Strategic Problems

In a lot of the work I’ve done and still do, the subject frequently comes up public funding for services and, in the last eight years or so, of public sector cuts. We all understand how important money is and I don’t think there’s a public sector professional around who isn’t keenly attuned to these kinds of debates because most of us are seeing how stretched things are. This post comes off the back of a financial bomb-shell to the police service that Chief Constables are, they claim suddenly, being required to fund a £457m hole in the police pension scheme and many of the bosses are warning of ‘dire consequences’.

Today, we’ve also seen two publications which are not unimportant – the Home Affairs Committee have published their report in to the ‘Future of Policing’ after hearing evidence from across the service over the course of 2018. As a complete aside, you’ll have to forgive me for briefly expressing my surprise and satisfaction that some of the more contrary things I said seem to have influenced the committees conclusions, after I sounded some reticence about street triage schemes. More broadly, the report sounds a warning and calls for increased funding for the police after setting out various problems with the core business we deliver, whilst sounding alarms about the changing role of the police. On mental health the report points out the police are now ‘the sole emergency service for mental health crisis in some areas’ and it calls for NHS funding to be spent in such a way as to reduce this burden on policing.

Also, we saw the publication of the 2017/18 UK Government statistics on policing: of interest to me are those statistics on the use of s136 of the Mental Health Act 1983. We are now topping out at 29,662 uses of this power each year, of which 471 people were removed to custody which is a 5% rise in the use of this power (despite those efforts of street triage schemes to reduce its use), but the proportion of those remove to jail is now just 1.6% of all of us detained under this power in crisis. << If you remember when I got started and interested, West Midlands Police alone were taking over 1,000 a year to jail for being unwell: it’s now less than half of that for the whole country and whilst this should be a success story, it comes at a cost which links to this context about funding, pressure and the expanding role of the police.

SOLUTIONS AND PROBLEMS

In my work, I have a growing number of particular phrases, questions or observations I find myself using again and again and again – like a dripping tap – to help ram home various important points I need to keep making, to be consistent. The one I need to pull out of my drawer on this occasion is my observation that “the solutions we’ve introduced to the problems we think we have are more resource intensive for the police than the problems were.” Everyone wants to focus on helping people, reducing stigma and criminalisation and working in partnership with all of the other statutory and non-statutory agencies relevant to our country’s wider system of mental health.

But at what cost? If you said to a Chief Constable, that for a few resources being spent we could massively improve a process which would then save resources overall – they’re probably going to bite your arm off, especially now. If the resource cost would lead to no resource saving, but better outcomes for the public, they’d still be interested – Chiefs have encouraged greater reporting of under-reported stuff in the past and that doesn’t save resources, it only increases work but because improved reporting of things like domestic abuse, hate crime and sexual offences. But that’s a good thing.

Where the issues become complicated is when a development costs the police significant resources, where we all agreed in advance that it wouldn’t and that position is forced upon the police at massive cost. For example, average detention time in police custody for s136 was 10.5hrs last time I checked. Most detentions which do occur in custody require both detaining officers only initially and then either, both are back on the street, or at least one of them is whilst the other does enhanced safety observations. Average. time in an NHS Place of Safety is around 5-6hrs – it’s often as much as 9/10hrs in some places. If you have a force detaining 500 people a year and you work out the police resource implications, it is MUCH more resource intensive to take people to health buildings if the officers must remain there for 5/6hrs.

WHAT PROBLEM ARE WE FIXING?

I’ve just returned from a conference where it has been genuinely useful, as well as both inspiring and frustrating in equal measure to spend a some days talking and listening with other officers and academics about all this stuff. Britain is not massively different to the various other places, but of course we have our particular peculiarities. We stand out because a) we’re not routinely armed – generally considered to be a good thing when it comes to de-escalating and safely resolving mental health calls; and b) we, along with New Zealand, have no legal powers in private premises – Australia, Canada, the United States, etc., all allow their police officers to keep people safe when they are in crisis at home.

There has just been a two-day discussion about policing and mental health, reviewing the evidence for the various ideas and interventions that we see applied around the world. I will be blogging about that on another occasion, but suffice to say here that the evidence is limited, it’s not great quality and to the extent that it tells us anything, it suggests that most things aren’t having a massive impact. We looked at Mental Health First Aid, co-responder models of various kinds as well as the world-renowned CIT programmes which started in the US. Before the event began, I kept saying that all of these things suffer from the problem that nobody involved in them seems to have defined the problem they’re trying to fix. This was acknowledged in the discussions.

So here’s what I think is going on, behind the more obvious difficulties of public sector funding restrictions and the particular position of UK policing at the moment. I think we’ve just spent 60years de-institionalising mental health care, only to find that we’ve accidentally just re-institutionalised everyone to prison; now, because the funding of NHS community MH services has never been great, we’re shifting associated costs of being unable to respond to everyone to other parts of the health system and to the police. Remember what the Home Affairs Committee said today, their words – “the police, are the sole emergency service for mental health in many areas” and the burden of this must be reduced.

DOING THE WRONG THING RIGHTER

For what it’s worth – and it’s probably not worth much – I think we’re trying to fix the wrong problem. Looking at the s136 data, we see more use of this power by the police – and you should bear in mind the street triage schemes which have been associated with significant reductions in 136 are probably saving us several thousand detentions a year, so the 29,662 figure for 2017/18 is a suppressed number, compared to the 18,500 in 2007/08 that the IPCC researched.

  • Police contacts leading to s136 or calls for triage appear to be going up, and rapidly.
  • The amount of resources per s136 contact is greater, on average, than 10yrs ago because the police are effectively staffing MH unit places of safety.
  • We are now in a position where around 4,000 to 4,500 people a year are being ‘cared for’ by the police in custody after their arrest, pending an inpatient bed emerging.
  • We are seeing instances of a dozen or more police officers in a single Emergency Department because the MH trust has used the MH unit Place of Safety as a bed.

I am receiving emails from colleagues stating that so many resources are tied up with MH unit staff, ED beds watches because of MH unit closure, requests for care in custody taking days because of a lack of available inpatient beds.

In a very significant way, we appear to be aiming to transfer the cost of crisis and emergency mental health care from health to policing and believing that it would assist in forging partnerships which would provide a return on investment in the future, senior officers have gone for it. And now, eight years down the line when we have parliamentary reports warning of ‘dire consequences’ to policing as a whole, I feel I have to pose the question: if policing has been cut by 24% and MH services by 8%, for how long can we continue to see ever greater demands made of the police by the MH system to staff street triage, MH units and provide short-term pre-inpatient stays in custody?

PRIORITISING THINGS

One Chief Constable has already stated that it costs much more to run their street triage scheme than it would to not do so. If Chiefs are pushed for resources, they could genuinely re-coup a lot by thinking about whether this is an essential or a luxury they can’t afford because it’s not sustainable against other competing demands. None of this has to mean poorer service, because as we found in Toronto, the evidence sitting behind the solutions we’ve come up with is actually very far from great!

The real issue before us, we’ve set about resolving the wrong problem.

  • We’ve decided to assume that demand faced by the police is largely unavoidable, unpredictable and unpreventable demand – that the problem is how to help the police manage it better.
  • All the reports internationally tell us that policing is not the majority of the problem here: and yet the solutions always focus on policing, not on society OR health and social care organisations.
  • The real problem is what we’re demanding of the police and the extent to which we’re choosing to rely on them for things they can’t do.

I sat yesterday listening to an academic tell a familiar tale of a police encounter gone awry, involving a person with a traumatic brain injury. It inevitably led to a description of some training offered on TBI and some more recent incidents better handled. It’s all about training and partnerships, right?!

Wrong – it’s about accepting the police have a limited role to play within our wider system of social responses to mental health emergencies and other incidents: anything involving time-critical responses, threats to life or crime, etc.. Beyond that, choosing to rely on the police is to make the strategic mistake.

It’s then we start Doing the Wrong Thing Righter.


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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5 thoughts on “Strategic Problems

  1. And I guess the final paragraph is the contenscious one and I’m pretty sure would be rejected by the vast majority of frontline facing MH professionals in the light of day. As an experienced crisis nurse and therapist I feel I have no legitimate immediate role in the overwhelming majority of instances which police would label ‘mental health crisis ‘ (which I have had sight of) which tends to be people intoxicated with emotions running wild and behaving poorly/out of control. I think the best response is that those folk are held accountable/given boundaries, not given the strong message that you’re probably ill and thus a nurse or doctor rushing here is appropriate,effective and required. This will likely fuel the behaviours and lead to repeats and escalations of risk etc. Pathologising poor human coping mechanisms tends to be deeply unhelpful to all concerned ultimately. Of course the small number of folk who are actually ill should be seen quickly and appropriate care available. Sad this doesn’t always occur but furthering expectations of MH services to focus on others has been generally deeply unhelpful so far and is leading to a worsening service for those among us with serious illness which is shameful. Funny how at these conferences and debates I never hear this view expressed which would be a given among the experienced qualified frontline staff I work with daily.

    1. I completely agree. A significant amount of “MH issues” my officers get tied up with, are not. They are the behaviours of attention seekers, drunks and people trying to avoid personal responsibility, which as you rightly point out, they get a pat on the head for and their perception that they have MH problems, reinforced. It is a smaller minority that we come across, where you genuinely feel they have serious problems. We are not experts, but we see it often enough to know the difference.

      Clearly though the issue is partly cultural. Cops are no longer allowed to say no, or to question what we are told. The public service aspect of policing, for a number of reasons, has moved way beyond service into unquestioning servitude, no matter which members of the public we are dealing with. I would suggest partly because too many people, with too little knowledge, have too much say about how we go about our business. I know when an individual who has phoned the police for the tenth time in as many weeks threatening to kill themselves, refuses to tell us where they are and makes it as difficult as possible for us to resolve the situation, is messing us about. I also know when someone who has never come to light before, uncharacteristically disappears without a word after a significant life changing event and switches their phone off after organising all their personal affairs, that its time to worry. However, the “shoulda squad” after the event with hindsight, who investigate me, wont allow me that professional judgement.

      When I read Jo’s comments, I find myself nodding in agreement. Why? Because they seem to be and expert in these matters (although I realise that these days, we don’t listen to experts. We listen to pressure groups and special interest groups). I can’t be the only person who is despairing that what used to be part of everyday life (stress, worries, pressures) are now routinely hyped up as “mental illness”. Nearly every person we now seeing booked into custody is “vulnerable” has “depression and anxiety” or is “suicidal”. We have normalised these as a get out of jail card for consequences for actions. Resilience is a dirty word and I genuinely worry as to what message we are sending out to our kids.

      Meanwhile, police, ambulance and MH services collapse under the strain and rather than say the Emperor is naked, in case we upset someone, we nod our heads in servitude, accept everything we are told and put more resources into dealing with a problem that isn’t anywhere near as bad as the hysteria suggests. The people that really end up suffering are the members of the public who just want us to turn up to their domestic burglary (we cant, because the whole shift is dealing with MH related incidents) or the genuinely mentally ill in crisis, who need us to protect them from themselves (but we cant because some attention seeker has shouted first and loudest).

      Controversial viewpoint I realise and I’ll no doubt get shouted down as a heathen for questioning the neo orthodox view that everyone is a victim of something, vulnerable or ill. Maybe, as a solution, we could start applying some common sense, calling it as it us, not hanging cops for making genuine errors and listening to the actual experts….

      We might find we don’t need quite as many solutions and allocated resources after all?

    2. Problem is, you get to see people in the light of day often HOURS after the police were dealing with situations that looked very different under neon street lighting. Notwithstanding that MH services now look at police related demand and argue this is “social” or “drugs”, a good majority of the people we meet and have to respond to are know to MH services, many of them currently in receipt of care from them. In some street triage schemes the proportion is as high as 88% known to services.

      One of my observations would be that MH services are constantly redefining the paradigm to suit themselves – day by day, year by year. One minute police criticised for detaining drunk people under s136, then criticised in a Coroner’s Court for not doing it; criticised for arresting people for crime and criminalising the mentally ill, then criticised for not doing it.

      I’d invite the many MH professionals on whom you rely to let us know what they want and what the rules of the game are: we keep being told you guys are the experts and your comment alone alludes multiple times to “experience” and “qualification” in this business you “work with daily”.

      It’s all part of the gentle reminder to us and everyone else that the police should just do as they’re told and yet history tells us very plainly that a) whatever the esteemed insight and expertise clinical qualification undoubtedly brings, it’s rarely if ever accompanied by anything like an adequate understanding of the law to allow proper judgement over what police officers often do; and b) if we do just do as we’re told we’ll have to simultaneously do contradictory things AND it will mean we end up in tricky legal situations trying to explain ourselves whilst the MH system rows away from its contribution saying, “they obviously need more training.”

      I’ll be honest: in policing effectively, I’m genuinely not interested in anything other than the law, the public and their rights. The MH system and the NHS as a whole have all too often be found to be pushing us in the wrong direction and I still see this daily.

  2. Mental health services no longer have beds available when people need them. Almost inevitably police will end up picking up the slack as the most keen crisis team will only be around for 3 hours out of 24. Also new rules on not using custody for s136 seems to have resulted in far worse experiences for patients. 136s if available is effectively a seclusion room with observation for hours through a glass panel.ourside major cities may also involve long journeys in handcuffs as they are single rooms dotted around county. At worst it seems to involve many hours in a police vehicle. At least custody has toilets food and a bed…. The patient seems to have been completely ignored in all of this…..

  3. Perhaps it will have to come to police forces refusing to stay on 136 detentions when they’ve got the person to the place of safety, as they’re perfectly entitled to do so. However, I often see people the police have brought in (not on a 136 usually) into ED because they’re drunk and saying they’re mentally ill, they then leave that person in A&E which I would argue is not safe!

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