Clinical Commissioning Groups

Clinical Commissioning Groups (CCGs) were introduced by the Health & Social Care Act 2012 – they are now the bodies in England which are responsible for healthcare. They are, in principle, led by GPs in the area they cover and, as the name suggests, they are responsible for ‘commissioning’ the medical care that is provided for their areas, having taken over this legal responsiblity from the Primary Care Trusts which they replaced. During this time, the structures in Wales remained unchanged: they had Local Health Boards (LHBs) in Wales prior to 2012 and they still do – health provision being a constitutionally devolved responsibility in Wales.  Both CCGs and LHBs have certain specific responsibilities under the Mental Health Act 1983 and it these responsibilities I want to touch upon here.

The health professionals reading this should try hard to accommodate my blatant over-simplification in this paragraph, bearing in mind it’s for a police audience, in the main! — the idea behind commissioning is that the CCG can ‘buy’ the required medical services from any competent provider, whether they are an NHS Trust or a private provider like Virgin Care. CCGs are given the budget by NHS England (who in theory hold CCGs to account, but who have also decided to uplift the money given to CCGs for mental health by less than that for physical health) and the GPs are assumed to be competent to take the best decisions for their local areas. Where thought appropriate, CCGs they can combine their efforts to buy care in order to achieve economies of scale: so for example, all the CCGs in Birmingham and Solihull have pooled their money for adult and older-adult mental health care and bought it from Birmingham and Solihull Mental Health Foundation Trust.  Just to give a sense of how complicated it can be, one of those ‘Birmingham’ CCGs is actually the Sandwell and West Birmingham CCG who have given some MH money for their Birmingham residents to the overall MH Trust for Birmingham and pooled their ‘other’ mental health money for their Sandwell residents with Wolverhampton, buying services from the Black Country Partnership NHS Trust.  Having worked in both Sandwell and west Birmingham as an operational cop, there is therefore a road bordering the areas where you have the same CCG but which MH trust supports you is determined by which side of Stanmore Road you live on – and they provide services in a very different way.  Hope that’s nice a clear for you!

This post is about CCG and LHB responsibilities under s140 of the Mental Health Act: this is a section of the Act few people may have heard about, but some of will be familiar with the fact that I bang on about this section with monotonous regularity, ignored as it is by CCGs!


At the end of 2013 I was sat at home one evening, frustrated by yet another story of police officers being asked to illegally detain people in police cells pending a MHA application to hospital by an AMHP. The AMHP was struggling to identify a bed in to which a patient could be admitted and in all fairness, it’s not the AMHP’s legal responsibility to find a bed when it’s required – that duty sits with the lead DR from the patient’s MHA assessment. The DR was struggling because the local trust’s ‘bed management’ system was saying everywhere was full up and they were struggling even to find an ‘out of area’ or private bed in any hospital further afield.

So I decided to dash off three dozen requests under the Freedom of Information Act: asking CCGs to provide to me the list of those hospitals they have a duty to specify to Local Authorities who oversee the operation of AMHPs. I’ll let you read up on the specifics of s140 in a previous BLOG if you want more detail.  Suffice to say here that NONE of the thirty-six CCGs could actually answer the question – some of them were even honest enough to admit they did not understand the question! Section 140 obliges CCGs to identify those hospitals within their area or to which they have access that may receive patients in “circumstances of special urgency”.

Where do AMHPs make urgent applications when risks are such that someone needs urgent admission?

Urgent admission is a human rights issue: we saw this in the case of MS v UK [2012] where even ostensibly lawful detention in a police cell under s136 MHA was deemed incompatible with Article 3 of the European Convention because a patient was allowed to get in to an extremely degrading condition when they were in ‘dire need or urgent psychiatric treatment’. So the ability to admit patients quickly is a legal requirement not only to manage any risks to the patient or, less frequently, to others; but it is also necessary to prevent patients who appear lawfully detained suffering extremely degrading conditions when acutely unwell.


When this discussion emerges, it is normally pointed out that s140 doesn’t actually oblige hospitals which find themselves specified from receiving those patients who admission is urgently sought – that if hospitals are full and there are no beds then “there are no beds and that’s the end of it!” said an AMHP to me on one occasion. These kinds of responses miss the point being implied by the section – it’s not so much about creating a duty on already stretched (or over-stretched) hospitals to find capacity to manage another unwell person; more importantly it is about an implied requirement on the CCG to ensure that within their overall commissioning arrangements, they have planned for peaks and troughs of demand and contingency for urgent admissions.

I was caused to think of this again earlier in the week when I read an open letter from the Chief Executive of Help for Heroes, responding to criticism that the charity had done too much, too well, in ensuring provision for injured military personnel. A minister had questioned the provision because beds were empty and Bryn PARRY replied “Recovery is not measured in the number of beds occupied on any particular night; we are not running a Travelodge.” This is the point: an empty bed in a Help for Heroes rehabilitation unit or in a mental health unit is not a disaster: in fact, it’s a necessity if you are dealing with complex service provision and levels of unscheduled demand, you may need available capacity to manage urgent admissions. This is what the court found in MS v UK: that making arguments about a lack of resources in the mental health system was not adequate to explain why someone’s human rights have been violated and it implied the need for contingency. That, to my mind, is all that section 140 is getting at: commissioning.

So back in the world of service delivery decisions by AMHPs and DRs, delaying applications for admission for bed management reasons may well be something advocated by the Code of Practice to the Mental Health Act, but a Code of Practice is legally far less significant than violation of the mental Health Act itself – which makes no mention of ‘beds’ as a threshold for admission – and less significant than violation of the European Convention. But these arguments are about the complexities of service provision: what is ultimately important is that when CCGs are sitting down to make commissioning decisions about mental health care, they anticipate the very obvious reality that from time to time, admissions to hospital are going to be required and that to delay at all will sometimes amount to a violation of Article 3 and / or Article 5. CCGs are public authorities under a proactive duty to prevent those violations in the way they do undertake their work, so they need to be commissioning slack in the system.

Probably best not to get going on supposed financial implications: more than one area of England has already found themselves in the position of having incurred more cost from our of area and private placements to cope with demand than they ever saved by reducing the number of beds in the first place.  Cutting beds to save £1m whilst incurring costs well over £1m to cope with resulting excessive demand?! … it’s just inane! Section 140 is not, ultimately, about tactical decisions by AMHPs or about forcing over-stretched hospitals to accept ever more admissions – it is about CCGs recognising a clear implication to ensure they commission just some hospitals in such a way as to maintain contingency options where AMHPs have to act urgently.  CCGs are currently doing to AMHPs what Stuart LANCASTER is doing to the England Rugby team – making the tactical execution harder than it needs to be by making some poor strategic decisions.

On that note: I’m now off to watch whether England become the first hosts to be kicked out of their own World Cup even before the end of the group stage.

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

Winner of the Mind Digital Media Award.


No Warrant Required!

I pen this BLOG post on behalf of AMHPs in England and Wales! – they seem a touch ground down by the Old Bill and I offered to write this as I am rather bored in a London hotel room whilst working down here for a couple of days.

I logged on to the Masked AMHP Facebook group earlier to see what’s happening in the AMHP world. If you haven’t read the Masked AMHP’s BLOG, it’s a multiple award winning insight in to the world of Approved Mental Health Professionals – the elusive Masked AMHP also set up a closed Facebook group which is primarily a discussion forum for AMHP issues but it does include several non-AMHPs who are interested in the interface they have with these under-recognised mental health professionals. I try to “skool them in pleecing(!)” on behalf of police officers but it’s fair to say they have some really embarrassing stories about how the police service have really left them with it.

I often say in presentations I do to AMHP events (like the Yorkshire AMHP event in Leeds in December, if anyone’s going to that one?!) – I wouldn’t do their job for all the money going and I really think I mean it! They are so often caught as the ring master of a circus: responsible for keeping the whole show going but not really in charge of anything and unable to command resources to ensure things that must be done, are done. I’d encourage you to read the Masked AMHP BLOG: I really learned a lot from it and it was partly responsible a few years back for me thinking there should be a police BLOG on mental health.  I disgress …

Tonight, an AMHP was asking questions about police responses after Mental Health Act assessments where police support is requested and I now need to ram home something I’ve noticed is repeatedly said by AMHPs when they ring for police support – and they can’t all be wrong!


Where an AMHP and DRs have attended someone’s home and ‘sectioned’ them, individuals who were thought persuadable, sometimes refuse to move to hospital. Efforts are often expended to persuade – perhaps paramedics present may try as well as the AMHP to persuade and influence; maybe the threat is made of having to call the police and all manner of verbal tactics are attempted. It may be that low level physical ‘encouragement’ is given: I’ve known AMHPs put their arm around a person and try to walk them to the ambulance; I’ve known the paramedics engage in what was beautifully termed ‘proactive blanketting’ in order to prevent someone’s arms lashing out whilst efforts were made to move them gently.

Officers and those involved need to be clear: this is all lawful – once a person is subject to an application for their admission to hospital, they are in legal custody for the purposes of the Mental Health Act and the AMHP may detain and convey the person to shopital with all the powers and privileges of a constable. The AMHP may also delegate these powers to others, including the ambulance crew and / or the police (who have no powers in their own right, under s6 MHA). However, the problem emerges when trying to determine at what point hte police, should be called and the extent to which it is always a role for the police to coerce patients who refuse to comply with the legal decision the AMHP has taken. There are therefore two things going on here –

  1. When and how should the police become involved
  2. What are the legal issues when they do become involved?

I’m going to tackle these the wrong way around!


There is one crucial error made by police control rooms and some officers – I repeatedly hear reported by AMHPs that when they seek police involvement in this situation, they hear a certain reply that is just legally very silly indeed. The Code of Practice to the MHA supports the involvement of the police where patients are ‘violent or dangerous’ (para 17.13 CoP MHA) – I’ve always held the view that this is different to patients who are resistant or what the police would call ‘passively resistant’ – sitting in their front room armchair, refusing to move but not actively assaulting people, for example. This is point  2 and I’ll come back to it.

In terms of point 1, the legalities for officers who do become involved, AMHPs report they are all-too-often find a refusal is given based upon the fact that they “do not have a warrant” under the Mental Health Act. Let me be completely clear about this: they do not need a warrant to act. Where the AMHP is lawfully on the premises and has completed a MHA application for admission, they are no longer obliged to leave the premises if requested because the person is in their legal custody and they may authorise others to act through the delegation of the AMHP’s power under s6 MHA. To refuse to assist on the grounds of there being no warrant is to make yourself look very silly because it makes no legal sense at all – warrants become irrelevant after the application was made as long as the AMHP remains on premises.

The person became ‘liable to be detained’ when the application was made and the patient may be conveyed to hospital on that basis alone: forces can choose to send officers if they wish and they would have all the legal powers they need. That takes us back to point 1 and not something the AMHPs have asked me to raise, but in the interests of balance it seems necessary to do so!


Point 1 is by far, the trickier question: whether to send police officers. Here are some more legal facts –

  • Nothing, specifically, obliges the police to attend such requests except where additional there are statutory duties to do so: to prevent crime, bring offenders to justice, protect life / property or maintain the Queen’s Peace.
  • Local protocols are required between police and mental health services to determine how situations will be handled without the poor old AMHP having to improvise their way through a nightmare where everyone refuses to get involved.
  • The organisations who employ AMHPs and assessing DRs bear responsibility under Health & Safety law to mitigate foreseeable risks and I’m sure we can agree: it is foreseeable that some patients who are ‘sectioned’ will resist admission.
  • The Code of Practice suggests that ‘violent or dangerous’ is the threshold for police involvement and that this should be reflected in the local protocol required by Chapter 17 of the CoP MHA.

Various things can be said here and it comes back to senior police officers ensuring the existence of good local protocols. It seems unbelievable really but in my last operational job, the local area only had two protocols for hte implementation of the MHA out of the four they should have had. So there was no document, anywhere which helped a duty inspector understand what their responsibilities were for ceratin common MHA situations. I know that AMHPs in that area took a dim view of my therefore taking decisions according to the law – it turns out they were used to police officers often doing as they were told but I took the view that as long as I am acting lawfully, how I expend the various resources my Chief Superintendent has entrusted to me was my professional business, against the objectives I was being asked to deliver, most of which were not around mental health care. That said, there were plenty of incidents during that operational posting where the incidents connected to mental health were absolutely the main operational policing priority.


This is REALLY difficult stuff, isn’t it?! … it’s not (just) legal pedantry that brings me to this point: there is the question of the extent to which it is a responsibility of the police to resource responsibilities that could just as easily sit with mental health services where officers have no legal duty to do so?

What about the NHS and LA managers responsibility under Health & Safety law to mitigate forseeable risks and co commission appropriate conveyance services (see Chapter 17 of the Code of Practice)? How are senior police officers and senior health & social care managers agreeing on roles and responsibilities where resistent, aggressive or violent patients are concerned? How are we guarding against the unnecessary involvement of police services in mental health care, to protect against the perception of stigmatisation and criminalisation that attends their involvement for so many vulnerable people in crisis?

The detail of this is important because without that level of attention, the risks is that a well informed police officer will pop up and take lawful decisions that don’t survive contact with other profesisonal’s expectations. It is precisely because front line staff should not be improvising that local protocols are crucial and thirty odd years after the introduction of the Mental Health Act 1983, you think we may have sorted this by now?!

But if you are a police officer, walk away from this post with one message: if an AMHP has ‘sectioned’ someone, you do *not* need a warrant!

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

Winner of the Mind Digital Media Award.


Immediate Need

The discussion about street triage continues and I’ve deliberately stayed clear of much of it, acutely conscious as I am that my views on the whole thing usually go down like a lead balloon just after they’ve been misunderstood or even misrepresented. This BLOG is my evidence that I’ve always been a massive fan of police and mental health services having closer, more integrated relationships and I’m especially keen that they learn to talk to each other in real time. I’m also keen that we should ensure this happens in full and open acknowledgement that the police and mental health services are not here to achieve the same thing: and that what the police exist to do is often contrary to what mental health services are trying to do. We are overlapping, correlated but unidentical public services and the police quite often must do things that are not in the interests of some individual’s health and welfare – that’s where the most interesting discussion about this interface occurs. More about that on another occasion.

What I admit I don’t get, at all, is the double (or triple) agency vehicle idea – I’ve never really understood it and have gone out of my way to learn more and to see it for myself whilst actually hoping for something of an Augustinian conversion about my concerns and questions. I had hoped that seeing it would allow me to learn things that can’t be known from outside and I know myself well enough to know for a fact that had I found myself ‘skooled’, as my ten year old would say, I would gladly write a BLOG saying so and ‘fess up. Learning more about triage has managed to increase the number of questions and concerns I have – mainly because of the cost to police resources in (just some of) the approaches I’ve seen but I also have some concerns about civil liberties and human rights which I want to raise in the context of a deliberately hypothetical example. I will admit, however, that this kind of example came to mind whilst spending time shadowing street triage in several nights around various police forces in England.


The police are called to the area of a young woman’s home address. Paramedics were originally called by the woman’s family whilst she was in crisis and after seeing the ambulance pull up, she ran from the premises – such were the concerns of family that they then rang 999 for the police and the paramedics were able to say, even after a brief interaction, they thought the young woman was experiecncing a serious epsiode of psychosis. Various police officers flood the area which contains railways tracks and a station as well as main roads, parkland and various canals. Within approximately 20 minutes, she is located by one patrol car on the basis of her description and officers attempt to engage her.  She is in serious distress.

Street triage schemes normally ask officers to consider involvement of the triage car so that information may be shared to influence any decision taken and, where possible, to avoid the use of section 136 MHA. After engaging the young woman, they shout up for the control room to inform triage and have the triage officer contact them via police radio.

My question already: is this young woman legally detained? The officers have not told her she’s detained and they have not explained what s136 is or that they may take her to a mental health unit Place of Safety for assessment … in that particular sense, she’s not detained. But is she free to walk away from those officers? … does she even have the capacity to make that decision about whether to remain with them if she’s experiencing a deeply distressing psychotic episode?! … would it be fully informed consent? Remember: the law presumes that she does have capacity to take her own decisions unless an impairment or disturbance of the mind or brain is accompanied by an inability to communicate, understand, retain and employ information relevant to that decision. There seems little doubt in my hypothetical example she may fail a capacity assessment about this interaction with the police.

So street triage are engaged in the incident, the nurse is busy looking up patient details on the mental health trust system – how immediate is this any about the use of s136 of the Mental Health Act? The nurse is only going to come back with two responses: either the MH trust don’t know the person at all; or they do – and if they do there could be information or advice attached which is helpful in formulating another response. But what if the person is not known at all? If the advice is “there’s nothing we can offer that presents a less restrictive alternative” with the implication or even an overt suggestion that s136 be used to facilitate an assessment? – how immediate was the need of the person if we’ve waited from the point of encounter for all that to happen? … how long would it take to complete all of that?!


Where triage is called to become involved in incidents, there are sometimes delays. This is very understandable – one triage car could be covering a population of a between half a million and a million people and I know they’re often juggling more than one incident at a time. Delays can be around half an hour for remote advice and I’ve seen it take 45mins to an hour for face-to-face attendance. What is the legal condition around the vulnerable person during that time? It is a requirement of the use of section 136 that the officer must judge their actions to be immediately necessary – I fully accept that officers don’t turn up to incidents and make instant decisions without attempting to find out more relevant information or attempting to influence a situation to avoid the use of police powers but stretching initial attendance to a forty-five minute delay and then arguing that you took action that was immediately necessary is stretching things, just a touch.

There is this period of legal limbo to further consider: if the young woman who was engaged by the officers wanted to leave the place where they’d found her, she would have to be  allowed to do so unless legally detained; which means if you’re not prepared to let her leave at that moment, she is legally detained – only without being told as much. This means her rights once detained are not afforded; it also means that whilst in this limbo state of being unable to leave and being denied the rights that attend detention, any decision not to formally implement section 136 is also a decision to unlawfully end what is, in reality, a de facto s136 detention. Only doctors and Approved Mental Health Professionals can lawfully conclude a section 136 detention, once it has been implemented – fudge the implementation of it in this way and you can then argue that because it was never instigated, the MH nurse info can negate the need.

Does that any make sense at all?!

Of course the correct legal approach would be to formally instigate the power as soon as you have taken a decision that the person is not free to leave because of any obvious risks to that individual or others you cannot allow to be realised. If this doesn’t fit in with the timescales preferred by street triage to offer alternatives, then that’s what happens when individual’s rights and organisational preferences come up against each other. Article 5 of the European Convention is engaged when considering section 136 of the Mental Health Act and individuals should be detained otherwise than in a process prescribed by law and both the police and NHS mental health services have a positive duty to give effect to this.

All hypothetical, obviously.

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

Winner of the Mind Digital Media Award.