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Honor’d In The Breach

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?!

MOVING TARGETS

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?

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Are We Going To Do This, Or Not?

I think I’m becoming a bit report weary, especially now I have to make sure I’ve read every one of them cover to cover and several, like the new one this week from Her Majesty’s Inspectorate of Constabulary, are hundreds of pages long.  Two hundred and twelve pages long, to be precise.

I’ve printed off this latest report and have put it on top of —

I could go on with other reports and yet more reports.  Then there is this list of statutory guidelines, many parts of which are routinely disregarded.   Only yesterday I heard a person from the Department of Health lamenting that no-one really knows about the new Code of Practice to the Mental Health Act that is coming in to play in two weeks’ time!

So rather than provide you with a running commentary on this new report, I’d refer you to the excellent summary coverage of it by @NathanConstable who blogged before I got the chance and said exactly what I think about it – rather than bore you in a similar way, I’d just encourage you to read his post and see it against the background set out above.  I’d just ask whether anything else needs to be happen before we accept that there is a serious human cost to our ongoing inability to get this right, a serious lack of strategic vision about what we’re trying to do and no remaining excuses for the interia because we can’t look grieving families and vulnerable adults in the eye and claim to be getting this right.  

Perhaps if we had children being detained in custody for days because a £100bn a year organisation can’t sort a quite, ligature proof room somewhere for them to wait safely until we get a plan in place we would realise we have to do something – but hang on, we’ve already had that, haven’t we?  Perhaps if we had hundreds of unnatural deaths a year across our coercive systems we the police and mental health services often interface in a range of complex ways, we’d have to do something – but wait:  we’ve already had that, haven’t we?  Perhaps if we had vulnerable adults detained in cells whilst extremely psychotic, covered in their own faeces, smearing bodily fluids all over the walls after drinking from the toilet and banging their heads repeatedly off concrete walls for protracted periods of time – but wait: we’ve already had that, haven’t we?!

I can think of just a few more shocking things that could happen but I’m just too appalled at the idea that we’d need to see ourselves reflected so badly and that it took such events to make us see that before the end of this century my grandchildren’s generation are going to look at us and wonder how on earth these things weren’t viewed as the outrages they are and more importantly, why we kept letting it happen.

Are we going to do this properly, or not?!

We should just decide and be honest with people – at least we can all get on with our lives knowing where we stand.  I know that change is happening at last and I know we can see various versions of furious activity all around us – it’s not good enough, it’s not fast enough and we should be ashamed that we are perfectly capable today of repeating the disasters that struck vulnerable people and their families a decade or more ago.

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The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.

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Wasting Police Time?

One part of the debate that is going on in policing, is the extent to which the service picks up ‘failure demand’ from other organisations.  You have to expect this debate, because policing is being cut to a far greater degree than many other organisations and the idea that as health and other services rationalise their own provision the police can pick up even more demand than they were before is highly counter-intuitive, to phrase it politely.  In addition, certain public sector service developments that would be sought even if we were not contracting are being done in such a way as to mean the police are having to invest more resources than ever before to make things ‘better’.

So this is a plea for compliance with the Royal College of Psychiatry Standards on Section 136 of the Mental Health Act, amongst other things.

Let me exemplify this and please be ready to do the maths in your head -

Take the fictional area of Wessex Police which serves a population of 2 million people with almost 5,000 officers.  They have historically been detaining around 800 people a year under section 136 of the Mental Health Act but one problem in the local area for the last thirty years has always been that the NHS did not have any Place of Safety provision whereby people detained under this power could be assessed in a health-setting.  Following a death in police custody some years ago, arrangements have now eventually been agreed for a “section 136 suite” to open in the near future.  As part of considering the planning of this new facilty, it has been established that an average detainee in police custody is held for 10hrs before the necessary treatment and care arrangements have been made and for most of those, the person is subject to an enhanced level of observations with an officer either sitting at the open cell door (20%) or observing the person in a camera cell (80%).  In half of those camera-cell observations, the officer was observing two detainees on a multiplex screen because someone else was in custody being observed anyway and cell visits occured every 15 minutes.

Then they opened the new s136 suite and everyone was agreed that this was much better all ’round – once it had settled down they found that the ‘average’ detainee was held in the Place of Safety for 5hrs, only half the previous period of detention and it was in an undoubtedly superior environment.

What’s not to like?! - the NHS had resourced the captial investment for the building but not the resource investment for the staffing because it wasn’t commissioned effectively to what we might call the Royal College of Psychiatrists’ standard – we are not quite where we should be.  In fact, the RCPsych standards outline how police officers should be able to deliver section 136 detainees to the health service and leave again within 30 minutes, even if they are disturbed (p8) – I can only admit that when I first read this bullet point, I thought the standard was exceptionally aspirational to say the least and I am aware of nowhere in England or Wales where it actually happens.

DO THE MATHS

So if you came in to assess the impact of the service change, from the point of view of police time, here’s the maths.  (And just so you know, a police officer working full-time will spend 2,080hrs at work, each year) -

  • Police station – 800 detentions, 10hrs each with one officer conducting constant personal or camera obs = 8,000 of police time.  Then deduct that half of those on camera obs, 320 were safeguarded in custody alongside someone else being watched anyway.  So deduct 3,200hrs of police time = leaving 4,800hrs expended.
  • Place of Safety – each detention lasts 5hrs and will usually involve two officers (because of force policy about detainees being held outside police premises), totalling 8,000hrs of time if the process has the effect of no-one going to custody.
  • In reality – a lot of areas find that exclusion criteria by the NHS means that a quarter of people are still going to custody and three-quarters to the NHS and that those going to the police cells are the more difficult and demanding cases, with an average detention time of 24hrs on personal constant obs.  This means 200 people at 20hrs each 4,000hrs; plus 6,000hrs in the NHS s136 suite.
  • Overall impact – police officers are now spending 10,000hrs administering the process, which is 2,000 hours more than before the introduction of the NHS service.  Or, roughly, the equivalent of a full-time police officer more than was previously the case.

Some while later, following reports to Wessex Police from other police forces, they seek to introduce a street triage process, to help reduce the use of s136 in that area and the use of police cells, thus saving all of the time they have been spending in custody and some of the time spent in the NHS place of safety.  So they set about it: develop a small team of police officers to work alongside mental health nurses after some joint training and one year later, s136 detentions in Wessex Police have reduced by 40%.  Some of the more demanding and difficult cases are still leading to detention in police custody, numbering 150 and the remainder of what is now 480 s136 detainees per year are now going to the NHS.

So having a process that was ‘costing’ 10,000hrs a year, 136 reductions are impacting upon this.  50 detentions in police custody, now averaging 20hrs each because of the challenge and complexity which amounts to 1,000hrs of time; plus 330 detentions in the NHS 136 suite amounting to 1380hrs.  So street triage saves 5,620hrs of time, right?!  No – because we haven’t factored in how many officer hours are spent staffing the street triage scheme.  Many of these schemes have four full-time equivalent officers, who will be working 8,320hrs each year.  Having started with 10,000hrs of commitment – most of which you shouldn’t be spending – you’ve then spent more than 8,000 more, to save over 5,000.  You’re now spending over 13,000hrs, or six full time-equivalent police officers.

Of course, I fully acknowledge two things -

  • This doesn’t even begin to address the amount of triage jobs which occur in private premises, which amounts to about two-thirds of their overall workload.  That’s another BLOG in its own right.
  • That police time and money spent on something is not the most important thing – up to a point.

AT WHAT COST?

Of course, the value we should place upon a far more dignified and humane process for vulnerable people should not just be measured in terms of police time or police budgets.  But paradoxically, it eventually has to be and I merely enquire where the line is?  If we told Chief Constables that we could reduce officer involvement in s136 detentions from 8,000hrs a year to 400hrs, they would welcome it.  If we were to tell them it would cost £1m of their budget they would almost certainly reject it because it doesn’t cost them £1m of cash to continue with the status quo and £1m is a big deal these days.  The current ‘expenditure’ is what some would call ‘opportunity costs’ – not a direct money saving that puts cash back in the bank but merely an opportunity to redeploy those officers to whatever the priorities are.  It’s this conundrum we have to grapple with.

But a broader point I want to make about policing and mental health over the medium and long-term past: we are seeing ever more activity.  Even when the IPCC published their report in 2008 they stated that 18,500 detentions were occuring, of which 11,500 were going to police custody.  We are celebrating the fact that in the intervening seven years, we have turned things around so that instead of 66% of vulnerable people going to custody, just 25% are.  But it is costing police resource to do this, even though the relevant national standards, agreed by all the multi-agency leads, states it should be reducing.  Then, having decided to do the right thing wrongly, we are now doing the wrong thing righter by developing street triage models which

We need to think this thing through, because police time to spend is becoming increasingly precious and we need to start accounting more for the individual hours because as a duty inspector, resourcing rising demand with fewer officers, there is an extent to which I perfectly well understand comments from colleagues about why they’d rather have one officer in custody doing a constant watch than two in a place of safety, neither of which should be there at all.

Incidentally, the death in police custody in Wessex is no more likely to be prevented now than it was when there was no 136 provision because officers still find it difficult to engage an ambulance at the point of detention and are still excluded from the NHS when detainees are highly resistant and aggressive.  Given that such presentations are a feature of most death in custody inquiries, some may wonder if we’re actually just fiddling at the edges of this?