I’m a bit bored this evening – sitting in a London hotel as I’ve had to stay over because of successive days of meetings in the capital. I’ve been to the National Crisis Care Concordat Meeting and discussed policing and mental health with the national policing lead, Commander Christine JONES at New Scotland Yard, amongst other things. The week has got me wondering about ‘policing’, by which I don’t mean the uniformed people you see dashing about the place answering 999 calls and arresting suspected criminals – I mean policing in a much broader sense, relating to the governance of our whole ‘system’ of mental health care, to which policing, the profession, all too often connects.
- We have a Mental Health Act for example. Last time I checked, thirty-six CCGs in England were breaching s140 of the Mental Health Act. Who’s policing that, then? I can’t arrest anyone for this – it’s not that kind of legal breach. It’s not an offence for CCGs to ignore s140, so if the police can’t police it, who’s policing it?
- We have a Mental Health Act Code of Practice. In fact, we’ll have a new one next week when the 2015 edition takes effect at the start of April. There are various parts of this document that get routinely ignored because services are not set up to give effect to it. Patients who are absent without leave from hospital whose location is known should be collected and returned to hospital by the relevant health services, not by the police. (Paragraph 22.13 in the old Code / 28.14 in the new.) I’ve never known it happen. Who’s policing that, then?
- We have Royal College of Psychiatry Standards on Section 136 of the Mental Health Act – I’ve jested previously that it must have been these to which Hamlet referred when he remarked “more honor’d in the breach than the observance”. Although published by the Royal College of Psychiatrists, they are, in fact, multi-agency agreed guidelines for the whole 136 system – including right across the police, health and social care systems. This includes all parts of the NHS – ambulance, A&E, mental health providers and relevant specialist providers like learning disabilities and CAMHS providers, if different.
Anyone know anywhere in the United Kingdom where we can see these standards in operation? Me neither.
I do sometimes wonder whether we should leave these agreements out there as the aspirational standard we are striving towards or whether we’d be better off ripping them up and accepting that no-one does it and no-one’s policing those that don’t do it. Why deceive vulnerable people that they can expect such treatment? Is it not morally quite unfair to raise expectations to that degree?!
Of course, the modern narrative about section 136 is that we need to reduce its use and we have seen all manner of initiatives to reduce the use of police cells as a place of safety and to reduce the use of the power itself. Meanwhile, in the real world, use of section 136 is rising – by 18% this year in London alone – and this is materialising before our eyes notwithstanding the impact of initiatives like street triage. And that’s another reason why smokescreens like triage hide the real problems, deep underneath: why are the police service having ever more contact with the mental health system, why is s136 rising so much and what are we doing to react to that?
One further problem here, is that we’re doing a binary comparison when we examine street triage – comparing this year’s figures with last year’s figures when last year was just another year over a decade or more where the general trend in section 136 is upwards. Correlation is not causation, of course, but as we’re all busy policing and working in the real world, I’ll just point out how much 136 has gone up (%) since the NHS Mental Health framework in 1999 where community mental health services and in particular, crisis services, were seriously eroded.
There is an argument that s136 may yet (need) to rise yet further, because if you look at how many people are arrested in public places for minor crimes who then receive a Mental Health Act assessment in police custody because of concerns that they may well be acutely unwell, the figure is HUGE compared to the numbers being detained under s136. I accept I’m not an academic – as you know – but in the absence of any academics I know looking at this (weren’t we all meant to be getting evidence based?!), I will just have to extrapolate from what we do know – that around 5% of detainees in one force area who were arrested for crimes were then assessed under the MHA. If that were even vaguely true nationally, it would mean around 50,000 people a year, which is more than double the number detained under s136, and 10,000 of those people were ‘sectionable’ which accounts for about one-fifth of all the MHA applications in England alone. Can that be right?!
Plenty of scope, then – for better training, information and risk assessment to divert boatloads of vulnerable to relevant assessment first. I can imagine CCGs haven’t considered this – data about people arrested for crimes is held by the police and I’m not aware of any areas developing their local Crisis Care Concordat plans who are asking for it, to lift the stone in an unfamiliar area of crisis care to see what is lurking underneath. Are MHAA data assessed at the population level in each local authority area to look for trends, repeats and particular problems? If not, why not?!
As I conclude this brief blog, one of Surrey’s most senior police officers is stood in an A&E department with someone who ran off from there a few hours ago and who was found on a roof threatening to jump. Chief Superintendent Matt TWIST is, ironically enough, the lead Surrey officer on all things mental health and he’s chosen to spend his Tuesday evening working a busy late shift with his front line officers. It is absolutely a core police function to protect life and this includes vulnerable people in crisis and using s136 where necessary. However, before 9pm he had already concluded on Twitter that officers may well still be there until the morning and all the while an already agitated, suicidal person is becoming increasingly distressed as psychiatric services stand-off, pending certain medical results becoming available.
I’m sure I read somewhere that there should be three-hour turn-around for assessments, once someone is medically fit to be assessed under the Act?
So who’s policing that, then?