Tricks and Tools

By working in a role that takes me around the country, I get to see the various differences that exist between police areas – and I don’t just mean the 43 police forces of England and Wales, but even more local than that.  I’m a West Midlands Police officer and my operational experience has mainly been in Birmingham but I’ve also spent three years working in the Black Country.  The Brummies and the Yam Yams will hate me for saying this: but those areas are not as different as they’d like to think they are – I hope I can get away with that, being neutral (a Geordie).  But there are differences in the way that services operate: different local authorities, different mental health trust albeit the same 999 services who often work across those boundaries.  Section 136 MHA works very differently on Shenstone Road, in west Birmingham depending on which side of the road you’re detained – one side of the road is in the Sandwell LA/MH area, the other is Birmingham’s.  Or maybe it depends which are the attending police officers have come from, because they’d likely resort to the process they understand for their area, even if they had wandered to the other side.  (And there’s nothing wrong with that, by the way!)

This is just one example: ramp that up hundreds, if not thousands of times across the country and we can think of even more variables that make our areas very different. Think of Cumbria, Cornwall, Camden and Cardiff –

  • The geography differs – two rural counties, a London borough and a capital city.  But those counties are not identical are they?
  • Cost of living varies enormously, especially on house prices.
  • Populations differ: in size and type as well as in other ways.
  • Local mental health services are funded differently by their respective CCGs or LHBs.
  • The are four different police forces, with their own pressures around funding, staffing and demand, etc..
  • One of those areas has its ‘own’ MH trust because the services are coterminous – this is not true in the other areas.
  • One force has two MH trusts, another has three, another has nine – this generates different challenges on training and local policy.
  • The psychiatric morbidity of these populations vary, as do social deprivation indexes.
  • The political instincts of the areas differ, both in local and general elections.
  • Two of the areas have devolved politics, but devolution with different implications for that area because it’s a different kind of devolved politics in Wales and in London.

These are just some of the variations we could list and you may wonder: what has any of this got to do with policing and mental health?!

LOCAL CONTEXT

In my experience, both the police and the NHS like to know about “what works” – whether we’re referring to the prevention / detection of crime or helping people recover from serious mental illness. It would be great if we could ring up colleagues who’ve struck gold in their local efforts to do these things and steal their ideas for use in our area. Since the advent of street triage schemes, I’ve had a number of enquiries at the College from forces who are at the early stage of setting up something similar asking, “What’s the best model to use?!” We see mental health services contributing their part to these police triage schemes without necessarily identifying that their trust is set up in a different way to the area they’re borrowing the idea from, without realising the differences will matter in terms of impact.

Of course one massive variable I left out of the list is “how often the local police force is using section 136 MHA?” Some areas historically over-use it; and I’m quite sure others probably under-use it. Will any initiative have a similar impact on different problems? Another variable: “how often are we using police custody as a Place of Safety across that force area?” West Midlands Police didn’t use police custody at all last year: not once. But other areas used it every week, sometimes more than once. So if you’re sitting in Birmingham trying to improve the world, it doesn’t matter whether street triage in Leicestershire or Northumbria has massively reduced the reliance upon police custody as a Place of Safety or not: it’s simply not a problem you need to fix.  (It has massively reduced it, by the way.)

My point is this – policing and mental health care involve providing complex responses to human beings who are un-alike by organisations who are staffed by human beings. Standardised responses to complex social issues like crime and mental health, including causes that will involved poverty, discrimination, substance use, etc., are never going to work: history actually already shows this. What areas need to do, first and fore-mostly, is understand their local demand for services and the context in which that demands occurs; and start by asking what problem(s) they are trying to fix. It’s my own view that we have nothing like enough information about this interface between mental health and criminal justice, so it’s difficult to avoid the temptation to reach for a box of tricks and show a sleight of hand, rather than using tools to engineer a truly workable solution.

TOOLS AT DUSK

If you look around the world, you’ll notice that there are only ever two solutions to whatever you think problem is: the police need more training and the police need to work in greater collaboration with mental health services. Apart from the (obvious) point that both of these ‘solutions’ begin with “the police need …”, as if to suggest that the only problem here is the police and police officers. My own experience is I’ve often tried to work in collaboration with MH services in operational incidents and often been told they can’t or won’t – it’s not for the want of trying in some cases! And there’s also the question of what we ask the police to *do* in response: we’re hearing more and more about the police (and others) doing Mental Health First-Aid training. Some areas are looking to roll this out quite widely to criminal justice and education, etc.. I know a couple of police officers who are MHFA trainers and whatever we think of it as an idea (and having observed an MHFA course, I’m not sure it’s relevant to police officers, quite honestly) we can probably agree on this: it’s a standardised course, taught to a standardised, MHFA-branded curriculum. Anyone can pay to go on such a course, and organisations engaged in a wide variety of activity are doing so, not just the public sector. But, being a standardised course: it doesn’t survive contact with all human beings who tend to have a variety of viewpoints on causes and responses to their illness / disease / distress

Standardisation, as a substitute for thinking and understanding demand, is what risks us bring a political (small p) solution to a problem that needs careful engineering. The risk to all this is, for various reasons, that policing and mental health could be seeing the dusk of its day in the sun. We had a CrisisCareCondordat in 2014 and since Mind handed over responsibility for the ongoing push, we’ve heard little more about it. I wonder how many CCC action-plans are now complete, three years after they were introduced? The legislation that has been developed to modernise the police-MH interface is done, we just need to see an administrative commencement order to bring that in to play; we’ve seen certain pots of money kicking about to improve a few things like Places of Safety, etc.. But we’re just starting to see a sense of drift on pushing those things, largely because any challenge around things can see confident deployment of stock answers around the CCC, new law and funding. Whether this is making any difference on the ground is something we can say is the responsibility of organisational leaders.

So one risk is leaders in police forces and mental health services reaching for standardised tools and tricks as we quickly look to put these challenges to bed so we can move on with other things – highly intuitive, attractive responses to non-defined or ill-defined problems are really easy. This is especially true if we’re not also ensuring evaluation of these solutions is sound.

  • Crisis Care Concordat action plan? – check
  • Street triage? – check
  • Liaison and Diversion? – check
  • MHFA and College of Policing training? – check
  • PaCA amendments understood? – check
  • Use of 136 and custody down? – check

Job done, right?!  You’ll notice that none of those things, inherently guarantees anything about the experience of the public or improved outcomes for vulnerable people and others. They may, but recent history shows they also may not. That’s why we need to continue to understand our demand, in its local context and to define the problem. If you want to give political (small p) responses to undefined challenges, you’ll need that bag of tricks – hence some are listed above, for your ease of reference. But if you actually want to make it far more likely you’ve engineered better outcomes for the public, you’ll need tools to engineer solutions to complex problems and you won’t know which tools to pick unless and until you understand what you’re trying to engineer in the first place.


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

Winner of the Mind Digital Media Award.


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Mental Health Expert

Today, I was invited to do something because I’ve been identified as “an expert in emergency mental health care.” I did wonder whether this was one of those mistakes made by someone who wasn’t reading closely enough, as when a medical recruitment company recently invited me apply for “vacant consultant psychiatrists’ positions in Birmingham, Manchester or London”. Apparently my CV had impressed them – my LinkedIn page, actually. It was obviously somehow beyond-impressive as it managed to distract their attention away from my utter lack of a medical degree or any professional registration as a medical practitioner. In fairness, I do have a first-aid certificate … but actually, even that’s expired if I’m being completely honest because I’m not currently in an operational role. I’m an associate member of the College of Paramedics, if that helps, but in fairness they don’t let me anywhere near the drugs or the cannulas. So nothing makes me an expert in emergency mental health care … I’m a policeman.

I can probably claim to have read certain medical or clinical guidelines from NICE and various Royal Colleges like Psychiatrists or Emergency Medicine that some doctors and nurses haven’t read (or heard of), but I’ll admit there were some large words in there based on Greek and Latin and I didn’t entirely understand them – I certainly couldn’t try to spell them in order to make this post look more impressive. So no, I don’t feel like an expert in anything, quite honestly. Me and my 4hrs of training (half of it was wrong, the other half was irrelevant in the real world) are still making this stuff up as I go along – sometimes literally. I’m trying to do that conscientiously, of course, and I want to understand things and make progress but nevertheless, that’s what this all amounts to – improvising. Most of this blog, is just me trying to put thoughts in order so it sounds vaguely coherent by the time I have to talk about it in meetings.

MENTAL HEALTH LAW

I realised early on that one key perspective missing from this emergency mental health care stuff, is the legal one and as a police officer, I can do something about that. Whilst I’m not legally qualified, I’ve done my legal exams for promotions and am used to making operational policing decisions based on my understanding of criminal and other laws. As a lot of the things I’ve been asked do to in my operational service and in policy work on mental health have been to consider the implementation of police powers or support for the administration of the Mental Health Act. It has always been true the majority of questions raised when I was the force MH lead for West Midlands Police and since being at the College of Policing these last three years were legal questions. “Have I got power to force entry?” … “Can I not rely on the Mental Capacity Act to do that?” and my favourite one, “Can English police detain an eastern European man who is missing from a CTO under Scottish mental health law if we found him near the wheelie bins behind Marks and Spencer’s in Nottingham?!” … err, just use s136, officer!

Even in my attempts to bring that perspective nearer the front of the considerations about how the police interface with health services of all kinds, I’m all too conscious that I have no qualified expertise. I was especially conscious of this when I spent several recent hours in the witness box of a Coroner’s Court … seven barristers lined up, none of them on my ‘side’ because I was an independent witness to the Court. I stood there before the questions started, just thinking to myself “this is where I’m probably going to be badly exposed” – for making it up and misunderstanding things! What I’ve noticed over the years is that when police officers ask police in-house lawyers for legal advice on mental health law, they often direct officers to me, so how solid our legal advice is, I’m not entirely sure! I even once raised a question with an in-house lawyer and he sent me a link to my own BLOG … you couldn’t make it up!

So it was with some relief to find that the only really challenging legal questions in court about the police guidance produced by the College of Policing in 2016 came from one barrister who merely insisted that we, the College, were wrong about how to interpret the some of the stated cases relevant to the issues before the jury; and wrong about whether the Mental Capacity Act could be relied upon to take someone from their own home to an Emergency Department. In fact, “precisely wrong” was the phrase used to describe it … I could only escape by insisting that we’d taken great care in producing this stuff, listened to many professional and individual perspectives from all over the place, including AMHPs, solicitors and other professionals who train the MCA to care staff and, of course, the we’d taken legal advice on it all. If I’m wrong, I’m wrong with a lot of people stood metaphorically behind me, helping me get this wrong.

A friend of mine recently posted a meme on Facebook, “The older I get the more I realise no one has a ******* clue what they’re doing. Everyone’s just winging it.” Be honest with yourself and disagree if you need to … but I certainly am and I couldn’t help but notice that whilst she was telling me I was wrong, she wasn’t telling me why I was wrong … and I’m still none the wiser today. Maybe she was making it up as she went along?! … it’s easy to accuse an unqualified policeman of talking rubbish without explaining yourself and then just move on to the next question after hearing his answer.

PARAMILITARY NURSING

I’ve worried for some time about police officers crossing the floor with mental health matters because they perceive themselves as gaining in expertise when they’re working so closely with their partners in NHS mental health services. And just to show I’m not the only one thinking about this sort of thing, I’ve had a few conversation with Claire Andre, the police liaison nurse at Northumberland, Tyne and Wear mental health NHS trust. She’s been asked if she’s actually a police officer and has had to explain she’s a nurse, just as I’ve been asked if I was a mental health nurse before joining the police – she like me, couldn’t work out whether to be flattered, offended or both! But we’re both alive to the idea the idea that police officers and nurses working closely at this interface can end up thinking of themselves as some kind of hybrid professional, rather than just a better informed cop, or nurse.

This kind of thing reached peak nightmare for my version of this concern when I happened to walk in to a street triage office somewhere in England last year to overhear one of the PCs on the telephone to a person I had to assume was a member of the public who’d rung the police in connection with MH issues. As I entered the room I heard, “Yeah, uh huh … you probably need to up your meds!” in an encouraging voice.

WHAT?! ……………………………………..

Turns out it was a known mental health patient who’d rung the CrisisTeam and been told to ring the police, but presumably not to get medication advice from an officer?! … we need to get a grip! What if that person now takes more than they were prescribed to take, already on a high dosage or are self-medicating, using other substances and they end up developing serotonin syndrome?! That sort of thing can prove fatal if properly qualified people aren’t advising patients what to put in to their bodies and you should alter medication only under clinical guidance or supervision, for various reasons …. and all because some PC over-reached their expertise, if they actually had any to start with. And just to back up the very point I’m making here about my lack of expertise in these matters, I can only protest about the consequences of ill-advised police advice about SSRIs because I asked a couple of clinically qualified people, including Claire how to construct this paragraph!  Why would I know, beyond me knowing it’s a BAD THING?! … I’m a policeman.

STRIKING A BALANCE

You have to work for three years at university to qualify as a mental health nurse so what chance we can pick this stuff up in police car by doing a few shifts with street triage?! … whilst there’s no university course for policing, you take prosecution decisions in the police at the rank of sergeant, so it usually takes even longer than an undergraduate degree and involves those legal examinations I mentioned earlier, in addition to years of experience of investigating crime, preparing court evidence and handling custody detainees. So this stuff works both ways round: I’ve had numerous MH care professionals telling me what they think the law is only to get it so badly wrong that it was genuinely difficult not to laugh and just pat them on the head. My point is: nurses nurse, the police police – we just have to learn how to better manage that interface without being unable to ask questions or even challenge on occasion. But we hven’t go this balance right yet and we must put the public and vulnerable people first in all that we do.

So, some kind of mental health expert? … no.  And this isn’t faux modesty or an attempt to be humble: it’s actually a real insistence that you’ve very badly understood what I’m trying to do here!  I’m not trying to fix the world, I’m trying to police it and that means ensuring rights and protections for vulnerable people as well as taking the most difficult decision of all: when those responsibilities mean I should use force on a vulnerable people to protect them and when, if at all, I should place them even further in to the criminal justice system than their contact with me.

That isn’t mental health care: it’s policing.


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

Winner of the Mind Digital Media Award.


The Coroner’s Courtroom

For the first time in my career, I gave so-called ‘expert’ evidence to a Coroner’s Court around a mental health incident. It all centred on the response to a vulnerable man in his own home and I will blog more specifically on that once the court has published its documents. Suffice to say here, I became quite concerned by the difficulty 999 crews seemed to face justifying their actions and inactions; as well as the extent to which other organisations tried to focus on those difficulties.

So leaving those specifics for later, here is a checklist for how to approach these issues so that as a paramedics or police officers you can’t be the one accused of doing too little or failing in your legal duties towards vulnerable people. This is what I want you to know, having read hundreds of pages of documents and given over 5hrs of evidence overall, just in case you end up there connected to an operational incident.

PRIMARY  ASSESSMENT

Imagine you enter a private premises and realise you are answering a mental health crisis call. You make that initial assessment of the person, the location and grab on to any information which is available. Here’s the quick checklist for what I will call the primary assessment – this means the assessment of whether the police can take action now, without referrence to others, almost immediately ensuring the safety and wellbeing of the person they’ve just met, pending assessment –

  • Mental Capacity Act 2005 – this appears first on the list purely so you ask yourself whether you have walked in to a situation which is already, more-or-less, life-altering or life-threatening?  It’s obviously vital that we don’t miss this!
  • If so and you are responding to someone you think is over 16yrs old and who lacks capacity about a specific decision, then you may have a duty to ensure their welfare and you would be able on rely upon the MCA if challenged about what you did. Call an ambulance if you’re a cop; call the police if you’re a paramedic who is going to need help to restrain the person and remove them to hospital and whichever you are: have a think of this problem from the other 999 crew’s perspective as to why they will want your support.  Scratch each other’s backs, as it were! #team999
  • Try to engage the patient in agreeing to attend hospital for assessment and care. If they decline and police or paramedics think the medical issues are already life-altering or life-threatening, you may consider removing them to hospital under the MCA.  Your legal justification will be around section 5, 6 and 4B of the Act because even if your actions amount to depriving the person of the liberty, s4B outlines how this can be justified if you are provide a ‘life-sustaining intervention’ or doing a ‘vital act to prevent a serious deterioration in someone’s condition’.
  • Unrestrictive options – in the absence of needing to act immediately to save a life, is there any ability to call upon other professionals to take over the clinical assessment of someone you think is mentally unwell?  Whether that is the Ambulance service, an out of hours GP, a community or crisis mental health team will depend on your area and the circumstances you face: make sure you know what your local options are!  In the absence of that being possible (for whatever reason), document what you did, what you may have tried to do or what you considered and ruled out, with reasons.
  • Criminal Law – if there is any evidence of a criminal offence, attempted or substantive, then you may have powers to arrest in respect of that offence in order to ensure the safety of the person. It may still be necessary to get clinical advice about risk if the intervention is still predicated upon concerns for someone’s mental health, because conditions that officers may think of as ‘just’ mental health issues can often be other maladies, from meningitis, serotonin syndrome, Addison’s disease, brain tumours or diabetes … other examples are also available!  Call an ambulance if you’re detaining and restraining someone who you think is mentally ill.
  • Common Law – history shows officers have often relied upon common law powers, usually to prevent a Breach of the Peace or its continuance, to intervene in private premises.  It’s almost been a proxy for the absence of powers under the Mental Health Act 1983 (MHA). Where a breach of the peace is actually occurring(!), this is perfectly legitimate but officers need to be satisfied that the legal basis is sound otherwise the risk is a custody officer will decline to authorise detention. The same concerns apply to detention and restraint under Common Law as criminal law: medical matters are not identified or managed in any way because of the chosen legal framework to be applied.
  • Mental Health Act 1983 – the police service have no powers in private premises under the MHA, except where someone is already liable to detention under the Act, for example an AWOL patient. You may not arrest for criminal or common law matters and remove a person from the property only then to detain someone under s136. The exception to this point, is where someone has been removed from a building or land where they are not allowed to be: trespassers who are evicted on behalf of property owners may be regarded as ‘found’ in the place to which they are removed, for the purposes of other laws. If you have got this far thought your primary assessment, you’ve just ruled out your use of legal powers.

SECONDARY ASSESSMENT

So if you’ve quickly checked off that list and you find that you’re still stood in a private premises with someone who you think is experiencing a mental health crisis. Next part … and this is the bit that’s crucial, based on what I went through in the Coroner’s Court two weeks ago.

  • Tell YOUR supervisor – get them engaged in this to take on some responsibility for this minefield you’re now navigating!
  • The Sessaycase (2011) tells us that where there are concerns for someone’s mental wellbeing in a private premises and no legal ability for the police to intervene, the route to assessment is via an Approved Mental Health Professional.
  • Section 13 of the Mental Health Act states –
  • “If a local social services authority have reason to think that an application for admission to hospital or a guardianship application may need to be made in respect of a patient within their area, they shall make arrangements for an approved mental health professional to consider the patient’s case on their behalf.”
  • Ask yourself (or ask the officer, if you’re wearing green) whether using section 136 MHA would have been an option if the person were to have been encountered in a public place? If yes, do not leave the incident without referring this to someone who takes on responsibility for what happened next. This could include responsibility for doing nothing next, as we’ll see below.
  • However, regardless of local policies and preferences in local authorities, mental health trusts or GP services there is nothing in law that prevents paramedics or police wanting to draw the local authority’s attention to the potential that s13  contacting the AMHP service for their area to discuss the matter.

SUMMARY

So to sum that all up! –

Primary assessment

  • MCA – life-threatening or life altering?
  • Any unrestrictive options: GP / street triage / other?
  • Criminal or common law – any offences / breach of the peace?
  • MHA – is the person in that location lawfully?
  • MCA – is it proportionate to remain pending secondary assessment?

Secondary assessment

  • MCA – consider s5 and s6 MCA as the basis to keep the person safe.
  • Inform your supervisor – request support.
  • Remember the Sessay / Seal cases – no legal ‘improvising’!
  • Consider whether you’d use s136 if found in public.
  • Can you or supervisor refer the whole thing to a duty AMHP / EDT / CrisisTeam / GP or whoever gate-keeps?

At this stage, you need to be clear about what you’re communicating:

“We’ve been called to a MH crisis incident where I’d be using s136 MHA if we met this person in public. I’m concerned for their immediate welfare and in the absence of legal powers of my own to remove the person and safeguard them, I’m seeking your support to consider the need for a Mental Health Act assessment.”

Document everything, including names and their verbal reactions – formal or informal. If you should ever have to stand in Coroner’s Court, you will want and you will need to be able to show your ‘working out’ for all of this, accepting you won’t be an expert in these areas of law. I would encourage you to refer to the Sessay judgement in your statements and if you’re really feeling confident, refer to paragraphs 33-38 to reinforce your understanding of MH issues in private premises is that the MCA cannot be relied upon (unless it’s life-threatening / life-altering) and that the MHA is the route to take, via an AMHP and a DR.

And on behalf of AMHPs everywhere, who will probably feel somewhat stitched up by what I’ve written above, please be prepared to help them with this if they ask for help.  The above has been known to lead to an AMHP turning out to premises with a doctor within 45mins (yes, really) and detaining someone under s4 MHA. They will face exceptional challenges however, if doctors are in short supply, if they need warrants from the court or if there are no beds. Help to the extent you can because any decision to walk away will also be questioned. And trust me – it will be questioned!

Finally: whoever may complain about this approach about resources or local policy, just keep coming back to this point: “Nothing I am asking for breaks the law and this approach reflects my assessment of the risks in these circumstances and I am legally entitled to draw to the local authority’s attention that s13 MHA may apply to this situation.  Your responsibility is to decide what your response going to be, bearing in mind it will be documented for the record and referenced in legal proceedings if necessary. This is the way Parliament have deliberately chosen to structure the law and I’m operating within it.”

This is about partnerships, but not just professional partnerships between the police and the other public services, it’s about balancing those against the partnerships police must maintain and develop with the public, because they are the ones we serve and who have legal rights which should be respected.


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

Winner of the Mind Digital Media Award.