A foot in both camps

Over the last few weeks I have enjoyed following @Northwestdoc. It has struck me that much of what Dr Holmes as said has rung true with what I have been saying and, coming from a medical professional, this really interested me.

I wanted to know more so I asked Dr Holmes to write a guest blog for me. I am delighted to present it here.

Enough from me – over to the good doctor.

I’ve been a Forensic Medical Examiner for years. Did my postgraduate exams in Forensic Medicine and Law. Was asked to be the Lead FME for my Force. Worked through the introduction of nurses, outsourcing and we are now working through the transfer to NHS Commissioning.

I’m lucky to work in a Force area which has excellent and established Criminal Justice Liaison Mental Health Teams and an experienced Force Lead in Mental Health. The CJLTs are mainly 9 -5 but we do have some weekend on call cover and they have worked very hard to establish good links with Crisis Teams and Liaison Teams OOH for when FMEs and Custody Nurses become the first line opinion on mental health issues in Custody. Our major gaps remain in CAMHS and Learning Disabilities but I don’t know of any Force area that’s well supported by those disciplines.

You will also be envious to hear that we only have hospital based places of safety for s136 detentions. Mainly in our Emergency Departments. And a Chief Superintendent who makes it clear to his Custody Sergeants that they never accept a s136 into Custody. Yes our EDs struggle at times from delays in Psychiatrist and AMHP attendance but the detainees are safe and physical health issues are identified and dealt with.

The Force have recently had to implement a risk assessment policy to allow them to leave detainees in the care of the Place of Safety as their average wait was 9.5 hours.

However at a recent meeting we heard this has been largely supported by the Emergency Department Staff.

Yet still as the Duty FME Mental Health services were a mystery to me. And seemed to be an impenetrable brick wall when I asked for assistance. So four years ago I decided to re enter NHS training as a Psychiatrist and also work part time as an FME. So far I’ve worked across inpatient and community settings. Acute care, Early Intervention, Old Age, Learning Disabilities and CAMHS. Done emergency psychiatry assessments in Emergency Departments of Acute Trusts. Worked closely with Liaison and Crisis Team Colleagues.

So what have I learned?

Well firstly I was amazed to find out how utterly reliant Mental Health Services are on the Police. There barely seems a day where Police cars are not parked outside our Emergency Department or Psychiatric Hospital. Responding to our requests for help. Detained patients who have absconded from wards. Voluntary patients who have left, as is their right, but we are worried about their risk so we want the Police to find them. Reports being taken on patients who have assaulted staff or damaged hospital property. Patients who the Police have been summoned to support their removal to hospital on CTOs or sections. Phone calls to report a patient making vague threats to kill which we want the Police to take responsibility for. Occasional calls for assistance where the ability to restrain and seclude aggressive patients is beyond the ability of our nursing team.

I then began to talk to my colleagues about how they saw the Police and was amazed at the range of attitudes. A feeling that the Police sometimes ‘dumped their problems on us’. The concept that a person intoxicated and distressed in a public place was first and foremost a Police and not a health problem. Yet these same colleagues lift the phone to the Police and expect an immediate response and a solution.

I then went off to a Forensic Psychiatry conference thinking therein must lie the professionals who would understand the interface between Policing and Mental Health. Not so. Although picking up the risky mentally unwell from the CJS they enter the frame at the Courts or Prison stage. They felt very firmly that Police station psychiatry lay in the realm of general adult psychiatry but my experience of general adult psychiatrists did not find much interest or understanding within their ranks.

So back to work as an FME I tried an experiment. I rang a Crisis Team about a case and identified myself as an FME. The shutters went up. I then told them I worked in the local Early Intervention Team. It was like the door to the Secret Garden had creaked open. Suddenly I was in their world and they would help me.

I have been branching out nationally in recent months and what I find horrifies me and reinforces my view that MH services expect the Police to problem solve for them but don’t feel they should problem solve for the Police. I came across Police bloggers on Twitter and find myself very much on ‘their side’ in this debate.

The current philosophy is that the Police need to improve their training around decision making in mental health. Training is always welcome but this is not the answer. If you look at the national s136 figures about 20% are detained under the MHA or admitted voluntarily. A further 30% are offered follow up by mental health services. Well that’s a pretty good hit rate in my view. Put me in a Police uniform and my hit rate for lawful arrests isn’t going to be that good.

Most Police Officers I know are instinctively very good at recognising those in mental health crisis and dealing with them sympathetically. The problem is when the Police can’t go with that person to a health care facility. A small proportion of these people will have significant physical health complaints that can’t always be ruled out in a Custody Suite. One death from a slow bleed in the brain of an alcoholic is too many. Why do we expect these people to take chances just because they have ended up with a Police instead of an Ambulance response to their crisis?

In the same vein Street Triage, although welcome, may be flawed as mental health nurses will not be able to rule out physical illness. Whilst it will reduce s136 detentions the alternative may be ‘triage to cells’ which leaves the same problem of a person in crisis in a Police cell.

Add in the dangers of the restraint that often happens in these risky crises and I firmly believe that all these cases have to be managed in the NHS (supported by the Police if necessary).

So what works? Well it’s the liaison part of liaison and diversion. The majority of mentally ill people do not need diverting from the criminal justice pathway if they have entered it because they have committed a crime instead of in a crisis.

A very small proportion (less than 10% in my experience) require diversion at the point of arrest as they have offended in a relapse of their mental illness and the pragmatic view is taken that prosecution should not be progressed.

However many people with mental illness offend in the same way as the non-mentally ill and have the ability to take responsibility for their actions and be supported through the criminal justice system.

We have a new initiative of a ‘Mental Health Court’ locally where a judge has taken an interest and takes a multi agency approach to disposal, making compliance with treatment, housing and advocacy part of the package.

Criminal justice sanctions often support the psychiatric management of patients allowing us to maintain them in community placements where they have been accustomed to assaulting staff and facing no penalties as they have a mental health diagnosis. Liaison is the key; if I have a known service user in Custody I get on the phone, put it in context and ask is this a deterioration that needs hospital admission? Are they compliant with treatment? Does the Crisis Team need to get involved? Do they need a visit from their care coordinator? Or are they stable and do we just let the CJS take its course with support for the detainee?

Liaison has also allowed advance planning. ‘Health Risk Assessment Meetings’ are held where the Police support the NHS in care planning and risk management. We look at repeat s136 detentions and agree pathways for the next crisis. We put markers on the PNC to say a MHA assessment needed if this person is arrested. I have also applied some of the lessons to managing some repeat cases with high risk physical conditions and agreed with the Emergency Departments that on arrest that person should go straight there for review before coming to Police Custody.

Yes the pathways across the NHS are complex as evidenced in @MentalHealthCop’s latest blog. But we must get a joined up pathway agreed by the new Offender Health Commissioning Groups for each Force area.

I don’t agree that all mental health crisis is predictable or preventable. Nor that the Police should not be involved in the response. Many people in crisis are not open to mental health services and do not have mental illnesses. But to see the Police as the agency who need to fulfil the roles of Law Enforcement, Protection of the Public, Paramedic, Nurse, Doctor, Drugs Worker, Mental Health Worker, Relationship Counsellor, Debt Advisor, Housing Officer……. is madness in itself.

It’s time the NHS stepped up to the plate.

Courtesy of Dr Holmes via Nathan Constable