted. Collating that feedback was a mind-consuming nightmare which I will never full tell you about because of the volume of it, the considerable contradiction within it and so on. But imagine if we hadn’t consulted and the College produced guidelines on matters affecting inpatient wards without speaking to staff who work there or more importantly with the patients who are detained there without liberty or autonomy?!
Yet in that time, I can think of at least three of four programmes of work or guidelines in health that directly affect the police where it seems highly likely that no effort was made whatsoever to consult with the police. I won’t embarrass those involved, but I could back this up, if required to do so. I suspect there are plenty of conversations going on in rooms to which the police are not invited about how responsibility, risk and liability can be transferred to the criminal justice system and we see this in police-mental health processes. New data on the use of section 136 MHA has been celebrated as progress because the number of people being removed to police custody as a Place of Safety has halved over the last year, whilst the use of the power is still rising over time. On how many of those massively increased number of cases are two officers now being required (despite national guidelines to the contrary) to remain at the PoS for assessment? “Most of them, in many areas”, is the answer and in some cases this means even more resource being expended by Chief Constables than was the case when cells were being heavily relied upon as Places of Safety under the MHA. Do the Chiefs realise this? – why would they unless they turned over the stone themselves. No data is being gathered on it and it gets buried beneath the argument, “We agree that cells are the wrong place and we don’t have enough staff.”
Any premise that section 136 tells us very much at all is fairly flaky. We saw the 2015/16 data published last week and immediate comparisons were being made with the previous year’s. Yet we know that the 2014/15 data was incomplete and that the data to is, at best, partial. I still can’t tell you how many patients were admitted to hospital on a voluntary basis following assessment under s136. But there is so much more to triage and to police liaison as a whole –
- What about criminal suspects who are mentally ill – the whole liaison and diversion debate? When and at what point do we prosecute someone for an offence and when do we divert them from justice? – this group is about four or five times the size of the cohort detained by the police under s136 but we hear far less and know far less about them. What is the re-offending rate of individuals arrested for offences who are ‘diverted’ from justice at the point of arrest? We don’t know.
- What about those in contact with the police who are not detained under s136 and don’t need to be – whether that is street triage encounters; welfare checks on vulnerable people, etc.. Police forces around the country are asked to undertake tens of thousands of welfare checks every month, most of the time where the person is not ‘missing’ and where there is no other urgent issue that justifies risking the psychological wellbeing of someone by ‘calling the police’ on them.
- What about matters pertaining to the administration and application of the MHA – things like AWOL patients and those who have otherwise absconded; calls for the police to attend wards to undertake restrictive practices on behalf of ward staff, etc.? We know that there is still too much reliance upon the police to undertake these functions where they have no legal duty to do so and, again; where it risks having a very negative impact on the public.
- What about allegations of crime on mental health wards – whether those allegations are made by patients or staff? We know that there is dissatisfaction with the consistency of the police in their investigations and that improvement in this area could bring many benefits to all. However, the NHS needs to understand how much damage their own approach around the recording of ‘medical factors‘ could do in this arena.
So I worry that we really are still making this stuff up as we go along; and that without a greater effort to gather data, we always will be. But first, we have to open our eyes to the questions and problems and an informed police view point is vital to that.
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