Missing The Point

Yesterday, Her Majesty’s Chief Inspector of Constabulary, Sir Tom Winsor said something extremely important in his annual review, known as the “State of Policing” report.  The main headline from the document was his argument that the police are now filling gaps in mental health services and that this represents a drain on resources which are being diverted from other policing responsibilities. It was his clear view that “the provision of mental healthcare has reached such a state of severity that police are often being used to fill the gaps.” He makes the point that the police “have often been used as the service of last resort. In some areas, particular where people with mental health problems need urgent help, the police are increasingly being used as the service of first resort.” He goes on, “We are still finding cases of mentally ill people – who have not committed any crime – spending the night in a police cell. This is because they are too vulnerable to be left alone but there is no bed for them in a healthcare facility. The provision of mental healthcare has reached such a state of severity that the police are being used to fill the gaps that other agencies cannot. This is an unacceptable drain on police resources and it is a profoundly improper way to treat vulnerable people who need care and help, not incarceration among criminals.”

He makes a comparison for mental health care with the police approach to crime prevention, “It is far cheaper to prevent a crime than it is to investigate and arrest the offender after the event.  The same is true of mental ill-health, which is not a crime.  It is an old adage that an ounce of prevention is better than a pound of cure and this is particularly true when the cure fails and an emergency intervention is required to protect the safety of an individual in distress and, often, people nearby.  By the time depression or some other mental disorder has been allowed to advance to the point that someone is contemplating suicide, or engaging in very hazardous behaviour, many opportunities to intervene will have been missed by many organisations. When that intervention takes place on a motorway bridge or railway line, or when someone is holding a weapon in a state of high distress, the expense to all concerned is far higher than it should be.  The principal sufferer is the person who is ill, especially when it is realised that his of her suffering could have been much less or even avoided altogether.”

I’m sorry to keep going, but his words are well worth reading, “There is the economic cost in terms of the expenditure of time and effort by the police and other public services, as well as the expense and trauma sustained by those adversely affected by the crisis at the time.  The economic arguments for earlier intervention intensify the health and moral ones ready in play. Furthermore, research, carried by Ipsos MORI for HMIC, shows that only two percent of people think that the police has the greatest for responsibility for the safety of people with mental ill-health or learning difficulties. With an estimate one in ten young people having a mental health problem, this is not a matter for the police alone. The inadequacy of mental health provision and the lack of parity with physical health provision in this country should disturb everyone. It should never be the case that someone who requires treaetment, for any condition, should become the responsibility of the police simply because other agencies do not have the resources to act.”

FIFTEEN YEARS

I did not know this report was coming out until it was published and I started to receive media enquiries about whether the College of Policing would allow me to be interviewed (listen from 19:55). Having downloaded the report, abandoned a colleague I was having lunch with to read it on a Tube on the way to a BBC studio, I couldn’t help but smile and shout “Yes!” to myself as I travelled down the Victoria Line in London. After tweeting the report, my reaction was to add, “I’ve been saying this for fifteen years – glad to see everyone’s catching up!” And this links to the way I’ve been recently summarising where we are with things now. We can talk all day and night about various things that have gone wrong in policing and mental health, up to and including controversial deaths in custody following restraint. When we do, we tend to find people saying “the police need more mental health training” and “the police need to work in real time collaboration with mental health services”.

Well, Sir Tom’s intervention doesn’t address either of those things, specifically – it goes far more directly to the real heart of the problem, to his credit: a problem I’ve flagged for many years now. Neither intervention even begins to address why we now rely so heavily on the police as part of our model of healthcare – what is driving people towards the police in the first place?! Professor Louis Appleby (former government tsar on mental health and criminal justice) was quite quick to dismiss the HMCIC’s assessment, tweeting –

Again, this misses the point being made. Positive collaboration isn’t addressing the reason why the police are being called in the first place and evaluations on these collaborations are known to be poor so we don’t know whether it’s decreasing police contact for vulnerable people, regardless of whether it’s improving it. Helping the police respond better is the second of the two solutions and it’s not necessarily preventing the deployment. Some so-called ‘street triage’ schemes will claim that they have identified calls coming in which don’t need the police and the triage nurses have handled callers directly, without officers deploying. But we also know that some healthcare professionals have started diverting more demand to policing because “the police have nurses now!” and the triage nurses have complained like hell but be unable to avoid deploying to situations police officers aren’t required at.  I’ve seen that with my own eyes several times whilst shadowing.

And no, we don’t have data – those who designed these things didn’t appreciate the need for it. They were told, but they didn’t listen. Can only say that I tried! … the blog posts are there to prove it!

ACADEMIC EVALUATION

We’re simply not sure whether demand because of triage is rising or falling, because it’s not being evaluated properly and in fairness to Mr Winsor, it’s not HMIC’s job to do research! — whereas it is Professor Appleby’s. Research funding for policing and mental health projects seems to be hard to come by. Professor John Baker mentioned on Twitter recently that his attempt to secure funding hadn’t been successful but that he’d be interested in doing it. I’m aware of two other academic bids for funding to take a more thorough and critical look at these collaborations which have been turned down by health funding agencies. What more can you do that try?! It’s not HMIC’s fault that ‘positive collaborations’ are collecting very limited data sets, that academics are choosing not to really look at this stuff and that research funding bodies are turning down applications. Until then, you might just have to make do with people blogging, and offering their opinions.

Of course, HMCIC’s views are not just opinions – this is the professional judgement of Her Majesty’s appointed adjudicator: he has a formal position in our society and a statutory duty to call it as he sees it, even if there are some remaining questions of detail. I hope his intervention prompts research to prove him right or wrong, then at least we’ll know, won’t we?! But however, you look at it, Sir Tom’s views will no doubt be predicated on impressive quantities of information and opinion that HMIC collect from forces in their various routine inspections around custody and around general effectivenss, amongst others. The CQC are involved in advising on some of those inspections because of the obvious overlap with health issues in custody and CQC is an organisation on whose board Professor Appleby sits and for the record, their opinions and reports don’t always survive contact with reality, either! … but I can’t just dismiss the statutory regulator for healthcare and the Mental Health Act out of hand, can I?!

Meanwhile, my good friend Nathan Constable has blogged very well and very quickly on this new report. I’d encourage you to read his views. He’s also busy working his way through a Master’s degree looking more deeply at the issues around the role of the police and his early work has uncovered much that supports HMIC’s position: that mental health professionals thirty odd years ago could see where community care was going, where the use of s136 MHA was going (up) and where the role of the police was going. You only have to look at other countries with non-public healthcare systems to see how the criminal justice agencies end up playing a massive role, because there are inadequate social justice mechanisms to stop it from becoming necessary. If some people have a problem with uneducated police officers with 4hrs of training trying to fathom out what the hell is going on and making some kind of in-roads in to handling the rapidly increasing demand faced by British policing, they should feel free to step up: do some quality research that I can’t climb through and I’ll stop blogging and go an arrest someone for something. Until then, it seems a valid use of police time to try and understand how we address some of these issues, firstly and foremostly by actually understanding them and then do what the police are charged with as their primary duty: prevention.p>


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 “Missing The Point

  1. Excellent points and good post as ever. Brings up the issue of proper evaluation of services including Street Triage, crisis and out of hours. There are people amply qualified to do this but most unfortunately I fear it is not sexy enough for most healthcare researchers and really belongs in the realm of service evaluation in respect of street triage. This brings up a much wider issue about the planning and commissioning, the research into and need for, different services of this kind throughout the land. The main objective then is to lobby for funding for proper evaluation as part of a wider move for evidence based government. In my opinion Street Triage services have been put in place in some instances as a knee jerk reaction to a badly understood problem. The ‘moral panics’ brought on by the notable cases of unfortunate mistreatment of mental health patients when held inappropriately in polcie custody has led to a headless chicken response of ‘we must do something – Street Triage sounds right?’. In many cases i probably is right but 1) More research and planning of these services is needed to target the services effectively and 2) Ongoing evaluation and continual service improvement/enhancement is also needed – probably the case for all public services. Ideally this should be collaboratively researched between the Home Office research department and a Mental Healthcare research establishment such as the IoPPN. ‘Realistic Evaluation’ (Pawson and Tilley, 1997) would be an appropriate model to follow to evaluate existing Street Triage models. Need could be assessed with reference to police held data such as the 434 forms kept when s136 is done. Text engineering/analysis could be used to examine further mental health and police records to get a better / more objective picture. Maybe Louis Appleby could suggest some ways forward too. Cheers, Matt

  2. Louis is 100% right. This is a complex problem. V majority of this “demand” is not from mentally ill folk. Medicalising their responses to life can be unbelievably damaging and undermine personal responsibility usually leading to escalating destructive behaviors. We see this modern day ‘psychologisation ‘ of normal human responses all around (‘we’re all mentally ill now’). As a recent discussion paper on Child and Adolescent services pointed out ( Wolpert 2017) -‘ dont assume access to a mental health professional is the best response to someone with mental health problems’. Seems counter-intuitive doesn’t it? But until you begin to understand the concepts behind that statement you’ll be in the dark and ,ironically ,
    potentially damaging people on mass ( albeit inadvertently )

    1. Nobody is saying it isn’t a complex problem, though! And no-one is saying that there isn’t an issue over-medicalising responses – I’m all too aware of that and have said so several times over the last few years, often to looks of complete bemusement from my colleagues in the police, it must be said. We can’t declare that he’s “100% right” though – he’s complaining about a lack of data from HMIC when that data, in fact, doesn’t always exist because mental health services and police forces aren’t gathering it. And he talks about positive collaborations which actually do have the effect of bringing mental health professionals more in to the order of things, which is precisely what you’ve just cautioned against.

      It’s ultimately never going to be for the police to make judgements about what the appropriate response for someone is, once things meet a certain threshold – just like it’s not appropriate for healthcare professionals to have to face violence once things reach a certain threshold. Introducing the police to risky situations often escalates things more than if we’d kept them out of it, but there are certain things it’s just unreasonable to ask healthcare professionals to manage. This is just a reversal of that argument: if someone’s threatening to jump from a bridge, they’re being brought in to contact with the MH system, one way or the other. Anything else is a clear and obvious neglect of the officer’s duty.

      Something unspoken here, of course, is that the mental health industry has been unilaterally evolving its paradigms of care and continues to do so; and rationing of service tends not to see discussion with CJ agencies about the obvious consequences of those decisions. It has redefined the role of the criminal justice system even within my 20yrs of service and now calls for ‘therapeutic jurisprudence’ in situations where it never did when I first joined – and it did this without reference to us then complained when we were surprised at the change of tack. This observation is not just about custom and practice issues, it’s reflected in formal documents from organisations like NHS Protect who call for prosecution in circumstances where statutory authorities for those matters think it’s legally inappropriate, based on Government policy and statutory guidance. (Note that neither the College of Policing nor CPS have endorsed the recent crime protocol from NHS Protect.). That’s just one example of how things keep changing within how our mental health system operates and my own view is it’s guilty of failing to communicate or discuss those changes of approach – hence the police and other agencies are constantly behind the times.

      Yes – it’s complicated: yes, we know that over-medicalising can be bad – we also know that over-normalising the policing of vulnerable people can be bad! If the MH system could just let us know what the frames of reference is, that would be great. But when 88% of people at the centre of calls to the police which involved a MH element are people known to local MH services, most of whom are currently ‘open’ to them, it can hardly be a shock when the police wonder what on earth is going on and why there isn’t greater prevention. The biggest irony of all, is that MH services spent years complaining that the police needed to improve on MH. Now that we understand it more, they’re not happy with the things we’re discovering and the extent to which we’re trying to do something about the problems we see – especially the legal problems, which we’re better able to understand!

    2. This is exactly the phenomenon crippling NHS mental health care at the present time. Inpatient, crisis resolution, community, child+adolescent are all jam packed with people who have sought mental healthcare to rationalise life events or prop up maladapted coping mechanisms that would otherwise be extinguished by the fundamental pressure to eat/work/sleep in the dry. The police are dragged into the vortex again and again and again and increasingly there are no services to receive the people they take off the streets.

      Street triage is in my opinion a sticking plaster over a bullet wound, if we are going to normalise mental ill health as is the current zeitgeist so to do then we need to fundamentally modify the mental healthcare delivery model so that those who make it into inpatient services are genuinely a risk to themselves or others.

  3. Sadly we still have the police blaming the NHS and the LA . I accept we should not criminalise mental illness but we should not be ignoring criminal behaviour and medicalising it . Officers are still arresting people under section 136 who are not in need of immediate care and control or suffering from a mental disorder , but they do not know what to do with them , So let’s do a 136 and leave the decision to others . The iissue around “black mamba ” is a good example , punched officer , spat in nurse face , punched. nurse , Officer said do 136 but no accountability for his behaviour no charges leave it for NHS as SGT said cannot charge if they are sectioned , this is not an isolated incident but very common . The most common is the intoxicated member of the public after argument with girl friend I will kill myself , let’s do section 136 And waste everyone’s time , then complain that the NHS are tying up officers from other duties .. come on let’s think global some people need police stations if they have committed offences , mental health needs can be met in prison ,.

    1. There’s a hell of a lot going in there, Keith! I remember once you passionately told me a story about the police using s136 after they’d encountered someone on your patch who as ‘waving a knife around’ and you were really concerned that they hadn’t arrested the person for an offence and assessed the whole thing in custody and made decisions from there. In October 2014, there was a death in Hampshire Police custody after a woman was arrested for ‘waiving a knife around’ and taken to police custody where she died and the Coroner went out of his way to argue that she should have been detained under s136 and taken nowhere near a custody office. He put this in a Reg 28 PFD report to the College of Policing and to Hampshire Constabulary.

      My point is: somethings are black and white when it comes to behaviours and crime – if you murder or stab someone, you’re probably going to get arrested and we sort that all out in custody. If you steal mars bars or sandwiches because you’re living rough, in crisis whilst seriously ill, you’ll probably be diverted from the CJS. There’s a whole host of complex people in the middle of those extremes with a cross-sectional history of contact with MH services and police services where even Liaison and Diversion schemes can’t agree what’s needed when they have hours within the 24 afforded by PACE to make decisions with access to records and you’re referring to decisions made by officers in the street in a matter of minutes, sometimes in seconds.

      No-one thinks we should be over-medicalising human responses to bad life events; no-one thinks we should be over-criminalising the seriously mentally ill unless it’s necessary in the public interest to protect them from harm. But what that looks like in practice is something on which there is no consensus at all – just look at attempts by NHS Protect to broke a crime protocol for evidence of that. They failed to secure support from the College of Policing or CPS for their vision of what it looks like. And whilst there is an element of truth to the point that mental health needs can be met in prison, we obviously should not and cannot rely on courts to send people to prison in order to meet their mental health needs. That is, quite simply, not what prison is for!

  4. A really complicated mix of arguments here.

    It is clear that the Police are taking on more demand where people in crisis haven’t got access to the care they need, or are being placed in environments not capable of managing the ill health or people not deemed as sub threshold for services who would have got them 5 years ago.

    It is also true that all too often we label someone with Mental Health issues and allow what is bad behaviour through fear of criminalising the vulnerable.

    Surely if you want to move this in the right direction then legislation should have lead the way. The Police and Crime Act however could do the opposite. By making the scope for using S.136 even wider and the need to consult the legislation is cementing the role of the Police as frontline Mental Health agents.

    Whilst care in the community continues to be a policy / direction without a massive increase in community services then where will this end /change direction?

    I wonder if they have issues like this in somewhere like North Korea? Perhaps training, awareness, offering more service, promotion is not all its cracked up to be?

    Anthony

  5. As an out-of-hours AMHP I’m left wondering what role HMIC and officers think they should have in relation to mental health? We’re all well aware of the impact of nigh on a decade of cuts in NHS and LA mental health resources – which seem to be glossed over in Tom Winsor’s report – nonetheless, the claim that police are the “first line of resort” strikes me as ill-informed, unsubstantiated and unhelpful, and does nothing to foster constructive relations between mental health workers/services, ambulance and police.
    Well over 50% of the people my out-of-hours colleagues and I assess in local 136 suites should not have been detained in the first place. Indeed, a number of these should probably be prosecuted for wasting police time (and NHS/LA resources), rather than brought to the suite. However, AMHPs and NHS workers generally accept that officers have very little knowledge and understanding of mental health difficulties and are acting in good faith in detaining people expressing distress.
    Just as officers do not lightly detain on 136 , we AMHPs do not make frivolous requests for police assistance. It is therefore galling to be told, on asking for police assistance in the community in order to assess or admit someone who is genuinely mentally ill and presents a danger to themselves, the ambulance service, their family, the public and/or me, that I “have the powers of police constable” once I have made an application to detain someone. That’s as maybe, it means nothing when you’re a 50kg, 155cm, 60 year old woman and liable to be flattened by someone who has no insight into their condition and, by definition, no intention of going voluntarily to hospital.
    On one occasion recently a colleague seeking to arrange an assessment of someone with a record of serious violence who, family claimed, had a loaded gun was told “He probably doesn’t have a gun but the AMHP should still wear protective equipment”!! Funnily enough, we’re not issued with stab vests, handcuffs, truncheons, radios or tasers on receiving our warrant cards.
    Having said all this, I don’t really want to get into a game of blaming each other – individuals or services – for perceived inadequacies in practice. We all have a role to play in safeguarding vulnerable people. Part of the problem is that our roles and boundaries necessarily overlap and none of us are quite clear when and where they should do so, and where they should not. More pertinently though, the real problem is that the entire edifice is crumbling because of systematic underinvestment in mental health services, compounded by a range of other social ills – not least benefits cuts and the dearth of social housing – that are blighting the lives of millions of our fellow citizens. I think it’s about time we all started pointing the finger where the blame really lies, with the government, rather than squabbling with each other.

    1. Well, that’s a piece of work HMIC are increasingly doing: what is the role of the police? Whilst agreeing with a lot of what you’ve said, I’d also make a few others points, if I may? – very much in the spirit of debate, and not dismissal! As I say, I agree with a lot of what you say.

      Your 50% is interesting: I’ve known areas say that they think their police are over-using the power, in areas like Devon and Cornwall where use of s136 is very high, both in simple number terms and in use of s136 per capita. When they (the trust!) analysed it, they found that 75% of the people detained by their local police were people currently open to or recently known to MH services. In another area where they examined their new street triage initiative, they found the number was 88%. If we look at s136, use varies enormously and as Baroness Hale points out: we’re not entirely sure what s136 is *for*, strictly speaking. I’d be interested to know more about why those 50% were not appropriate.

      The criminal arrest point is one well made and I agree with you, in general terms. However, I know that not everyone agrees with us! In a recent death in police custody inquest the Coroner was really clear that a mentally ill woman waving a knife around in the high street of a small town was something which should have led to s136 detention, not criminal arrest. I haven’t met too many people who agree with that, but it shows how views differ and it’s obviously up to the courts to give views where they think they’re important and help shape the approach. So it begs a question I often ask: how do you advise officers on how to choose between s136 and arrest, if they’ve decided someone should detain? Interested in your view.

      On the ‘powers of a constable’ thing: accepting fully there will be things that are beyond the ability of AMHPs and even their organisations, when are those powers to be used, then? Parliament allowed AMHPs their own powers, allowed them to delegate to people other than the police and we have a code which does not support the idea that the police do all coercion under the Act (out of hospital), when do we see otherwise? I admit, I’ve only seen it once in about fifteen years of looking. Your organisations have Health and Safety responsibilities, apart from the other arguments.

      And whilst I recognise your political and funding point, of course, it’s far from the whole answer. If you look around the country, many things are better now we have less money than they were when MH services were riding on the top of 59% real-terms increase in funding up to 2010. I sometimes think this stuff is down to the simple issue of will: do we WANT to sort this? It’s often sortable, but it means answering the above questions. I know what I think, I all too often meet people who haven’t really thought about it. That much! Largely agree with you, though – especially about the overlaps and blurred boundaries. More realistically, I think they’re gaps we’ve allowed to emerge.

  6. To add to the above comments I also largely agree with most of the comments made by the AMHP with the exception of our use of S136.

    86% of the S136’s in my area are known to secondary mental health systens. Also now we have a much greater understanding of the system we find more often that S136 is a symptom of the system not working.

    Up to 10% of S136’s take place on ED and often it is known they won’t be admitted but the psychiatric liaison teams ask for Police to use it anyway as it diverts the complex issues away. I could go on with examples but my point is with Triage Schemes etc we are largely left with S136’s that are symptoms of missed opportunities or inadequate support for people who are well known to suffer.

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