Stepping on Toes

Over the last few years, we’ve seen a massive extension to ‘liaison’ work in mental health services. ‘Liaison psychiatry’ is now a sub-specialism for those psychiatrists who work in acute and other medical settings, giving specialist mental health support to those doctors in Emergency Departments, medical and surgical wards, for patients with co-morbid mental health problems. We see this in mental health nursing too.  We’ve known for decades that many of us would like to see more mental health nurses based in police custody and as time has gone on it has increased and 70% of the population of England is now covered by Liaison and Diversion schemes.  In just the last few years, we’ve seen this accelerate significantly:

  • We have mental health nurses in police cars doing ‘street triage’.
  • We have mental health nurses in ambulance vehicles working with paramedics doing ‘street triage’ without the police.
  • MH nurses are in police control rooms.
  • They are also in ambulance control rooms – indeed, they are in ambulance control rooms which cover forces where they are also in police control rooms; AND out doing street triage in police cars … or ambulance cars.  Or both.
  • We see mental health nurses working in 111 call centres to give clinical advice to non-clinical call handlers and talking to patients.
  • In addition, of course, we still have crisis teams operating in each mental health trust, albeit many are much smaller than they were before – which probably won’t come as a shock after reading all that lot.

Just to emphasise how far the overlaps between agencies has gone, we also see police cooperation with ambulance services – and this adds to the mental health mix!

  • Some street triage initiatives are a three-person endeavour – a police officer, a mental health nurse and a paramedic.
  • In some areas, we have joint police-paramedic patrols, not specific to mental health, but involving such 999 calls.
  • We see paramedics in some forces in police control rooms, including forces where there are attempts to get MH nurses in the police control rooms.
  • If you look around you will see that paramedics are now able to apply to some private medical companies to work as healthcare professionals in police custody, alongside the MH nurses doing liaison and diversion.
  • They are also appearing occasionally in Emergency Departments.

CONFUSED LANDSCAPE

It begs even more questions, doesn’t it?!  I had enough unresolved, unanswered questions about street triage before areas who swear by it also brought about the introduction of ambulance-flavoured street triage.  It immediately made me wonder: if a 999 call came in about an agitated, distressed mental health patient who had taken an overdose and was threatening to harm himself with a weapon, would we send the police and the ambulance-triage car; or the police-triage car and a first-responder ambulance; or something else?  And who decides? – the 999 operator?!  They normally ask which service you need so would the answer be police or ambulance … or both?!

I also had questions about efficiency – if we have mental health nurses in call centres, whether that be 111, police control room or ambulance control room, do we really need them all when they’re broadly doing similar things, often at the same time.  Advising non-specialist staff, sharing information from relevant health records and talking directly to prior to people. Do we need three nurses spread across this function or could #Team999 not just access the 111 nurse(s) for support and information? When calls come in which involve co-morbid mental health and physical healthcare issues, does the Force Control Room sergeant call upon the paramedic, the mental health nurse or both?!

The landscape here is getting increasingly cluttered – we’re stepping on each other’s toes a bit. It’s not that any of these initiatives is an appalling idea, but these various things are often being done in isolation, no doubt for genuine reasons, but in such an overlapping and confused way that it prompts to ask my favourite question of all: “What problem are we trying to solve” and my second- favourite, “Why is this the solution to that?” As an old superintendent of mine used to regularly say: form follows function – you work out what you’re trying to do, having understood your demand, and then you design a system to meet that demand. I can’t help but think that these initiatives are reactions to circumstances that were themselves unintended consequences of other decisions in the wider health system.

I’ll leave you to contemplate my point – I’m off to enjoy two weeks of annual leave in France.  And my point is essentially an old one; and I’ve made it before – this is not a health system, in many important respects, it’s just a coincidence.


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

Winner of the Mind Digital Media Award.


AMHPs and AMHPing

I’ve got to know a fair number of AMHPs in my time. In fact, I’m going to come clean on this occasion – some of my friends are AMHPs and I’ve been known to take refreshments with them on a clear evening.  Tony now owes me at least one beer for writing this for #AMHP17! … incidentally, it’s pronounced ‘amp’, before we get much further in to all this. I’ve been known over the last few years to go out of my way when they ask for inputs on CPD events because a clear understanding of who these people are, what they do and the circumstances in which the operate is crucial for operational police officers. I also think the opposite is true: they need to know more about the police and the learning we’ve gone through over the last ten or fifteen years. I’ve had some of my most interesting professional disagreements with some AMHPs(!) but in all fairness, it was usually based on things I’d learned from other AMHPs who had been kind enough to help me get my head around things when I first started working properly on this stuff.

I will forever treasure the disagreement about the grounds for s135(1) warrants which became necessary in February 2014 … my favourite, ever s135 story and I got to be the duty inspector for it! AMHPs helped me win that debate with another AMHP and it meant resolution of a siege that had gone on for 9hrs without anyone being seriously injured when there was a point we thought someone may get killed. AMHPs are the mental health professionals who get the decent legal education – and they are the non-medical people, to protect the rights of those who could become embroiled in coercive mental health care. They are vital to the system – in many respects they are the system.

Yet we have a problem – when I ask in a room full of police officers or paramedics “Does everyone know what an ‘AMHP’ is?”, a good number of people will have no idea. Some of those who do won’t necessarily know what the acronym ‘AMHP’ stands for – it is Approved Mental Health Professional.  Not ‘Accredited‘ mental health professional, no, No!! … not approved mental health ‘Practitioner‘ … no, No, NO!!! – these won’t do at all. In fact, it is getting the acronym badly wrong that usually winds them up a complete treat. It’s not quite as funny as the reaction from our dear friends in green being referred to as ‘ambulance drivers’, but you get the general idea! “Accredited Mental Health Practitioner”, usually works best – just in case you ever need to know ……

STEREOTYPING

AMHPs are easy enough to identify as a breed: they will not be some walking stereotype wearing brown sandals or bearing leather elbow patches on a checked tweed jacket – there’s no need here for poor stereotypes about social workers, involving bean bags or joss sticks. A better stereotype, however, might be the one fully-loaded with the standard-issue AMHP kit: a lanyard of some kind, possibly with an IT security dongle and a pen hanging from it; a well-thumbed copy of Richard Jones’s Mental Health Act manual, replete with coloured post-it notes or pages marked with highlighter pen; and a hardback A5 diary, page-per-view, stuffed with folded pages of A4 and elastic bands wrapped around it. If you were to search the boot of their private vehicles, you’d probably find emergency food and drink and an extra jacket, jumper or a blanket. These things are the cuffs, baton and CS of AMHPing, it would seem – the basic tools of the trade.

More seriously, I couldn’t be clearer about this: these people are absolutely crucial to the operation of the mental health system and as I usually tell them, I wouldn’t do their job for all the money in the world. They are put at the centre of so many aspects of how our system operates at key points of crisis and whilst enjoying almost all the responsibility for things, they usually have absolutely none of the authority whatsoever to direct organisations and resources around the outcomes they must ensure. They are completely reliant upon the NHS, the police and the ambulance service to know their roles and pull their weight. Some AMHPs spend their days working as mental health social workers in community mental health teams, not specifically undertaking the AMHP role until they need to pull on their capes (or blankets) as their CMHT has a need for it. In addition, they may perform a ‘duty AMHP’ role for the area for a few days each month. Elsewhere, there are permanent ‘AMHP hubs’, where a certain number of AMHPs are AMHPs every day and do little else beyond this important statutory role. Ideally, there should be an AMHP available 24/7 for urgent MHA assessments and assessments under s136 – it is the latter where officers are perhaps most likely to meet an AMHP.

I’ve mentioned they are the ones with the formal, examined legal knowledge: they must do this to qualify and many of them are quite formidable legal eagles, it must be said – I’ve been grateful over the years to several of them who’ve let me buy them coffee and helped me get my head around the legal issues. They undertake a certain amount of CPD each year to ensure they remain up to date with developments in the law, some of this being run by specialist solicitors firms or university law departments. It was thanks to AMHPs that I learned a lot when I first worked in this area around mental health law – it was an AMHP who first properly explained the Mental Capacity Act 2005 to me (thanks, Matt!) and who introduced me to Richard Jones’s Mental Health Act manual. This is a major publication, usually updated each year to keep current, and is often regarded as the last word on how to interpret mental health law. Most AMHPs are given a copy by their employer each time a new edition is published. One claim to fame on the manual: Professor Jones once emailed to say my blog had made him change his mind on a couple of police-related issues on s135 MHA and he amended his manual accordingly!

QUICK FACT CHECK

On the role played by our AMHP friends, did you know, for example –

  • It’s not the Doctors who ‘section’ patients under the Mental Health Act 1983 – it’s the AMHP?
  • An AMHP can decline to make an application, even if each Doctor thinks it vital – that’s how important and legally significant they are.
  • They act independently when it comes to making statutory decisions – regardless of who their employer is. Like police officers cannot be directed to arrest someone if the officer honestly believes the grounds are not satisfied, they cannot be directed to ‘section’ someone.
  • 95% of AMHPs are mental health social workers.
  • Most of the other 5% are mental health nurses.
  • AMHPs carry a warrant card and have legal powers that the rest of us don’t have – it’s a criminal offence to obstruct an AMHP in the course of their duty – see s129 Mental Health Act 1983 – and this includes failing to follow any instructions to withdraw from a Mental Health Act assessment.
  • Contrary to popular policing myth: AMHPs do not request police support in the majority of the MHA assessments they undertake – it varies by area, but roughly 1 in 3 MHA assessments in the community involve the police.
  • AMHPs are NOT responsible for finding ‘beds’ for patients! – such duties fall to the lead Doctor in the MHA assessment.
  • Blaming an AMHP for a lack of beds is like blaming the police for a lack of AMHPs – it’s pointless, and it just won’t help. All they can do, is pass the police’s frustrated message to the DR or bed manager.
  • There are similar roles in Northern Ireland and Scotland to the English and Welsh ‘AMHP’:
  • Northern Ireland still use term previously used in England and Wales until 2008, Approved Social Worker – and only social workers may do the role in NI.
  • Scotland has Mental Health Officers who play an analogous role to the AMHP under Scottish mental health law.
  • AMHPs have powers to enter premises to check on anyone thought to be mentally disordered, under s115 MHA – however, they can’t force entry in order to do so.
  • They also undertake a whole host of MHA work that the police or paramedics rarely see – this includes attending hospitals to consider other types of legal decision.
  • Perhaps a s2 patient in hospital needs reassessment for detention under s3 MHA; or perhaps a s3 patient needs consideration of a Community Treatment Order ahead of discharge? – AMHPs get involved in all of this and much more besides.

AWARENESS DAY

The 29th June is #AMHP17 day, promoted by the Adult Principal Social Workers Network as an awareness raising day for this most important of roles – I’m often not a fan of ‘awareness days’ but I’m right behind this one.  If you get the chance to discuss things with AMHPs whilst you’re at jobs requiring police support, try to take the time to learn a bit about their role, its highlights and its frustrations. I always encourage 999 staff to understand: whilst the police and ambulance service are busy arguing about who will attend an MHA assessment to assist in conveying a patient, there is an AMHP, recently abandoned by the two Doctors, who is still with the patient and the family, trying to keep things safe whilst #Team999 are busy working out whether the ambulance will come before the police arrive or whether the police will despatch officers before the ambulance is available.

We often create a catch-22 in which the AMHP and patient are trapped where we refuse to despatch one emergency service until the other confirms they are en route! << This is the single-biggest frustration AMHPs voice in my direction, in the hope I can encourage officers in particular to help break the deadlock. If you’re a control room sergeant or an operational cop and you can help do this, please do – AMHPs who favour the police’s support are AMHPs who may go that extra mile for us in other circumstances, so build trust and relationships where you can because we also need them to help us.

So this is why experienced AMHPs have emergency food and clothing in their boot, in addition to their basic AMHP-kit! – it’s not uncommon to hear tales from AMHPs that they started an assessment at 3pm, had concluded the decision-making by 5pm after a difficult assessment and were still there at midnight trying to get #Team999 to break the catch-22 deadlock, all the while conscious that the longer the delay, the more likelihood that the hospital may have to give away the bed to someone who needs it and who can actually get there this side of Christmas.

NEAREST RELATIVES

But if you want to get to know an AMHP well, you could ask them to explain to you something about their very favourite topic: who is the Nearest Relative under the Mental Health Act? In order to undertake their legal decision-making, AMHPs have to identify and engage in discussion with patients’ Nearest Relatives for various purposes under the Act. Nearest Relatives have a host of weird and wonderful rights and authorities under the Act and working out who this is for a particular person can be very simple – so my wife is my NR and I am hers, but I am also my mother’s NR (she is widowed and lives alone) and I’m also my son’s NR (because I am older than my wife).

But sometimes it is a nightmare and AMHPs are obliged to obsess a little over this important safeguard of patient’s rights. Failure to get this correct can invalidate someone’s legal admission to hospital and occasionally AMHPs have to go to County Courts to displace Nearest Relatives who exercise unreasonable objections to MHA decisions. So when AMHPs get going on social media with their nightmarish situations involving a patient with one parent they never see and who cannot be traced plus six siblings, some of whom live abroad, and some of which are step-siblings and half-siblings and where the patients non-intimate flat-mate is providing some level of ‘care’ to the person … you’ll need popcorn, quite honestly. So if you want to a distraction from increasingly poor quality television, go and read section 26 of the Mental Health Act which outlines how to determine who the NR is, work out your own and those for your immediate family and your best friend and then ask yourself: who is Harry Potter’s Nearest Relative?!

Many AMHPs are working in LA or NHS organisations which have fewer than half the AMHPs they actually need, attrition is high and pressure immense on a group of people who are invariably spinning plates all the time they’re at work. Some areas have fewer than half the full-time equivalent AMHPs they need to cover 24/7 – their system is wobbling, to say the least and they really aren’t just there filling in forms for the Doctors: they are the key legal officer in our mental health system and I, for one, am immensely impressed by anyone who is both willing and able to do the job they do.

Look after the AMHPs you meet – even if you do find the odd one here or there who is wearing sandals.


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

Winner of the Mind Digital Media Award.


The Important Partnership

We hear a lot about partnerships in public services, the need for various agencies to do them, to have them or the need to improve them. Simplifying horrifically, the narrative seems to be that there are gaps and overlaps between different public agencies and if only managers could bridge the gaps and cooperate on the overlaps, all would be well. Indeed, you could argue that this is what sits behind the Crisis Care Concordat, one of the most significant ‘partnership’ documents we’ve seen on the issue of mental health crisis care. Don’t forget: the Concordat came from discussions specifically about policing and mental health, following the tragic case of Olaseni Lewis in south London in 2010. The concern was that it was a failure of the police and mental health services to work in partnership that caused the death of this young man.

Of course, we now know that’s only a part of the story and legal processes rumble on regarding the various parts. What this and several other cases have recently caused me to wonder is whether this simplistic idea of ‘partnerships’ between agencies misses out some very important people AND puts the focus in the wrong place, on occasion?

What about the partnership between the police and the public?! – those of us who like the Peelian Principles know a part of the seventh principle very well: “the police are the public and the public are the police” and this is etched in stone, literally, at the new headquarters of the Metropolitan Police in London, New Scotland Yard. What we see many times over is police officers, usually junior and frontline officers and staff, effectively advocating for the rights and welfare of vulnerable people: to access support which might otherwise be denied, or resisting requests by mental health services to undertake tasks which should not be for the police because we risk making the outcome worse for that person.

A RECENT EXAMPLE

A duty inspector from a police force rang me a few weeks ago on a weekend evening. He had a young woman in police custody under a s135(1) warrant, officers having attended the lady’s home two days earlier with an AMHP and a Doctor to assess her under the Mental Health Act 1983. Her clinical history and presentation on the day indicated it would be necessary to remove her to a Place of Safety for assessment and they took her to local a mental health unit. Whilst waiting for the second doctor to arrive for a full MHA assessment, the lady, in her distressed state, proceeded to cause damage to the PoS unit and the decision was then taken to transfer her to police custody. Following assessment, it was decided admission under the MHA would be required and the usual hunt began for a bed – this time, a psychiatric intensive care unit bed. Around two days after the warrant was first executed the bed emerged and the application was potentially able to be completed.

The logistical problem which caused a delay to the AMHP completing the application was how to move the patient almost 300 miles to the hospital where the bed was identified?! – nowhere any nearer could accept the patient as she was still exhibiting challenging behaviour whilst acutely unwell. The journey would obviously take a long time to complete, there was the question about food, drink and access to toilet facilities along the way and the issue of medical or nursing supervision. Officers were told that a 999 ambulance was not appropriate, the patient would ideally need to be sedated but that this couldn’t happen in her case because of other medical factors beyond everyone’s control. A private, specialist ambulance contractor had been contacted but the police were told this could not be sourced for well over 24hrs – so could the police undertake the transportation on behalf of the AMHP?! … and unfortunately, no medical or nursing support could be provided either in custody or during that journey.

This shouldn’t really be a hard decision, should it?!

The answer is just a plain and simple, straight-forward refusal: point blank. There’s all manner of danger and illegality within that request … but shouldn’t we be working in partnership with each other?! My colleague stated openly he felt under significant pressure to agree to this and could feel in the pit of his stomach that it was the wrong thing to do but he was reluctant to say, “No!” in a way that didn’t expose the patient to further risks or delay in custody. But this is where my point comes in about the important partnership: that which needs to exist between the police and the public, around how we handle these specific and sensitive requests. If the request had been something which roughly met the police half-way in terms of resources, risk and safety, then it there could be a discussion about things. But not otherwise, because it puts people are legal and clinical risk.

SCRUTINY

You can imagine what would happen if that had been agreed to and reviewed, either by the IPCC, a civil court or heaven forbid a Coroner’s Court after an adverse development? Why were officers moving someone three hundred miles on their own, when it was known they needed medical or nursing supervision because they ultimately needed intensive NHS care not readily available in the back of a police van or on the hard shoulder of a motorway?! … what role here does the law play, in terms of mental health services? Well one of the first ones is it’s up to the NHS to commission healthcare services; it is up to AMHPs to make legal applications under the Act, once the grounds are met; and to detain and convey people to hospital as a result of all that. All of this MUST, by law, be able to occur in a way which survives contact with health & safety legislation and with human rights frameworks, such as Article 3 which prevents inhumane and degrading treatment, and so on.

The role of the police, where these things are being compromised because of pressure on the overall mental health system is to weigh up whether they should provide assistance that may not necessarily make things any worse, indeed it might assist in not aggravating things – or to resist doing so because they absolutely think it will. For example, the Code of Practice indicates (Paragraph 17.14 in England; 17.18 in Wales) that the police may be called upon assist in ensuring safety during admission where someone is ‘violent or dangerous’ – but this doesn’t mean that where such an assessment may reasonably be formed, the police should be doing this entirely alone! Indeed, it is one of many factors that should be considered and both Codes refer to the need to preserve people’s rights and their dignity, in conveyance. Not sure how that’s achieved if officers end up frog-marching a distressed patient in handcuffs in to motorway services to use the facilities.

The issue here between the organisations is not about partnerships and how we work together: it’s about each organisation ensuring we don’t make unreasonable requests of each other, causing undue and intolerable pressure, beyond their ability to cope. It’s about ensuring the legal rights of the patient and the legal duties owed by the non-police organisations in the particular example – of course, there are other examples where the police need to be careful they’re not doing that to AMHPs and NHS staff. Officers could, in theory, have said, “Go on, then!” and tried their best, but we can all imagine what would have been said if a clinical emergency developed en route and / or restraint was used and / or a predictable set of degrading circumstances emerged? We would be back to the sorts of things we saw in the Seni Lewis, Sean Rigg and other cases where scrutiny would be on those using force and not on those who created the conditions within which it became more likely to be used.

WIDER DISCUSSION

In the operational police work I’ve done, I’ve often found that the important partnership that needs to be forged is actually between the police and those of us with mental health problems – or their families and friends. It is genuinely gratifying to become involved in something and find that the police have been able to help the public directly and where this is consistent with good partnership working with the NHS, that’s all very well. It should always be borne in mind, however, that the police are not on anyone’s side, that they have a duty to the law, first and foremost and that we cannot always be expected to act a certain way when we are invited in some way, shape or form, in a conflict that exists between NHS resources and patients’ rights.

It should always depend on specifics as to how any situation like that is resolved because, I repeat: as police officers, we are not on anyone’s side during a legal conflict. But enabling the police to do the right thing so they may professional acquit themselves is usually the same thing as ensuring the rights and dignity of patients – unless something gets in the way.


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

Winner of the Mind Digital Media Award.