Attention to Detail

Last year, the National Institute for Health and Care Excellence (NICE) published their Standards on the Mental Health of Adults in the Criminal Justice System. This involved NICE reviewing the best available evidence and practice around the contact that vulnerable adults have with the criminal justice system. Subsequently, NICE published what they call a ‘quality standard‘ – this is the subject of a comment piece in the recently published issue of Progress in Neurology and Psychiatry (volume 22, 2018).

I’ve just spent a whole week in Cornwall (picture above), trying really hard to step away from work – it’s been quite a busy few months during which I’ve had to do things which are quite new to all the work I’ve ever done on policing and mental health. I’ve also been consumed in the recent months that the net effect of what we’ve ended up doing to make the world a better place is merely making it worse. Not just slowing down how much worse it’s getting – but actually accelerating things in the wrong direction. I know it’s not a view that many people share; I’m very aware of all the mantras that come out when these kinds of views are articulated – that the only way to do things is in partnership, etc., etc.. So upon return from annual leave, I read the comment piece about the NICE Quality Standard and found, yet again, reason to question those kind of underlying assumptions and – like the reports I’ve had to write in recent months for various legal processes after deaths in police custody – I found myself wondering about attention to detail.

I need to repeat one more thing, about which I’m at risk of becoming really boring whilst I drip like a tap: if you think that the work to be done here is improving policing and criminal justice responses to the mental health demand that we face, you’re fundamentally mis-identifying the problem. The problem here is not the police: it is the extent to which we deliberately rely upon the police to triage and gate-keep mental health demand that we increasingly decide should be criminalised. We rely too much and we need to work out how to stop because having just spent the last fifty or sixty years gradually and subliminally shifting institutionalised mental health demand from health to prisons and then regretting it; we need to make no mistake we are now seeing a similar shifting of crisis and community care from health to police and probation. And this Quality Standard and the arising expectations in comment pieces are just helping us reinforce this, in my own strictly personal opinion.

110 RECOMMENDATIONS

The comment piece claims that the Angiolini Report (2017) contains “110 recommendations for improving the way that the police manage vulnerable people at the point of arrest”.

No, it didn’t – did the authors of the piece actually read the Angiolini report?! It contains 110 recommendations (see page 235 of the report – they’re all laid out, one by open) and you’ll notice the majority of them do not relate to the management of vulnerable people at the point of arrest or contact. Those which do relate to that, barely relate to the police – they relate to the National Health Service and its need to improve accessibility and its interface with policing. Around 70 of the recommendations relate to processes after a death in police custody has occurred; processes connected to investigations carried out by the Independent Office for Police Conduct, to the whole coronial court process and certain specifics, such as a call for families who are bereaved after a death in custody to have access to Legal Aid.

If you look at the roughly 40 recommendations which do relate to how vulnerable people are managed, you’ll see that fewer than 10 relate to matters over which the police have sole control. In other words, most of the ‘Angiolini recommendations’ are about improvements in post-death procedures; less of it is about preventing deaths from happening in the first place and those which do have that bearing are about how accessible our NHS is.

POLICE CELLS

The comment piece correctly states that Angiolini claims “Police cells should not be used to hold those detained under mental health powers.” This is correct – it does call for that. But it goes on, “The NICE Quality Standard seems to accept that this sort of change will be a lengthy process” and “that procedures can be put in place in the interim, to keep people in custody safe and minimise any potential unnecessary harm.”

No, no, and again, no – history and evidence shows it cannot and it shows that moving to a position where areas do not rely upon police cells as a Place of Safety can occur in a relatively short period of time, given the will to achieve it. Areas without any Place of Safety provision at all have shown it is possible to get from nothing to working in a matter of weeks. I’ve been part of making this happen and these services still exist in the real world, where no-one is taken to police custody whilst detained under the MHA, ever. Yes, it will take careful multi-agency working and a commitment by Chief Constables to perhaps take more than a fair share of the resourcing in the interim transition period, but it’s possible. See West Midlands Police, for details.

In the comment piece, little mention is made of prevention, yet this is the bedrock of most crime reduction and public health strategies: so how do we prevent vulnerable people from getting to police contact in the first place? You could be forgiven for thinking that the authors have assumed all CJ contact is unpredictable, unpreventable and unavoidable demand where the task, as outlined in the Quality Standard, is merely to better respond to what is happening, primarily through the medium of improved policing largely dependent upon improved training and competence. These are the standard traps to fall in to – look at s136 data, look at street triage data, look at Liaison and Diversion or arrest data: those I’ve analysed show that most of the people in contact with the police are non-offending, known patients with requirements best satisfied by the NHS and which do not, for the main part, need the police at all. And of course, the fact that policing and criminal justice can be an anxiety aggravating, even pathologising process is left more or less untouched.

And as for ‘accepting’ lengthy process: the Code of Practice to the MHA has called for the use of custody to be ‘exceptional’ or a ‘last resort’ since at least 1999 – is two decades enough to ensure that every area of England has a ligature proof room? Just think of how many far more complicated things we’ve managed to sort in much less than two decades and then ask yourself whether the urgency of tectonic plate shift is inevitable.

THE QUALITY STANDARD

There are four planks to this thing: my own view is that it reinforces that responsibility mainly rests with the police and it relies heavily on this mantra we repeatedly here in the UK and elsewhere: that the most important thing we can do is give the police more training. It’s as if policing is all that’s gone wrong here. “Training for police officers to use non-contact and appropriate communication styles with disturbed individuals is clear available, but like the introduction of body-worn cameras, is probably not consistent or mandatory.” I’ll again be honest: the irony of NHS professionals highlighting inconsistency in policing is not lost on me after I learned that there are 27 different training courses in London alone, for restraint in mental health nursing. And of course, none of them are operating to a validated standard. Then add to that the 57 mental health trusts being commissioned by over 210 Clinical Commissioning Groups so that even one mentla helath care provider trust is not providing a consistent service across two different CCG areas and that this is because the NHS want it that way.

In policing, despite 43 different territorial police forces and a few other specialist ones, we have one personal safety training manual and all police forces operate to it. They may run their officer safety training in different ways, combine their OST with other things like first-aid in some forces, but not in others: but it’s one national standard around the use of force and for all of my twenty years in policing, it has emphasised verbal communication and de-escalation.

A quick word on Liaison and Diversion teams, seen by Lord Bradley as key to whole diversion / criminalisation thing. Around 85% of the population of England is now served by a LaD scheme. Many of them operate on the basis of referrals made by the police to the nurses on duty in custody. I’ve known areas look for ways to improve the number of referrals made by the police, because of an ongoing suspicion that the police are ‘missing’ some vulnerable people in custody. Of course they are! – they always were and they always will. Doctors with access to medical records get this stuff wrong when they have hours to assess someone, so I’m not sure what standard the police are being held to, if I’m honest, when they often have minutes to make decisions about who is vulnerable.

THE WIDER PICTURE

“The true challenge is not knowing what to do”. I couldn’t possibly disagree any more profoundly with this. I meet people regularly who do not know what to do – have no idea of what is possible and think their problems insurmountable. But one thing I can agree with, is the comment’s view that none of this stuff is new: they mention the Reed Report from 1992, and the Bradley Report from 2009. We’ve since had the Adebowale Report (2013), the Home Affairs Committee report (2015) and then the Angiolini Report (2017). In between all of those, we’ve seen countless individual Coroner’s inquiries, human rights cases, IOPC death in custody investigations, which all raise similar issues … over and over and over, again and again and again.

This would almost be boring if it weren’t for the loss of dignity, safety and humanity – the extent to which the learning is there to be had, but ignored.  Instead, a preference of pushing an agenda that may help at the margins but doesn’t address the core issue of why were are increasingly seeking to criminalise vulnerable people as a gateway to healthcare? We did it to prisons and probation and we’re now doing it to the police. Until we stop just looking at the police, calling for ever greater levels of training and start looking at why vulnerable people come in to contact with the police in the first place, we’re going to keep getting our analysis of this wrong. And of course, I would suggest we have  for far too long.

So, we’re off to a flying start to my return from leave! – the mission for us all is to combat the covert criminalisation of vulnerable people which emerges from the unintended consequences of public policy being disaggregated, yet run on the pretence that we need to improve policing and police training which ultimately, at its best, is just an overly attractive half-truth.  If you think otherwise, then I suspect we’re trying to fix different problems.


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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My Health and Yours

My healthcare, and that of my family and friends, is absolutely none of your business. None whatsoever, with all due respect! Yours is none of mine and I’m only professionally interested in a very limited and particular way.

I’ve been asked a few times whether I’m interested in this area of policing because I have personal experience of mental health problems, or perhaps via a good friend or relative? That’s none of your business, as I’ve said. This reply should not be used to construe that the answer is ‘Yes’ and that I’m trotting out privacy rights in order to avoid revealing things. To be honest, I’m trotting out my privacy rights (and those of my friends and relatives) just because I can and because it’s up to me whether I reveal things about my or their health. I’m afraid, I’m a bit like that – private, contrarian and rather fond of my rights as well as being very content with the attendant obligations that always accompany rights. It’s my decision what I choose to reveal about my healthcare and it’s not for me to reveal things about the health of my friends or relatives without their consent or another damned good reason.

If you’re asking, last year, I did have a small health problem and it was my wife who pointed out something I hadn’t realised: that this was part of an emerging pattern which could be a greater cause for concern. Seemed like wise advice from her, so off I trotted and the Doctor gave me some malady-specific advice and medication in addition to one of those fat-man-over 40 MOTs which I’d managed to avoid for three years and it all helped in the short-term whilst putting my mind at rest about a range of other things you start thinking about when you’re a bloke over 40 who rarely goes to the doctor. But when it was more recently suggested I might go to a doctor for another reason, I exercised the right of every sentient person to laugh at the very idea of it, munch on some painkillers and crack on. I have been known to make doctor-related decisions without prompting from anyone else, to take complete responsibility on my own, too – to decide to go to the Doctor without any outside support or encouragement from anyone.

That’s enough of my medical history and it was my decision to share that much of it with you – as was it my decision to keep details about particular maladies private! It’s none of your business, obviously! … I’m sure you’re getting the hang of this already!  This is the thing about healthcare, and other aspects of our personal lives: it’s private stuff and we can all choose from where we take advice, whether we act upon that advice or whether we reject it all and do our own thing; and whether we tell the world. Ultimately, it’s up to individuals to make decisions about their health and their healthcare – most of the time. It’s almost never going to be your responsibility.

CAPACITY AND CULPABILITY

Obviously, there are circumstances where these important principles are compromised. Children have far fewer individual rights in these situations and their parents or guardians routinely act on their behalf. Some adults can’t take decisions about their own health, because of injury or illness – if you’ve just been knocked over and knocked out as a pedestrian in a traffic collision, you’ll probably want your friends and relatives, or helpful police and paramedics to start making decisions about what they think is in your best interests and act accordingly.

You can also imagine that if your healthcare issues are driving your behaviour to a point where it affects others, we may expect the police to step in and then work with healthcare professionals to determine what must be done. Do we prosecute the drug addicted burglar or robber, if they are offending to fuel their chemical dependency? – of course, we most usually do. We also do this in some cases where a person has experienced psychosis, but most usually in those rarer cases where they’ve hurt someone else or been found in unlawful possession of items which could be used to cause harm. History shows we do incarcerate people in prisons and in mental health units who pose a risk to others because of their health and addiction issues.

So you could summarise all of this, more or less, as follows –

Decisions about the healthcare of sober, conscious, non-vulnerable adults who have not broken the law is ultimately a matter for them and not for anyone else.

ADVICE AND GUIDANCE

Most of us reject healthcare guidance to one extent or another, whether that is because we eat too much, drink too much or exercise too little. I’d be genuinely interested to know how many adults of working age could say they moderate alcohol within Government guidelines, whilst taking the relevant amount of exercise, eating their Five-a-Day portions of fruit and vegetables within the recommended calorie limit, etc., etc.. We recognise that our autonomy allows us to reject advice because most of us do on at least one of those areas, even where the advice is based on the best available medical and scientific evidence.

So what’s different in policing or medicine, where someone’s healthcare decision isn’t perhaps what we, as professionals advising and guiding, would hope they do? How many police officers and paramedics attend a mental health incident where things are not so serious as to justify restrictive and coercive interventions but where we find it difficult to accept the decisions of people who are nonetheless vulnerable, even if just in our view, if they are rejecting advice. I’ve recently heard a few police officers talking about how they still have to ‘do something’ in a situation where they’ve (correctly!) established they have no legal powers to override someone’s autonomous and, no doubt, unwise decision.

But here’s the legal nugget of this post: an unwise, even stupid decision can still be lawful – a person does not lack capacity by virtue of wanting to behave in a reckless or dangerous manner with regard to their own health. You want to stop taking medication, or walk out of A&E before treatment is completed; you want to decline an ambulance trip to hospital after you fell – all of this is a matter for you, not me … subject to those caveats of whether you have capacity to take your decision; and whether your behaviour amounts to an offence which is impacting upon the rights and safety of others. (And by ‘rights’, I mean the actual legal rights of others, not the ones we make up to justify a moral intervention that has little basis in law.)

GOOD REASONS

Final point: some people have reasons for healthcare decisions which are profoundly important to them and which are morally and intellectually sound, from their perspective. The fact that any professional may disagree and even think the reasons risible, is neither here nor there. If you doubt this, look at the kidney dialysis / paracetamol overdose case where a lady refused treatment because she didn’t want a live of relative poverty and loneliness ‘in a council flat’ getting old. Doctors at the hospital argued that she lacked capacity to take decisions for herself and the Court of Protection rejected this, citing an earlier case –

“An adult patient who… suffers from no mental incapacity has an absolute right to choose whether to consent to medical treatment, to refuse it or to choose one rather than another of the treatments being offered,” … “This right of choice is not limited to decisions which others might regard as sensible. It exists notwithstanding that the reasons for making the choice are rational, irrational, unknown or even non-existent.”

There are lots of examples in policing where we assume that the right thing to do is to take healthcare choices away from people where we would, perhaps, be better advised to help people make choices for themselves. Once someone is under arrest or detained under the Mental Health Act, things are different, but prior to that or where such thresholds are not met, it’s actually none of our business, beyond ensuring people have been advised or sign-posted to options they may not have been aware of, which they may or may not find helpful.

Your healthcare choices are a matter for you – and that means public professionals should respect your right to make your own choices, even if they can’t respect the choices themselves.


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

Winner of the Mind Digital Media Award.


Interim Report: MHA Review

Last week, Professor Sir Simon Wessely published his interim report after being asked in 2017 by the Prime Minister to look at the Mental Health Act 1983. A lot of people have been interested in this since the moment it was announced – a lot of people have a vested interested in this, full stop. It’s important stuff and I don’t think I under-estimate things when I say that the state of our mental health law partly characterises us as a country, because it speaks to how we see ourselves looking after some of the most complex and most vulnerable people, at their most difficult time. By Christmas we’ll have absorbed what Sir Simon is putting forward as his final recommendations.

A review of what we’ve got raises some of the most fundamental questions: when, if ever, should the state take away someone’s autonomy and, potentially their feelings of dignity and self-respect? When, if ever, should we force people to receive treatments against their will – including treatments where even psychiatrists themselves are unable to agree on long versus short-term benefits? Should our law be ‘capacity’ led legislation: that you should be allowed to take any decision as long as you have capacity to do so? – plenty of patients and mental health professionals of various stripes will say some people are subsequently thankful that someone took control of their welfare and wellbeing when they were at their darkest point and that pure ‘capacity’ based legislation will cause some people with certain kinds of mental health conditions to die.

For me, I was just really glad to see that the police were included in this review early. We have remained involved throughout and you’ll notice in the interim review, that the police and policing will be one of several special interest groups in the second half of the review. My boss, Chief Constable Mark Collins is the policing lead for the National Police Chiefs’ Council and he’s submitted various ideas to Sir Simon for consideration, as well as various problems we’d like to see him address in some way, and been an active member of the Advisory Group referred to in the report. So, we’re in there trying to help people understand what an important role the police can play, but how we are probably over-relied upon already.

POLICING

The report isn’t that long, as these things go – barely 60 pages by the time you strip out the standard guff that all reports have! Policing is covered in section 7.4, page 24, but you’ll have to excuse me copying it all here as I’d like you to read it all –

“The police recognise that helping people with mental health issues is a part of their core business. The police are key partners in the community-based model of mental health care. This is particularly true in cases of immediate responses to people in mental health crisis, where the police have specific powers under the MHA to section people for short periods of time under sections 135 and 136. The use of these powers has remained at a high level over the last decade. This underlines the importance of the police role, but also challenges the NHS to ensure that services are available and ready to take over responsibility at the most appropriate time.

The contribution of police officers to crisis care has been praised by the CQC, but nevertheless should not have to make up for gaps in health care provision. This is especially so because for many people, interactions with the police can be upsetting and stigmatising, and at the very least not therapeutic. This is particularly the case for certain BAME [Black and Minority Ethnic] communities, such as African and Caribbean individuals. There has been a significant reduction of the use of police custody for people held under section 136 but not yet enough to end this practice entirely.

Another emerging issue is that people who are arrested under criminal law stay in police cells for too long after an approved mental health professional (AMHP) has decided that they should be admitted to hospital. It should be a matter of principle that those who are unwell should be treated within the NHS rather than a police cell. This principle should extend to the transportation of service users under the MHA which should under most circumstances be conducted by NHS ambulance services.

We believe that the care of people in cells is as much an issue for health and social care as it is for police. We will consider whether NHS England should take over the commissioning of police custody health care services, or otherwise create a plan so that people in police custody get better care, and faster transfers out to NHS and social care services.

Finally, but crucially, equality issues are of the utmost importance when it comes to all police work, and we will consider how new approaches and innovations from forces have helped to address the experience of people from BAME communities who come to the attention of the police when needing mental health support.

We will consider further:

  • How recent legislative changes to sections 135 and 136 are changing service approaches and whether it is right to bring an end to having a police cell designated as a place of safety. If so, what safeguards and resources are needed to do this safely?
  • Why people who are arrested under the criminal law are staying in police cells for too long after an approved mental health professional has decided that the person needs to be admitted to hospital, and what can be done to address this.
  • Why police vehicles rather than ambulances are still transporting the majority of people under these sections, and what can be done to address this.
  • The practicalities and benefits of NHS England taking over the commissioning of health services in police custody, as has been recommended in both the Angiolini and Bradley reports.
  • Equality issues, particularly police interactions with people from BAME communities under the MHA.

This covers the main issues that police forces and police officers raise with me, when they are asking questions that come down to the problems with our mental health law. Others might include addressing, in some way, shape or form, the very real problem that the UK currently cannot ensure the right kinds of professionals respond in a timely way to someone in a house when they are in crisis – do we also need to look at how we safeguard people in their own homes when they are at risk?

IF I MAY?

If I were to offer an observation as someone reading the report and trying to think from the outside, as if I hadn’t been to the meetings or discussed this at all, I think I’d wonder aloud, as I am constantly doing at the moment, about whether the problem to be fixed in policing is the issue of NHS support, delays in achieving that support (for beds, for conveyance, for place of safety spaces, etc.) or whether the real problem is the extent to which we appear to over-rely upon the police as a de facto mental health care provider. The fact that the police are praised for their contribution and that patients themselves report the police as displaying a better attitude towards them and their needs whilst they are in crisis, is welcome, but not relevant to me. My decorator is nicer than my plumber, but when the heating goes in my house, I’m not ring the guy with the brushes and roller.

One thing that’s been obvious throughout this review process, including the various comments I’ve seen from those of us with mental health problems on social media, is that many of the things that people ‘want’ are not, directly, issues with legislation. They are issues with resources: ahead of going to one of the first Advisory Group meetings, I asked on social media what people and police officers would like to see. Often, the answers were things like, “Crisis Teams that can actually respond in a timely way when there’s a crisis incident” or “more inpatient beds”, etc.. Of course, you could have both of those now, without changing the Mental Health Act itself – the NHS just needs to take the necessary action to increase staffing on crisis teams and to open up more beds. (Before anyone attacks my use of the word ‘just’, I am aware of the nurse recruitment problems, funding cuts, etc., etc.. – I use the term to distinguish between choices that could already, in theory, be taken and choices which require amendments of primary legislation.)

So I’m fairly happy enough so far, because a special interest topic group in Phase 2 of the review is bound to get in to the detail of these things and for what it’s worth: I know Sir Simon, who took some flak on social media for even being appointed to lead this review, is trying hard to do the impossible. From whatever perspective you want to look at this, it’s a near-impossible job because when I sit and listen to those parts of the discussions and debates that don’t professionally concern me, I can see there are many people passionately arguing their case for things which are equally passionately opposed by others just across the room. It doesn’t matter what he does or what he recommends here, he is going to disappoint plenty of people for daring to even suggest certain things and for not daring to do so. And whoever was chairing this review, they could be accused of vested interests as well. All I can say is this: it looks to me from the parts I am seeing as if this is being done as fairly and openly as possible and that the various conspiracy theories I hear are ill-founded.

Let’s now see what the second phase brings.


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

Winner of the Mind Digital Media Award.