I heard the Health Secretary Jeremy HUNT deliver a speech at today’s Crisis Care Concordat Summit in London, the first major speech he’s delivered on mental health, we were told. Almost the first thing he did was praise the police service for the leadership shown on the subject of mental health crisis care, driving much of the debate that led to the creation of the Crisis Care Concordat itself. I might be wrong, but my sense was the comment did not land well with everyone! One service user tweeted about this, wondering whether it should be the police driving certain aspects of healthcare provision – and of course, I don’t think there was a police officer in that room who wouldn’t happily see the issues we face being confronted head-on by senior health leaders and commissioners.
History shows another approach became necessary, for a range of reasons perhaps uniquely understood by the police.
BACK SEAT DRIVERS
Following his speech, the Q&A session saw Commander Christine JONES from the Metropolitan Police, the lead for the National Police Chiefs Council asking, “Mental health services are underfunded: at what point will parity of esteem be matched by parity of funding?” Almost immediately, we saw reaction about how senior health leaders were unlikely to challenge as directly as this. Again: the police driving the debate, literally, with the Secretary of State for Health on the general topic of mental health, not a question specifically about policing! Would Commander JONES be asking that question if a senior health leader were doing it or likely to do it? … I doubt it.
After I woke this morning, my attention was drawn on Twitter to an article by Lord BLAIR in today’s Guardian, a former Commissioner of the Metropolitan Police. This article was bouncing around the conference room at the Oval, in hardcopy … “have you seen this?!” and so it was handed from person to person. It quite obviously divided opinion amongst the non-police professionals present (and on Twitter). It ranged from ‘flabby opinion’ that was ‘not offering any solutions’ to some who thought it was imprecisely making perfectly valid points about the outcomes we see from our current arrangements. It’s obviously not for the police, serving or retired, to tell the health system how or when to ensure upstream intervention in mental health care any more than it is for health professionals to get specific about how the police should discharge their responsibilities under criminal law. However, it is perfectly fair comment for NHS staff at all levels to flag up problems in policing and say, “What are you going to do about it, Copper?!” Or similar.
The main agenda at the CCC today was all about health – a couple of the workshops focussed on policing and legal issues but the main room was all about health. Quite right, too! – the police should be much less of a voice in this, ideally. That they aren’t does lead to certain observations which I make very reluctantly after today’s events. We need to see achievement and progress in this area: not just activity – and this means we also need to describe what we’re actually trying to achieve. The Concordat obliged local areas to produce an action plan, uploaded to the Mind website in 2015 – I’m told this plan should be refreshed and updated by all areas in early 2017. In addition, we heard today about the Five Year Forward View plans that are required, in order to deliver on the NHS England strategy for mental health during the remainder of this Parliament. Of course, those following developments in health will know that various areas have grouped together to produce Sustainability and Transformation Plans (STPs), in order to make the NHS as a whole sustainable in coming years.
PLANS ABOUT PLANS
So what about those 2015 Action Plans – how many areas have ensured delivery of the majority of their contents? If you remember the mapping process set down by Mind: areas were to go from Red to Amber when they’d agreed to some principles to work in partnership; and then Green once uploaded to the Mind website. I remember commenting at the time there should be another colour for completion of the plan, even if just 80% complete. However, one police officer today described his local CCC leadership group as a talking shop where “nothing gets done”. It’s not the first time this month I’ve heard that said, quite honestly. So in addition to those plans, which now need revising, we see then need for more plans after the Five Year report and all of that has to fit in to STPs concerning overall NHS efficiency – the plan of plans!
We know from recent media coverage, that more than half of CCGs are cutting the funding they give to mental health as a proportion of their overall budget, despite suggestions from Government that the proportion should increase. That is the context within which any plan needs to be seen and we know that the trend in terms of crisis care is an upward one – barely a week goes by without coverage on increases in crisis related issues: whether systemtic or individual. No-one who follows current affairs in any detail could fail to understand that there are dynamics at play in society that effect mental health which do go beyond the health service but none of that explains decisions we see to situations ever more towards the social justice safety net that is policing and criminal justice.
I also prepared a question for Jeremy HUNT, in case no other police officer put their hand up. I was going to ask, “What should we conclude about mental health and crisis care if more people than ever before are being detained under s136 MHA, more people are going missing whilst mentally ill, more people are being arrested for offences and then being assessed under the MHA in custody?” There was a sense today amongst (at least some of) the police officers that whatever progress is being made on CrisisCare – and there is lots of it! – it seems to be at the expense of upstream interventions. Those of you who follow along on social media know I’m all too fond of quoting Archbishop Desmond TUTU: “There comes a point you have to stop pulling people out of the river, get upstream and find out why they’re falling in.”
POLICING IN MENTAL HEALTH
When I first got involved in working on the policing interface with our mental health and wider health system, I remember specifically saying to myself that I wasn’t ever going to get myself in to the position of being caught telling healthcare professionals how to run their health service or how to deliver on their professional obligations. This was partly a question of manners: I’d be prepared to listen to anyone about the impact of the way we police on them, but it is ultimately for the police to square away competing demands and priorities in how police services are run, held accountable as they are through various processes. I took the view that that the reverse courtesy should be applied in how I worked on mental health.
But if I’ve learned anything in the last twelve years on this topic, it is a conclusion very reluctantly reached and best summed up in a matephor from my other area of professional interest: public order policing. Progress on mental health has come when police officers or police services form a cordon, take ground and hold the line. History shows that problems in health-based Place of Safety provision actually came not from the Concordat – no doubt it helped – but from some forces saying, “Enough is enough: this will have to change and it will change with or without the consent of the health system”. We’ve heard recently about problems in partnerships where the police are being routinely expected to handle the fallout, often unlawfully, of a health system that has decommissioned too many inpatient and specialist beds whilst apparently disregarding s140 MHA and other obligations. History shows that resolution of those operational problems has come from senior officers tweeting to publicly shame the system in to gear and from actual or threatened legal action.
So the lesson appears to be this: the police are bungling around in this arena, still – not always getting it right and we sometimes miss the subtleties or complexities. We are not experts, we are not clinicians and we’re not trying to be. We just have a unique perspective on some of these important issues and one that is all too misunderstood and disregarded. History shows that unless we shout loud and / or agitate on behalf of vulnerable people, we don’t make progress. I’m far from alone in wishing this were not so. As a natural introvert and an experienced public order commander I can tell you that shouting and agitation is occasionally a tactic in taking ground and making progress: it is to be used sparingly, recognised as a restrictive or coercive practice and it is not without collateral intrusion. However, it does remain a legitimate tactic and leadership is recognising when it is required, when the collateral intrusion may be worth the risk and involves not over-playing it. If we want that voice to quieten down, I suspect we need to see fewer, clearer plans about what the destination is and how we get from here to there without violating the rights and expectations of vulnerable people who are all too often caught up in it.
Notice the above didn’t really focus on the public we serve? – neither did today.
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