Those of you who have read this blog since it began will know how often I’ve bemoaned the fact we keep reading and hearing the same things said over and over again in cycles which last over a decade. When the Bradley Review (a wider ranging review of mental health and criminal justice, 2009) it was widely lauded and well received, quite rightly – but it many respects it just repeated much of what we already knew from the Reed Review (1992) and indeed from the Percy Review (1957). They each had slightly different reason and focus, but ended up saying many of the same things about mental health and criminal justice. Of course, we have also had review of the Mental Health Act specifically, the Richardson Review (1997) and more recently the Wessely Review (2018) which were not criminal justice centric, but touched upon those issues.
This week, a new Joint Thematic Inspection has been published by Her Majesty’s Inspectorate of Probation, jointly endorsed by other inspectors for policing, CPS and prisons as well as the Care Quality Commission and I’ve already added this to the list of Big Reports housed on this blog and at 117 pages and given the list of signatories, it’s comprehensive in its scope. This post is necessarily partial coverage, not an exhaustive examination because apart from anything else, I don’t need to cover every page to make the points I think are worth making.
The first an most obvious one is made up front by the report itself: we’ve heard all of this before. Many, many times. One thing occurs to me, though: when Lord Bradley published his 2009 report we were at the beginning of a period where there would be significant political weight behind the idea of progress – we were about to see Home Secretaries, high profile mental health ministers and indeed Prime Ministers talking about the mental health, criminal justice and the role of the police. Those now seem to be the projects of the last decade and it seems we’ve moved on. What appetite there will be for the implications of this report, which we’ve known about for decades and been unable to progress even with that significant oversight, I’m not sure.
To cover a few specific observations quickly and keep it brief, please forgive the bullet point style —
- The report states “There is no common definition of mental health across the CJS. This leads to inconsistencies.” — There’s no common definition across the NHS or the various mental health professions, either so I genuinely wonder what chance the CJS has of sorting this for them when the experts can’t agree. You only need to read philosophy of mental health texts or observe the clash between psychiatry and non-psychiatry to see this.
- There is “Poor information exchange” — we’ve always had this and indeed poor can more over and under-exchange of information. If you haven’t spotted examples of both by watching media coverage of high profile untoward incidents being untangled in Coroners’ courts recently, then you weren’t paying attention.
- The report states there is poor understanding of GDPR and we need a National Memorandum of Understanding across agencies — yet another example of people thinking a joint agreement will fix the world – history shows it won’t. Only proper training on the law for staff will fix this, because if staff knew the law well enough, the process would (more-or-less) work most of the time. It’s not just on the subject of GDPR that we find organisations putting faith in MOUs to fix problems that are really about training and legal knowledge.
Elsewhere on here, I’ve written that we suffer from a lack of understanding of what problem were trying to fix. You may remember I told of a colleague who threatened to get that on a mug or t-shirt for me. Since blogging a little less, I’ve actually wondered that we’re not trying to fix a problem per se but strike a balance. There will always be a balance to be struck about how much we rely on our criminal justice and emergency systems as part of our social response to mental health because they will always have some kind of role. My view for years has been that the problem we need to fix is our over-reliance upon CJ and 999 as a de facto service for emergency (and sometimes non-emergency) mental health care. Regardless of whether I’m right, I submit it remains unarguable that over the last decade of activity we’ve seen only two answers to the problem we’re fixing or balance we’re striking is 1) training; and 2) liaison schemes. On the latter, there are typically two: 1) street triage and 2) liaison and diversion in custody (L&D).
No matter than problem, no matter the balance – those are the things we’ve chosen to do to fix the problem. Training is quick an easy to address: we haven’t done it properly (see Recommendation 4 of HMICFRS 2018 report Picking Up the Pieces.)
This report covers both ideas and mentions the NPCC Strategy on policing and mental health which looked at both (I authored this whilst at the College of Policing) —
‘In recent years, the two main partnership initiatives through which progress has been forged are Street Triage and Liaison and Diversion in police custody. At this time, evaluation of both has been partial and this reflects the understanding the service has of mental health related demands’.
Evaluation remains partial, as far as I can tell and hence the report’s coverage of L&D is something I wonder about. “There is very good coverage of L&D services across England and Wales in police custody.” What do we mean by good, precisely? If we mean it exists, fair enough – it’s largely everywhere. If we mean it’s effective, then I have to disagree even if just to point out that it’s not well evaluated so we don’t really know its impact (see research by Prof Edit Jones from Nottingham University: it highlights longer stay, impact on prosecution decisions being mixed and the need for more research about long-term impact / follow up). This is complicated stuff, folks!
It also struggles to achieve its most important objective of all — better identification of vulnerable people arriving under arrest. The ideas and research on the need for L&D concepts going back to the 1990s highlights that police are not great at identifying those in custody with mental health problems. Some of this is training and some of it is the natural disincentive for detainees to be open with officers (because if you tell us you’re mentally ill, the time you’ll spend in custody will at least double whilst we get professionals of various kinds and appropriate adults – all of that takes time.) Some of it is also the fact that police dont have access to mental health trust or medical records to look up whether someone is known to services and of course, some mental health conditions can be indistinguishable to non-medical, non-nursing professionals. Remember: it can take a doctor with postgraduate training up to 28-days of detention in hospital assisted by a team of nurses to establish whether someone is mentally ill and even then we know they’re not always right. What chance the police will get it right in a 10-minute booking in procedure?!
I bore you with all that to make this point about L&D: they (usually) don’t screen everyone in custody, the only see those referred to them by the custody sergeants. Can you see the flaw? The fact also is, many of them are schemes which operate extended office hours inc weekends; they’re not there when many people are arrested at 2am so by the time a sergeant has referred someone to L&D the following morning, many important legal decisions about the CJ issue may already have been taken. Ive said for years, including when I was involved in this work formally, unless L&D screen everyone soon after the point of arrival, you’ll still hear stories about people failed by the CJ system and this report helps prove me point for me. (There are other ways we could ‘screen’ without having a nurse in custody 24/7 – covered elsewhere on the blog.)
There is a similar point about street triage services which I won’t over-emphasis because that’s also covered elsewhere on this blog: but the report makes assumptions about efficacy that I submit cannot be supported by research evidence (indeed, dont they make that point when highlighting the NPCC strategy quote, above?) and they also state that “the control-room-based services offer a good service” Do they? – what’s the evidence for this?! What do you mean by good, how was that evaluated in terms of things like information sharing (which the reports states is poor) and where there is no mention of the follow up people get (or often dont get) after referral by street triage schemes to local services. An no mention of the various Coroner’s cases one of which led to a PFD report about the difficulties of telephone based approaches. Last time I checked, there was a dearth of quality evaluation. NICE state in their guidelines on MH-CJ that even the best evaluations are “poor” or “very poor” and an include an excess of before / after or anecdotal snapshots that don’t qualify as either. I submit: there is so much still not known about actual impacts and implications that any confident comment risks the response of “What’s the evidence for that?” It may or may not be of relevance to point out, some police forces are deliberately withdrawing from their schemes – why would they (other than funding) if they’re so obviously a good service? Also worth noting, many of these schemes are police-funded, at least in part, if not in whole. Why?
Perhaps it depends on what problem youre trying to fix or balance you’re trying to strike?
There are other aspects of the report I could highlight but like the material it’s covering, its all been said before. This is yet another report that makes basic errors of terminology (the AMHPs are already jumping up and down about “advanced mental health practitioners” (p72) which is always a basic error given it’s a statutory title for one of the most important professional groups in all this discussion. Never the less, here are the four police-specific recommendations.
14. Ensure that all dedicated investigative staff receive training on vulnerability which includes inputs on responding to the needs of vulnerable suspects (as well as victims). This should be incorporated within detective training courses.
15. Dip sample (outcome code) OC10 and OC12 cases to assess the standard and consistency of decision making and use this to determine any training or briefing requirements and the need for any ongoing oversight.
16. Review the availability, prevalence, and sophistication of mental health flagging, to enhance this where possible, and to consider what meaningful and usable data can be produced from this.
17. Assure themselves that risks, and vulnerabilities are properly identified during risk assessment processes, particularly for voluntary attendees. They must ensure that risks are appropriately managed, including referrals to Healthcare Partners, Liaison and Diversion and the use of appropriate adults.
18. Police leadership should review MG (manual of guidance) forms to include prompts or dedicated sections for suspect vulnerability to be included.
“As an emergency response service, the police, in particular, will often find themselves responding to reports of people who are suffering from an acute mental health crisis. Decisions then frequently need to be made on an appropriate place of safety and on whether a criminal charge is in the public interest or whether an alternative approach would be more appropriate. Police forces with the most advanced flagging report that mental health issues are involved in up to 13 per cent of the incidents they record and up to 24 per cent of the crimes.” (p15).
It’s welcome to see focus on crime which in many respects is the un-discussed aspect of the police-MH interface – if I see one more email asking about investigative decision-making because someone “lacks capacity”, I will scream!
This report outlines progress against previous recommendations from 2009 (p16) – in short, there hasn’t been much, despite all the efforts and activity around the two things that are always seen as the solution: street triage and liaison and diversion. This attends to my experience and my ongoing fundamental concern that progress claimed over the second decade wasn’t really progress worth claiming – I worry things are worse and not just because of demand or social / economic factors. In particular, I was interested in the 2009 recommendation about policies on places of safety and claims in this report which say all forces have joint policies with partners about MHA issues. You only need to go on the internet and look up s136 policies for certain areas to find that some areas don’t have policies; and that various areas policies are extremely inadequate. This contentious observation isn’t my opinion: it was an observed feature of the Leon Briggs PFD notice published only two months ago, to give just one example.
The big question, though seems unaddressed even if just for the report to emphasise it needs deciding: when someone who is mentally ill (to whatever degree) has exhibited behaviour which arguably touches on the criminal law (to whatever extent), how are we asking police and prosecutors to make the prosecution decision? This is an extremely complex, important and impactive decision and striking the balance between individual dignity and right to treatment when ill, versus wider public protection where that’s relevant is the stuff of textbooks and theses but every day, police, nurses and others are wrestling with this and fundamentally, my sense from this report is its highlighting all the difficulties we can see around us without clearing the path to create conditions in which frontline professionals who work Saturday nights and Sunday mornings can maximise their change of getting this right.
In addition to most of this report having been said before; we therefore also see left unmentioned that which has been left out before — what problem are they trying to fix; what balance are they seeking to strike?
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2021
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