Everything’s Connected to Everything Else

Since the turn of the New Year, I seem to have been in a lot of meetings where I’m discussing policing, mental health and criminal justice with the police, OR I’m doing so as the only police officer in a room with health colleagues. What I notice is this: everyone is wanting more from other, with rarely any offer of insight in to what effect the conduct of their own profession and organisation has on the other. We have a ‘partnership’ or relationship predicted on taking, not giving. And don’t get me wrong: there’s plenty to want if we were to write a Christmas list –

  • The police service would, for example, love to see more health-based places of safety and that they be staffed in accordance with Royal College of Psychiatry Standards on s136 so that they are not detained in healthcare settings for days, if not hours on end, pending assessments and beds being identified. There are resource and legal arguments as to why this is often mentioned.
  • The mental health system would love to able to secure police attendance in a more timely way at the execution of s135(1) warrants or Mental Health Act assessments in private premises where risks need managing, because it’s hard enough coordinating doctors, AMHPs, families and patients, without things becoming too complicated with 999 services standing off and being difficult.
  • The police service would love the health, ambulance and mental health systems to have a greater understanding of mental health and capacity law because of demonstrable problems where a lack of knowledge about policing, police powers and police obligations has led to inappropriate requests for officers to act ultra vires, beyond their role, remit and responsibility.
  • The health system, no doubt, would also like officers to have a greater understanding of mental health and capacity law because of demonstrable problems where a lack of knowledge from police control rooms, officers and investigators has ensured a non-response to things which really do require police support and cooperation – or prosecution after allegations of crime.

So is that balanced and fair? – just four examples off the top of my head, two in either direction?! Could have become more specific but I’d highlight the last two examples where actually problems right across the board and the one thing I highlight when asked if I could ensure one thing changes: improved legal education across all of our professions on mental health and capacity law. If you look at policing and mental health interactions and interfaces clinically or ethically, you may see things a certain way: look at things legally, and it can start to look very different. Things which some mental health professionals would prefer were police responsibilities just aren’t; and things the police would like the NHS to just take care of themselves, can’t be done that way.

Legal education all ’round!

BACK TO THE POINT

My main argument in this post is that these things are all connected: policing and mental health professions are made up of finite resources and by definition, that means they have a finite capacity to operate. As they say, you can only spend each pound once and you can only ask a police officer or mental health nurse to do one thing at a time. If I’m currently sitting in a health-based place of safety for 9hrs of my shift, I cannot, by definition help and AMHP execute a s135(1) warrant; if an AMHP is busy making 25 phone calls for a s12 doctor, several phone calls to 999 services in the hope of persuading one of them to break the catch 22 deadlock of “we won’t come until they’re on scene” then, by definition, that AMHP may not be available to discuss the mental health crisis in private premises which police officers are seeking help for.

You can move beyond individual examples and think about things more organisationally: yes, it’s difficult and resource intensive to put staff in a room for a day or, heaven forbid, half a week and really train them on the stuff they need to know about the other organisation and the laws which govern how they and we need to operate, individually and collaboratively, but if proper training meant we then spend far less time making inappropriate requests of each other it could be that a middle to senior manager would need to spend fewer resources getting ‘stuff’ done. As a duty inspector in my last operational job, I spent fewer resources on certain things that before, because I knew more than when I was first promoted to that rank in 2003.

All of this comes back to one point, the very point that’s been missing in the meetings I’ve attended this year. When people talk earnestly about the need to “work in partnership”, it most usually a euphemism for “we need you to do more”. I rarely see health managers – OK, OK: I’ve never heard health managers – saying, for example , “I know the s136 process should involve Places of Safety being staffed so officers can leave within an hour in all but the most exceptional cases so we’re going to look at that and come back with proposals.” Equally, police leaders could add “we need to make it easier for MH patients and services to report allegations of crime and improve the quality of our investigations to build confidence and improve outcomes for all”.

GIVING, NOT TAKING

So what we need much more of, if partnerships and to be true partnerships, is greater introspection in to our own attitudes and our own organisations. Ask yourself: if I were a police officer, what would I be needing from the mental health system … if I were an AMHP or a frontline mental health nurses, what is it the police do that would really grind my gears?! A psychiatrist on twitter the other day asked whether or not it really should be necessary for mental health patients and staff to beg the police to investigate allegations of race hate crime. No! – it should not. If any aspect of crime reporting is subject to intensive oversight it’s race hate crime regardless of who it is towards and whilst there may be additional complexities and considerations where mental health is involved, the principle that it should be looked at and investigated is beyond question.

And finally, we need to look at motives behind assumptions we make about what others will do. I keep hearing how great street triage is and recently a very senior member of the NHS telling a room of very senior people that it “needs to be rolled out further”. Whatever your view on street triage and, of course, I have mine: the inspectorate for policing, the evidence based guidelines for the health system and academics at a range of Russell Group universities have all pointed out that we’ve got almost no evidence for this stuff. There are perceptions, instincts and anecdotes galore about it and many people think it’s doing a wonderful job – perhaps it is. My point simply is, that cops think it’s saving time, as they often want more of it because they want even more police resource to be saved – again, taking, not giving. Many mental health professionals want it expanded because it’s improving access to mental health services and because it’s preventing the need for expensive AMHP-led assessments after great use of s136.

But what if it’s not?! – what if street triage, liaison and diversion and other initiatives that are not predicated on greater understanding of mental health and capacity law amongst those who commission services is causing outcomes and outputs which are counter-intuitive to those who support these ideas with little evidence? As one professor of mental health nursing once said at a meeting, if he offered an academic hypothesis that street triage and liaison and diversion were absorbing more resources, denying access to service and worsening outcomes for patients, what evidence could be offered at the systemic level (ie, something beyond stories we’ve all got about where things went well or went badly) in order to refute the hypothesis? Well, we know from Professor Eddie Kane at the University of Nottingham, that one effect of Liaison and Diversion is that people flagged as having a mental health problem in police custody remain there for longer than those who are not flagged and are more likely to be charged.

CHALLENGE YOUR ASSUMPTIONS

Counter-intuitive, right?! … he went on: it does not appear that health outcomes are necessarily improved and there’s certainly no evidence that justice outcomes (ie, prevention of offending; reductions in re-offending) are improving. So we might be spending lots of money to make little or no difference to either health or justice outcomes and we’ll need a lot more research to help us understand what is going on. Same for street triage: I do remain in a condition of being deeply stunned to see publicity and analysis of expensive schemes which fail to take account of things you might imagine would be of obvious interest. Follow-up rates after contact, suicide rates after contact, healthcare outcomes in the medium to long-term – after all: these things are six to seven years old now. Could we imagine any other medical intervention running for that long without a robust evaluation being designed in to its roll-out?!

Everything’s connected to everything else: because you can only spend your police officer and your mental health nurse once, they can only be in one place at any given time, to do more-or-less one thing at a time. If you run lots of nurse-led liaison services (like street triage, control room initiatives, liaison and diversion in custody, as well as liaison services in Emergency Departments) … you can have all of that if you want, but you can’t also then have those nurses in community mental health teams, for example. We know that CMHTs are stretched if not struggling – I was told a year or ore ago that some had a 100% uplift in caseload in the preceding 12mths.  These facts are connected: we know that in some areas, as a street triage partnership has evolved with the police, the mental health crisis team for the area has ended and that CMHTs struggle to handle referrals from street triage.  So oddly enough, the work previously considered the role of the crisis team now has nowhere to go – except to the police because “the police have got nurses now”. Elsewhere, the CrisisTeam has been maintained and we know from street triage nurse feedback that some of their role is preventing demand deflection from other parts of the health system to the police, because of this perception amongst many, including GPs, that “the police have got nurses now”.

We know the big problem goes unaddressed: look at all the big reports over the last decade or more – they all describe difficulties for people who are trying access mental health services, they describe problems in social care and ambulance agencies as well as the problems they uncovered in policing. Yes, the police need more training – who doesn’t?! But it’s not just the police who need more training: we urgently need to know whether the 46% of street triage demand which I’ve witnessed whilst shadowing that comes from the NHS is typical or atypical – it was only a few nights out in a few schemes across the country, but if it were typical, it probably means we need some fairly quick reflection about what we’re doing. In particular this matters because I saw jobs where the police were forced to choose between the partnership they’re trying to build with the mental health system and the legal rights of the public we’re here to protect and police.  It’s really interesting when you get out of a street triage vehicle to find that your job is to stand up for patients’ rights against the NHS.  << Real example.

ASK NOT

Policing is not the problem here … not really.  Over-reliance upon the police and the criminal justice system is the main problem and if partnerships with mental health services are to ‘work’, we all need to recognise what the inquests, inquiries and investigations keep telling us very loudly and very clearly: ensuring the police know how to respond to emergencies is one thing, but learning from what has occurred from things gone awry, we almost always end up wondering about the build up, the missed opportunities and the role of the health service in supporting and sometimes guiding the police response.

If we had truly absorbed all of that, we’d need to enter partnership discussions asking what we can give and what the concerns and problems of our partners organisations were? … in other words, and to do a rather huge disservice by misrepresenting President Kennedy, we should be asking not what local partnerships can do for us, but what we can do for our local partnerships.  At the risk of over-doing the Kennedy references, I also remember his line, “You can’t negotiate with people who say what is mine is mine and what is yours is negotiable.”  I don’t think that we’re really, Really listening to each other.  Not REALLY listening – we’re seem generally far too focussed on what we can take from each other.  Exceptions to this generalisation of course, exist.

What value could we add? … remember: everything’s connected to everything else.

Some of the reasons why your partners frustrate you are that you frustrate them – you can’t help them where they need your support and the impact it has upon them means they can’t help you where you need it.  This game can go on all night, if you let it – somebody, somewhere needs to break the catch 22 by asking what they can do more of, to help.  In turn, you slowly build trust and you start to solve some problems.  Then, as we seek to resolve all of what comes out, we can put the public first and try to meet their needs – currently very difficult to argue we’ve sincerely done that when they are precisely the people we’ve ignored whilst busy criticising our partners for what they’ve not done, without insight in to our own shortcomings.


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


2 thoughts on “Everything’s Connected to Everything Else

  1. Hi Michael,

    Really interesting read.

    ‘Professor Eddie Kane at the University of Nottingham, that one effect of Liaison and Diversion is that people flagged as having a mental health problem in police custody remain there for longer than those who are not flagged and are more likely to be charged’

    Do you mind pointing me to the direction of research this relates to? I’m very interested in reading more about this in particular.

    Thanks

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