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All CLEAR?

Last Friday the Royal College of Emergency Medicine, in conjunction with the Royal College of Psychiatritsts, launched the ‘CLEAR’ campaign, concerning mental health emergencies – see the poster, above. It’s the last of the five points that has seen a bit of discussion on Twitter today and of course: that’s the one that affects the police –

  • Co-location of liaison services
  • Liaison services should be available 24/7 in ED
  • Education for ED staff
  • Adequate access for adolescents
  • Right person to the right Place of Safety

I’m not sure anyone would put forward an argument that emergency mental health care is entirely adequate. Indeed, the CQC published a specific report on this last year, touching upon patients’ experience of crisis services, A&E departments, the operation of s136 of the Mental Health Act, etc., etc.. So it has to be welcome that two medical Royal colleges want to do more and do better on emergency mental health care but we also know the rising pressure that ED is under at the moment as well as the rising pressure on MH services.

There are problems with ‘R’; and if you read the whole poster it goes on to say that Emergency Departments should not be the default option as a Place of Safety –

  • This implies the ‘right’ Place of Safety actually exists – we know this isn’t always true.
  • It implies that we actually know what the ‘right’ Place of Safety is for any given patient – we also know this isn’t true.
  • It says that an ED is not the default destination – is there actually any evidence that it ever was?!

The UK has detailed plans for various things in healthcare but one thing they’ve struggled with for decades is the question of where an intoxicated, suicidal mental health patient should be taken if they were detained under s136 by the police. We have no clear idea what would happen.

HISTORY

I’m one of those police officers guilty of having used an Emergency Department as a default option – in May 1998.  You see, they trained me on s136 MHA in Pleece Skool and told me that a ‘Place of Safety’ under the Mental Health Act 1983 was ‘a hopsital, a police station or anywhere else temporarily willing to receive to the patient’. Having detained a man I had concerns about on the Dudley Road in Birmingham, I was only 150 yards or so from the front door of A&E and not knowing of any other hospital in my area, we walked him up there. I’d already been in that Department various times, arresting drunks for threatening and assaulting staff and it seemed to be a place where people were keen to see the police. They often gave us a cuppa to keep us hanging about in the department when it was busy, it kept us acting as a deterrent against people causing problems in there.

But turn up with someone and say ‘section 136 of the Mental Health Act’ and it was a very different kettle of fish.

In 2008, the Independent Police Complaints Commission published one of the first truly national surveys of the use of this power. Based on 2007 data, it revealed that approximately 18,500 individuals were detained under this legal provision and that 11,500 of those were taken directly to custody. Of the remaining 7,000 people, many of them were taken to a Place of Safety in a mental health unit – London was more or less completely covered with PoS provision so that accounts for a further 3,500 of those. Of course, within the remaining 3,500 will be all those people who were presenting with conditions that made an Emergency Department the appropriate place: those patients who had potentially overdosed, who were physically injured by self-harm injuries or who had other medical problems. But this brings us to one problem: in what circumstances is ED the ‘right’ place? – even ED can’t agree about that.

The idea that ED was a default option most of the time is just not borne out by what we know about how this power has been used – that distinction is claimed by police custody and we do know that this has contributed to deaths in custody. Since 2008, other data have emerged and as the use of police stations has reduced, I’ve no doubt that ED has copped for a proportion of that demand. Whilst I understand ED frustrations about this for cases other than where ED is specifically clinically required, there are legal reasons why officers might be inclined to chance their arm there – and there is nothing unlawful about them asking the question! But by the time we get to the end of this post, I hope to convince you that all of this debate is a red-herring and that the real problem no-one discusses is – proper alternatives to detention for people in contact with the police; and sufficient services to which those who are detained can be removed where it can’t be avoided.

LEGAL PROBLEMS

There are further difficulties we cannot ignore: this initiative assumes that there is agreement about where various people detained by the power should go. Remember the case of Toni SPECK in York from 2011? – she died from serotonin syndrome according to the Coroner and her inquest led to various legal arguments, both during and subsequently, about whether there was a legal duty to provide a specific Place of Safety in a hospital that isn’t an ED. The High Court quite quickly dismissed an application for judicial review by stating that there was no such duty in law; and where police officers have immediate concerns about wellbeing, they could go to a hospital ED. Of course that Coroner’s jury also ruled it was not reasonable or fair to expect police officers to pick up all those potential medical problems with which patients detained under the provision may present and it also heard evidence that if she had been taken to ED her life may well have been saved.

The police cannot do this alone, as Lord ADEBOWALE told us – several years ago!

So if officers work in a place where there is no specific mental health unit Place of Safety; where that location is unstaffed by anyone who works for the NHS; or where the ambulance service either will not or do not respond to a request after detention – where do the authors of the poster want the police to go? … what is the ‘right’ PoS in that situation?

And what about those pesky things like statutory guidelines and caselaw? – it’s been a statutory guideline since at least 2008 that police stations should not be used as the automatic first or even second choice, but only as a last resort. Before giving in to that inevitability, officers should consider the alternatives – so is ED an alternative for someone who does not require it on clincial grounds, but where another health setting is unavailable? What about the police detaining an 87yr old woman with dementia and when you shout up to the control room, you learn the 136 suite is unavailable – do we lean towards police custody or ED – where do you want your elderly parent or grandparent taken? Does it matter if she’s not 87yrs old, but 57 … or 27?!

IN THE REAL WORLD

It’s all very well saying ED is not the default option, but that assumes we live in a world where the ‘right’ options are actually available to the officers who can then be expected to make the correct choice. What happens about acute behavioural disorder? – I refer you to another post for the ongoing debate about whether that’s a ‘thing’ or ‘not a thing’, but I can completely assure you, ED departments take a very different view about these issues. Only this week I had a conversation with a force mental health lead who was contrasting the attitudes of two ED departments in his force area towards the police when dealing with people in crisis. One of them even formally wrote to the police to tell them that they ‘weren’t a Place of Safety under the Mental Health Act’, helpfully quoting from the Act itself to emphasise their point. The only problem was they omitted the word ‘hospital’ when they were cutting and pasting section 135(6) MHA.

I’m sure it was just an error.

I’m curious as to what the poster authors recommend the detaining officers should say to the custody sergeant when they arrive in custody and the sergeant quite rightly asks, “What alternatives have you considered and tried before coming here to satisfy the obligation on us all under paragraph 16.38 of the Code of Practice to the Mental Health Act?” In case of doubt, the UK’s highest court ruled in 2005 that a Code of Practice is not mere advice, it is a statutory guideline “which should be followed unless there are cogent reasons for departure.” So read paragraph 16.38 and ask yourself what you would do as a police officer.

IT’S GOOD TO TALK

Bearing in mind the CLEAR campaign is collaborative initiative between professional colleges, it seems unusual that the College of Policing weren’t involved, bearing in mind that 20% of the headlines they’re hoping to raise awareness about are connected to the use of a police power. (I also wonder whether patients could have been involved, bearing in mind Twitter didn’t seem to have anyone popping up in discussion to say they thought it was a positive step.) It would be unlikely that a query to the College of this type wouldn’t end up with me and Friday was the first I’d heard of it. Of course, it’s not the first time the police (or patients!) have been left out of discussions on mental health that affect the police. It’s traditionally been seen as our role to do as we’re told and we quietly did that for many years, subcontracting our responsibilities for leadership and training to others.

But we’re now in a time where the police have had to learn some hard lessons and push back against a system that inadequately integrates the commissioning of ambulance, emergency and mental health services to allow the lawful discharge of the duty of care which is owed by the state to those who are detained in crisis. The frustration about this is evidence within the NHS itself, especially in ED – patients told the CQC last year that attitudes towards them are often poorest in ED.

I saw a tweet today during the debate about the above where a Consultant in Emergency Medicine and clinical lecturer at a University told the world that he was “happy for ED [to be used] as a PoS if guaranteed 1hr to see an AMHP and psychiatrist + immediate transfer if admission required.” No wonder service users were today wondering whether he makes similar protests to other medical specialists – that they MUST respond within a certain time and admit within a certain time, otherwise patients shouldn’t come in. Let’s be honest, that’s the inference of the tweet.

So on this basis, I’m really looking forward to going to the Royal College of Emergency Medicine mental health day in late February to see if I can stop us talking about red-herrings and see if we can focus on the real problem together!

– The RCEM and the RCPsych have issued a clarification statement on this very point, in respons to concerns. I’m not sure it helps me, but all credit to them for responding.


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

Winner of the Mind Digital Media Award


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Normalisation

This is a guest post by Em, or @DrEm_79 from Twitter – our various discussions on there made me realise she has a lot to say that is important and relevant for police officers responding to mental health crisis incidents. I think there’s a lot going on here and much of it is contradictory: but that seems to me to be precisely the point Em is trying to make – the normalisation of the police as a de facto mental health service is something to caution against and worry about

I’m giving a trigger warning, too: Em’s post contains descriptions of suicide attempts and restraint  that may disconcert some who read this —

It takes eleven minutes to walk to the GP surgery, but I only made it halfway. I don’t remember deciding to die. I don’t know why I chose the wooded embankment, and I’d lost consciousness before the police search helicopter, the ambulance and resus. When you’re unconscious in intensive care, as well as the life supporting interventions, they remove your contact lenses. Several days later, when I woke up, it was to a blur. There was a tube and ventilator supporting my breathing, fluorescent light and blurry hi-viz. The hi-viz turned out to be police, still waiting in the relatives chairs opposite my bed.

I have what are referred to as severe and enduring mental health conditions, and started hurting myself when I was five. Over the thirty years since, I’ve had a lot of contact with police because of my mental health. Police have saved my life more than once. They’ve listened to things no one else has, stepped into my flat when everyone else has walked away, seen me at my most terrified and vulnerable, and selflessly got themselves into trouble arguing for me to have mental health assessments when other services were trying to shift responsibility. They’ve also restrained me for hours, detained me in cells, vans, handcuffs and leg restraints, unwittingly contributed to the destruction of my career, and a hate attack by my neighbours. Police intervention when I’ve been unwell has left me at times too frightened to stay in my own home, with a front door that didn’t close. It’s fair to say our relationship is uneasy. The intersection of mental health and policing is complex, and there are as many experiences of mental health as there are people. I can only speak from my own perspective. Changes to the way mental health care is provided and policed where I live over the last ten years have not helped me. In crisis I need help from clinicians who know me, can recognise I’m ill and respond early. But now early intervention is rare, and crises are left to escalate.

My mental health care plan stated that if I or others call mental health services because I’m unwell, mental health services are to advise calling police if I’m at risk. Sometimes it’s the mental health staff, sensing risk and needing to do something with the sense of responsibility, who call. A “welfare check” by police is now seen as a health intervention. This normalisation of police as the first responders to mental health is stigmatising, distressing, and for people like me who are known to be unwell, just adds to the resource ultimately used in a crisis. I’m not sure police being the planned response to people who are looking for mental health help is a good thing in a sophisticated society. As someone on the receiving end of that shift from health holding responsibility for mental health response to police, it frightens me, and at times has made me more unwell.

Over all of the contact I’ve had with police when I’ve been unwell, there are some things that have helped, and there are others, both at the individual and systems level, that haven’t.

Things that can help –

Beware short term thinking for long term problems –

Many mental health conditions, by definition, are not one-off events. Most people with mental ill health will have more than one mental health related crisis in their lifetime. In responding to mental health crisis there’s a need to consider both immediate need and also the longer term implications of that response. My experience of police in mental health crisis is that they are good at thinking in immediate terms, especially when dealing with someone at risk to themselves, but that this short term thinking can sometimes take over, which can lead to consequentialist ethics – as long as the immediate crisis is resolved, it doesn’t matter what you do to get there. Short term focus applied to a long term or recurring condition can create problems in future.

For example, last year the mental health team reported a concern for my welfare. I wasn’t at home. A police sergeant called me and asked me to tell them where I was and for me to meet with them. They promised I wouldn’t be made to go to the hospital, that all they wanted do was talk. On meeting them, I was immediately put into the police van and taken to hospital. I can see this may seem justifiable; a promise they were never going to keep achieved the short term outcome they were looking for, but longer term what that created was a person with severe and enduring mental health problems, very likely to have further crises in future, who no longer believes the police will tell them the truth. In the long term it has made things harder for everyone. Many people with mental health conditions have experience of trauma and trust in others may be fragile. Expediting an outcome by not telling the whole truth may jeopardise the only opportunity for that person’s trust.

Radios, the third person, and remembering I’m there –

When I’m experiencing hallucinations and delusions, routine aspects of police work can be menacing and frightening. Being aware of this and making even small allowances can help.

For example: radio use. When I’m hearing voices, and may be paranoid that people are talking about me and planning to hurt me, disembodied voices coming from radios or officers repeatedly leaving the room to talk into the radio, often only partially out of earshot, can add to the fear and beliefs I already have. You can’t stop the voices I’m hearing or the delusional ideas I have when I’m unwell, but if you’re able to, explaining what you’re doing and why, as you’re doing it, can help: “I’m just going to speak to my Sergeant on the radio, to let him know where we are..”

I often don’t feel in control when I’m ill. That’s part of what is frightening. You may not feel able to let me have control over what happens, but keeping me informed and talking to me rather than about me in my presence can help. Even if it doesn’t seem like I’m taking in what you’re saying please keep talking to me, acknowledging my presence, and telling me what’s happening as much as is possible. Try not to talk in the third person about me when I’m there, it can worsen feelings of paranoia and threat. Many people’s experience of voices is a commentary in third person. Even if someone isn’t interacting, talking to them about what you’re doing as you’re doing it, letting them know and including them can prevent the situation from becoming worse.

Restraint –

Unless you’ve experienced hallucinations, flashbacks, or other perceptual disturbances, it can be difficult to imagine what it’s like, but we all know what it is to feel afraid, or that you can’t trust someone. When I’m unwell that fear can exist at another level, which is partly why I think restraints can often go so wrong. Whereas someone who isn’t experiencing a disturbance to reality might observe they are being restrained, perhaps in a cell, and realise they aren’t going anywhere, and eventually relax, the things I am frightened of in crisis often aren’t proportional to what is being done to me. When I fear someone is trying to hurt me, that belief doesn’t just go away if my movement is restricted. The fear will likely be escalated by restraint. It isn’t ‘acting up’; it’s terror.

Some of the times I’ve been restrained by police were before anybody even tried alternatives such as talking to me. Restraints have lasted hours, with me becoming more and more frightened, but once restraint is started I become so much more afraid the only option to stop is chemical sedation or further restraint. Restraint while mentally unwell is confusing, terrifying, and traumatic. Where it is not essential, avoid it, or at least know what you are getting into, and have a plan as to how you’ll get out of it.

Stigma; and leaving a life to go back to –

In mental health crisis the focus from police I’ve met has sometimes seemed to be to contain and transport me to the hospital as swiftly and by whatever means possible. This has often involved transport in police vans or cars, handcuffs, even though I’ve never been violent to another person and there has been no crime. Although I can guess some of the pressures that might make the quickest form of transport seem like the best, be aware of the effect very public police interventions for mental health can have at somebody’s home.

For example, I live in a tenement building, when attending my flat, police have had discussions with bystanders including my neighbours where police have disclosed my history of mental health problems. More than once I’ve been filmed by people being put into a van for transport to hospital. There is a stigma to being with the police; people assume you are criminal, dangerous, disruptive, undesirable. I’ve lost professional status and career because of stigma that still exists about mental health. Police aren’t responsible for my neighbours’ intolerance of people with mental ill health, or their subsequent attack when I returned from hospital, but protecting me isn’t just about containing me in a van and waiting with me at hospital until I’m detained, it’s also about being aware of the impact you’ve had on my life and my community, and leaving me a life to go back to.

Think about language –

I don’t expect police to be therapists, or have endless time and full knowledge of a situation, but thinking just a bit about the words you use and the way you ask questions can make a difference to the responses that you get when I’m unwell, and ultimately can make a difference to the amount and reliability of information you can gather to help decision making.

For example, when there has been a call with concern for my welfare and police want to ascertain whether I am at risk. Commonly, officers do this by asking: “Are you planning to do anything silly?”

This tells me a value judgement the officers are making about self harm and suicide. It makes me less likely to think that person understands, wants to help, or can be trusted. It also directly impacts the content of my answer. When I’m unwell often nuance and turn of phrase are lost and I interpret things quite literally, or ascribe them more meaning than I might on a day I am well. I also don’t think suicide is silly, and at times I’ve been unwell I have felt it is the most sensible thing in the world, either because I’ve felt compelled to do it by external forces, or because I’ve felt so depressed it has seemed a rational choice. The answer you get can depend on how you ask.

Other ways to explore suicidal feelings are, if there is time, gradually in a stepwise way. Start by showing you are interested, there aren’t set words, if it doesn’t sound authentically from you that’s easy to pick up, but things like: How have you been feeling today? … Have things ever been this bad before? … You said you can’t cope, are you having any thoughts of ending your life? Ask explicitly about suicide. There’s good evidence it doesn’t put the idea in someone’s head, and there is a lot of stigma, suicidal thoughts may not be volunteered if you don’t ask directly.

If someone does say they are feeling suicidal be aware that’s an incredibly difficult thing to say; it’s taboo in society, and there are even more barriers to talking to police about it. So often if I have spoken about suicide to officers they don’t even acknowledge it, as soon as they have that information their next movement is to press the button on their radio and start talking to their Sergeant “Yes, yes, admits is suicidal..”. It would have taken a few seconds longer to acknowledge to me that they’d heard that and that they wanted to help. Those few words can make a massive difference. In crisis it is easy for the needs of the person who is unwell to become peripheral to service protocols and needs. Try to avoid this.

Say you want to help –

Professionals often implicitly and sometimes explicitly assume when a person is in crisis that the person will trust them because of who they are, and that the person will believe that the professional’s motives are to help. This often could not be further from what the person believes. It isn’t enough to assume that I think you want to help, you need to say that, and act in a way to back that up.

People without mental health training often feel uneasy talking to people who are mentally unwell. Often this comes from a place of concern – they don’t want to make anything worse, but it has an isolating, dehumanising effect on people who are unwell, and in crisis can increase risk. In an acute crisis listening to someone who is ill is one of the best strategies to help them feel calmer and start to trust, and may be the difference in making it possible to help them.

Filling out a form does not make somebody safe –

Beware mistaking following process for mitigating risk. After being called out to me, police almost always have to fill out a form for their vulnerable person database. I’m seen as a vulnerable adult, and coming to my home they’ve often had concerns for my welfare – risk of harm to myself, lack of food and heating, lack of security, risk from others. There have also been many forms submitted to report adult Protection Concerns under the Adult Protection act with concerns about self neglect and risk from others. These forms are sent to social services. Yet despite dozens of these forms, and hours of police time, not one of these concerns has resulted in changes to my treatment or care. There are complex reasons for that – uncertainty over which service, if any, holds responsibility for care and treatment and crisis response. Even when Adult Protection meetings have been held there has often been ambiguity, obstacles, or no outcome. Yet because it is procedure, still the forms are completed and sent.

It seems the process was followed and there was a partnership in place, but nobody had oversight as to what impact that process had on the risk it was trying to manage. Even the fact the forms contained the same concerns over and over didn’t alert anyone that the situation hadn’t been addressed. I don’t know if there are other systems like this, where ticking a box or completing a form gives mistaken reassurance that risk has been managed? Protecting someone may involve a form, but the form alone does not help me.

Planning and prevention –

Although uncertain and frightening for me, and often portrayed by the media as unpredictable and dangerous, there is a predictability to mental ill health. If police are going to be part of the response to mental ill health, could planning and prevention have a bigger role?

For example: When unwell my awareness and perception of the world around me can change. This can lead to me travelling miles and finding myself somewhere, often with physical harm, sometimes unaware how I’ve got there. If police are alerted by somebody concerned where I am, I become a resource intense high risk missing person. Yet there is often a predictability to my travel. In the days or hours before I become unwell I have sometimes tried to seek help but not been able to access it. There are also patterns. I’ve been missing and unwell and hurt a number of times, but for years nobody sat down with me afterwards when I was more well to talk about what the triggers were, the types of places I found myself, or tried to ensure there are safeguards in place so the situation could be managed more safely if it recurred.

I don’t think providing mental health care is the role of the police, but this is the sort of area where working with me has benefitted everyone. A few months ago a local Sergeant spent time talking with me, being reliable and straightforward, and rebuilt some of the trust I had lost in police. He listened (a lot) and started to understand what was going wrong in responses to me, what helped and didn’t. It’s far from fixed, but that time has helped police start to develop a more informed, safer response. They understand more where I am likely to be when unwell and the safest ways to respond, and have saved resource in doing so. It isn’t a high profile media lauded scheme, and that Sergeant has had no recognition; but by gaining my trust, getting to know me and what happens to me, and thinking with me about how police can help me to be safe, he’s helped police to save my life more than once.

Don’t give up hope –

I’ve been critical of police responses to mental health, but there is one way in which police response has been consistently more helpful than many other services, including mental health services. And just now, I’m worried this may soon be lost.

When someone has been ill for a long time, health services can sometimes develop something called therapeutic nihilism, a feeling that nothing is going to help the person. Unfortunately sometimes without realising they then stop trying to help. This is often seen at suicide inquests, when people report clinicians having said to the person who has now died that they could not help them, or other negative or very hopeless statements.

Hopelessness is associated with completed suicide, and this type of response can be immensely damaging. Clinicians also have a different view on responsibility of people who are unwell to the police, again we know from inquest evidence and service user experience that with some disorders in particular, professionals may say things such as: “it is up to you whether you die”, “we can’t stop you” (which may be true, but..), “if you wanted to do it you would have”. Such negative statements may not be said with harmful intent, but that is often their effect.

Yet the response of the police, perhaps because of their duty to protect life, seems more hopeful. They will keep trying to intervene, keep trying to help, and don’t refuse to come to help people as health services may end up doing with some patients. This persistence can be lifesaving. When a person is totally without hope it can help, even fractionally, for someone else to believe they are helpable, and importantly that they are worth helping. People who are feeling suicidal often feel they don’t deserve help. One of the best ways to challenge this is to show them you want to help and you aren’t giving up on them. I wonder if this is one of the reasons service users report contact with police in crisis is often positive, in some cases beyond the time that the police are with them. Just acting as though there is never no hope at all sends a message that may make a crucial difference to somebody.

This is one of the reasons I’m not entirely convinced about some of the current co-response plans between services. I hope they won’t lead to the nihilism some other services show to people with the most complex problems starting to affect police response. Police are good at not giving up in mental health crisis in a way that other services are sometimes not. It can be harder to give up on yourself when there is someone else not giving up on you. I hope that isn’t lost.

Even when I’m most unwell, treat me like a human, talk to me and listen, and be as compassionate as you can to another person who is suffering. Even when unwell I can sense hostility and value judgements and they do not help. Be aware of the effects of stigma that exists around mental health, the assumptions people make about criminality when police are involved, and where you can, try not just to protect my immediate physical safety, but leave me some dignity and a life I can face again after the crisis is over.

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Subcontracting Responsibility

It was several years ago that I first sat in a room listening to a mental health professional delivering legal training to the police about mental health and capacity law and found myself thinking, “But that’s not right!” More than once I’ve had cause to review protocols between the police and mental health services which have been written by health or social care professionals and found myself thinking, “But that’s not right!” … legally speaking. When I first had these thoughts, I usually scuttled off to do more reading or re-reading on different aspects of mental health and capacity law but as the years have progressed, I’ve become more confident in just saying so. In the last eighteen months of being at the College of Policing, forces have been kind enough to invite me to attend training events that they’ve run, where they have asked professionals of various kinds to deliver training to police officers. I have had several occasions to flag up to forces that they’ve been given duff information and was recently in a meeting where a training proposal was largely based around the idea of calling the local mental health trust and inviting them to deliver inputs to staff.

So I want to caution against subcontracting responsibility, whilst accepting that this probably comes about because of a lack of national training standards on mental health across policing – something I am actively working on correcting this very week!

In recent examples –

  • One mental health trust asking officers to believe that they would have to use section 136 of the Mental Health Act 1983 (MHA) on inpatient wards in general hospitals because section 5(2) MHA can only be used on psychiatric wards. << This is wrong – it can be used in any inpatient situation by any registered medical practitioner and in fact, things go further. The Code of Practice (2015) to the MHA makes it clear in paragraph 16.20 that section 136 should not be used on wards, that staff should use powers under section 5 to ‘hold’ patients for assessment under the Act where this is required. We all know what can go wrong when the police are unnecessarily called in to inpatient settings in connection with mental health issues.
  • Another force invited training on the Mental Capacity Act 2005 (MCA) for officers and a lead trainer, who was an AMHP by background, told the assembled operational constables and sergeants that they are empowered to use force to remove a person to hospital and hold them there “if a paramedic tells you they need to go to hospital and that they lack capacity to refuse.” << This could be correct, but it requires additional factors and considerations that were left entirely unmentioned. This advice, with further qualification, is wrong. We all know what can go wrong when the police start misapplying the MCA in private premises.
  • I always love the debate about warrants under s135(1) MHA, something which I recently addressed in Liverpool at an AMHP event. I’ve more than once heard and seen AMHPs telling the police that warrants under this sub-section may only be obtained where access to the premises cannot be gained with permission. << This is wrong – it’s also the misunderstanding that sat at the bottom of one of the most testing operational incidents I’ve ever dealt with! … an incident that would be have been as easy as pie if only the AMHP involved had known what this sub-section allows. We know what can happen when the police enter premises to mitigate risks without any legal powers to do so!
  • Finally, there was the street triage training I saw – no wonder I’ve ended up concerned about civil liberties in this context. I am particular inclined to recall an email review of an incident where front line response officers disagreed with the advice of nurse who, in my view, seemed professionally affronted that their advice on a man in crisis was ignored. The escalation email betrayed a lack of knowledge by the nurse and the officers were quite right (as well as legally entitled) to take a different view – but how many street triage schemes are predicated on the basis of nurses being experts?  They are on mental health issues, of course – just not necessarily on mental health law on which they receive surprisingly little training.

I could go on. The point here is not to denigrate mental health professionals, although I realise that’s the a real risk here – there are many mental health nurses in particular who have impressive legal knowledge and of course formally study mental health law in order to qualify. I’ve learned an awful lot from such professionals and continue to do so. The point here is to caution against the notion of subcontracting responsibility for officers training requirements to another organisations without quality assuring that content.

VESTED INTERESTS

Only today, we saw publication of a Guardian article which claims that police incidents connected to mental ill-health have risen by 33% in three years, based on Freedom of Information requests made by journalists to police forces. The College of Policing is quoted as stating that between 20-40% of police time is spent on mental health related matters.  A few quick incidental points about this article, before returning to the point about training –

  • It may be thought that’s a very wide range to claim: 20-40% – these figures were the lower and higher numbers that we know some forces use, not our estimate overall.
  • And the claim was not about the percentage of police time spent, but about the percentage of overall police demand connected to mental health.
  • There will, undoubtedly, be an element in the rise of better data collection – the police have been learning more, recognising more and therefore recording more of our work as involving mental health.
  • So not all of this ‘rise’ will be real – my personal view, for what that’s worth, is that most of it is.

Returning to the original point: I’ve often wondered about the extent to which the legal arguments adopted by some mental health trusts or professionals is motivated – not maliciously – by their vested interests?  An AMHP who can persuade an officer that a warrant cannot be secured doesn’t have to undertake the considerable extra activity associated with doing so; a mental health trust who can persuade the police to come and use s136 on an inpatient ward will not have to work out how to apply section 5 and administer the implications of such a decision.  And so on.

I really don’t think this stuff is motivated by any kind of malice – not at all. I’m rarely, if ever, convinced these things are about deliberately misleading officers. It just becomes convenient for the police to absorb risk and responsibility and so received wisdom develops that this is the way it should be done – or maybe in some areas that is the way it has always been done?  Of course the most common legal error heard in all of this stuff is the one about physical restraint and the use of force, in various situations: outside the example of restraint for seclusion or medication in an inpatient setting, I’ve heard countless times that “only the police have the power to restrain.” You could apply this to situations where AMHPs have ‘sectioned’ someone; to situations where AWOL patients are located and need to be returned to hospital; or to situations where paramedics wish to remove someone to hospital for urgent or emergency intervention under the MCA. It may be true that only the police have training, but it’s certainly not true that only they have a legal authority to do so. That subtle distinction becomes important when you get in to details.

Policing and mental health is usually all about the details!

QUALITY ASSURANCE

So where forces are contemplating training or informal briefings, it must be worth checking what’s actually being delivered – and not just on legal issues. Many MH trusts still argue that those members of the public who are detained under section 136 of the Mental Health Act 1983 who exhibit aggressive or resistant behaviours should be taken to police custody as a Place of Safety purely on that basis.  The examples continue to build, if they weren’t already convincing, about officers making a perfectly reasonable assessment that someone may be suffering from a mental disorder only for it to emerge later that they were actually suffering from a serious undying medical problem. In due course, I’ll tell a story about section 136 and meningitis that will make every officer in the country question whether it is ever right to take someone to custody unless they’ve first been medically cleared by the NHS.

It remains the case that some mental health trusts actually still want the police to do exactly that for which the IPCC would arrange to criminally investigate them if the worst happened after assumptions had been made about aggressive resistance on detention. So is that trust the best organisation to explain to local police how to discharge their legal duty of care? Perhaps we should accept on mental health, as we do on almost everything else in professional policing, that we work in partnership with many organisations but we are not blindly beholden to them where they advocate wrongdoing – however motivated – and we should be confident we’re developing the expertise to make our own decisions about how we lead our staff and live up to our responsibilities.



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

Winner of the Mind Digital Media Award