Do you remember where you were on 23rd December 2016? Were you one of the other nine people with me, somewhere around 9pm at a house in the West Midlands, present at or dealing with a healthcare incident that had been reported to 999? Chances are you weren’t – this probably means you don’t have the first clue why we were there, what we were doing, who rang 999 or what the context was. And yet, the Chair of the Royal College of General Practitioners told me today in a letter to The Times that to suggest there was a shunt from a GP was “disgraceful, disappointing and demeaning”. The RCGP tweet highlighting the letter denied that shunting occurs – “absolutely not the case”. (Apologies for emphasising this: the link to the letter to the RCGP’s website – the Times printed only an abridged version, which does not include the quotation on which I’ve just relied to evidence denial of shunting.)
We were not “picking up the pieces” from a GP who had pushed a job to 999 that did not need the police, based on a false and basic mis-understanding (or a blatant misrepresentation?) about the legal powers we have. This is despite the fact that I could take you to that house; I can show you a police incident record on the command and control system; I can name the police constable I was there with and we could look up the records to get the name of the mental health nurse and the three paramedics who ended up there too. The patient’s family members will no doubt remember us being in their house so close to Christmas and the conversations we had to have with them about why the promises that had been made to them when they rang their relative’s GP were actually misinformed and why we did not have the legal authorities that they’d been told we had. And yes, we do have the GPs side of this story – it’s recorded on the 999 tape. We know they requested something that was not legally possible.
And yet, it didn’t happen – GPs don’t shunt jobs to the police at the end of their working day; and yet their phone was turned off within 15mins of ringing 999. For the record and the absolute avoidance of all doubt: no-one is saying this is every GP in the country, that GPs don’t work hard or even this kind of thing is most GPs; nor- is anyone saying it’s only GPs who ever do this – we know it’s actually more like to be community mental health services and crisis teams who sometimes advise GPs to do so (according to a GP on Twitter who said so yesterday!). And absolutely no-one, anywhere is saying the police are perfect and don’t do similar things that also need addressing, like over-calling ambulances and inexcusable inconsistency in investigating violence within inpatient mental health settings. I’ve said so many times and I work actively to reduce it, which is why I feel entitled to call it out when it happens to us.
That’s just one example, of course – I have plenty of others and I do admit to still being fairly annoyed about what happened on 23rd December 2016. I regularly use it as my example because it helps make relevant points about inter-agency shunting, about street triage schemes creating demand for the police and about the legal issues that arise from it. But I could have given a mass-scale example about the police expending large amounts of resource on managing situations which arise purely because the NHS find difficulty in ensuring the timely admission to hospital of patients requiring inpatient admission on about half of all occasions. This difficulty within this kind of example is believed by the Cabinet Office to occur once in every two MHA admissions from police custody.
And if you weren’t there in police custody when officers were busy reassuring, feeding, talking to and otherwise looking after and securing the wellbeing of thousands of people each year for days on end, purely and precisely because the NHS were having those protracted difficulties identifying a bed within a timescale which prevented the detention in custody becoming an obvious human rights violation (article 5), then I’m not sure how we can say that never happens either. As it happens, the figures suggest it happens 3,900 to 4,500 time a year, but perhaps they’re wrong, too? And this is only admission from custody after ‘diversion’ from arrest: a whole other piece of work would be needed for difficulties arising from s136 detention. If the ‘one in every two’ admissions estimate is even vaguely correct, then it’s probably another 2,500 on top of the 3,900 to 4,500 – so 6,400 to 7,000 cases a year: or 17 to 20 times every day.
Or perhaps I misunderstood what “picking up the pieces” means – perhaps when police officers are doing such things for five or six days after the legal point was reached where s13 MHA states unambiguously that an AMHP “shall make the application” is not really the police “picking up the pieces”? Maybe if the police feeling obliged to do things with their resources which would have been completed and entirely avoided, if an AMHP had been in a position to comply with s13, which may in turn have been helped if the relevant CCG actually knew about s140 MHA and had some workable policy which gives effect to its implications – maybe that’s not “picking up the pieces”?! I admit to feeling it is, but what do I know … I’m just a police officer. I don’t even have Mental Health First Aid qualification.
REACTION TO HMIC
What’s been most interesting for me this week, in response to the HMIC report “Picking Up the Pieces” is the sheer number of people telling me that things I’ve done, things I’ve seen and the professional problems on which I still work day to day, either didn’t happen or don’t amount to any kind of “picking up the pieces”. It’s made things difficult to navigate, because I don’t know how to have a discussion about this interface, for example, between the police and GPs on mental health demand if Professor Stokes-Lampard from RCGP starts with her asserting that what I know happened to me professionally on the 23rd December 2016 when she was not there, didn’t happen and that to suggest it did is ‘disgusting’. I may need some help here, because I do so vividly remember being in that house, I remember the patient and their family; I recall the frustration in the office when the call came through asking us to go somewhere and break the law; only to find that when we quickly rang back to discuss that, the GP had already turned off their phone and effectively disappeared.
Meanwhile, if you read the New Statesman, you’ll see a piece which takes a strike at the police for the fact that HMICs report fails to mention deaths in custody and excessive force. Apart from the fact that HMIC cover custody related matters separately in other kinds of inspection, the deepest possible irony here is that this is yet another territory where I would and where I do argue that the police are often picking up the pieces, albeit I would not dream of doing so without accepting that we must be able to police properly, even if we are having to undertake work that was quite avoidable and which shouldn’t have been necessary. What I say next is in no way intended to imply that the police mustn’t learn from these tragedies and do everything possible to prevent them regardless of the background to our requirement to act.
But I seem to recall the Coroner’s jury after the inquest for Sean Rigg finding that several days of neglect and missed opportunities to ‘section’ him by south London mental health services ‘more than minimally contributed’ to his death. Was in not their precise finding that if MH services had delivered appropriate clinical care, the necessity of Sean’s contact with the police would almost certainly have been averted? Was it not the case in the death of Seni Lewis that a mental health ward was busy unlawfully detaining a voluntary patient without apply in the MHA holding powers to him and when challenging behaviour occurred they were unable to mobilise nursing resources to handle it and they called the police? Did that inquest jury not also find there were basic failures by NHS staff to intervene medically and save his life? Was then death of Jospeh Phoung in 2016 not a case where the Metropolitan Police spent almost 24hrs being unable to access the NHS in London (no ambulance attended, no Place of Safety would accept a detention under s136; A&E asked the officers to leave), before eventually a bed was found?
The HMIC report was trying hard to say, as far as I’m concerned, was that there is plenty of good work going on and everyone is working hard to make the world a better, safer place – see the page reference 8, 16 and 41-16; and see the headlines and the foreword. It’s not blaming people, of any level, in policing or mental health, but criticising the overall system which anyone who knows anything about this interface understands is part evolution, part reaction, part improvised necessity – it’s not really a system at all: it’s a collision of coincidences. We know that police services and their officers are a part of that system and do things which have wide and regrettable impacts upon the NHS, so it’s hardly a revelation to argue the reverse is also true – I spent last night on Twitter challenging a local police Federation tweet which defends the over-calling of ambulances which is precisely why I also feel entitled to suggest where I think the police are over-relied upon, often to do things beyond their legal powers and their ‘clinical’ scope.
But all this is a product of all that complexity and misunderstanding which gives us the system we’ve currently got, helped beautifully, of course, by the fact that we are policing and caring around mental health issues using mid-twentieth century laws. The fallout from this report on a widely-used mental health nursing group on Facebook shows how badly misunderstood police legal responsibilities are and I’ve spent all morning responding to those, too. Some no-doubt excellent nurses on there had little insight in to aspects of the police role on day-to-day mental health demand, beyond that we’re involved s135/s136 and AWOL patients. And even in that example, more than one nurse didn’t realise that AWOL patients are not always the responsibility of the police (see paragraph 28.14 of the Codes of Practice in both England and Wales).
No-one can pretend the report doesn’t say what it actually does – and in case of any doubt, its a reality on the internet, easily available to us all. It’s just saying that systemic problems mean things have now gone too far. Policing is replete with examples of officers being asked to do things they can’t legally do (use the MHA in private premises); or to do things they can’t clinically do (safe and well checks of suicidal patients); or things being forced upon them at little notice because of an obvious lack of planning and a failure to ensure legal compliance (inpatient beds pressures). And we know that the consequence of this is unanswered 999 calls and untoward outcomes.
WE NEED TO TALK ABOUT THIS
That’s what is meant by the ‘intolerable burden’. It’s NOT that those of us with mental health problems are a burden: it’s that making junior police officers professionally responsible for things they cannot do, as above; is just plainly unfair. So why is the report adopting this more forceful, provocative tone? Well, we’ve had a number of reports, Crisis Care Concordats and other inquiries from courts and elsewhere which have tried to bring various kinds of pressure to bear on problems which are repeatedly acknowledged. It should be borne in mind that the Angiolini Review, the Adebowale Report and the Home Affairs Committee have all published documents suggesting similar things. They may not have adopted such a direct phrase as “picking up the pieces”, but they evidence things which amount to this. I suspect this report is just trying to deliberate push the envelope on this debate because, quite frankly, many of the things we’ve tried in the past, haven’t delivered the high level outcomes we all agree we need.
If we can simply disbelieve or dismiss our police inspectorate and our police service about what they see in the course of their work, we are in a quite a dangerous place. The Royal College of General Practitioners and its Chairwoman have absolutely no idea what one of their members did or didn’t do on 23rd December 2016 and I find suggestion that what I had to deal with didn’t happen and / or that it doesn’t represent pieces being picked up by the police, fairly fantastical, if not downright insulting. But I remain grateful to those healthcare professionals who have contacted me or said publicly that they recognise what this report describes, that it chimes with their clinical reality day to day and that they are grateful for any pressure HMIC’s report might bring to bear on healthcare and other system managers to improve things. One person has even asked to know more about this, to understand the problem better.
And finally, nothing said here or anywhere else means the police are perfect and that they don’t have many things they need to do, generally and specifically, to improve around policing and mental health. We need to find a way to talk about all this stuff – difficult though that may be and especially so for some, in particular. If you think it outrageous to suggest the police are picking up pieces, listen to the examples and let’s discuss them – in real detail. You may find, as I’ve done countless times listening to NHS staff and AMHPs, that you didn’t fully appreciate the position your partners were in legally, amongst other possibilities of things often misunderstood. But many reactions have been to suggest instead of ‘blaming’ we should somewhat generically ‘work together’ … I couldn’t agree more – but we can only work together if we can agree we need to talk about everyone’s perceptions, either to sort out the problems they contain or to understand why those perceptions are predicted on misunderstanding. It means talking about really difficult issues, where no one has a monopoly on the truth and which naturally invoke emotion because we’re all protective of our own precious professions and their increasingly difficult role in serving the public.
We need to find a way to talk about this.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2019
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – http://www.legislation.gov.uk