Attention to Detail

Last year, the National Institute for Health and Care Excellence (NICE) published their Standards on the Mental Health of Adults in the Criminal Justice System. This involved NICE reviewing the best available evidence and practice around the contact that vulnerable adults have with the criminal justice system. Subsequently, NICE published what they call a ‘quality standard‘ – this is the subject of a comment piece in the recently published issue of Progress in Neurology and Psychiatry (volume 22, 2018).

I’ve just spent a whole week in Cornwall (picture above), trying really hard to step away from work – it’s been quite a busy few months during which I’ve had to do things which are quite new to all the work I’ve ever done on policing and mental health. I’ve also been consumed in the recent months that the net effect of what we’ve ended up doing to make the world a better place is merely making it worse. Not just slowing down how much worse it’s getting – but actually accelerating things in the wrong direction. I know it’s not a view that many people share; I’m very aware of all the mantras that come out when these kinds of views are articulated – that the only way to do things is in partnership, etc., etc.. So upon return from annual leave, I read the comment piece about the NICE Quality Standard and found, yet again, reason to question those kind of underlying assumptions and – like the reports I’ve had to write in recent months for various legal processes after deaths in police custody – I found myself wondering about attention to detail.

I need to repeat one more thing, about which I’m at risk of becoming really boring whilst I drip like a tap: if you think that the work to be done here is improving policing and criminal justice responses to the mental health demand that we face, you’re fundamentally mis-identifying the problem. The problem here is not the police: it is the extent to which we deliberately rely upon the police to triage and gate-keep mental health demand that we increasingly decide should be criminalised. We rely too much and we need to work out how to stop because having just spent the last fifty or sixty years gradually and subliminally shifting institutionalised mental health demand from health to prisons and then regretting it; we need to make no mistake we are now seeing a similar shifting of crisis and community care from health to police and probation. And this Quality Standard and the arising expectations in comment pieces are just helping us reinforce this, in my own strictly personal opinion.

110 RECOMMENDATIONS

The comment piece claims that the Angiolini Report (2017) contains “110 recommendations for improving the way that the police manage vulnerable people at the point of arrest”.

No, it didn’t – did the authors of the piece actually read the Angiolini report?! It contains 110 recommendations (see page 235 of the report – they’re all laid out, one by open) and you’ll notice the majority of them do not relate to the management of vulnerable people at the point of arrest or contact. Those which do relate to that, barely relate to the police – they relate to the National Health Service and its need to improve accessibility and its interface with policing. Around 70 of the recommendations relate to processes after a death in police custody has occurred; processes connected to investigations carried out by the Independent Office for Police Conduct, to the whole coronial court process and certain specifics, such as a call for families who are bereaved after a death in custody to have access to Legal Aid.

If you look at the roughly 40 recommendations which do relate to how vulnerable people are managed, you’ll see that fewer than 10 relate to matters over which the police have sole control. In other words, most of the ‘Angiolini recommendations’ are about improvements in post-death procedures; less of it is about preventing deaths from happening in the first place and those which do have that bearing are about how accessible our NHS is.

POLICE CELLS

The comment piece correctly states that Angiolini claims “Police cells should not be used to hold those detained under mental health powers.” This is correct – it does call for that. But it goes on, “The NICE Quality Standard seems to accept that this sort of change will be a lengthy process” and “that procedures can be put in place in the interim, to keep people in custody safe and minimise any potential unnecessary harm.”

No, no, and again, no – history and evidence shows it cannot and it shows that moving to a position where areas do not rely upon police cells as a Place of Safety can occur in a relatively short period of time, given the will to achieve it. Areas without any Place of Safety provision at all have shown it is possible to get from nothing to working in a matter of weeks. I’ve been part of making this happen and these services still exist in the real world, where no-one is taken to police custody whilst detained under the MHA, ever. Yes, it will take careful multi-agency working and a commitment by Chief Constables to perhaps take more than a fair share of the resourcing in the interim transition period, but it’s possible. See West Midlands Police, for details.

In the comment piece, little mention is made of prevention, yet this is the bedrock of most crime reduction and public health strategies: so how do we prevent vulnerable people from getting to police contact in the first place? You could be forgiven for thinking that the authors have assumed all CJ contact is unpredictable, unpreventable and unavoidable demand where the task, as outlined in the Quality Standard, is merely to better respond to what is happening, primarily through the medium of improved policing largely dependent upon improved training and competence. These are the standard traps to fall in to – look at s136 data, look at street triage data, look at Liaison and Diversion or arrest data: those I’ve analysed show that most of the people in contact with the police are non-offending, known patients with requirements best satisfied by the NHS and which do not, for the main part, need the police at all. And of course, the fact that policing and criminal justice can be an anxiety aggravating, even pathologising process is left more or less untouched.

And as for ‘accepting’ lengthy process: the Code of Practice to the MHA has called for the use of custody to be ‘exceptional’ or a ‘last resort’ since at least 1999 – is two decades enough to ensure that every area of England has a ligature proof room? Just think of how many far more complicated things we’ve managed to sort in much less than two decades and then ask yourself whether the urgency of tectonic plate shift is inevitable.

THE QUALITY STANDARD

There are four planks to this thing: my own view is that it reinforces that responsibility mainly rests with the police and it relies heavily on this mantra we repeatedly here in the UK and elsewhere: that the most important thing we can do is give the police more training. It’s as if policing is all that’s gone wrong here. “Training for police officers to use non-contact and appropriate communication styles with disturbed individuals is clear available, but like the introduction of body-worn cameras, is probably not consistent or mandatory.” I’ll again be honest: the irony of NHS professionals highlighting inconsistency in policing is not lost on me after I learned that there are 27 different training courses in London alone, for restraint in mental health nursing. And of course, none of them are operating to a validated standard. Then add to that the 57 mental health trusts being commissioned by over 210 Clinical Commissioning Groups so that even one mentla helath care provider trust is not providing a consistent service across two different CCG areas and that this is because the NHS want it that way.

In policing, despite 43 different territorial police forces and a few other specialist ones, we have one personal safety training manual and all police forces operate to it. They may run their officer safety training in different ways, combine their OST with other things like first-aid in some forces, but not in others: but it’s one national standard around the use of force and for all of my twenty years in policing, it has emphasised verbal communication and de-escalation.

A quick word on Liaison and Diversion teams, seen by Lord Bradley as key to whole diversion / criminalisation thing. Around 85% of the population of England is now served by a LaD scheme. Many of them operate on the basis of referrals made by the police to the nurses on duty in custody. I’ve known areas look for ways to improve the number of referrals made by the police, because of an ongoing suspicion that the police are ‘missing’ some vulnerable people in custody. Of course they are! – they always were and they always will. Doctors with access to medical records get this stuff wrong when they have hours to assess someone, so I’m not sure what standard the police are being held to, if I’m honest, when they often have minutes to make decisions about who is vulnerable.

THE WIDER PICTURE

“The true challenge is not knowing what to do”. I couldn’t possibly disagree any more profoundly with this. I meet people regularly who do not know what to do – have no idea of what is possible and think their problems insurmountable. But one thing I can agree with, is the comment’s view that none of this stuff is new: they mention the Reed Report from 1992, and the Bradley Report from 2009. We’ve since had the Adebowale Report (2013), the Home Affairs Committee report (2015) and then the Angiolini Report (2017). In between all of those, we’ve seen countless individual Coroner’s inquiries, human rights cases, IOPC death in custody investigations, which all raise similar issues … over and over and over, again and again and again.

This would almost be boring if it weren’t for the loss of dignity, safety and humanity – the extent to which the learning is there to be had, but ignored.  Instead, a preference of pushing an agenda that may help at the margins but doesn’t address the core issue of why were are increasingly seeking to criminalise vulnerable people as a gateway to healthcare? We did it to prisons and probation and we’re now doing it to the police. Until we stop just looking at the police, calling for ever greater levels of training and start looking at why vulnerable people come in to contact with the police in the first place, we’re going to keep getting our analysis of this wrong. And of course, I would suggest we have  for far too long.

So, we’re off to a flying start to my return from leave! – the mission for us all is to combat the covert criminalisation of vulnerable people which emerges from the unintended consequences of public policy being disaggregated, yet run on the pretence that we need to improve policing and police training which ultimately, at its best, is just an overly attractive half-truth.  If you think otherwise, then I suspect we’re trying to fix different problems.


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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9 thoughts on “Attention to Detail

  1. Another great piece. My experience as a relative has been that services are desperate to prevent people being admitted to hospital and have lots of targets for not admitting them, or discharging them asap. Care outside hospital, even at its best isn’t an adequate substitute, Even if you see a psychiatrist once every couple of weeks, all they have to go on is the patient’s self reported symptoms/side effects/activities. Seeing a care co-ordinater even once a week leaves every other hour of the week for you to look after yourself. My ‘very unpopular’ view is that if people can’t look after themselves then appropriate support needs to be provided by the NHS, which is the only provider of mental health services.. All too often the only service actually available is the police, who can’t actually do anything apart from save lives in emergencies.

  2. The Government allocates money to Mental Health Trusts in conjunction with the NHS. What the Chairman of the Mental Health Trusts or whosoever decrees where the bulk of the cash is spent : is to be honest not something I have direct knowledge thereof.
    However : as I reside in Merseyside – and therefore that is the place I have the most experience of : I will tell you what I was told by someone who’s name I will not mention for obvious reasons.

    Merseycare/NHS Trust covers quite a large area.

    However : for reasons unknown to myself there does not exist a Mother and Baby unit for women who have a mental breakdown following or even just before the birth of their baby.

    However 8 years ago part of the Admin of a Merseycare Department was based at Princes Dock near to the Liver Building : I visited there : it was extremely lush and very expensive overheads. And yet ….people including myself were wondering whether Merseycare/NHS Trust could possibly afford??? To pay for Psychotherapy Staff : Psychotherapy Services.
    I personally have had recently trauma based therapy AFTER a GAP of seventeen years. After making a complaint about my treatment : or lack thereof : I received two assessments around September and therapy began about The end of March.
    In my opinion the police are puppets who are being constantly manipulated by the state or Local Authority.
    After my husband and then my brother were violent towards me : the police put me in their police car then locked me in a police cell with no explanation for several hours. I still have flashbacks of that day nearly 22 years ago. I NEVER received TRAUMA based therapy for the abuse and bullying I received from my family, ex husband and from my treatment by the police and the way the authorities treated me at that stressful time.
    So no wonder that I am still getting flashbacks.
    Nevertheless: I have decided I want to get better and stronger and nothings going to stand in my way.
    Bless you for working to improve the work which the police do.

  3. Completely agree. We seem to be producing ever more documents and procedures which formalise our involvement in MH response, setting up more departments to support that position and deploying to evermore MH related logs, which I can often find no rationale for other than there is no one else who will deal with it. I despair at how many logs I see where relatives of persons with MH illnesses state MH services have told them to phone the police, when they have sought help. We are not, and cannot be, the armed emergency response wing of MH services.

    We partly have ourselves to blame. As you rightly point out, the fashion within our service seems to be a partnership working which accepts partial responsibility for issues that should not be a police issue.
    I appreciate its not a fashionable view point and will cause cold sweats and hyper ventilating in some of our colleagues, but not all safeguarding and vulnerability is a police matter. Immediate risk to life related MH issues, definitely, where we can bring a policing power to bear. Out with that, if we continue to produce policies and guidance which call for our involvement, is it any wonder that the NHS will seek to utilise us to paper over the cracks?

    Regardless of NPCCs position on the matter, many of us at the coal face do not consider MH as a core policing role. Preservation of life and limb, at an ABC response level, absolutely. Response to and triage of illnesses of the mind, def not.

    Rather than calling for better training for police, I’d like to call for better funding of and consequently an improved response from MH services.

    1. Great summary. Definitely need police for life threatening emergencies. But even then services often seem happy to ignore peo
      ple when they say they are suicidal.

    2. Forgot to mention, the threshold level for police involvement on suspected risk to life, should be at the sort of level which would meet the requirements to utilise sect 17 powers of entry, (Baker v CPS 2009) i.e. more than suspicion that it might happen at some point in the future. It has to be an immediate and real risk that would necessitate either use of powers to arrest, or use of force to enter premises.This would negate the use of “magic words” scenario where police are told that patients are a self harm risk to guarantee a response, thus initiating the situation where police have no choice but to act, sometimes unlawfully, in a risk averse manner.

      In regards the oft quoted need for police to get more training in de-escalation. In my experience, we are head and shoulders above in that respect, because its what we do, day in, day out, at great personal risk and often facing hostility and violence. To suggest that we need more training is downright patronising. We do this conflict de-escalation and escalation for a living. At times it will go wrong, or the outcome may just be undesirable, because there was no other way it was going to end, regardless of what police did.

      If we are so bad at de-escalation, why do my officers get so many calls to assist ambulance staff in persuading patients to go to hospital every week?

  4. Completely agree with this blog. There appears to be an ever increasing vacuum being caused as NHS resources shrink and people fall through the widening gaps created.

    The Police are stifled by their very open and all consuming common law duties that almost any circumstances can be argued as in some way fitting into. I also despair at the amount of incidents whereby family, friends or the public have been advised to ring the police for a non crime mental health incident, normally by a mental health professional. I despair when I see A&E staff quote they aren’t a place of safety when actually the term is irrelevant because a member of the public turned up of their own accord to seek emergency help for their mental health but felt they weren’t welcome so left feeling even worse.

    In my area our community services have just been reduced even further with patients who don’t meet the new threshold to be dealt with by primary care. The inevitable rise in A&E, ambulance and Police calls awaits round the corner as people desperately in need of support look for someone to help.

    The key to all this lies with the top of government. If they want the Police to POLICE and not become ever increasing back up for the NHS then they need to act to change the legal expectations of both the Police and the NHS. I suspect they will continue to misunderstand the issue at that level when seemingly in previous debates they cannot even understand what data they quote even means!

    1. Also agree (most) police officers are great at de-escalation, way better than most mental health staff. Will just keep talking whatever the circumstances! Also if you have had frequent contact with police they will generally know more about you than any mental health professional, who sometimes seem to think the less they know about you the better. It needs a really hard look at what mentally ill patients actually need as opposed to the service user jargon that gets thrown around.

      1. JUDYB – From a policing perspective, its good to hear we get it right more than we get it wrong. Thanks for the feedback. There are obviously cases where there isn’t the best conclusion, but we seem to get positive comments back from persons in crisis more often than not. Supports the whole tone of the blog narrative.

  5. As a doctor medic (FME)
    who works in Custody I agree with a great deal of what is said in the blog and comments. My experience in several forces is that the Police dons great job with people who have mental health problems. As for Dame Angiolini I would be interested to know if she has ever actually been involved in trying to calm a detainee down who may be under the influence of drugs/alcohol or have mental health problems. Does she understand£ the risk to the Police and Detention Officers who have to do this? The Police show themselves to be caring and compassionate in my experience.

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