Surviving or Thriving?

I’ve been trying to think about the question posed by the Mental Health Foundation for this year’s mental health awareness week in the context of policing and our involvement in responding to mental health related demand: surviving or thriving?

I’m all too aware of comments realised in recent weeks by frontline officers on social media that demands and responsibility connected to mental health are rising and it’s getting harder and harder to manage this demand across response and neighbourhood teams which are under pressure around how they spend their time. We have also seen senior figures like Sir Tom Winsor, HM Chief Inspector of Constabulary, voicing concern about the extent and the nature of the role the police are now playing in our wider mental health system and the effect this is having on frontline policing.  I can’t be the only police duty inspector who has stood in the middle of the night making the decision to order two police officers out of a Place of Safety where NHS staff had asked them to stay because it was the lesser of the various things I must police and for which I did not have enough resources because of a quick succession of serious crimes.

Are things not just getting worse?

Indeed, if you look, you will find plenty of information which can help you build an argument that the police are, at best, surviving – and I’m sure some police officers would add “and only just”.  You could point to the rise in our use of s136 of the Mental Health Act, it’s up 10,000 in 10yrs since 2007, which means more officer hours spend removing people to various settings and often, remaining there with them for many hours until assessments can take place.  We could add that mental health professionals are struggling sometimes to arrange assessments in a timely fashion – national guidelines state s136 assessments should occur within three hours and we know it’s often double that and more.  We have heard in the media recently that police coding of mental health incidents shows we have experienced a rise of around 26% in three years in the overall number of incidents which are classified as mental health related.

In his ‘State of Policing’ report, HM Chief Inspector of Constabulary reported that the police are all too often a first-resort contingency plan for our mental health system and that the extent of this problem is forcing Chief Constables and duty inspectors to make frequent decisions about what they will prioritise; and how. Only over the weekend, a mother who lost her son in one of London’s latest knife-attacks has stated that the police are not doing enough on knife crime. We could do more about knife crime and various other things if officers weren’t remaining in health-based Places of Safety routinely, because NHS commissioning decisions have ensured the facility they opened for assessment wasn’t fully staffed. You can only spend your pound or your police officer, once.

Could we look at this another way?

Since that report in 2007 on police use of s136, the proportion of people detained under s136 taken to police custody as a Place of Safety has massively reduced: from 66% in 2007 to 7.5% in 2016. That’s a drop in numbers from 12,000 a year to jail for being ill down the just 2,100 – I strongly anticipate this figure will reduce again when the next figures are published in a few months. I was beyond chuffed to learn, for example, that my own force in the West Midlands has had the first ever year where no-one was taken to police custody as a Place of Safety, thus demonstrating a total turnaround in the position from ten years ago where everyone went to jail.

I also get a sense that we know more about this stuff now: we find examples of police officers delivering training about policing and mental health to mental health professionals, not just the other way ’round.  We see that partnership relationships on mental health have improved beyond measure: not just around the development of initiatives like street triage, although they are very positive examples of innovation in many cases, notwithstanding the longer-term questions. In the West Midlands, a senior police officer is seconded to the Mental Health Commission chaired by Norman Lamb MP as part of the overall revision and delivery of a wide-range of mental health services, not just those connected to policing or criminal justice. And although, I’m nervous about offering this next view, I’m starting to wonder whether we’re seeing a reduction in either the number or the controversy of some policing and mental health incidents. In the last IPCC report, the only s136 related ‘death in custody’ was, in fact, a death which occured in a health setting after the police involvement in the s136 process had ended.

Should we look at this more positively?

Mental health demand isn’t going to go away: the police service have been credited by many senior figures in mental health and in politics for driving the mental health agenda to a degree: it was a police officer, Commander Christine Jones QPM, who caused the creation of the Crisis Care Concordat. It was the police who drove the reduction in the use of police cells as a Place of Safety and convinced the Home Secretary that wicked problems could be solved, something which has since become enshrined in law. It was police forces who sought out the opportunity to create street triage schemes in many of the areas we see them and in many instances, it is ‘the police’ via Police and Crime Commissioners who are directly paying for that, not our NHS. It is the police service which came out better in the eyes of the public, better than many NHS organisations, for the positive impact of our attitude and response when dealing with mental health crisis incidents. We’re not perfect, but we’re more often valued by the people who call us for help.

So it all comes back to your perspective: we know the police have a role to play in our mental health system – we always have had and always will do because not everything is predictable or preventable. Of course, there needs to be limits on the extent of the role – we don’t want police officers on mental health wards handing out medication – but we need to understand and accept that we have a perspective on mental health issues in society that even some mental health providers don’t have and a key role to play in tough decisions about criminal justice issues. We are positioned to drive the agenda to a degree and are doing so. Indeed, history shows that if we don’t, we will be pushed in directions that are neither in the interests of police services nor the public we are here to serve. It also shows that if we are active in this arena, we can and will impact upon it.

In that sense, despite demand rising and things getting tougher, is this not a form of thriving we can be proud of?  I think it is.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


Medicalising and Criminalising

So, we’re still discussing the fallout of Sir Tom Winsor’s comments almost one week after they were made. A few of us have blogged our thoughts on this and many of you have commented on those posts and social medica more generally. We all share a view that there is a problem, but I’m not sure we share what it is, never mind a shared sense of what we should do about it. Some people have spent the week arguing that we are criminalising mental health and mental illness by relying upon the police to the extent that we do, but what I think has been interesting this week is the number of representations that we’ve got this the wrong way ’round: we’re not criminalising illness, we’re medicalising human behaviours.

Look at the literature on this stuff and you’ll see both positions well represented. The US academic Professor Linda Teplin did a lot of work in the 90s arguing about criminalisation; another US professor, Allan Horwitz wrote a book called ‘creating mental illness’ which argued we over-medicalise behaviour. Australian academic Deidre Grieg devoted a whole book to the discussion of one man and his journey through the mental health–criminal justice interface: Garry David from Melbourne ended up having a whole Act of Parliament targeted at him and him alone, given that politicians were unable reconcile the public safety issues that arose from their perception that neither system was able to keep citizens safe from obvious risks. Less academically, we see a public narrative about the relationship between mental health and crime that seems all too often to assume that if someone with a mental health problem has offended, they must have offended because they have a mental health problem.

Then we need to remember we’re not always discussing things fully: acuity of someone’s condition is rarely discussed – not everyone who is mentally ill is psychotic and unable to lead a full and meaningful life full of employment, family and personal responsibility. But a few are. When you compare a range of issues for those who are often unable to function because of serious mental illness you see differences in approach by mental health services and by the police and prisons, compared to where we see the police called to a person with a non-acute illness that neither affects their personal responsibility for actions undertaken or means they should necessarily be treated any differently by the police.

CRIMINALISATION

This word is used in a couple of different ways, so as ever, we need to be careful with this kind of terminology – apart from anything else, some people just don’t like it. I’ve been told to remove this word from reports I’ve written on a couple of occasions, because it’s a bit opaque unless you spend time explaining it. Do we mean a) whether a person’s attempts to secure care occured via the police or criminal justice system when they were prevented from just accessing it directly? Or do we mean b) the extent to which the police and criminal justice agencies take different types of decisions when in contact with someone who is thought to have a mental health condition than they otherwise would – and of course this could be to a greater or to a lesser extent than they otherwise would.

It’s certainly true to argue that we have some set-ups which now mean patients and mental health professionals think it’s easier to access care via the police than otherwise. Street Triage schemes have often reported that they feel other parts of the health system, from GPs to Community and Crisis Teams, are occasionally pushing demand towards the police for someone who is not what you might think of as someone needing policing services. This ‘normalises’ the involvement of the police in healthcare, about which many patients have things to say, if you ask them!

However, if you have a situation in which 100 people are alleged to have committed an offence, you’ll see the range of responses from the police from arrest, to warnings to cautions or criminal charges, as thought appropriate. However, if those situations involved individuals suspected to be mentally ill, we are less likely to see arrest and / or prosecution outcomes because of diversion or referral to health services. Does this mean we ARE criminalising illness because care access was via the police or NOT criminalising because the officers took punitive CJ decisions less often?  Depends on your politics (small p).

MEDICALISATION

The other perspective is to look at whether we’re medicalising behaviour. I will admit, I’m less aware of any research that has been done on this issue so if anyone reading this knows of any, please leave a comment below and let me know. But yet again, this could mean one of a couple of things. Are we a) arguing that there may only be a limited and indirect relationship between behaviour and the panoply of health conditions which can be aggravated by social factors, but that social, non-punitive responses can be better than traditional criminalisation and punishment-rehabilitation?  Or are we b) assuming a causal relationship between someone’s condition and their behaviour and arguing that if you address the underlying condition, you affect future behaviour – there is some evidence that this is true, however, certainly not for all types of mental health condition, all of the time.

Human beings will suffer very bad events in their lives which are entirely predictable and awful: bereavement is one that will affect most of us at some stage. Other people suffer from traumatic accidents and injuries, redundancy, abuse or divorce to list just some examples. All of us will struggle to some degree to cope with such matters when they happen, but this does not automatically mean they ill. A few of us may need additional, sometimes professional support to handle our live experiences and some may become ill, usually for more than one reason as people are complicated things. But the difficult issue is where you draw the line between looking at someone’s behaviour and choosing whether to see it as ‘crime’ or ‘illness’. Indeed, there may be a need to see it simultaneously as both: the dichotomy between ‘mad’ and ‘bad’ is false one, both medically AND criminally! But however interesting this is, however philosophical you want to get about it and however much academics have written, if you’re a front line police officer and you’re going to have 43 seconds to take a decision as profound as this, we may have to accept here people are going to get it ‘wrong’ from at least some people’s subjective perspective.

THE 9 AM JURY

It’s quite easy to walk in as the morning hindsight squad and have a view about what some frontline cop should have done last night, in the dark, but always fascinating when you ask people to put themselves in the officers position. What the reaction this week has shown me, categorically and beyond doubt, is that there are a wide range of passionately held, solid views that officers are over-medicalising behaviour AND that they are over-criminalising the vulnerable; AND they are making these calls in situations most of us aren’t prepared to place ourselves. The person in the high street who is waving a knife around, you have a minute to think about it: should they be arrested for possession of the knife or detained under the Mental Health Act. No, you can’t have any more information, you have to decide and you have thirty seconds left.  Have you decided yet? … not easy, is it?!

In other words, this touches upon my very favourite question in all of policing and mental health and the very thing that could be profoundly interested in this stuff when I was custody sergeant fifteen years ago: when is it “right” to prosecute someone for a criminal offence if we know they have a mental health problem? The public policy answer (in Home Office circulars 66/90 and 12/95 as well as the DPP’s Code for Crown Prosecutors) is “the more serious the offence, the less relevant a person’s mental health issues are to the police / CPS decision to prosecute.” This is my attempt to summarise pages and pages of stuff in to one sentence, so please forgive the deliberate over-simplification! Where someone is stealing food whilst psychotically unwell and living rough in crisis, we probably don’t want them prosecuted for being hungry and very poorly. However, if they stabbed a supermarket security guard whilst doing so, it becomes a different assessment to make. If that assessment were influenced by a history of non-engagement with mental health services, absconding from hospital and / or a background which showed they posed a serious risk to the public as a whole, it becomes easier still to start taking these decisions. But make that a less serious but non-trivial offence, mix in social distress and substance use? How easy is it now?! … you have thirty seconds to decide.

Remember, only the criminal courts can issue certain kinds of protective orders under our mental health legislation which balance an individual’s right to treatment with the need to protect the public, where necessary – that’s true in most jurisdictions around the world. But given how far apart the views were this week – we need decide what we want our police to do and back them because whatever they get right or wrong, I know this: frontline officers only have blunt tools to take decisions that require sophistication and finesse.  Have you ever tried playing a musical instrument gloves?


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


Missing The Point

Yesterday, Her Majesty’s Chief Inspector of Constabulary, Sir Tom Winsor said something extremely important in his annual review, known as the “State of Policing” report.  The main headline from the document was his argument that the police are now filling gaps in mental health services and that this represents a drain on resources which are being diverted from other policing responsibilities. It was his clear view that “the provision of mental healthcare has reached such a state of severity that police are often being used to fill the gaps.” He makes the point that the police “have often been used as the service of last resort. In some areas, particular where people with mental health problems need urgent help, the police are increasingly being used as the service of first resort.” He goes on, “We are still finding cases of mentally ill people – who have not committed any crime – spending the night in a police cell. This is because they are too vulnerable to be left alone but there is no bed for them in a healthcare facility. The provision of mental healthcare has reached such a state of severity that the police are being used to fill the gaps that other agencies cannot. This is an unacceptable drain on police resources and it is a profoundly improper way to treat vulnerable people who need care and help, not incarceration among criminals.”

He makes a comparison for mental health care with the police approach to crime prevention, “It is far cheaper to prevent a crime than it is to investigate and arrest the offender after the event.  The same is true of mental ill-health, which is not a crime.  It is an old adage that an ounce of prevention is better than a pound of cure and this is particularly true when the cure fails and an emergency intervention is required to protect the safety of an individual in distress and, often, people nearby.  By the time depression or some other mental disorder has been allowed to advance to the point that someone is contemplating suicide, or engaging in very hazardous behaviour, many opportunities to intervene will have been missed by many organisations. When that intervention takes place on a motorway bridge or railway line, or when someone is holding a weapon in a state of high distress, the expense to all concerned is far higher than it should be.  The principal sufferer is the person who is ill, especially when it is realised that his of her suffering could have been much less or even avoided altogether.”

I’m sorry to keep going, but his words are well worth reading, “There is the economic cost in terms of the expenditure of time and effort by the police and other public services, as well as the expense and trauma sustained by those adversely affected by the crisis at the time.  The economic arguments for earlier intervention intensify the health and moral ones ready in play. Furthermore, research, carried by Ipsos MORI for HMIC, shows that only two percent of people think that the police has the greatest for responsibility for the safety of people with mental ill-health or learning difficulties. With an estimate one in ten young people having a mental health problem, this is not a matter for the police alone. The inadequacy of mental health provision and the lack of parity with physical health provision in this country should disturb everyone. It should never be the case that someone who requires treaetment, for any condition, should become the responsibility of the police simply because other agencies do not have the resources to act.”

FIFTEEN YEARS

I did not know this report was coming out until it was published and I started to receive media enquiries about whether the College of Policing would allow me to be interviewed (listen from 19:55). Having downloaded the report, abandoned a colleague I was having lunch with to read it on a Tube on the way to a BBC studio, I couldn’t help but smile and shout “Yes!” to myself as I travelled down the Victoria Line in London. After tweeting the report, my reaction was to add, “I’ve been saying this for fifteen years – glad to see everyone’s catching up!” And this links to the way I’ve been recently summarising where we are with things now. We can talk all day and night about various things that have gone wrong in policing and mental health, up to and including controversial deaths in custody following restraint. When we do, we tend to find people saying “the police need more mental health training” and “the police need to work in real time collaboration with mental health services”.

Well, Sir Tom’s intervention doesn’t address either of those things, specifically – it goes far more directly to the real heart of the problem, to his credit: a problem I’ve flagged for many years now. Neither intervention even begins to address why we now rely so heavily on the police as part of our model of healthcare – what is driving people towards the police in the first place?! Professor Louis Appleby (former government tsar on mental health and criminal justice) was quite quick to dismiss the HMCIC’s assessment, tweeting –

Again, this misses the point being made. Positive collaboration isn’t addressing the reason why the police are being called in the first place and evaluations on these collaborations are known to be poor so we don’t know whether it’s decreasing police contact for vulnerable people, regardless of whether it’s improving it. Helping the police respond better is the second of the two solutions and it’s not necessarily preventing the deployment. Some so-called ‘street triage’ schemes will claim that they have identified calls coming in which don’t need the police and the triage nurses have handled callers directly, without officers deploying. But we also know that some healthcare professionals have started diverting more demand to policing because “the police have nurses now!” and the triage nurses have complained like hell but be unable to avoid deploying to situations police officers aren’t required at.  I’ve seen that with my own eyes several times whilst shadowing.

And no, we don’t have data – those who designed these things didn’t appreciate the need for it. They were told, but they didn’t listen. Can only say that I tried! … the blog posts are there to prove it!

ACADEMIC EVALUATION

We’re simply not sure whether demand because of triage is rising or falling, because it’s not being evaluated properly and in fairness to Mr Winsor, it’s not HMIC’s job to do research! — whereas it is Professor Appleby’s. Research funding for policing and mental health projects seems to be hard to come by. Professor John Baker mentioned on Twitter recently that his attempt to secure funding hadn’t been successful but that he’d be interested in doing it. I’m aware of two other academic bids for funding to take a more thorough and critical look at these collaborations which have been turned down by health funding agencies. What more can you do that try?! It’s not HMIC’s fault that ‘positive collaborations’ are collecting very limited data sets, that academics are choosing not to really look at this stuff and that research funding bodies are turning down applications. Until then, you might just have to make do with people blogging, and offering their opinions.

Of course, HMCIC’s views are not just opinions – this is the professional judgement of Her Majesty’s appointed adjudicator: he has a formal position in our society and a statutory duty to call it as he sees it, even if there are some remaining questions of detail. I hope his intervention prompts research to prove him right or wrong, then at least we’ll know, won’t we?! But however, you look at it, Sir Tom’s views will no doubt be predicated on impressive quantities of information and opinion that HMIC collect from forces in their various routine inspections around custody and around general effectivenss, amongst others. The CQC are involved in advising on some of those inspections because of the obvious overlap with health issues in custody and CQC is an organisation on whose board Professor Appleby sits and for the record, their opinions and reports don’t always survive contact with reality, either! … but I can’t just dismiss the statutory regulator for healthcare and the Mental Health Act out of hand, can I?!

Meanwhile, my good friend Nathan Constable has blogged very well and very quickly on this new report. I’d encourage you to read his views. He’s also busy working his way through a Master’s degree looking more deeply at the issues around the role of the police and his early work has uncovered much that supports HMIC’s position: that mental health professionals thirty odd years ago could see where community care was going, where the use of s136 MHA was going (up) and where the role of the police was going. You only have to look at other countries with non-public healthcare systems to see how the criminal justice agencies end up playing a massive role, because there are inadequate social justice mechanisms to stop it from becoming necessary. If some people have a problem with uneducated police officers with 4hrs of training trying to fathom out what the hell is going on and making some kind of in-roads in to handling the rapidly increasing demand faced by British policing, they should feel free to step up: do some quality research that I can’t climb through and I’ll stop blogging and go an arrest someone for something. Until then, it seems a valid use of police time to try and understand how we address some of these issues, firstly and foremostly by actually understanding them and then do what the police are charged with as their primary duty: prevention.p>


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.