If you were to try to determine the purpose and priorities of any organisation, you would probably need to look way beyond its spoken and printed words. You would examine what it did and what was critical, literally, to its leadership. So think, as an example, about the purpose and priorities of prison: we are repeatedly told that the prison is about the punishment and rehabilitation of offenders and yet what constitutes adequate punishment is way outside the control of prisons – it is determined by the courts; and any evident failure to rehabilitate rarely causes HM Prison Governors to have to resign. Inspection reports from HMIP often talk about rehabilitation and the improvements that need to occur, but the truly damning stuff in prison history tends to come from riots, escapes and other things quite unconnected to what they say their priorities are, like suicides and levels of violence or restraint.
So let’s look at mental health and our NHS! —
What the system says
If you look around the system we have built, as it stands today, you can see how we have structured our priorities and purpose. We have divided the health system into over-functionalised silos: Emergency Services commissioned by one part of “the system” and mental health services commissioned by another. And at the risk of picking on A&E as a prime example, it is clear that they don’t really want much to do with mental health issues, otherwise we wouldn’t learn of such variable standards of care, in breach of national guidelines as we did today when we learned that more than 40% of self-harm patients leave without specialist mental health or psychological assessment. We know that some A&Es sub-contract their mental health operations to liaison psychiatry services, albeit that you can’t access those services in many areas if you’re in the custody of the police; and that other A&Es don’t have liaison services at all. A&E will repeatedly say in official documents that they are “not a place of safety”, when nothing in law gives them the right to opt out of the potential status that was imposed upon all hospitals by the Mental Health Act 1983. Far more importantly, some people with mental health problems in the custody of the police can lay a perfectly legitimate claim to having emergency, even life-threatening needs and they need a place of safety.
You only have to look at the College of Emergency medicine mental health toolkit to see the extent to which they are attempting to put distance between A&Es and mental health, especially when it is connected to policing. This professional body cared enough about it all to imply very straightforwardly that the Code of Practice to the Mental Health Act should be breached for s136 MHA detentions rather than them be affected by providing healthcare assessment to people who may well be ill. It is my experience that A&E will not blink before attempting to cover themselves by deflecting to the police requests for “safe and well checks” on non-vulnerable patients who have exercised a capacitous decision to leave hospital before obtaining treatment, but react quite surprisingly to the suggestion that they may have a role to play in clinically risk assessing whether people detained in the custody of the police who may or may not have a mental health problem or another physical condition that would put them at genuine risk in custody.
The impact of the CEM toolkit is that a 92yr old dementia patient detained by the police under s136 who cannot access a place of safety in mental health unit, should be gaoled by the police in custody rather than allowed to sit in an A&E cubicle, pending support from liaison services. Of course, whether she has dementia, or diabetes or a brain tumour, will be beyond the police officer. But let’s just use custody anyway ……
This tells us a lot about its priorities. —
Parity of esteem and the burden of disease
We recently saw in Part 1 of the Keogh Review into Urgent and Emergency Care that mental health was mentioned just once and in passing. We also know that almost 10% of Health and Wellbeing Boards forgot to mention mental health at allin their recently published strategies and that many who mentioned it highlighted something specific, like children’s mental health provision. Interesting that two recent political developments in the oversight of Health and of Policing have led Police and Crime Commissioners to state publicly that they are committed to tackling mental health disadvantage in our society and improving the lot of those in contacted with the police and more generally. And yet not all of our Health and Wellbeing Boards seem to think this is a priority, even in public words, never mind deeds. What was that about “No Health Without Mental Health“?
We know the government has repeatedly said that there should be a parity of esteem between mental health and physical healthcare and yet it is too easy to point out how the financial reality of healthcare does not match up to that, nor do the rights of access to treatment and care. We are not even close. It is systemically built into our NHS to ensure that people with mental health care get a different experience, that they get excluded from services others would get into and that those most vulnerable who end up being detained and supported by police officers, get access to even less appropriate care. It’s when you start hearing NHS professionals saying that unless severely unwell mental health patients are prosecuted for something (even when evidence doesn’t exist) that they cannot have access to services that clinicians say they need , you realise words and deeds are two very different things.
Premature death following enduring mental ill-health is right up there on the World Health Organisation burden of disease, and is forecast to overtake heart-disease and strokes as a cause of death. We know that people living with serious mental health conditions have a life expectancy in the UK that is 15-20 years below the general population, which many would suggest is something of a scandal. We know that health inequalities in mental health are significant, with men accounting for 75% of suicides and particular male age groups being especially at risk – BME communities are massively disproportionately affected by MHA decision made by both the police and by mental health services. Yet work in the area of mens’ mental health is so behind any measure of the impact it is having upon British men, that we need constant third-sector initiatives to try to raise awareness of what a problem it is. For BME communities, we know that the broader mental health process results extensively in the criminalisation and over-detention of many as a conditional gateway to care.
So that’s where we see implications for policing and criminal justice. —
What does this mean for policing?
As mental health care was deinstitutionalised in the last forty or so years, there was supposed to be a corresponding shift in investment to community care. It is broadly accepted that this has not happened and there are genuine question marks over the capacity of the mental health system to handle demand. Over the last three years, the number of mental health professionals of all kinds who have informed me that thresholds for GPs to refer patients to community services and for admissions to hospital are rising. We know that beds are in shorter supply, 9% down on a few years ago at a time when the number of MHA admissions is rising, having exceeded 50,000 in a year for the first time in recorded history. The police service are consequently playing a far larger part in picking up deflected demands. We see this in many ways.
The use of section 136 MHA has increased significantly over the last ten and the last twenty years – and yet we’re still no closer to properly examining that to understand the make up of demand. How many section 136 detentions are current, known MH patients or repeat detentions and what does that tell us about care plans and joint responses to repeats? A view of the police as the coercive arm of the mental health system has progressed apace in recent years – as mental health professionals openly state that they have become risk averse to undertaking coercion for themselves, something the Mental Health Act absolutely allows them to do. There is no operational capacity in the NHS to undertake therapeutically appropriate restraint for use when s6 and s18 MHA are being implemented.
As so we currently have a few dozen of your operational police officers suspended and moved away from operational police duties whilst the IPCC determine whether or not they should stand trial for criminal offences, in circumstances where officers have previously said or may be able to say again that regardless of what they personally may or may not become accused of, they were operating in an environment where expected standards of clinical practice simply didn’t exist or they were actively resisted by (just some of) the health and social care professionals they work alongside. So we send officers into situations where they end of dealing with what are straightforwardly clinical risks, in a vacuum of support a lot of the time; and then resist them as they attempt to access support for the vulnerable people they have by then become responsible for.
Words and deeds
Despite a stack of guidelines sitting on a shelf in my study about a foot high – each one of which, incidentally, will be an exhibit if I ever have to write a statement of evidence under caution about my operational role in death in custody – we find that those who are all-too-often managing crisis mental health events are uniformed people with a first aid certificate, no great amount of information and pair a of handcuffs. If you don’t believe this assertion: read my last five blogs on the issues arising from recent death in custody incidents.
So what I see when I look at the NHS is a coincidence of seperate, overly functionalised organisations which are not sufficiently or effectively brigaded to give reality to stated priorities and purpose. As soon as we take the high-level documents mentioned above and start attempting to give effect to them in the real world, we hit up against bureaucracy that is intractable and quite incapable of seeing through a conflated plethora of contracts, commissioning and clinical confusions. It is the vacuum created by the bureaucracy and the politics of it all that sucks in the unsuspecting police officer, left managing vulnerable people with levels of clinical risk that some junior doctors wouldn’t be prepared to handle without immediately bleeping the on-call specialist registrar.
And this where words and deeds differ greatly — because of systemic pressures on frontline staff and commissioning managers.
These people, we will remember, didn’t build the system to start with. That is, very probably, the problem.
Courtesy of Michael Brown at Mental Health Cop