The Two Solutions

No matter what you think the problem is, there are only ever two solutions in policing and mental health —

  • The police need more training; AND / OR
  • The police need to work in partnership with mental health services.

All the emphasis is on the police here, isn’t it?! It’s almost as if the only thing we need to talk about going wrong or being in need of improvement, is policing. It’s a part of a subtle narrative that is far more widespread than we realise, if we actually just look for it consciously – and it works because it’s highly intuitive: the police are not mental health experts and we’ve seen incidents where things go badly wrong when they come in to contact with vulnerable people … ergo, some expertise (achieved through training) would be good, but better still would be actual expertise (achieved through collaboration).

You can see the flaw with this, though, I’m sure – whilst the police are not perfect and no-one is pretending they are, whilst the police would undoubtedly benefit from real, good quality training on mental health (and on mental health law!); whilst the ability to call upon mental health professionals in real situations may well be of help – it’s just simply not enough to explain what we know because it’s not JUST the police who are cause the problems.

Let me pick you a real, high-profile example: the death in police custody of Sean Rigg.

MORE THAN MINIMALLY

Primarily cited in more recent years as evidence of need to improve things in policing, the tragic death of Sean Rigg is most usually thought of as a death in police custody – and of course it was. It’s not often thought of as a case which highlights lessons for mental health services or for the training and responses of mental health professionals. This is highly curious, in my own view, because whilst the events following Sean’s contact with the police bothered me enormously and raised obvious questions, I was fundamentally at least as interested in why the Metropolitan Police needed to be called in the first place – and so was Her Majesty’s Coroner. The inquest jury returned a narrative verdict which outlined two things ‘more than minimally’ contributing to Sean’s death. Yes, one of those findings concerned the police response, their use of restraint and officers’ reaction to him collapsing, but the first thing the jury highlighted was an earlier lack of care and reaction by mental health services. This included administering inadequate quantities of medication, a lack of care and crisis planning, a ten-day period in which concerns were not escalated after signs of relapse and to call a Mental Health Act assessment.  Both systematic and individual problems.

Subsequent to those omissions, the Metropolitan Police were called and yes, various things went badly wrong. Some of them were systematic issues for the police as a whole, others were individual matters for the officers involved – just like those for the trust. It was one of those police encounters where you might wonder why Sean was arrested rather than being detained under the Mental Health Act and removed to hospital. Notwithstanding that point, once the police detain someone and restrain them on the ground, a certain set of considerations need to follow to ensure the welfare of any detainee who has been subjected to such a high-intensity restraint event and in no world where I work does that involve removal to police custody without reference to NHS expertise about clinical welfare. The jury found that these issues also ‘more than minimally’ contributed to his tragic death.

But here’s the thing I can’t stop wondering: had the first set of short-comings by the South London and Maudsley NHS trust simply not occured, we have to wonder whether Sean would have encountered the Metropolitan Police at all? — so is the ‘problem’ we need to face just about police training and police collaboration? Absolutely not – it is also about how our mental health services and / or our mental health professionals operate. It is for others to get in to specifics of that but it’s hardly unfair to point out this narrative when all we now hear, years later, is how this was a failure in policing that means we need far more training and more collaboration for the police. We do – but we need more than that.

POPULATION

The death of Sean Rigg was an individual incident, but it wasn’t entirely isolated – I could have used any number of examples to make this point. And we can also look at certain things best viewed at the population level to make the same observation.:

We need to reduce s136 MHA, we are told – that is the publicly stated objective of many street triage schemes and indeed, most evaluations we’ve seen for these initiatives have as their sole metric of interest, the impact of triage upon the use of this legal power. More than once, I’ve had to protest on social media about mental health trusts describing street triage as necessary to stop ‘inappropriate’ use of s136 MHA; and more than once, I’ve protested against the over-focus on s136. (Most street triage doesn’t occur in the street and most of it isn’t triage, so s136 is irrelevant to the majority of incidents being examined.) Again, it’s the “police don’t know what they’re doing” narrative seeping out which is actually contradicted by data from within the NHS itself. It often suggests the opposite and it should be making us wonder about those same things raised by the London Coroner after Sean Rigg’s inquest.

Within s136 data and street triage encounters from some areas, the proportion of people who are currently open to specialist mental health services in their area is a clear majority. In one example, 50% of people detained in a large city under s136 MHA were known MH trust patients in that same city and we’d have to assume that at least some of the others are known patients in adjacent areas, because c20% of detainees were people who lived outside the policing and mental health trust area where they were detained. In another example, one area was concerned at high rates of usage by the local police and kept telling me that detentions included high numbers of tourists from outside the force area who came on holiday and were inappropriately detained for drunkenness and other shenanigans. A short ramble through the management board papers on the trust website revealed an internal report on s136 which included the nugget of information that c75% of those detained by the local police were local residents AND known to mental health services.

So how wrong are they getting it, these ill-informed police officers?!

Finally, in a recent discussion with one force about their control room triage scheme, which is still quite new, they sought a couple of us from the College of Policing to do a quick and dirty review of their first internal report looking at their scheme. One statistic they uncovered was that half of all the people at the centre of the ‘triage’ calls were known patients with the local mental health trust and a further third of patients were recently discharged or disengaged patients with that trust.  In total, as few 12% of those encountered were entirely unknown to the local trust, but who knows how many of those were patients known to surrounding areas? Now all those people in these last three paragraphs were patients who had a crisis care plan and in theory, had access to a care coordinator and / or the trust crisis team. Why was that not sufficient or why did it not work for them?

My own 20yrs of experience, police contact with known mental health patients includes a mix of things, both entirely unavoidable and completely preventable. I do wonder about how routinely forces and trusts are working together, sharing information and reviewing practice to work out how much of each they have? – and how do they use that stuff to improve the police responses to the unavoidable stuff and to reduce the need for the police in the preventable stuff?!  There is not only a risk to vulnerable people from inadequately trained police or police working in isolation; there is a risk to vulnerable people in criminalising them by over-normalising the police and this is where I think we need to look much more closely.

MISSING SOLUTION

We need to work out why so many people, with care plans and theoretical access to services are coming to police attention in ever-greater numbers – and why, the mental health system is evolving in ways which actively encourage this. Quite frankly, it often relies on it – as when it is expected the police will unlawfully hang on to people for days whilst we frantically bed manages resources to ensure admissions. We don’t hear too much about the community mental health teams who say their workload has increased by 100% in 12 months; the CrisisTeams whose staffing is now 1/3rd the level it was about 10yrs ago; the fact that inpatient mental health beds have been reduced by 25% over the last few years, at a time when the number of people under the care of our mental health services is up nearly half a million patients. I could go on – abolition of early intervention psychosis services, reduction in the number of assertive outreach teams, etc., etc..

No-one doubts that the police need more training for the role they play and no-one, anywhere, is arguing that the police should play no role. However, accepting that there is a role, that we need more training to do it better, is not to agree the police should be staffing mental health units for those detained under s136 or that reaction to crisis incidents is sufficient. It is accepting things like, the need to improve the way the officers respond to and investigate allegations of crime, to ensure that victims of crime with mental health problems are not discriminated against within the criminal justice system. It is about ensuring that police expertise in criminal investigation and offender management is brought to bear on mentally unwell suspects, including through a model of liaison and diversion that actually thinks beyond health outcomes and addresses the question of when it is appropriate to prosecute a mentally disordered offender.

Policing has largely been motivated to look at mental health and improve its responses because of the legal fallout from serious untoward events. There aren’t many of them that don’t raise questions at least some questions about how partnership organisations operated at the point where policing went badly wrong. It’s frequent quip of mine when presenting on this topic to joke that I still have just a few hours of training and that half of it was wrong. But I also remark that the other half of my training didn’t work in the real world because the real world doesn’t always look like the Mental Health Act or its Code of Practice. In 2014 we published a Crisis Care Concordat and this document merely reflected a load of problems that were well-known and reflected in other reports and inquiries. Three years later, the police have completed all its actions from the national action plan – but has the NHS?!

And yet somehow it’s still all about police training and police collaboration. This simply doesn’t add up, does it?!


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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11 thoughts on “The Two Solutions

  1. Excellent blog! MH trusts ‘efficiencies’ mean less staff & less beds with more & more people seeking help & support. Frontline resources stretched across the whole system police & ambulance too. CCC has not produced real change for many (staff & public) but ‘hey we got an Action Plan!’

  2. Insightful blog. From a recent Kensington Police seminar on vulnerable children and adults there was an obvious issue in that when points are made about the ‘police’, ‘social services’ or ‘health’ (to name a few of the departments) the individual behind the group is unable to reconcile all the information about the person. The scraps of information are physically impossible for a dedicated person to analyse, let alone a single person who has been called out from whichever department. Services cannot spend too much time collaborating as they are needed to serve the cases, so most of the services end up investigating what has happened rather than being preventative. We are speaking to MASH organisations in collating this data to provide operators and practioners with real-time information at the time of a call and be preventative.

  3. You are right on the subtle undertone of Police need more training so we can deal with increasing Mental Health demand. This feeds into the other subtle pushing / demand deflection of Mental Health incidents towards the Police. This happens all too regular!

    In terms of Street Triage the best performance indicator in my view is actually referrals. Many of these referrals require a clinical assessment and this gives Street Triage the chance to divert back to the NHS at an earlier stage. S136’s are often not the first incident the Police get on an individual as their Mental State is declining.

    I also have found from reviewing 136’s that this power is all too often a symptom of poor care, too early discharge from services, poor access to their care teams or barriers in place and so on.

    I often argue with our Trust that we have done the training (often at the expense of other Police areas of business) and we have invested in Triage. If you want to reduce S136 further then you need to get your own houses in order and sort out your system issues. It’s amazing that I have Officers thinking about least restrictive practice but Health professionals in ED for instance still don’t get it.

    Very good article.

  4. The Police should not be involved in mental health care. It criminalises seriously ill individuals. Try Trieste, Italy for a model of care that is very nearly Police free.

  5. If police were held to account when they kill people, l’m sure the number of deaths in custody would drop dramatically.

    1. In what way are they not held to account, Clive? — police officers have been prosecuted many times for criminal offences, they have been disciplined for gross misconduct and received sanctions up to and including being sacked. That sounds like some accountability doesn’t it? – or do you mean that if someone has died following police custody / contact and the officers are fully acquitted by a jury, that they haven’t been held to account by having to face trial that may jail them and cause them to lose their jobs?

  6. Great piece. I’ve personal experience of s136, also experience of A&E and have found the police have better understanding, in A&E its just usual OBS and put in a cubicle with all leads removed. Police made it priority to get me to somewhere safe, where i was properly assessed. The actions of A&E are understandable, they are mega busy and ill-equipped for MH patients. I once had to wait 36 hrs+ in A&E for a MH acute bed, s136 & police got me assessed and a bed in a 1/4 of the time. But this is just my experience. Like most things, it asllcomes down to money, if all services were better funded, there would be more acute beds, better trained staff etc. Money is the solution, if only it was really that easy though.

  7. I am someone who suffers with poor mental health, and as a result of this I have been detained by the police on S136 MHA on numerous occasions these past six years. Learning from my own experiences, what has become evident to me is that once I am discharged from the mental health services back to my GP there is no immediate way of re-accessing the service again if I suddenly find myself heading towards another crisis. I am obliged to make an appointment with my GP (or any other available GP) in order to be referred back to the Crisis team. The problem is that so often I have had to wait between ten days and two weeks for the next available appointment to see the GP. Inevitably, during this time, my mental health will have deteriorated so badly that I have once again presented as suicidal in a public place. Which in turn involves the police again having to take responsibility for my immediate safety. Of course, I do have the option of admitting myself to Accident & Emergency, but more often than not this feels more like a war zone than a place of safety when my mind is in such a fragile state, and so this option becomes highly unfavourable. Better to go it alone than sit for hours upon hours in a place of high anxiety and immense psychological discomfort. It seems to me that if there was a way to access GPs more promptly during a mental health crisis then people like me would never need to become the responsibility of the police. I am just one example of the many thousands of people who follow a very similar pattern to me. It’s surely not just a coincidence that when I am detained on a S136 and subsequently admitted to hospital as an in-patient that I am already familiar with more than 50% of the patients already admitted. And as the days pass by, even more familiar faces are admitted.

  8. Excellent blog again – the underlying causes for the increase pressure on the police being the Transforming Care Agenda which has created huge pressure to discharge patients from hospital care and that this sits alongside local authority budgets being decimated – this creates a perfect storm; greater numbers and complexity in the community with little in the way of adequate provision.
    What do we do change police officers JD’s to include the role of social worker / CPN etc?
    Will anything straight ever be built out of the crooked timbers of humanity?

  9. Great blog. as a relative i would say that there just isn’t enough care driven partly by lack of money but also by (I think, professionals please comment) an ideology that says people ought to be able to manage in the community, so they will be left to manage in the community for far longer than is sensible, so the police get involved. And if your diagnosis is a personality disorder then it can mean that everyone believes that a hospital admission is bad for you, so you are left to revolve through crisis, A&E/ police, back home…..until the diagnosis changes or …………

  10. The sad fact is that until money for MH is ring fenced and MH, primary and community care services properly commissioned and staffed the police are going to be picking up the pieces.

    We now have a situation where people are expected to know when they are becoming unwell, phone at 8 in the morning to get a GP appointment (if they’re lucky) in two weeks. Maybe they’ll be referred to CMHT and only have to wait a few months for assessment and be assigned a care co-ordinator who has far too many people on their caseload to help properly.
    Or they can call a Crisis Team (named for their ability to create a crisis is a justified joke) and be told to have a cup of tea, bath, bag of chips, sex, or a walk (all real examples) and someone will call them back or visit a week on Thursday if they are still alive.

    It is ridiculous that cuts are simply creating greater costs further along in the system. Dealing with MH is part of the job for the police (because the general pulic includes us), it should not be as much as it is.

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