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I’m Really Sorry, but! …

I’m not trying to get on anyone’s nerves here, I’m really not. I just feel really passionately about this and we can probably agree that it is actually my job to keep chipping away at all aspects of policing and mental health issues. So with considerable regret, I must again raise the topic of street triage, something which I’ll admit I often go out of my way to avoid discussing, not least because it tends to go down like the proverbial balloon. So I’m really sorry and not I’m trying to bore anybody here, or to undermine hard-working professionals who no-one doubts are trying to make the world a better place by supporting vulnerable people. I have to just hope it can be understood, I’ve been given a job that is around the application of the law and newly developed guidelines which needs to sit within a culture of robust evaluation. I am also subject to the police service’s Code of Ethics, which makes it clear we have a duty to challenge, question and discuss. I do again, because I know from discussions yesterday that I’m not the only person with questions and with concerns. Others who said so yesterday, include psychiatrists, AMHPs and police officers.

An academic article was published yesterday in the BMJ (no less) about street triage in the North-East of England, operating in the Northumbria Police area alongside Northumberland, Tyne and Wear NHS Trust, undertaken by Newcastle University, a Russell group institution (no less). There have subsequently been several media pieces covering the highlights from this publication, most of them within professional online articles rather than in the mainstream and through the magic of social media further discussion by people who know of such collaborative approaches elsewhere in the country. On this occasion, the main highlight seems to be that ‘street triage’ cuts the use of police powers in half; it has brought about significant cost savings (estimated at around £1m for a large mental health trust like NTW) and improved outcomes for vulnerable people who now often experience a far less restrictive approach to their crisis care.

So far, so good, right – who could possibly object? My objection is not to street triage, per se, my whole point is we don’t know enough about it to know whether we should be objecting to it or not! My objection is to extremely partial evaluation that fails to even acknowledge, never mind address, very obvious issues that should influence any assessment of the risks versus the benefits. I keep hearing that street triage ‘works’, but no-one can tell me what it’s trying to do. I also hear some say, ‘it works for us’, to quickly sidestep the whole discussion about what’s for and what it’s doing.

I’ve suggested that this article would be a good thing to give to university MSc students looking at research methods: it would allow them considerable scope to think about what this article is NOT saying and what the authors have NOT considered as relevant to an evaluation of the scheme as a whole or the use of s136, for therein lies the interest for me. I note (from what I can tell by looking them up), that none of the authors of the article appear to be police officers or lawyers – yet the primary aim of their focus is an analysis of the use of particular legal power and it’s mainly the legal perspective that’s missing, for me. Although that’s not all that’s missing.

OFF THE TOP OF MY HEAD

So here’s a list of thoughts in no particular order –

  • Are we really surprised to discover that if the police can now take mental health services to vulnerable people, they have to take vulnerable people to mental health services far less often than they previously did?! I’m not sure we needed a two-year research study to tell us that would happen. I’m infinitely more interested in why the police are involved at all, accepting that they will always play just some role in our wider mental health system. I worry this is inappropriately expanding the role, increasing risk and stigma – see below.
  • As early as the second paragraph, I had to pause when it was claimed that “three broad outcomes” result from use of s136 – involuntary admission, voluntary admission or referral to community services. Of course, it fails to mention the fourth outcome which is ‘absolutely no follow-up whatsoever’ and which can occur for a variety of reasons. This is reflected to a degree, in NHS Digital data on the use of s136.
  • But what are the unintended consequences in terms of how this service fits in to the wider health economy? – we know from observing street triage teams more ethnographically, there are several unintended consequences and I’ve written about them before. They go unmentioned here but can include even more MH related demand being deflected to the emergency system via the police by GPs, community mental health services, etc.; and sometimes, it leads to later, not earlier, intervention for people seeking support. We don’t know the extent of this, precisely because no-one’s looking at it in the evaluations! That’s why I’ve spent about many nights in the back of street triage vehicles, watching what they do and it’s a mixed bag, in my limited experience.
  • We know that street triage does not mostly occur in the street: this is yet another academic article where the main focus of evaluation is the use of police powers under the MHA which can only occur in the public sphere – what is going on in the 50-odd plus percent of ST incidents which occur in places where use of s136 is not lawful? It’s barely mentioned, as UCL barely mentioned it in their evaluation of the nine so-called pilot schemes (that weren’t actually pilots at all – triage had been up and running in three police forces for quite a while by the time those nine began). Whilst we’re on the subject, co-responding by police and mental health services didn’t begin in the USA in the 1980s: “car 87” has been operating in Vancouver since the 1984 and co-responding with health in Canada goes back to the 1970s.
  • There is no reference to what we know about the use of other police powers – you can easily reduce the use of s136 by simply using other powers instead: did they? We know that police forces have different cultures around the use of powers, for a variety of reasons to do with training, history and partnerships. This is why Nottinghamshire Police and West Midlands Police were using s136 MHA about the same amount prior to instigating street triage schemes in 2013 despite the fact that West Midlands Police is three times the size, with three times the population.
  • What is the follow-up rate for all of the referrals that are being made – community mental health services in that part of the world told the Crisp Commission that they had seen a 100% increase in workload in the year to May 2015 with an attendant reduction in staff. We know from some triage teams that they put in referrals at 10pm when someone is in crisis, and they’re not followed up by CMHTs the following day.  I have no idea whether this is a rare or a frequent occurence, because no-one’s recording and evaluating it.
  • “ST teams typically comprise a Police Officer and Mental Health clinician working together to attend incidents” – except that they don’t, do they?! Several schemes involve putting the mental health professional in the police control room (Norfolk, Devon and Cornwall) and others involve the clinician responding alone to support front line officers attending incidents (Hampshire, Cleveland), but even in the Northumbria scheme and those like it which have a multi-agency vehicle, they report not physically attending most of the incidents they were contacted about. This was also true in Leicestershire and elsewhere. So any analysis of a particular scheme, especially where it is getting in to cost-benefit analysis, needs to acknowledge they have an expensive resource, in the form of a police officer, who is not physically attending incidents because other officers are there and a nurse is giving remote advice and information that could be given from anywhere. I would suggest that is important to understanding the whatever dynamics of inter-agency working you want to understand; and to any health economics that are being attempted as a result.
  • On my night out with street triage in this area, all of the incidents we attended were generated by the NHS which was unable to cope with a kind of demand that did not need the police: it needed mental health professionals who didn’t have the capacity to help. None of those calls were from members of the public asking the police for urgent help in a context you would recognise as a policing incident. Across my nights out with ST as a whole, just under a half of all incidents were like this and several were explicitly referred to triage where they would not have been if it hadn’t existed. Make your own mind up about what that means about the role of the police in mental health crisis care but one research question I’m interested in would be “To what extent does the existence of street triage cause the system to refer incidents relating only to health issues to the police service, because of the ability to deploy a mental health nurse who would otherwise be unavailable?” We know that the answer to this question is not “To no extent at all” so we need to know more what the answer is, far more precisely.
  • I have been a regular presenter at CPD for AMHPs in the North-East of England over the last few years and the last time I did this, they expressed concerns about ST-type approaches that are not reflected in the evaluation. It is AMHPs who become excluded from the public contact where s136 usage reduces, because the AMHP plays a formal role in the assessment. So what do this crucial professional group think – I suspect many don’t know what to think because they, like me, can’t find any full evaluations to read.
  • Why so little mention of other schemes who have NOT found these outcomes? – I know of three police forces who have started doing the kind of street triage being evaluated here, but have pulled away from it completely or substantially because notwithstanding an impact on the use of the s136 legal power they found other reasons to think it not worthwhile. In one case, that was because of a view by the police that they were being expected to burden excessive costs for benefits the health system welcomed but for which they were not prepared to pay. The authors in this example haven’t touched upon these matters so I’m wondering if they considered them, or knew?
  • The paper notes the research evaluation of Dr Margaret HESLIN et al from the Institute of Psychiatry in London who evaluated the Sussex street triage scheme. From a health economics point of view, they note that street triage was cost neutral but that it involved a significant transfer of cost around public service provision from health to policing. So a public policy question for you: “To what extent is it the responsibility of Chief Constables to pay for efficient healthcare pathways?” We know the answer to this is not, “Completely!”
  • What is the understanding of s136 MHA, on which so much of the analysis rests: it refers (without a footnote) to ‘inappropriate’ use of s136 – what does that actually mean in the minds of the authors?! … we don’t know.
  • Leading on from that point, we also see no overt consideration of what is happening legally whilst these incidents are being handled in a new way. Section 136 is a power whose need must be immediate, in order to be lawfully used – given that street triage in south of the Tyne is moving around in an unmarked van, without lights and sirens and can take up to 45mins to reach an incident, what is the status of vulnerable people encountered by the first-responders who call for triage?
  • Do the attending police officers point out to the encountered person that they are not detained and not obliged to remain with the officers? … or are they, in reality, detained pending triage’s arrival to make the decision?! From other schemes, on just some occasions, we know they are and this can be both ethically and legally dubious – informing people that they are not detained and free to leave is common and legally required during other kinds of police encounters in order to remove ambiguity. It should be here, too; not least because of the questions around vulnerability and mental capacity that aren’t always features of those other kinds of policing situations.
  • And the title of the piece: “Too much detention” – I presume the authors are unaware that Baroness HALE, the deputy President of the Supreme Court who often gives the lead judgment on mental health and capacity law rulings like Cheshire West (2014), argued in her 2010 textbook on mental health law that s136 is, quite probably, under-used overall. Paradoxical though this may sound, it is quite possible to reduce the use of something that was already under-used: it’s a logical fallacy to assume that because something can be reduced, it must have been over-used to start with. The police could arrest innumerable people for offences or Breach of the Peace instead of using s136 in order to reduce the use of the power: any decision to do so tells us nothing at all about use of s136 before or after that change of approach because it could be true that arrest powers were already over-used prior to their increase!
  • Finally, the costs savings of £1m or so – even allowing for acknowledgements of estimates being made and so on, the thing that seems to be missing from the economics of it all, is the issue around cost to policing. I’ve already mentioned the piece by HESLIN which is referenced in this article, and that showed a transfer of cost for less restrictive healthcare pathways shifting from the NHS to the police. In order to run this kind of street triage team, forces are contributing between four and seven police officers.
  • This amounts to between 8,000 and 14,000 hours of police time and between £200,000 and £350,000 a year of cost, which needs to be offset against all the other calculations of time and money whilst remembering that any comparison to what was previously occurring in an area needs to remember that it was a s136 pathway already over-reliant upon the police because of an under-commissioned PoS service where the police were, in effect, asked to staff the mental health unit, requiring 10hrs of resources per detention. This doesn’t happen everywhere and amounts to a different partnership context against which to evaluate the impact of an ST scheme.
  • I also can’t omit to mention the reference in the penultimate paragraph about the use of police custody “when clinically indicated” –  I notice that’s left hanging in the air, entirely undefined, as are the current proposals to define ‘exceptional circumstances’ for reliance upon police custody in the forthcoming revision of Mental Health Act. I’ve got no idea what it means and suspect that health guidelines suggest it will more or less never be ‘clinically indicated’.

AND BREATHE!

I could go on … and on. It remains my view that street triage is very under-evaluated, that nothing we’ve seen so far gets us close to having a clear under-standing of risks versus benefits and that this week’s publication is encouraging but an extremely partial view. And you’ll have to forgive me repeating this point: my objection is not to street triage – it is to limited evaluation of these new ways of working! We didn’t even mention deaths following contact with triage assessment, have we? … they need looking at, too.

That’s why when I see things like this and find that people claim it’s an obvious success that needs to happen everywhere on a 24/7 basis, it does get me fairly exercised because it’s put across as a self-evident truth, beyond discussion. In reality there are many professionals and services who say otherwise but then again, they haven’t fully analysed it either!  I’m far from alone in having unanswered questions, although it sometimes feels that way – I actively want someone to come and show me I needn’t worry, because I’d love to be convinced about all this, given the obvious upsides to a collaborative approach.

But I want loads of data, quantitative AND qualitative.  So whilst we’re on the subject: where are the patient’s and public’s voices in all of this?  Exactly.

Other posts touching on street triage and those aspects of s136 MHA referred to above –


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

Winner of the Mind Digital Media Award


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What *Are* You Doing?!

Imagine this: someone rings the police to express concern for a friend or relative’s mental wellbeing, asking the police to ‘check on them’ to see that they’re OK. The officers attempt to do so, ringing a phone number that the friend provided and knocking on the person’s front door.  No reply and no response. There was no information to suggest the person was suicidal or self-harming, just that the friend or relative had non-specific concerns. Phone calls are put in by the police control room several times, including in to the early hours of the night and a note with a reference number is posted through the person’s front door.

What is going on here, precisely? It all falls back to that whole discussion about ‘welfare checks’, sometimes known as ‘safe and well’ checks and I’ve written about them before. Whether or not the police realise it, they are going to struggle to do them even if they do locate the person concerned; so let’s remind ourselves of the problems where the safe and well check is connected to mental health issues.

  • Ability – on what basis will the police make their decision about whether someone is, in fact, safe and well? Will they do a mini-mental state examination or use some form of risk assessment tool, perhaps using their psychiatry or nursing skills? – of course not. We know from history, that trained mental health professionals have massively mis-identified risk issues connected to mental health problems and suicide has followed contact with trained, experienced mental health nurses. It’s no sillier to expect the police to always get this right than to argue that because nurses are trained in restraint and personal safety, that they should deal with patients on wards who threaten them with knives. There are some things that are just way beyond the skill set of the people involved and it needs different professionals to handle a situation they are specifically trained for.
  • Location – even if the police find a person and can tell that person has obvious and serious mental health problems, they may be quite powerless to do anything about it. Remember, the police service in the United Kingdom has no legal powers in private premises, which is precisely how your Government want it, having reviewed police-MHA powers in the last two years. We should also remember, if we believe the data that street triage teams produce, that private premises is precisely where most of the mental health crisis incidents occur. Therefore, does it matter whether the police see someone in person or speak to them on the phone? – to an extent, it might. Police officers may see things during a personal encounter that may influence whether they detain someone or not – but if the person is in a place where they cannot lawfully be detained, does that matter or add anything?
  • Power dynamics – when a uniformed police officer asks you if you’re OK, do we think we get consistently accurate answers which assist in assessing the level of distress someone is in, or the risk they may pose to themselves? This isn’t a point about telling lies to the police – it’s a point about vulnerable people having often had difficult experiences before, being detained in police custody, for example and we’ve seen more media about that today. Many people are perfectly aware that if police officers have serious concerns about someone’s wellbeing, they may find themselves removed to police station or NHS factility for assessment by someone who has access to background records and does actually have the professional skills and responsibilities to assess. So knowing concerns on the part of an officer may mean removal to a police cells or Place of Safety and possibly being strip searched or constantly monitored, do we think people are always upfront about their mental state?!

The problems go beyond this, however: they also need considering and a recent experience highlights a few of them –

  • Feeling stigmatised – some people just don’t want to have contact with the police when they are unwell, for various legitimate reasons. It may be previous experiences of contact made things worse; it may be that being in contact with officers makes someone feel criminalised; and it obviously raises the potential question, “Are they going to detain me?!” with everything that involves. Remember, even where people find that officers were as kind, patient, compassionate as they could be, it is often factors beyond the control of the police that mean the whole thing, overall, was seen as a negative experience. I’ve lost count of the times service users are quoted as saying, “The officers were great, they made a bad situation much more bearable for how kind they were, but at the end of the day, they had to lock me in a cell because there was nowhere else to go” … or similar.
  • The police as a ‘stick’ – the police are, on occasion, used by mental health professionals or services as the ‘stick’ with which to threaten patients with coercion unless they comply with professionals wishes. You only need to look at Twitter to see how many people have had this experience. “If you don’t come to be assessed under the MHA at 10am, we’ll call the police!” To do what, precisely?! … it all goes back to the above: call the police to find someone and conduct a ‘safe and well’ check and you might find the police stuff that up, despite their best efforts. Let’s imagine that the call results in a missing person inquiry and the person is found at 8pm that night: will the MH service who called now turn out to support the officers, especially where the officers find themselves powerless in the circumstances?
  • Adding to distress – and how does all of this affect the mental wellbeing of someone who may be unwell, whether acutely or otherwise? – is it actually helping?! I worry that the intuitive need to ‘do something’ means police officers and services sometimes start down a path without understanding the difficulties they unleash for themselves and for the person concerned later down the line. What are you going to actually do once you find the person – what can you actually do to help that person? Is the process of attempting to find or meet them, making the situation worse, potentially to the extent that you decrease the likelihood of finding them at all, whilst simultaneously raising the risks to that person by increasing their distress?

Obviously, where the police receive information that a vulnerable person may be self-harming, suicidal and or a serious risk to themselves, they have a clear duty to protect life – but not all situations are like this. Also important to acknowledge that an accurate risk picture may not be known when a member of the public or a mental health professional chooses to report a concern. But it seems to me a legitimate public policy question about whether the police can actually do what is asked of them; and whether the police themselves realise their limitations? I’ve seen more than one report investigating an untoward outcome – including reading another one just yesterday! – where the decision of police officers to fully absorb responsibilty for asserting someone else’s wellbeing, without calling upon others and amidst a lack of ability to do anything other than refer the matter to others, has taken them in to gross misconduct territory.

This post doesn’t say anything I haven’t already said but the message bears repeating: police officers are NOT mental health professionals and cannot always do what mental health professionals can do, or what various people think they can do. This is not about a lack of training – it is about unreasonable expectations being placed on officers which do not always seem unreasonable. If we are going to rely upon the police in terms of searching for or checking on people, officers and police services need to feel entitled to say, “OK, we’ve found this person – others now need to support us in making sure we get this right.”


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

Winner of the Mind Digital Media Award.


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Police Leadership

I heard the Health Secretary Jeremy HUNT deliver a speech at today’s Crisis Care Concordat Summit in London, the first major speech he’s delivered on mental health, we were told. Almost the first thing he did was praise the police service for the leadership shown on the subject of mental health crisis care, driving much of the debate that led to the creation of the Crisis Care Concordat itself. I might be wrong, but my sense was the comment did not land well with everyone! One service user tweeted about this, wondering whether it should be the police driving certain aspects of healthcare provision – and of course, I don’t think there was a police officer in that room who wouldn’t happily see the issues we face being confronted head-on by senior health leaders and commissioners.

History shows another approach became necessary, for a range of reasons perhaps uniquely understood by the police.

BACK SEAT DRIVERS

Following his speech, the Q&A session saw Commander Christine JONES from the Metropolitan Police, the lead for the National Police Chiefs Council asking, “Mental health services are underfunded: at what point will parity of esteem be matched by parity of funding?” Almost immediately, we saw reaction about how senior health leaders were unlikely to challenge as directly as this. Again: the police driving the debate, literally, with the Secretary of State for Health on the general topic of mental health, not a question specifically about policing! Would Commander JONES be asking that question if a senior health leader were doing it or likely to do it? … I doubt it.

After I woke this morning, my attention was drawn on Twitter to an article by Lord BLAIR in today’s Guardian, a former Commissioner of the Metropolitan Police. This article was bouncing around the conference room at the Oval, in hardcopy … “have you seen this?!” and so it was handed from person to person. It quite obviously divided opinion amongst the non-police professionals present (and on Twitter). It ranged from ‘flabby opinion’ that was ‘not offering any solutions’ to some who thought it was imprecisely making perfectly valid points about the outcomes we see from our current arrangements. It’s obviously not for the police, serving or retired, to tell the health system how or when to ensure upstream intervention in mental health care any more than it is for health professionals to get specific about how the police should discharge their responsibilities under criminal law. However, it is perfectly fair comment for NHS staff at all levels to flag up problems in policing and say, “What are you going to do about it, Copper?!” Or similar.

The main agenda at the CCC today was all about health – a couple of the workshops focussed on policing and legal issues but the main room was all about health. Quite right, too! – the police should be much less of a voice in this, ideally. That they aren’t does lead to certain observations which I make very reluctantly after today’s events. We need to see achievement and progress in this area: not just activity – and this means we also need to describe what we’re actually trying to achieve. The Concordat obliged local areas to produce an action plan, uploaded to the Mind website in 2015 – I’m told this plan should be refreshed and updated by all areas in early 2017. In addition, we heard today about the Five Year Forward View plans that are required, in order to deliver on the NHS England strategy for mental health during the remainder of this Parliament. Of course, those following developments in health will know that various areas have grouped together to produce Sustainability and Transformation Plans (STPs), in order to make the NHS as a whole sustainable in coming years.

PLANS ABOUT PLANS

So what about those 2015 Action Plans – how many areas have ensured delivery of the majority of their contents? If you remember the mapping process set down by Mind: areas were to go from Red to Amber when they’d agreed to some principles to work in partnership; and then Green once uploaded to the Mind website. I remember commenting at the time there should be another colour for completion of the plan, even if just 80% complete. However, one police officer today described his local CCC leadership group as a talking shop where “nothing gets done”. It’s not the first time this month I’ve heard that said, quite honestly. So in addition to those plans, which now need revising, we see then need for more plans after the Five Year report and all of that has to fit in to STPs concerning overall NHS efficiency – the plan of plans!

We know from recent media coverage, that more than half of CCGs are cutting the funding they give to mental health as a proportion of their overall budget, despite suggestions from Government that the proportion should increase. That is the context within which any plan needs to be seen and we know that the trend in terms of crisis care is an upward one – barely a week goes by without coverage on increases in crisis related issues: whether systemtic or individual. No-one who follows current affairs in any detail could fail to understand that there are dynamics at play in society that effect mental health which do go beyond the health service but none of that explains decisions we see to situations ever more towards the social justice safety net that is policing and criminal justice.

I also prepared a question for Jeremy HUNT, in case no other police officer put their hand up. I was going to ask, “What should we conclude about mental health and crisis care if more people than ever before are being detained under s136 MHA, more people are going missing whilst mentally ill, more people are being arrested for offences and then being assessed under the MHA in custody?” There was a sense today amongst (at least some of) the police officers that whatever progress is being made on CrisisCare – and there is lots of it! – it seems to be at the expense of upstream interventions. Those of you who follow along on social media know I’m all too fond of quoting Archbishop Desmond TUTU: “There comes a point you have to stop pulling people out of the river, get upstream and find out why they’re falling in.”

POLICING IN MENTAL HEALTH

When I first got involved in working on the policing interface with our mental health and wider health system, I remember specifically saying to myself that I wasn’t ever going to get myself in to the position of being caught telling healthcare professionals how to run their health service or how to deliver on their professional obligations. This was partly a question of manners: I’d be prepared to listen to anyone about the impact of the way we police on them, but it is ultimately for the police to square away competing demands and priorities in how police services are run, held accountable as they are through various processes. I took the view that that the reverse courtesy should be applied in how I worked on mental health.

But if I’ve learned anything in the last twelve years on this topic, it is a conclusion very reluctantly reached and best summed up in a matephor from my other area of professional interest: public order policing. Progress on mental health has come when police officers or police services form a cordon, take ground and hold the line. History shows that problems in health-based Place of Safety provision actually came not from the Concordat – no doubt it helped – but from some forces saying, “Enough is enough: this will have to change and it will change with or without the consent of the health system”. We’ve heard recently about problems in partnerships where the police are being routinely expected to handle the fallout, often unlawfully, of a health system that has decommissioned too many inpatient and specialist beds whilst apparently disregarding s140 MHA and other obligations. History shows that resolution of those operational problems has come from senior officers tweeting to publicly shame the system in to gear and from actual or threatened legal action.

So the lesson appears to be this: the police are bungling around in this arena, still – not always getting it right and we sometimes miss the subtleties or complexities. We are not experts, we are not clinicians and we’re not trying to be. We just have a unique perspective on some of these important issues and one that is all too misunderstood and disregarded. History shows that unless we shout loud and / or agitate on behalf of vulnerable people, we don’t make progress. I’m far from alone in wishing this were not so. As a natural introvert and an experienced public order commander I can tell you that shouting and agitation is occasionally a tactic in taking ground and making progress: it is to be used sparingly, recognised as a restrictive or coercive practice and it is not without collateral intrusion. However, it does remain a legitimate tactic and leadership is recognising when it is required, when the collateral intrusion may be worth the risk and involves not over-playing it. If we want that voice to quieten down, I suspect we need to see fewer, clearer plans about what the destination is and how we get from here to there without violating the rights and expectations of vulnerable people who are all too often caught up in it.

Notice the above didn’t really focus on the public we serve? – neither did today.


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

Winner of the Mind Digital Media Award.