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Nature or Degree

It was the timing and tone of yesterday’s newspaper headlines that crossed the line for me: not any of the discussion about mental health and airline safety.  Of course, occupational health and fitness standards for pilots should be rigorous and we heard yesterday about annual testing, psychological testing, etc., etc..  By now, it may be easy to forget that when papers went to press on Thursday night, we still knew comparatively little about the pilot of the doomed flight.  We certainly did not know that he appears to have ripped up sick notes that were relevant to the day of the crash or what kind of condition they related to – we still don’t, as the German police have not confirmed it.  Whilst we did have suggestion that he had experience of depression and ‘burnout’ – whatever that means – we don’t know the nature or degree of this, do we?

There are other pilots, probably some of them flying as you read this, who have lived experience of depression.  For that matter there are people doing all manner of professional and other private things who have too.  I wonder how many moving cars you walked or drove past today and how many of their drivers have had or do have depression?  And yes, some people do end their own lives in ways that involve the use of vehicles – but we’re not proposing that everyone with any degree of depression, no matter its nature, should be stripped of their driving licence.  “How on EARTH was that man allowed to drive a car?!”  In case anyone is already thinking that the pilots actions cost another 149 lives remember there are well over 3,000 deaths a year on UK roads and that some of those figures will involve lives lost after deliberate actions involving vehicles.

NATURE OR DEGREE

Mental health professionals and mental health law talks about the ‘nature or degree’ of mental disorders.  (I still detest that terminology – it is legal language).  The Masked AMHP has written about this from his perspective as someone who has to interpret those terms in professional practice, but it essentially boils down to how acutely unwell are you and what is the nature or impact of that condition upon you.  To give an example, 1 in 100 people have schizophrenia which can be accompanied by auditory hallucinations of one kind or another.  For some patients, this is just another voice to listen to amongst many and causes little particular difficulty against the backdrop of a condition that they can live with an operate a relatively normal life.  For others, internal voices are so devastating that it can lead to incredibly self-destructive behaviours and / or substance misuse to ameliorate the impact of them.  Two patients such as these would be assessed differently, in terms of the ‘nature or degree’ of their condition.

And my point on this issue is that we still don’t really know what’s going on factually and even if we did, we could not yet understand the ‘nature or degree’ of any depressive condition this pilot may have had.  Certainly not within 72hrs of the crash happening.  This is why the newspaper headlines were premature: maybe that pilot was diagnosed with a terminal condition a week before hand and took an impulsive decision as he struggled to come to terms; maybe he did have a serious depressive condition that he was hiding from his employer and was actively suicidal?  If that latter were true, then of course no-one would question a decision to ensure he didn’t fly a plane into a mountain at 500mph.  But let’s wait and see the full facts – even the German police added on Friday to what the prosecutor in Marseille has said about their working hypothesis and they kept that development vague, so who knows what it means?!

Nevertheless, whatever we end up learning here, we do know that ‘depression’ is not and will not be the sole explanation for the crash, even if it is the most convenient or intuitive one.  Even if we do end up learning that this young co-pilot was acutely unwell and that he had concealed this well from his employer and his colleagues, I will still be more interested in learning that we have reflected on airline safety system for reasons that are far broader than concerns about a pilot’s mental health.  You can only crash a plane deliberately into the French Alps if the broader systems within which pilots are making decisions allows for such a catastrophic choice to be made by one person.  Nuclear missiles cannot be launched from submarines on one person’s say so – it is fairly obvious why things are set up this way.

JUST ONE RISK AMONGST MANY

So absolutely none of this means that we shouldn’t be having a debate about how to mitigate against this happening again – whether for reasons connected to potential mental illness or for any other reason.  I admit to wondering initially whether the crash was caused by some other human factor:  terrorism.  If my instinct had been correct and we weren’t discussing mental illness, we would still be wanting to know why it were possible for one person on a flight deck to islote the other pilot and take the decision to kill 149 other human beings.  You will have noticed that some airlines have already started putting a third qualified pilot onto their flights with a rule that two people must be present on the flight deck at all times.   There are so many other reasons why this could also prove wholly insufficient to stop similar tragedies in the future!

My point here is: the newspaper headlines we saw on Friday morning shame us all and make it more likely that such events may occur.  It is perfectly possible to write speculatory headlines as events unfold and as new information comes in without ensuring that other pilots with depression will feel they will be stigmatised for seeking help or support.    And of course if we’re not going to let people with depression fly planes, we’d best have all the driving licences back and start thinking more carefully about our military commanders, amongst other things.  The reality is we all rely upon people with a range of mental health problems to do a wide variety of things:  you have police officers and paramedics out there who have mental health problems – some have even been ‘sectioned’ under the MHA whilst very unwell and are perfectly professional people who are helping keep you alive and well after recovering.  There are other 999 emergency services personnel who have medically retired from service because the nature and degree of their condition meant it was appropriate for them to do so.  All cases on their indiviudal merits.

This post, in the end, is merely a protest against premature generalisation – we should see individuals in their specific context and if it is the case that this event looks predictable in hindsight, then let’s talk about safety systems that aren’t just targetted at pilots’ mental health problems but also those other issues that have caused even more deaths over the years.

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Honor’d In The Breach

I’m a bit bored this evening – sitting in a London hotel as I’ve had to stay over because of successive days of meetings in the capital.  I’ve been to the National Crisis Care Concordat Meeting and discussed policing and mental health with the national policing lead, Commander Christine JONES at New Scotland Yard, amongst other things.  The week has got me wondering about ‘policing’, by which I don’t mean the uniformed people you see dashing about the place answering 999 calls and arresting suspected criminals – I mean policing in a much broader sense, relating to the governance of our whole ‘system’ of mental health care, to which policing, the profession, all too often connects.

  • We have a Mental Health Act for example.  Last time I checked, thirty-six CCGs in England were breaching s140 of the Mental Health Act.  Who’s policing that, then?  I can’t arrest anyone for this – it’s not that kind of legal breach.  It’s not an offence for CCGs to ignore s140, so if the police can’t police it, who’s policing it?
  • We have a Mental Health Act Code of Practice.  In fact, we’ll have a new one next week when the 2015 edition takes effect at the start of April.  There are various parts of this document that get routinely ignored because services are not set up to give effect to it.  Patients who are absent without leave from hospital whose location is known should be collected and returned to hospital by the relevant health services, not by the police.  (Paragraph 22.13 in the old Code / 28.14 in the new.)  I’ve never known it happen.  Who’s policing that, then?
  • We have Royal College of Psychiatry Standards on Section 136 of the Mental Health Act – I’ve jested previously that it must have been these to which Hamlet referred when he remarked “more honor’d in the breach than the observance”.  Although published by the Royal College of Psychiatrists, they are, in fact, multi-agency agreed guidelines for the whole 136 system – including right across the police, health and social care systems.  This includes all parts of the NHS – ambulance, A&E, mental health providers and relevant specialist providers like learning disabilities and CAMHS providers, if different.

Anyone know anywhere in the United Kingdom where we can see these standards in operation?  Me neither.

I do sometimes wonder whether we should leave these agreements out there as the aspirational standard we are striving towards or whether we’d be better off ripping them up and accepting that no-one does it and no-one’s policing those that don’t do it.  Why deceive vulnerable people that they can expect such treatment?  Is it not morally quite unfair to raise expectations to that degree?!

MOVING TARGETS

Of course, the modern narrative about section 136 is that we need to reduce its use and we have seen all manner of initiatives to reduce the use of police cells as a place of safety and to reduce the use of the power itself.  Meanwhile, in the real world, use of section 136 is rising – by 18% this year in London alone – and this is materialising before our eyes notwithstanding the impact of initiatives like street triage.  And that’s another reason why smokescreens like triage hide the real problems, deep underneath: why are the police service having ever more contact with the mental health system, why is s136 rising so much and what are we doing to react to that?

One further problem here, is that we’re doing a binary comparison when we examine street triage – comparing this year’s figures with last year’s figures when last year was just another year over a decade or more where the general trend in section 136 is upwards.  Correlation is not causation, of course, but as we’re all busy policing and working in the real world, I’ll just point out how much 136 has gone up (%) since the NHS Mental Health framework in 1999 where community mental health services and in particular, crisis services, were seriously eroded.   

There is an argument that s136 may yet (need) to rise yet further, because if you look at how many people are arrested in public places for minor crimes who then receive a Mental Health Act assessment in police custody because of concerns that they may well be acutely unwell, the figure is HUGE compared to the numbers being detained under s136.  I accept I’m not an academic – as you know – but in the absence of any academics I know looking at this (weren’t we all meant to be getting evidence based?!), I will just have to extrapolate from what we do know – that around 5% of detainees in one force area who were arrested for crimes were then assessed under the MHA.  If that were even vaguely true nationally, it would mean around 50,000 people a year, which is more than double the number detained under s136, and 10,000 of those people were ‘sectionable’ which accounts for about one-fifth of all the MHA applications in England alone.  Can that be right?!

Plenty of scope, then – for better training, information and risk assessment to divert boatloads of vulnerable to relevant assessment first.  I can imagine CCGs haven’t considered this – data about people arrested for crimes is held by the police and I’m not aware of any areas developing their local Crisis Care Concordat plans who are asking for it, to lift the stone in an unfamiliar area of crisis care to see what is lurking underneath.  Are MHAA data assessed at the population level in each local authority area to look for trends, repeats and particular problems?  If not, why not?!

As I conclude this brief blog, one of Surrey’s most senior police officers is stood in an A&E department with someone who ran off from there a few hours ago and who was found on a roof threatening to jump.  Chief Superintendent Matt TWIST is, ironically enough, the lead Surrey officer on all things mental health and he’s chosen to spend his Tuesday evening working a busy late shift with his front line officers.  It is absolutely a core police function to protect life and this includes vulnerable people in crisis and using s136 where necessary.  However, before 9pm he had already concluded on Twitter that officers may well still be there until the morning and all the while an already agitated, suicidal person is becoming increasingly distressed as psychiatric services stand-off, pending certain medical results becoming available.

I’m sure I read somewhere that there should be three-hour turn-around for assessments, once someone is medically fit to be assessed under the Act?

So who’s policing that, then?

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Are We Going To Do This, Or Not?

I think I’m becoming a bit report weary, especially now I have to make sure I’ve read every one of them cover to cover and several, like the new one this week from Her Majesty’s Inspectorate of Constabulary, are hundreds of pages long.  Two hundred and twelve pages long, to be precise.

I’ve printed off this latest report and have put it on top of —

I could go on with other reports and yet more reports.  Then there is this list of statutory guidelines, many parts of which are routinely disregarded.   Only yesterday I heard a person from the Department of Health lamenting that no-one really knows about the new Code of Practice to the Mental Health Act that is coming in to play in two weeks’ time!

So rather than provide you with a running commentary on this new report, I’d refer you to the excellent summary coverage of it by @NathanConstable who blogged before I got the chance and said exactly what I think about it – rather than bore you in a similar way, I’d just encourage you to read his post and see it against the background set out above.  I’d just ask whether anything else needs to be happen before we accept that there is a serious human cost to our ongoing inability to get this right, a serious lack of strategic vision about what we’re trying to do and no remaining excuses for the interia because we can’t look grieving families and vulnerable adults in the eye and claim to be getting this right.  

Perhaps if we had children being detained in custody for days because a £100bn a year organisation can’t sort a quite, ligature proof room somewhere for them to wait safely until we get a plan in place we would realise we have to do something – but hang on, we’ve already had that, haven’t we?  Perhaps if we had hundreds of unnatural deaths a year across our coercive systems we the police and mental health services often interface in a range of complex ways, we’d have to do something – but wait:  we’ve already had that, haven’t we?  Perhaps if we had vulnerable adults detained in cells whilst extremely psychotic, covered in their own faeces, smearing bodily fluids all over the walls after drinking from the toilet and banging their heads repeatedly off concrete walls for protracted periods of time – but wait: we’ve already had that, haven’t we?!

I can think of just a few more shocking things that could happen but I’m just too appalled at the idea that we’d need to see ourselves reflected so badly and that it took such events to make us see that before the end of this century my grandchildren’s generation are going to look at us and wonder how on earth these things weren’t viewed as the outrages they are and more importantly, why we kept letting it happen.

Are we going to do this properly, or not?!

We should just decide and be honest with people – at least we can all get on with our lives knowing where we stand.  I know that change is happening at last and I know we can see various versions of furious activity all around us – it’s not good enough, it’s not fast enough and we should be ashamed that we are perfectly capable today of repeating the disasters that struck vulnerable people and their families a decade or more ago.

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The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.