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Thinking of the Future

I’m really conscious that there will come a point where the focus on policing and mental health will wane – my view would be, it has already peaked and we need to capitalize on the time we have until the sun sets. During that period, the College of Policing will publish its national guidelines and training, forces will have the chance to do something with them and by the time we get to the end of 2017/18, attention will begin to focus on other issues, both within policing and without.

I’m not necessarily sure we’ll have sorted the relevant issues by then: but we’ll have found some ways to make them seem less outrageous and attention will begin to fade as other priorities take hold. Within policing, the view may be taken that once we have national guidelines and training, reflecting on the former in local policing and delivering the latter, surely that will do?! Some police officers still think (or hope?!) mental health is something we can ‘sort’ as a project and then move on to real policing. If Lord ADEBOWALE’s vision of core police business is to mean anything, it may rather be something to which we will need to pay ongoing attention just as we do with domestic abuse and youth justice issues, amongst others.

There are few problems we need to start watching for –

POLICIES

Towards the end of 2016, forces will have realised that the contents of College APP don’t necessarily accord with their local practices and will be experiencing the cognitive dissonance that comes from trying to adhere to national guidelines as well as to local partnership practice. There will be combination of reasons for that, some within policing itself; others without. As APP focuses on the essential and non-negotiable aspects of this interface, forces will need to realise that where it doesn’t easily fit, this will be connected to their internal policies and their partnership arrangements. Work will be required and some of that won’t be easy.

Section 136 of the Mental Health Act and the whole ‘Place of Safety’ debate still exemplifies this: police forces point out that word games about the meaning of ‘PoS’ are still rampant – despite it being very clear in the Act! – and exclusion criteria are still applied by MH service providers notwithstanding what the CQC say in their reports. The reality is that there remains work to do on conveyance arrangements for those detained under the Act with ambulance trusts arguing that they are not commissioned to undertake various functions and of course, we know that forces still approach the use of section 136 very differently.  That all needs ironing out and it will be about partnership work, not policies.

TRAINING

You might imagine training is the silver bullet in all of this: it is mentioned with monotonous regularity whenever a report is written on this topic and partners in health seem fairly determined to make sure we realise the problem is with officers not sufficiently understanding mental health. Of course, it’s quite likely that there are significant training needs amongst health professionals – especially legal education for them – as well as remembering that the bulk of police training requirements are around legal issues. I receive almost no queries at all about how to raise officers’ awareness of conditions; ongoing relentless deluge of questions about legal duties, legal opportunities and legal difficulties. So  the key thing about training may well be the way in which trained staffed are deployed and used, rather than anything else – we have some trial and error to work this out.

There is also the issue of information retention – police officers will encounter the situation of recalling a CTO patient perhaps once a career, if they’re lucky … or unlucky, depending on your view! We need to be realistic about what we’re asking officers to achieve after their training: I would expect them to know that whenever you detain or re-detain anyone under the Mental Health Act 1983, you transport without using a police vehicle wherever this is possible, you consider the health & welfare of the person detained at every stage. I wouldn’t expect any front-line police officer to freely recall the three different ways in which to serve a recall notice under s17E MHA or the subsequent time at which they allow officers to remove the patient back to hospital. It’s the job of mental health professionals to know what they’re doing around recall and be able to explain that legal point where officers have the power to act. << That’s why this is not just about policing!

INSPECTION

Of course, who knows what will take the focus of inspectorates or independent investigators? If history tells us anything, it is that there will be one or two deaths and half a dozen or so ‘near-misses’ each year, following the use of section 136 of the Mental Health Act. Some of those will mean independent investigation of the circumstances by the IPCC who will use the College of Policing APP and training as a benchmark – did forces’ policies adhere to the national guidelines; were officers properly trained; did officers adhere to the basic requirements of their training?

It wouldn’t surprise me if mental health featured in future inspections by HMIC in conjunction with other partners. We’ve already seen focus on these issues in the Core Business reports, the PEEL inspections as well as other in thematic inspections around custody and vulnerability.

FUTURE PROOFING

I repeat my point: I wonder whether we have reached or are just approaching the peak of interest in this subject? – we seem to think we’ve found the solutions in guidelines, training and street triage. I also suspect we can infer this from ongoing force rationalisations, some of which may see full-time positions as mental health coordinator vanish – and this is despite the net effect of ongoing pressures in the health and social care system is to deflect greater demand in crisis care to the whole emergency system (including A&E and the ambulance service) and initiatives like Liaison and Diversion and street triage raising newer questions and challenges. We also know that we haven’t even begun to properly discuss the role we want the police to play – I think this is where we should have started to avoid the conclusion that we see activity at the expense of achievement in this arena.

The trap to fall in to – and I see evidence that it’s proving to be an effective snare in the meetings I attend – is to think that ‘improved’ policing responses to ever greater demand, some how represents early intervention. Yesterday we saw publiciation in the British Medical Journal of an article which evaluates street triage: the first such academic paper to arise, instead of local evalution documents. It claims that street triage is more or less cost-neutral, bordering on cost-saving but it takes for granted the arrangements in Sussex as the basline and it fails to consider the data that the street triage scheme did not gather.

The police service needs to make sure it does get lost in the smoke and mirrors that can surround these issues: the danger of not driving through national guidelines and training to have the necessary impact upon partnerships is that vulnerable people will continue to find themselves criminalised and stigmatised by the impact of the justice system upon their crisis care. We need to make sure that as focus and resource may deplete, we maintain our ability to tell the difference between that which appears highly intuitive and that which will be highly impactive – to do so, we need to start that proper conversation about the role we are attempting to forge for the police in our broader mental health system. And we haven’t really started to do so, distracted as we are on the minutae of whether A&E is a Place of Safety and whether ornot street triage and training are the silver bullet.

What are we actually trying to do here? – we don’t have very much longer to decide.


IMG_0053IMG_0052Winner of the President’sMedal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


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Do We Have Enough Beds?

The Commission on Acute Adult Psychiatric Care has published its final report! – and the publication was headline news on BBC Breakfast this morning with a range of people welcoming its findings.  I have been very interested to be a Commissioner in this inquiry, not least because I’ve never done anything like that before but also because the subject matter is something that many would imagine is not immediately linked to policing or criminal justice.  And yet at every stage of the Commission’s work, I found myself with things to think about and say, relevant to policing, mental health and criminal justice. I have learned a lot, quite honestly!

So here are the resources –

This has been a major piece of work and I know the staff within the RCPsych policy unit who did a lot of research and running about at the whim of the various Commissioners have worked tirelessly to produce it. The risk with any such thing is that it becomes ‘yet another report’ that can be filed away – in my case, I print them off and put them on a shelf in my house.

DO WE HAVE ENOUGH BEDS?

The Commission’s essential task was to address the question of whether England has sufficient inpatient psychiatric beds for adults. It was obvious to everybody at the first meeting of the Commissioners that the answer could not be a ‘Yes’ or ‘No’ and that is reflected in the final report. You can get talking if you want to about whether mental health care should be more balanced towards inpatient care or community models of care: it was really interesting for me listening to very senior and experienced people as well as service users all over the country talking about their views. But ultimately any local health economy is going to be a balance of inpatient and community provision – the issue is whether local areas have got their balance correct.  The report concludes that there are enough examples of imbalance to suggest urgent action is necessary – not least on the long journeys some patients undertake when first admitted (see the recommendations, above)

Policing seemed throughout the inquiry to be connected to the issue of sufficiently minimising imbalance to prevent instability becoming too great, although even there we came across examples of where it could not do so (see example one on page seventeen of the full report) and therefore the final report highlights the need for a ‘systems’ approach to our mental health care – this means seeing various public functions as directly connected to achieving a balance. If 16% of patients don’t need inpatient care but do need community care that doesn’t exist, some will become hospitalised, some will become criminalised, others may develop informal coping strategies like drugs, alcohol or self-harm. If 16% of patients are in hospital having required admission but are now medically fit for discharge and have no housing or other vital social supports, it prevents discharge occuring and forces the system to rely on the most expensive resource of all: an acute inpatient bed.

So my concluding thought about all this, having spent a year working on the Commission is that you can have as many or as few alternatives to admission as you like, you can plan properly for that by understanding demand, or not – as you prefer. Either way, we will end up paying for it anyway with out of area and private sector admissions costs; with criminal justice interventions and imprisonment; or with a cost in human suffering from unnecessary institutionalisation, predictable self-harm or avoidable suicide.

So we may as well just do this properly and accept it needs planning and paying for.


IMG_0053IMG_0052Winner of the President’sMedal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


Tour of the new Patchway Police Centre. Inside a custody cell.
Photo by Dan Regan
04/08/2014
Reporter - Rachel Gardner
Copyright - Local World

Reforming the Mental Health Act

A parliamentary bill containing proposals to amend the Mental Health Act 1983 has been introduced to the House of Commoons by the Home Secretary and will progress through Parliament in the coming months. Specifically of interest to me, this bill will seek to amend sections 135 and 136 of the Mental Health Act and the proposals seem more or less in line with the recommendations from the consultation document that was published in December 2014. You can trace the progress of the Bill on the UK Parliament website and the initial draft of the Bill is now available to read in full.

The main proposals are –

  • The scope of s136 will be widened – this will allow the power to be used anywhere ‘other than a dwelling’, thus bringing in to play private workplaces, railways lines and any other kind of private place.
  • Detention time will be reduced – from 72hrs in a Place of Safety to 24hrs overall, thus matching the maximum time for similar detention in Scotland. We may need to look north!
  • The ‘Place of Safety’ definition will be restricted – to prevent children (u18s) from being removed to police custody in any circumstances; and to prevent adults being removed to custody other than in ‘exceptional circumstances’.
  • The ‘Place of Safety’ definition will be expanded – there is mention of allowing other places to act as a Place of Safety. This proposal confuses me because s135(6) already allows for “anywhere that is temporarily willing” to act as a PoS under the Act.  Not sure what this new proposal means!
  • Introducing a consultation requirement – it is proposed that officers will be required to consult health professionals before instigating use of section 136 of the Act.

You can take your pick as to what you think this announcement means: it’s either a milestone which heralds a new era of crisis intervention by the emergency services which will mean that far fewer people detained under these powers are removed to custody and criminalised when they have not broken the law; or you could argue it’s a a final acceptance that we must force the NHS to ensure basic crisis provision for those in need because there will be no back-up plan. Or will there?! … we know that the words ‘police station’ were removed from the Scottish definition of a Place of Safety in section 300 the Mental Health (Care and Treatment)(Scotland) Act 2003 – but just see s297(5) for the Scottish ‘get into jail’ card. Looks like England / Wales are going for ‘exceptional circumstances’ instead!

I’m inclined to think these are actually not mutually exclusive positions and I’m not too greatly troubled whether NHS services do this willingly, as they have in Birmingham for more than five years and to great impact; OR whether CCGs which have historically ignored this in the hope it will go away are now dragged to the table and compelled to get their heads around it. I’m sure my mental health colleagues in Birmingham will attest that either way, they are going to learn that this stuff isn’t so problematic that it can’t be overcome with decent partnership working that will actually enhance relationships across the whole interface of policing and mental health.  Some areas of England achieved all of the above without the need for legislation and operate creatively – they must be wondering why other areas can’t.

WHAT WE NEED TO KNOW

To fully understand these proposals and their potential impact, we will need to know more details so this post won’t be long.  The obvious point is wonder what ‘exceptional circumstances’ will mean.  This is unaddressed at this stage and reference is made to Regulations being drawn up in the future. In the original consultation, it was defined as acceptable if a person’s behaviour  “is such that it cannot otherwise be safely contained.” That is the story behind most of the controversial, restraint-related deaths in police custody over the last quarter of a century so we will need to be careful if we’re defining police station PoS detentions based on resistant or aggressive presentation.

We know that resistant, aggressive behaviours can be caused by serious medical emergencies – recent examples include acute renal failure, meningitis and serotonin syndrome so before we exclude people to custody somewhat ‘exceptionally’ what clinical triage mechanisms will be there to support officers’ decisions so these things don’t get missed?

We will also need to know more about the availability of specialists to asses those who are detained, especially out of hours. I’ve often used the example under the current 72hrs law that if you are a 15yr old girl with a learning disability, detained at 6pm on Good Friday, your s136 detention will expire at 6pm on Easter Monday and during all of that time, many areas will be unable to resource that assessment using a CAMHS or Learning Disabilities specialist, as recommended by the Code of Practice to the MHA. Whilst that is a point of good practice, rather than a binding requirement, there are some areas where non-CAMHS or non-LD specialist s12 DRs will not assess children or known learning disabilities patients. So with a 24hrs detention timescale, such situation is a potential problem in some areas not just on Easter weekend but every weekend and that will need to be borne in mind.

NHS CAPACITY

Tomorrow will see publication of the report of the Commission on Acute Adult Psychiatric Care – we already know from the interim report last July that it will highlight significant problems in the availability of inpatient admissions beds even for adults.  CAMHS and LD beds have historically been even more difficult to find, as we have seen in high-profile news reports. Where an Approved Mental Health Professional decides to make an application for admission under the Act following the use of section 136, there will be a significantly reduced timescale in which to manage the process of finding a bed. In 24hrs, there may be a period spent in A&E receiving treatment for injuries; and / or a deliberate delay to allow sobriety to return to allow a meaningful assessment and that could easily take 6-12hrs. If 12-18hrs remains to find a bed, we know that will prove challenging unless CCGs see this amended legislation as a clear indicator to change how they commission services. It will also add weight to the importance of effective arrangements to manage the implications of section 140 MHA which I still maintain is massively ignored and misunderstood!

The thing that is not in the proposals that I know some were hoping to see address is a solution to the widely acknowledged problem of police responses to mental health crises on private premises. We know from street triage that most of these incidents occur in dwellings, not in public places and it remains true that police officers have no legal powers to intervene where somebody is in immediate need of care or control. This matter was considered in the 2014 consultation and no proposal is brought forward on this point. Sir Paul BERESFORD MP raised a Ten Minute Rule motion in the House of Commons in 2014 after his experience of shadowing two Metropolitan Police officers at an incident where they were powerless to deal with a situation of significant risk and unable to mobilise the professionals who were empowered to manage the situation. Unless someone brings forward a proposed amendment to the Bill during its parliamentary journey, officers will still find themselves in this position, from time to time.

Finally, we will need to understand more about this consultation requirement – I can’t be the only police officer in Britain whose experience of attempting to contact 24/7 crisis services is patchy because of their capacity problems. Some cities with 250,000 population and 2,500 of those open to mental health care services are known to have one or two mental health nurses on duty out of hours. We know that the reduction in CrisisTeam staffing levels is not fully made up even by the introduction of street triage schemes and that it will be necessary to think creatively about how such consultation is to be achieved at 5am. (For what it’s worth, I’d encourage areas to look at what Leicester do with street triage, liaison and diversion and psychiatric liaison services.) We also need to know what role of that health professional will be in the subsequent decision. What if the nurse suggests a course of action that the officer disagrees with – who ‘wins’?!

Like a few other things implied by the announcement, we’ll need to wait and see!


IMG_0053IMG_0052Winner of the President’sMedal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award