A little medium and long-term thinking on mental health and its relationship with policing, if I may? We know from the last decade the problems the police service has tried to highlight and do something about. A large number of untoward incidents including deaths in police custody and fatal police shootings as well as more day to day concerns about the use of police custody as a Place of Safety under the Mental Health Act and the over-criminalisation of vulnerable people has caused a national debate during this second decade of the century, of a kind we have never seen before. An unprecedendent number of thematic reports, inspections and reviews have occurred and they all say largely similar things about policing and mental health –
- We over rely upon the police and the criminal justice system,
- The police cannot fix what needs fixing on their own
- The role of the police is defined by default, relative to the context built by others.
- No amount of police training or partnership response is going to ensure the things we want less of will happen.
- The real partnership work required needs to take place away from the frontline where we expect a PC and a MH nurse to fix or manage problems caused by systemic factors:
- What’s really required is partnership work in meeting rooms with middle and more senior managers making system-level decisions about prevention and upstream intervention.
- Oh … and we have almost no detailed data or good evidence about anything at all.
As we prepare to enter the third decade, the one in which I will almost certainly retire from the police service, we are still grappling with tactical level difficulties and hoping the most junior staff, with the least influence over the system, can fix the consequences of the political and strategic decisions, which fail to take account of so much that’s important.
STRATEGIC HEALTH CONTEXT
Because the strategic and thematic inspections of policing tend to focus on policing (see the various big reports to which I’ve provided links elsewhere), it’s probably worth spending some time looking at the health-specific strategic context. This is timely because of the very recent publication of the NHS Long-Term Plan (2019). We also need to look at mental health strategy specifically, as the LTP is a broader health strategy, albeit one in which mental health appears to have been prioritised (see pp50-53; pp68-73; and p118). To that end, we’re still within the period to which the Mental Health Five Year Forward View (2016) relates – this is not to be confused with a similarly titled ‘Five Year Forward View’ document from 2014 on the NHS more generally and it was an independently chaired report for NHS England on mental health which set out various things around strategy in England for the period 2016-2021.
In presentations I have heard about the Long-Term Plan, the +£2.3m funding that will come from the investment announced last year’s budget, will mainly come during Years 3-5, because of the need to recruit and train additional staff. This means, the financial year 2021/22. When that funding starts to take effect, the strategy focusses on improving access to crisis services 24/7, largely by schemes that will be run through the 111 telephone service, perhaps similar to that already enjoyed in Cambridgeshire. In that area of the country, for example, anyone can ring 111 of unscheduled mental health support and only 3% of the calls are then diverted to the emergency services because of an urgent, pressing need. The remaining 97% are handled via that 111 centre or the local mental health trust.
When the funding kicks in following recruitment, the emphasis will be on further improving community mental health care, not expanding the inpatient bed base of the country’s services. As such, there should be more ‘alternatives to admission’ to support people in crisis to help prevent the need for admission. However, the LTP is a n NHS plan, so what can’t be entirely covered are the problems which we know exist in post-discharge support for people who need social care supports after having been in hospital. I’m not quite sure where that fits in and so it might mean, as was found during the Crisp Commission in 2015, that some patients requiring discharge on medical grounds, cannot yet go home because that social support is absent. The LTP is a vital step to another strategic part of our medium-term future.
THE WESSELY REVIEW
As we sit here in February 2019, we’re still not sighted on the Government’s response to the 2017/18 review of the Mental Health Act by Professor Sir Simon Wessely. Whether particular recommendations are supported or rejected and whether this will translate in to a Parliamentary green or white paper or a Bill to be considered, we don’t yet know. But Professor Wessely himself said at the launch of his review of the law, that the recommendations within were somewhat contingent upon service development and investment, without which the review recommendations were unlikely to be successful on their own.
You may remember from my posts at the time of its publication, the emphasis is also upon improved community care, greater rights and autonomy and a suggestion that the bar be lifted for how unwell someone needs to be in order to be hospitalised under the MHA.I think we can all agree, that if a greater proportion of mental health care is, quite rightly going to be community oriented, but the necessary service investment and development is not delivered, then legal reform on its own may mean a greater role for our emergency system – police, paramedics, AMHPs and Emergency Departments.
I hope I’m wrong in this predication, but I do struggle to see it differently. It is for that reason the delivery in reality of the Long-Term Plan is key to rolling the wicket ahead of any legal reform. If it doesn’t happen, for whatever reason, then the ambition within the LTP to reduce pressure on police services (p118) is unlikely. In fact, the opposite is likely, as we’ve potentially seen with various other initiatives to reduce pressure on policing over the last decade. I say ‘potentially’ because of the fact we still have an appalling lack of evidence and data about the things we’ve done to fix the problems we think we have AND because I’ve argued for a long while now, that I think we’re trying to fix the wrong problems.
WHAT DOES THIS MEAN OFFICER?
So, if you are a frontline cop, what does this all mean for you?! Well, it broadly means that most of the indicators that some things may happen at the national level of the health service are things that may impact upon the operational problems you currently in about three years. The delays we see around identifying mental health beds; the difficulties accessing s136 suites after use of this power; the support of appropriate methods of conveying patients (conveyance after use of s136 MHA is still largely done by the police). I’m sure we all realise that the problems generating our frustrations are largely caused by strategic and systemic decisions in healthcare, not by frontline staff who are working as hard as frontline cops are to keep a wheel safely turning.
So between now and then, you need to understand the legal and operational reality in which you police is sub-optimal, that expectations upon you and your colleagues will probably involve things you should not be doing but may have to; history suggests it will also still include expectations that you do things you cannot professionally do (welfare checks and actual self-harm / suicide risk prediction); and some things you cannot legally do (use legal powers in private premises, etc..). You will need to ensure you understand the traps which are laid out before you, such as the advice of mental health professionals about the law – we know they don’t always get this right because some of them have had less training on it than us. Legally speaking: don’t believe anything anyone says and check everything for yourself.
For operational supervisors, it means you may have to get yourself interested in mental health and capacity law and be prepared to take on professional discussions about police deployments and police roles. If the control room has asked officers to undertake a welfare check on someone because of a concern, is this something we must do or can we politely decline? Remember, the legal obligations to be involved in a welfare check is something which arises when there is a credible belief of a threat to life. The police service do not have legal powers to do ‘welfare checks’ on people who choose not to answer the door; we do not have legal powers to keep people detained beyond 24hrs after use of s136; we do not have legal powers to hold people in custody for best part of a week whilst searches are made for available inpatient beds.
There is a lot of talk about the need for good partnerships – we often hear about the need to get out of our silos, etc.. I don’t think many of us having objections in principle to such ideas, close cooperation between public services seems inherently advantageous – subject to one caveat, in my own opinion: we need to remember that we ‘silo’ things for a reason. Providing an armed response to a terrorist or hostage situation is never going to be the role of an acute mental health service. Providing medication to patients detained in hospital under the MHA is never going to be the business of the police. Yes, there may be times a MH professional supports an armed response to a hostage situation – that is different; yes, there may be times officers attend inpatient mental health settings to make a safe a very dangerous situation that arose from a confrontation about the lawful administration of medication – that is different, too!
But for me, an undiscussed aspect of what we keep calling partnerships is that the law of the country is non-negotiable. And when we find situations in which the law is not complied with, because of pressures we all understand on our mental health system and hardworking mental health professionals, it doesn’t automatically follow that the police can fix this. It doesn’t actually matter how hard it is to find an inpatient mental health bed, if an AMHP has reached the threshold specified in s13 MHA for making an application for a patient’s admission; if a bed is not available and a patient remains at risk in the community, it doesn’t automatically become the responsibility of the police to pick up the pieces from that difficulty. Nor does it even follow that because a situation of risk exists in the commuinity that police have any legal powers to pick up the pieces, even if they are trying to be as helpful as possible! We learned this (again) during the inquest after the death of David Stacey, last Christmas.
To raise concerns police officers are being expected to act unlawfully to help fix problems they didn’t create is not, in any way, shape or form, to ‘fail to work in partnership’ or to reject the need for good partnerships. The rub is this: the police service is not just in partnership with other public services, but perhaps more importantly they are in partnership with the public we all exist to serve; and the public who are also patients have legal rights which the police are obliged to uphold. These include fundamental rights like the right not be deprived of liberty, except by a process defined in domestic law; not to subject people in inhumane and degrading treatment, etc., etc.. Where the difficulties faced by our mental health system create a conflict between the public partnership which is the bedrock of policing by consent and the professional partnership we all want to see between services, there is a really easy way to referee that conflict and find the answers: the law tells us most of the answers, most of the time.
As a Chief Constable recently said (about the public’s need to access a mental health system which is struggling), “I can’t fix that for them.” Policing is not a solution to many problems: it is a safety net and a checking mechanism.
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