Strategic Problems

In a lot of the work I’ve done and still do, the subject frequently comes up public funding for services and, in the last eight years or so, of public sector cuts. We all understand how important money is and I don’t think there’s a public sector professional around who isn’t keenly attuned to these kinds of debates because most of us are seeing how stretched things are. This post comes off the back of a financial bomb-shell to the police service that Chief Constables are, they claim suddenly, being required to fund a £457m hole in the police pension scheme and many of the bosses are warning of ‘dire consequences’.

Today, we’ve also seen two publications which are not unimportant – the Home Affairs Committee have published their report in to the ‘Future of Policing’ after hearing evidence from across the service over the course of 2018. As a complete aside, you’ll have to forgive me for briefly expressing my surprise and satisfaction that some of the more contrary things I said seem to have influenced the committees conclusions, after I sounded some reticence about street triage schemes. More broadly, the report sounds a warning and calls for increased funding for the police after setting out various problems with the core business we deliver, whilst sounding alarms about the changing role of the police. On mental health the report points out the police are now ‘the sole emergency service for mental health crisis in some areas’ and it calls for NHS funding to be spent in such a way as to reduce this burden on policing.

Also, we saw the publication of the 2017/18 UK Government statistics on policing: of interest to me are those statistics on the use of s136 of the Mental Health Act 1983. We are now topping out at 29,662 uses of this power each year, of which 471 people were removed to custody which is a 5% rise in the use of this power (despite those efforts of street triage schemes to reduce its use), but the proportion of those remove to jail is now just 1.6% of all of us detained under this power in crisis. << If you remember when I got started and interested, West Midlands Police alone were taking over 1,000 a year to jail for being unwell: it’s now less than half of that for the whole country and whilst this should be a success story, it comes at a cost which links to this context about funding, pressure and the expanding role of the police.

SOLUTIONS AND PROBLEMS

In my work, I have a growing number of particular phrases, questions or observations I find myself using again and again and again – like a dripping tap – to help ram home various important points I need to keep making, to be consistent. The one I need to pull out of my drawer on this occasion is my observation that “the solutions we’ve introduced to the problems we think we have are more resource intensive for the police than the problems were.” Everyone wants to focus on helping people, reducing stigma and criminalisation and working in partnership with all of the other statutory and non-statutory agencies relevant to our country’s wider system of mental health.

But at what cost? If you said to a Chief Constable, that for a few resources being spent we could massively improve a process which would then save resources overall – they’re probably going to bite your arm off, especially now. If the resource cost would lead to no resource saving, but better outcomes for the public, they’d still be interested – Chiefs have encouraged greater reporting of under-reported stuff in the past and that doesn’t save resources, it only increases work but because improved reporting of things like domestic abuse, hate crime and sexual offences. But that’s a good thing.

Where the issues become complicated is when a development costs the police significant resources, where we all agreed in advance that it wouldn’t and that position is forced upon the police at massive cost. For example, average detention time in police custody for s136 was 10.5hrs last time I checked. Most detentions which do occur in custody require both detaining officers only initially and then either, both are back on the street, or at least one of them is whilst the other does enhanced safety observations. Average. time in an NHS Place of Safety is around 5-6hrs – it’s often as much as 9/10hrs in some places. If you have a force detaining 500 people a year and you work out the police resource implications, it is MUCH more resource intensive to take people to health buildings if the officers must remain there for 5/6hrs.

WHAT PROBLEM ARE WE FIXING?

I’ve just returned from a conference where it has been genuinely useful, as well as both inspiring and frustrating in equal measure to spend a some days talking and listening with other officers and academics about all this stuff. Britain is not massively different to the various other places, but of course we have our particular peculiarities. We stand out because a) we’re not routinely armed – generally considered to be a good thing when it comes to de-escalating and safely resolving mental health calls; and b) we, along with New Zealand, have no legal powers in private premises – Australia, Canada, the United States, etc., all allow their police officers to keep people safe when they are in crisis at home.

There has just been a two-day discussion about policing and mental health, reviewing the evidence for the various ideas and interventions that we see applied around the world. I will be blogging about that on another occasion, but suffice to say here that the evidence is limited, it’s not great quality and to the extent that it tells us anything, it suggests that most things aren’t having a massive impact. We looked at Mental Health First Aid, co-responder models of various kinds as well as the world-renowned CIT programmes which started in the US. Before the event began, I kept saying that all of these things suffer from the problem that nobody involved in them seems to have defined the problem they’re trying to fix. This was acknowledged in the discussions.

So here’s what I think is going on, behind the more obvious difficulties of public sector funding restrictions and the particular position of UK policing at the moment. I think we’ve just spent 60years de-institionalising mental health care, only to find that we’ve accidentally just re-institutionalised everyone to prison; now, because the funding of NHS community MH services has never been great, we’re shifting associated costs of being unable to respond to everyone to other parts of the health system and to the police. Remember what the Home Affairs Committee said today, their words – “the police, are the sole emergency service for mental health in many areas” and the burden of this must be reduced.

DOING THE WRONG THING RIGHTER

For what it’s worth – and it’s probably not worth much – I think we’re trying to fix the wrong problem. Looking at the s136 data, we see more use of this power by the police – and you should bear in mind the street triage schemes which have been associated with significant reductions in 136 are probably saving us several thousand detentions a year, so the 29,662 figure for 2017/18 is a suppressed number, compared to the 18,500 in 2007/08 that the IPCC researched.

• Police contacts leading to s136 or calls for triage appear to be going up, and rapidly.
• The amount of resources per s136 contact is greater, on average, than 10yrs ago because the police are effectively staffing MH unit places of safety.
• We are now in a position where around 4,000 to 4,500 people a year are being ‘cared for’ by the police in custody after their arrest, pending an inpatient bed emerging.
• We are seeing instances of a dozen or more police officers in a single Emergency Department because the MH trust has used the MH unit Place of Safety as a bed.

I am receiving emails from colleagues stating that so many resources are tied up with MH unit staff, ED beds watches because of MH unit closure, requests for care in custody taking days because of a lack of available inpatient beds.

In a very significant way, we appear to be aiming to transfer the cost of crisis and emergency mental health care from health to policing and believing that it would assist in forging partnerships which would provide a return on investment in the future, senior officers have gone for it. And now, eight years down the line when we have parliamentary reports warning of ‘dire consequences’ to policing as a whole, I feel I have to pose the question: if policing has been cut by 24% and MH services by 8%, for how long can we continue to see ever greater demands made of the police by the MH system to staff street triage, MH units and provide short-term pre-inpatient stays in custody?

PRIORITISING THINGS

One Chief Constable has already stated that it costs much more to run their street triage scheme than it would to not do so. If Chiefs are pushed for resources, they could genuinely re-coup a lot by thinking about whether this is an essential or a luxury they can’t afford because it’s not sustainable against other competing demands. None of this has to mean poorer service, because as we found in Toronto, the evidence sitting behind the solutions we’ve come up with is actually very far from great!

The real issue before us, we’ve set about resolving the wrong problem.

• We’ve decided to assume that demand faced by the police is largely unavoidable, unpredictable and unpreventable demand – that the problem is how to help the police manage it better.
• All the reports internationally tell us that policing is not the majority of the problem here: and yet the solutions always focus on policing, not on society OR health and social care organisations.
• The real problem is what we’re demanding of the police and the extent to which we’re choosing to rely on them for things they can’t do.

I sat yesterday listening to an academic tell a familiar tale of a police encounter gone awry, involving a person with a traumatic brain injury. It inevitably led to a description of some training offered on TBI and some more recent incidents better handled. It’s all about training and partnerships, right?!

Wrong – it’s about accepting the police have a limited role to play within our wider system of social responses to mental health emergencies and other incidents: anything involving time-critical responses, threats to life or crime, etc.. Beyond that, choosing to rely on the police is to make the strategic mistake.

It’s then we start Doing the Wrong Thing Righter.

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

Winner of the Mind Digital Media Award.

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Minimum Standards

This one’s longer than normal – sorry! Thoughts just kept coming, so it’s probably best you put the kettle on first and ensure you have more than a few minutes!  And treat yourself to a biscuit – non-chocolate hob nobs are best.

There are a lot of conversations occurring nationally at the moment, at operational levels of policing, about what I might call ‘minimum standards’ in partnership working. Everyone knows that both policing and health services are stretched, mental health services in particular being more negatively affected than non-mental health services, as ever. But I‘m increasingly hearing from duty inspectors and sergeants that they are sometimes having to decide which 999 calls for urgent help they don’t answer, because their officers are sitting calmly in healthcare settings with people detained under s136 MHA for periods of time that seem only to be lengthening: lengthening in how long it takes to secure an assessment; lengthening in how long any admission takes to organise, because of difficult in finding beds, for example.  Having been that duty inspector, I know that I’m not the only one who has occasionally decided that I’m obliged to take a big risk by leaving someone with NHS staff who are not willing to take responsibility for that person, because those officers are more required elsewhere and that if I have to explain to the Chief why I had to stuff something up, I chose that rather than the armed robbery, the shooting or the child rape incident.  << That sentence alludes to a real decision in my own career from 2013.  Which of those things would you rather not resource at all because your officers are in ED guarding a man who is asleep with no sign in our future of an assessment?

Many times over the last decade we have seen police forces sitting down with their partners because of a variety of initiatives and reforms, to plot how the future will operate because of a new report, changes in the law, a new Code of Practice or whatever. Working backwards: we had legal change last December (2017), we had the Angiolini Report just before that; we had new Codes of Practice (Wales, 2016; England 2015) the NHS England Five-Year Forward View (2015) and a whole range of things coming out from the Crisis Care Concordat (2014). We might as well keep going: in 2013, we had new ‘commissioning standards‘ from the Royal College of Psychiatrists’ group on s136 MHA which came only two years after the last revision of their Standards on the Use of Section 136 (2011) and that was only the year or so after the Bradley Review injected some focus in to policing and mental health in the review of all mental health / criminal justice stuff. So that (non-exhaustive) list takes us back only to the start of the decade – real historians of this agenda will know we could go back further, to the first decade and even back to the last century.

Here’s the thing: whilst we can point to some areas where some progress has been made; anyone who wants to argue that it’s all been progress is not paying enough attention to the detail of this OR they are not interested in it. It’s really easy to make a ‘political’ (small p) argument about the vast progress we’ve seen: let me explain what I mean by that.

POLITICAL APPEARANCES

If a member of the public wanted to contact a senior official in healthcare or policing; for that matter, if they wanted to contact their MP, a Government Ministers or even the Prime Minister and argue that things were getting worse or not as they should be, it would be child’s play to come out with a superficially convincing response that has the effect of dismissing the concerns and deflecting them away. “What do you mean things are getting worse – we’ve changed the law to reduce the use of police cells as a Place of Safety, there has been £15m of funding for extra Place of Safety services and more funding again for initiatives like ‘street triage’ and ‘liaison and diversion’ in addition to which the Crisis Care Concordat has proved vital in bringing organisations together to improve crisis care pathways to ensure people get the right treatment at the right time.”

This is hard to argue with: firstly, because it’s all true and has had some positive effects; secondly, because to argue that those positive effects need to be seen against any neutral or negative impacts. (Anyone who has ever tried to change large systems and cultures will know that nothing has unintended consequences that the impact of some very necessary and welcome change will be negative. It’s how you weigh the relative values of those things which help determine the overall desirability of the thing.). But thirdly, you actually have to know your stuff to be able to analyse this: it’s no good shouting at me (as has actually happened, more than once) that something is good when your own analysis shows you have failed to take account of very important things in reaching your conclusion; AND when your exposition of the benefits of your thing show that you lack the legal knowledge to realise that the thing you’re shouting about breaks the law!

POLITICAL REALITY

It is my own view that we have made lots of progress in many areas since 2010 – there is no doubt in my mind at all. I’m always going to be particular pleased and proud that the use of police cells as a Place of Safety under the MEntal Health Act has reduced from 11,500 in 2008 to just 1,015 in the last set of figures. The next set of figures, it has been hinted, will see that reduce again by more than 50%. I have heard from more than one Political source (capital P!) that the work West Midlands Police did in 2005-2010 with partners after the death of Michael Powell is what convinced many that there could be a real and permanent reduction in the number of people we jail for their trauma and distress. But because this is my favourite example, I want to use it to demonstrate the claim I made in the previous paragraph that you also need to look at neutral and negative impacts of this ‘progress’.

• It is more resource-intensive for the police to remove someone to a healthcare setting than to jail, unless that Place of Safety service is operating to the very high standards suggested in the Royal College of Psychiatrists’ (2011) Standards on Section 136.
• Incidentally, ‘street triage’ is often more resource intensive than not having street triage.  << Not (just) my view: that of a UK Chief Constable whose force has a very well regarded scheme which blazed a trail.

When we started with the Place of Safety work in 2005-2010, West Midlands Police had it is a red-line that we would not, could not and should not remain in any health-based Place of Safety that was set up with every single person who was removed there. Plenty of reasons for that: a) it’s simply not necessary for vulnerable people to have the police hovering over them in all cases – to suggest it is to reinforce the assumption mental health services often campaign about that patients (most people detained under s136 are known MH patients) are violent; b) it’s not the nationally agreed standard about what should happen – the 2011 standards had a 2007 predecessor which said the same thing on this point; c) the effect of a policy where officers remain with all people detained is that it would cost West Midlands Police double the resource (or more) to staff the MH unit in this way – at a point where we knew massive reductions in officer numbers was coming, that simply wasn’t an option and the Chief Constable would have rightly asked why I had just cost him that resource, especially given that the national agreement is that it wouldn’t be done this way.

I won’t pretend it was easy to convince partners that this was a necessary red-line: I won’t even pretend that in principle, some of them agreed and then in practice we had early bumps where operational staff would disagree with the very clear process we had set up to determine whether the police remain and an escalation process for disagreements. But I will say, that after the whole things settled down, it worked well enough to be tolerable for all, with occasional incidents reminding us all of the need to keep an eye on things. Overall, after the first period of operating, we actually found that the force we saving resources, compared to the previous use of police custody – around 50 full-time-equivalent constables per year.

MAKING PROGRESS

We have more change-inspiring initiatives coming down the line: in less than two-months, Professor Sir Simon Wessely will have published his final report reviewing the Mental Health Act 1983. That will set off a process in Government of looking at his recommendations and decide whether or not, and when, to bring forward a Bill for consideration in Parliament. Being realistic and knowing how long it took for the Richardson Review in to the Act to lead to the Mental Health Act 2007, it will be a number of years yet before we see further legislative change. However, the overall point I’m making in this post is that we have LOTS of work to do before then in many areas. And the example I’ve chosen about resources and Places of Safety was a deliberate one for another reason, in addition to being my favourite.

The Wessely Review has asked the Policing Topic Group to look at and advise on whether the use of police custody as a Place of Safety for adults may be entirely banned, in the Act. The topic group advised that it could and should be done. Ultimately, of course, it is up to Professor Wessely to decide whether or not to make that recommendation in his final report; and up to the Government to decide whether to accept that and put it in to any Bill they produce in the future. But we also know that this will represent a different kind of challenge in different parts of England and Wales because of where things stand today – in October 2018.

Some areas use of police custody is negligible: West Midlands and Merseyside were down to zero-use of custody in the last figures; Hertfordshire were also there recently but along with Leicestershire, Northumbria and so on, had only a couple of people. I’ll bet, if they’re honest with themselves when reviewing those cases, that there probably wasn’t a particularly problematic reason why those individuals couldn’t have been managed in a non-police setting and for all those areas, things will be relatively easy in terms of reducing the use of custody to zero, if the law should change. However, will the officers from those forces have to remain in the Place of Safety every time, with every detained person, regardless of risk, in violation of the nationally agreed standards from 2011? Currently, in some of those areas, the answer is yes.

NEGATIVE AND NEUTRAL

If you have surveyed social media in recent weeks, you will see that there are problems in this sphere: this is what I mean with ‘negative’ and ‘neutral’. It sounds great that we’re reducing the use of custody, but what we do know, for definite, is that this does NOT mean people are easily accessing relevant MH unit Places of Safety where a consideration can be given to handover. Some areas of the country do not have sufficient Place of Safety provision for the numbers being detained and when officers find that they are unable to access such places, they default now to Emergency Departments because of the severe legal restrictions on being able to use custody. People can have their views on whether ED is, in fact, better than custody but most police and ED staff would probably agree with each other that neither is great unless the person is a) accused of a crime sufficiently serious to mean that has to be the priority; OR b) medically unwell or physically injured in such a way that ED has to be the priority – neither environment is designed to be the ‘right’ kind of place for a vulnerable person needing a quiet space to stay safe until they can be assessed.

But Twitter tells us(!), that in Lancashire a few months ago, there were seven – yes, seven! – detained people in one ED at the same time, purely because officers couldn’t access a Place of Safety in a mental health unit. Most of the mental health trust’s 136 suites were being used as temporary ‘beds’ for patients requiring inpatient admission under the Mental Health Act, thus denying access for anyone detained by the police under section 136. Of course, seven detained people means fourteen police officers in ED ensuring that people remain detained and this problem was compounded further because some of those 136 detentions remained detained way beyond the permissible 24hrs because patients needed inpatient beds that weren’t available – which we knew, because that’s the problem meaning they couldn’t access the Place of Safety in the first place! This week on Twitter, a response inspector was also tweeting about 5 people being detained in ED with inordinate delays for assessments and difficulty securing beds with many police resources ‘off the road’

So, even with the 2017 amendments to the police provisions of the MHA we know there are problems delivering upon them. Further amendment in the future will only compound this if, before then, we do not get to grips with the problems we already face. Later this month, the Government will publish the latest s136 figures which will be capable of a positive spin, because it seems highly likely the numbers going to custody will have more than halved from last year, continuing a downward trend from 2008; and we also know that most of the use of custody in the forthcoming figures will relate to that part of the reporting period before the law changed to restrict custody. One police force told me, they’d used custody more than 100 times up to December 10th 2017, but from 11th December they hadn’t used it once. So I’ve every confidence that when we sit here in October 2019 looking at the first set of figures which cover a whole year of activity under the laws amended in 2017, we will see the use of police custody down to double-figures nationally. When I remember that 10yrs ago West Midlands Police accounted for over 1,000 uses of police custody, double-figures nationally would be quite an achievement.

UNINTENDED CONSEQUENCES

However! … has it come at various kinds of cost that are not sustainable? Have we got large queues of police vehicles in EDs purely because someone thought to need mental health assessment has been removed there, purely for a want of other options? Are police forces effectively staffing s136 suites because CCGs have commissioned a room in which to wait, but no staff to receive, assess and supervise the patient so the police can be release in appropriate cases, as per national standards. If these standards mean nothing, perhaps they should be ripped up? – because it creates an expectation on the part of the police and I still regularly hear stories that CCG MH commissioners don’t know of these standards and dismiss the need to consider them because the police are still ‘over-using’ section 136. It leads to the argument ‘why should we have to resource a unit to look after people who should never be detained in the first place?’. Those arguments have been addressed elsewhere and remain, largely, fallacious.

I’m yet to have such discussions with NHS staff, CCG commissioners or police officers for that matter, where it isn’t obvious very quickly that their definition of ‘over-use’ is predicated on a less-than-full consideration of what ‘appropriate’ use is. Of course, you can point to examples of where s136 was used when we’d probably all agree it shouldn’t have been. But I can also guarantee that if I walked in to custody or analysed street triage encounters, I could find you concrete examples of incidents that led to arrest or led to no detention at all, where s136 should have been used and wasn’t. As Baroness Hale (President of the Supreme Court) said, in her textbook on mental health law (2017), section 136 is both over-used and under-used because officers will almost always have another power and my own view is that some police officers and mental health professionals push for the criminalisation of people who should be detained under s136 because in so many important respects it’s simply easier and less resource intensive to arrest people.

The police service could unilaterally end the use of police custody as Place of Safety today, if we wished. Just lock people up for other legal reasons and then custody is not being used as a Place of Safety under the Act. But is that really what we want?! If it’s not, we need to re-agree that our previous commitments to work together need to see police forces ensuring that they use s136 ‘appropriately’ (see College of Policing guidance, for what that actually means!) and then health services need to ensure sufficient capacity, including staffing, to ensure the experience of the patient looks a bit like what we all thought it should, when we last discussed it in 2011. And we need to do those things in the next year or two, to ensure that if custody is fully banned, we haven’t just ensured that the police service are spending double or triple the resource per detention, compared to those times we’d hope to forget where the United Kingdom used to jail its most vulnerable subjects at their most desperate time.

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

Winner of the Mind Digital Media Award.

‘Mental Health Related’

For some while, it has been suggested that the police service need to define what they mean by an incident being ‘mental health related’. You know those claims you’ve heard may times about how X percent of police demand or police time is connected to mental health related jobs? … well, it’s always been true that we’ve never been entirely consistent or sure of what we’re counting.

When I first ventured the 20% figure on this BLOG many years ago, I knew what I was counting: I’d been keeping tallies as a response inspector of things going on whilst I was at work and would often take a snapshot of –

• Detainees in custody flagged as having a mental health condition, or a warning marker for suicide or self-harm.
• What percentage of people who are currently reported missing are absent from mental health care or whilst suspected to be at risk of their mental state?
• Of all the 999 and 101 calls that land in a snapshot period (usually one or two hours), what percentage were in some what ‘mental health related’.

I was very clear that I was looking at police demand, not police time.

DEMAND v TIME

As the service became more interested in making similar claims, forces applied different terminology and definitions. One force said that something was a mental health incident if the officers or anyone else identifies any element of the job involves someone with mental health problems. Some forces gave percentage figures involving how much ‘demand’ was MH related, others said they thought a percentage of their ‘time’ was spent – you’ll notice those are two very different things!

Compare these two jobs –

• One officer deals with a man as a victim of crime who woke up to find his shed had been broken in to and his tools and lawnmower stolen.  It takes them 1hr to complete the response, the handling and the paperwork.
• One murder investigation occupies 100 detectives for a week, then occupies 20 detectives for a further week, then 2 detectives for a further week, largely completing the paperwork for a full trial.

Two pieces of demand: vastly different amounts of time spent. Imagine if the shed burglary victim had mild depression, was cared for by their GP, with a low dosage of a common antidepressant and their depression was in no way, shape or form, the causal factor in the offence and nothing prevents them reporting their crime or even giving a statement.

Imagine the murder suspect was seriously mentally ill – sectioned shortly after arrest, interviewed and charged with the offence much later and then, at trial, pleaded guilty to manslaughter on the grounds of diminished responsibility.

Are both incidents ‘mental health related’; or just the second of the two?  I’d say just the second – the first incident is not about someone’s mental health in the way that a crisis incident is, and it doesn’t affect how the police responded to it.  Their mental health condition is incidental.  But to use the force’s definition, above – does anyone in this incident identify as having a mental health condition?  Yes, but it’s a non-serious condition that isn’t relevant to the incident or its handling.

OVER-MEDICALISED RESPONSES

This post is part-consultation: I have to come up with a definition of a ‘mental health related’ police incident, for adoption by the police service as a whole and one which could be used the HMIC, the College of Policing and others to influence how policing and mental health is looked at, defined and delivered. We have undertaken some preliminary work with some forces who have already started looking at this, taken some feedback from outside the police and now have a draft definition on which we need opinions to see if it survives contact.

This effort is to make sure that we don’t over-medicalise responses, that we can gather data more consistently and then have a better understanding of how mental health conditions influence behaviours and needs that may require a police response. We don’t want to over-medicalise our response to people; we don’t want to over-criminalise vulnerable people either. It is argued that if we get this right, we’ll avoid both. So the definition below arises from some limited early discussion with some inside and outside the service who have had to think about this already where I’ve taken all their ideas with some of my own and slammed them together. To that extent, if I’ve ruined anyone else’s good ideas, I’m very sorry – my jobs is to reconcile the various competing interests in to something we can all live with.

Here goes! —

Mental Health Incident Definition —

“A policing incident is ‘mental health related’ if the primary purpose of any response is –

– A concern for the safety or welfare of someone, connected to a mental health condition*;

– Any disability hate crime where someone has been victimised because of their mental health condition;

OR

– Any other kind of policing incident, including crime, where officers are responding to something which requires a reasonable or legal adjustment to be made in their handling of it because of someone’s mental health condition.

* Someone will be regarded as having a ‘mental health condition’ if the officers involved have any reason to think this may be the case or where this has been suggested in good faith by anyone else.”

Your thoughts on this are welcome.

Feedback in comments below, via Twitter (@mentalhealthcop) or on email to –

michael.brown2@college.pnn.police.uk

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

Winner of the Mind Digital Media Award.