The publication of the CQC report on mental health care provision (Right Here Right Now) very clearly demonstrated that there simply isn’t enough of it. Not only is there not enough of it but those who end up dealing with it instead are neither properly equipped or trained to do so. The current system is nowhere even close to being able to deal with demand and the overall outcome is that people in crisis are being knocked from pillar to post when they are at their most vulnerable. When they are not at their most vulnerable, there is nothing in place to help them from reaching that point in the future.
The organisations charged with either providing this care as their primary role and those who fill in the widening gaps are struggling to cope and whilst this is a source of massive frustration across the board it is those in crisis who are suffering the most.
The current model of response for a lot of agencies is based around Monday to Friday office hours and those services who do offer a more flexible 24/7 presence are finding themselves being called upon more and more frequently to manage risk and situations which they were never intended to cope with.
On the day of the report I posted a short blog with some initial thoughts which led to a conversation with Commander Chris Greany on Twitter. We were both agreed that the way most services are currently set up is simply no longer appropriate for the 21st century. This got me thinking about what a truly responsive public sector might look like.
There has been much talk recently about combining the police and fire service. In some places this is already in fairly advanced stages of development and emergency services are already co-locating in a bid to save money. This has led to much hilarity on social media as the concept of the PolAmbulEngine has taken hold.
Pic courtesy of @martinwoods
Much of the teasing and ridicule has been born of the incredibly simplistic arguments being used in some quarters to justify such mergers. Apparently it is wasteful to send a fire engine or two, an ambulance and a police car to the scene of a road traffic collision when you could just send one vehicle containing everybody and everything you need instead. Practitioners will know that this argument is, frankly, bobbins when you think about the logistics and management of such scenes and the issue of what this vehicle and its occupants do when they aren’t dealing with road collisions.
In Devon and Cornwall there is even a Police Community Support Officer who is a qualified paramedic AND a fire fighter. He has been hailed in some papers as the solution to all kinds of problems as he patrols with three different communications systems and can effectively put on any of three hats according to whatever is going on at the time. It must have taken a lot of time and training for this man to achieve accreditation in each of these fields and I suspect the refresher training for all three will take up another chunk of his annual roster.
I admire anyone with that much dedication but I have to say that I am not in favour of either of these as long term solutions to the current budget restraints but if you scratch the surface of the idea then, actually, there is something approaching logic in there.
One of the biggest complaints made by police officers is that they can’t fight crime anymore because they are spending so much of their time dealing with things other people should be dealing with. The reason for this is that the out of hours provision for most aspects of social work is bordering non-existent. Another reason is that many other service providers simply do not have any form of response element. If a patient leaves a hospital there is no-one from the hospital who can leave and go and look for them. Crisis Teams run on skeleton staff and apply a very tight definition of “crisis” which seems to fly in the face of what everyone else considers to be a “crisis”. There is no real and appropriate response to someone who is suicidal.
This then leads to people ringing the service they THINK can most help them and being unhappy with the response. Still feeling they need help they then call one of the services who are operating 24 hour “call-outs”. This usually involves the ambulance service or the police. All of the other emergency services end up calling the police when they run out of resources or if the situation doesn’t fit their often very tight remits. Quite often, the original service called will re-direct the caller to the police or even call the police themselves.
Consequently, this funnel effect leads to pretty much everything landing on a police command and control system as an outstanding call for service for which there is no alternative path.
I recently posed the question of whether the police should simply start saying “no” to these requests but the more I think about it the more I realise this isn’t going to solve anything – least of all for the person calling for help in the first place.
Ultimately, it is these people who are most important. It is they for whom these services are in existence in the first place and simply shutting doors in their faces is contrary to their primary functions.
If you think about it – the police have reached this situation because so many other agencies have put up the shutters and said “we can’t / don’t / won’t deal with this.” It has now reached the point where the police themselves are on the verge of doing the same.
I think it is absolutely right that the police begin to push back against some of this deflection of demand and risk and, indeed, I appealed for the National Police Chiefs’ Council to take a stand and start doing exactly this.
Should they do so and the police start saying “no” then the true picture of just how short some agencies are of being able to meet their own demand will be exposed. This will lead to all sorts of problems and might just force the issue with regards commissioning and finance.
It might also force some of these organisations to step up to the plate and manage their own responsibilities because they have no escape clause anymore.
The problem with this approach is that it doesn’t really solve anything. It might free up police time but you can bet your bottom dollar on the fact that the police will end up on the wrong end of an IPCC investigation for not responding. It will be individual call takers and dispatchers and officers facing that heat – not the organisation itself.
It doesn’t really help the person in need either as it just means that the final door has been shut in their face.
The more I spend time dwelling on this the more I question if there are already too many doors – most of them shut or shutting – and if the answer isn’t, in fact, ONE door.
Forget multi-hatted, tri-service parafirecops turning up in their PolAmbulEngine and think instead of how much more effective and efficient things could be if there was a central hub which managed all calls for service and then routed them, immediately, to the right agency or department. And that each of those agencies and departments had a fully effective 24/7 response capability.
Commander Greany summed it up when he suggested that instead of being asked “which service?” when people dial 999 they are asked “what is the problem?”
This would mean that a call would simply be logged for what it is, triaged and then sent directly to someone who is properly trained to deal with it.
Suicidal people could be transferred directly to a counsellor. Calls could be transferred directly to social services, NHS, crisis team, police.
Personnel from all of these agencies would be in the same place at the same time and could freely walk over to each other for advice or, in the most difficult situations, call an immediate emergency case conference to decide on the best approach to a given problem. You then send the right people in the right combination to the right job.
Before anyone suggests I am describing a Street Triage scheme here (lest we forget my reservations about that concept) please note that I am specifically saying that the RIGHT people could be sent to the RIGHT job in the RIGHT combination.
Instead of everyone being scattered to all four corners of police force boundaries constantly ringing one another to deflect demand you would have everyone in the same place working towards the same ends.
There are some barriers to this idea:
1. Cost – initially it would be huge. Trying to locate everyone in the same place and get technology to speak to other technology would be incredibly expensive. This capital cost would then need to be supplemented by ongoing revenue costs for the increased number of staff you would need to ensure that all elements of the programme could be truly responsive. Combining budgets and commissioning may help here but it would still be a very costly thing to create. However, I am convinced that over time this cost would pay for itself and it would rapidly reach the point where money was being saved in vast amounts. This is very much a “spend to save” solution.
2. Culture. All agencies are used to working in silos and have become very defensive. The one positive I have seen from the various triage pilots around the country is that most of the staff within them are reporting a whole new working relationship and understanding of each other. I have seen this myself in the many partnership programmes I have worked in during my time in neighbourhood and community policing. It doesn’t take long for this culture to break down and lead to cross-pollenation of aims and ideas to become the norm. Very quickly, adversaries become colleagues.
3. Data-protection. This is something we simply have to get over. It is absolutely right that there are proper policies and procedures in place so that information is protected and privacy is maintained but when six agencies are all working with the same person it is ridiculous that they cannot simply and quickly share information with each other in order to resolve the issue.
4. Political will. I don’t just mean politicians here – at least not at government level. There are now lots of new levels of politician in the forms of commissioners and each has one specific portfolio to look after. Ultimately, they are all really dealing with the same people and the same issues – just as the organisations they oversee do. It has the potential to become a power struggle if the real aim and objective is lost.
This is a whole new way of working and it relies on each sector investing and completely redesigning its response model. It relies on setting aside the false barriers and obstacles which currently stand in the way of helping people.
The solution involves people working together more closely and more frequently so that they can actually spend MORE time concentrating on their own portfolios and less time straying into each others.
From a purely police perspective I believe it would allow police officers to concentrate on fighting crime but it cannot work unless all the other agencies increase their response capability.
It is nothing more than a seed of an idea in my head but I am convinced it holds the key to a more efficient and effective future which would serve the people who need us far better.