Apply Brakes. Check Mirror.
I am extremely grateful for the invitation from Inspector Michael Brown (pictured above) which allowed me to attend the College of Policing Mental Health and Policing National Conference.
It was very well attended and I think every police force was represented along with about 40 other agencies involved in this aspect of work.
There really is so much that could be said following this event but above all else it served as something of a reality check on the progress and direction of policing and mental health.
There has been progress – significant progress – the fact that it is now so high on the agenda and has its own conference is testimony to that. There are also many people from the world of policing and health doing work every single day to improve the response to and outcomes for people suffering mental health crisis.
But – and it is a big “but” – what this conference highlighted was the distance still to travel, the obstacles which still need to be overcome and, crucially, it asked the difficult questions about whether the measures that have already been put in place and are being hailed as the solution are actually achieving what is being claimed.
With regards to Triage in particular there were some serious questions raised as to its methods, the lawfulness of some of the interventions, the supposed outcomes and benefits and also whether it potentially overlooks physical medical risk.
I have always had doubts about Triage but I left with even more. Real and genuine concerns about safety, legality, officer protection, the welfare of the person concerned and a sense that the wrong “results” are being seen as the marker of success.
Concerns that the police and others are about to throw even more significant sums of public money at something which just “does something” about mental health response and based on questionable data and research.
Concerns that we are still concentrating far too heavily on the crisis end rather than on prevention and that this response still isn’t the correct one anyway.
Most pleasing for me was that these views were shared and amplified by a number of other speakers of various professions, a charity and even an extremely brave speaker with lived experience.
If you look hard enough at Triage you will quickly see a number of problems with it – some quite serious – the question for me has always been whether people were actually looking.
My sense after yesterday is that some people may now be casting a slightly more critical eye. At least I hope they will.
There were so many good speakers at the event. The day was kicked off by Chief Constable Simon Cole of Leicester who asked us all to “refresh our anger” over the subject. There had been progress but there is still so much to do and still so much inertia. Even Simon started asking the difficult questions about Triage. Does it have a place at the moment? He says yes. Is it a long term answer? No.
We then heard from Emma McAlistair @DrEm_79 who gave the most personal and impactive talk on lived experience of mental health that I have ever heard and how interactions with the police over the years have compounded the problems. This talk was so effective that it received a standing ovation from many of the delegates and everyone else referred to it throughout the day.
What became clear to me here was that we may think we have an understanding of what and who we’re dealing with but we really, truly, do not. Mental health illness is multi-faceted, complex and indeed bespoke to the sufferers own personal history and circumstances. Saying or doing the wrong thing could have catastrophic impact and often we simply do not know what the wrong thing is.
We learned how the police turning up remains a stigma and still criminalises sufferers even if no criminal action is taken. The simple sight of police cars outside an address frequently is enough to cause accusations and community tension.
Emma is highly qualified but had to leave her dream job because of the impact of police action in relation to her mental illness. She is articulate and academic and had even conducted her own research into whether people actually want the police dealing with their mental health crisis.
Unsurprisingly, a majority of respondents do not.
This research was done to counter the official evaluation on Triage from the University College London. During the course of the day this particular document came under fire from a number of eminent sources.
The College of Policing supported the research with information and data but refused to endorse it because the research methods were not rigorous enough. We heard that unfavourable data had been excluded. We heard that qualitative responses had been filtered and a large section of the work of triage schemes (in fact the bulk of it – which takes place in private places) had not been evaluated at all.
When the report was first published I, others and indeed eminent academics all questioned the data, the methodology and how the limitations then led to Recommendation 1 which was to roll out triage 24/7.
It looked to me and others like a classic case of policy based evidence. Another example of a police project being “doomed to succeed.”
Fortunately, the delegates heard this same argument from people who are far better qualified than me and it was a powerful message.
A number of speakers talked about the needs of those people who do not meet the criteria for sectioning. In my recent talks to students at Christ Church University, Canterbury I discussed the demand from people who could be classified as “sub-sectional suicidal.”
Dr Em discussed the circle of unmet need
Christina Marriott from the charity Revolving Doors then elaborated further on those who are “sub-threshold” and how there is very little in place to support them pre crisis in a way which can prevent things becoming a crisis. There is nowhere to point people towards save for a few excellent examples of third sector provision in a few places.
In relation to Simon Cole’s request for us to refresh our anger, Christina made the point that it is notable that it only seems to be the police who are getting worked up about this. Other agencies do not seem to be reacting or responding with the same sense of urgency. In fact, Christina told the conference that the health service is being outpaced by the police when it comes to providing response to mental health.
Conference broke into workshops and I was only able to be present for one of these – mostly because I was assisting Michael Brown with the presentation. In our talk Michael really broke down the issues with Triage schemes.
What are they set up to actually achieve? How are they being evaluated? Are they saving the time and money people claim they are? Is that the right reasons for doing it in the first place? Where do we go from here? How claims that schemes have saved “the equivalent of a full time officers time” by not having them sat on constant obs in custody are undone when you work out that actually, the Triage team consists of four full time officers. You’ve spent four times salary to save the equivalent of one.
My brief input was to review television footage from a recent BBC 3 short documentary called Don’t Section Me.
Michael sent this link to me a while back without saying anything and asked me to view it and then tell him my thoughts. When we compared notes we had come up with identical issues.
There are numerous questions arising from what is seen in the 12 minute film but we concentrated on the segment where a lady has been pulled to safety from a bridge. She is then held in a police car against her will (she tries to escape several times) whilst officers wait for the Triage team to come and see her at the roadside. At the end of this process she is voluntarily admitted to hospital (from where she later leaves and is then sectioned.)
The question I posed was – under what legal powers are the officers operating when they keep this lady in the police car and prevent her from escaping?
It isn’t Section 136 because they haven’t invoked that.
Is she free to leave? No – because they have prevented her from doing so. She is therefore de facto detained.
It can’t be the Mental Capacity Act either because they would have determined she lacked capacity and the attending mental health nurse determined that she did have capacity.
The issue here isn’t that the officers weren’t trying to do the right thing – they clearly were. The issue is that they had no legal basis for taking the action they took.
Had they immediately detained under Section 136 then both they and the lady herself would be legally protected. But they didn’t do that – because the purpose of Triage seems to be to reduce the use of Section 136.
So they have detained a lady so that she can be detained for the purposes of a discussion with the Triage team, so that the triage team can determine whether they think she needs to be detained for a full mental health assessment which will determine if she needs to be detained in a hospital.
Read Section 136 of the Mental Health Act and tell me how it fits those circumstances.
The first two parts of that sentence are not covered. There is no power to detain someone for the purposes of an initial chat with a triage team and yet this is happening across the country every single day.
It is a civil liberties issue. It is an Article 5 Human Rights Act issue and it is a huge issue for police officers who, if it call goes wrong, would be acting outside the boundaries of the law irrespective of that person’s best interests. It is a legal minefield and no one has questioned it.
The waters become even muddier when we move into private places and homes.
Later we heard from Dr Jenny Holmes. Jenny is a highly qualified psychiatrist and FME with many years of experience of working in a police setting.
It is hard to convey the impact her talk had but my appeal would be – if you are reading this and have anything to do with commissioning health services in police custody then please make contact with Jenny before you do anything else. Ask her to come and deliver her talk to your team. You may then see the gathering storm and unfolding disaster for yourself.
And it really is a recipe for disaster with unqualified police officers being asked to make unsupported decisions about medical risk of detainees. Police custody is also the only area of medicine where health care practitioners work with minimal training and supervision.
When you look at the complex nature of many detainees health issues and their severity it is clear that provision is nowhere near adequate or even safe.
Jenny went on to talk about Triage and said that actually what now needs to happen is for it to be paused and properly reviewed. The UCL research hasn’t done that.
Jenny assessed the idea of the control room based triage model. The commonly assumed positive is that the nurses will have access to someone’s notes. The problem is that these are likely to only relate to their mental health and not their physical health. There is so much cross over between the two that it is essential to see both. GP’s cite “patient confidentiality” and won’t even share info with other parts of the NHS.
Jenny listed some very serious physical conditions which can present in the same way as an acute behavioural disturbance. The chances of error are not reduced if no one can see a patient’s full medical history.
This actually isn’t a question. It is a statement. Yes – we are.
Jenny, Christina and Emma all made the point that too many people’s care plans simply say “call the police.” Often it is the case that the police are unaware of this and they have no background knowledge to inform them.
If a care plan consists of “call the police” then it is not a care plan.
Jenny’s final view was that “we do need health crisis responses but they shouldn’t be being led by the police.”
Commander Christine Jones from the Met who is the national NPCC lead for mental health then spoke and posed a number of other difficult questions about the way things are heading.
The police still being relied upon as “the muscle” and often being asked to act unlawfully.
Commander Jones challenged the legal and ethical basis of many actions and responses which are assumed to belong to the police. There is a great deal of work to be done in this area.
For me this was compounded by the input from NHS Protect. They provided a range of data about assaults on clinical staff and seem to me working on a protocol which will lead to more prosecutions.
Whilst no member of staff should expect to be assaulted I couldn’t help but think they were looking at this from the wrong end.
Rather than focus on prevention they are trying to make sure that more patients enter the criminal justice system.
Whilst they were right to point out that officers often made incorrect assumptions about capacity they were wrong on a number of issues about charging decisions and public interest.
Furthermore, they said that 85% of assaults on staff in a mental health setting were unpredicted. Surely, SURELY this is therefore a foreseeable risk which needs to be mitigated? Prevent rather than punish.
If so many unexpected assaults are happening in mental health environments the questions have to be “WHY?” and then “what can we do to reduce the likelihood?”
The cynic in me found it hard to see beyond whether there are sufficient staff on wards and whether they are adequately able to diffuse situations or even see them coming.
When you link this to Christine Jones comments about the police being the muscle called upon to deal with those deemed “too tricky” then you have to ask questions.
For all this bad news there was some very good news. That came from Claire Andre who is the Police Liaison Nurse in a North Eastern force.
Here is a role I can fully support. The difference between what Claire does and what Triage do is marked and they are not trying to achieve the same things but what Claire brings is STRATEGY.
Claire acts as the bridge between the police and the NHS. The interpreter. If you are a Hitchhikers Guide To The Galaxy fan then Claire is the Babel Fish we all need.
Every force needs a Claire. In fact, I think several forces tried to poach Claire during the course of the day.
Claire worries about the relationships between the silos. She brings people together. She knows where to send people. She worries about long term problems like managing persistent missing people. Claire can now speak “police” and “NHS” and for me, if I was running the mental health show in my own force (which I am not) I would be wanting to spend money on this role over, above and before a single penny was spent on Triage.
Get this right and Triage might not even be needed. (If it is at all)
For all the lows and concerns raised throughout the day – this was a highlight.
So – to summarise:
There are clearly examples from around the country where people (particularly those working on the schemes) believe that Triage is making a positive difference. The question is whether the people having the service delivered to them feel the same way.
They have had no choice in it. It is what they have been given and it appears to be the only thing on the table.
It isn’t the same anywhere. The evaluations thus far have been ….. Less than robust.
In addition to this there are legal issues over its use which have not been properly recognised never mind addressed.
The concern is that it is charging ahead in various different guises and stands to become the default response before too long. It plugs a gap which means that those better qualified and placed to do so do not have to.
There is evidence to suggest that it is directing MORE work to the police as other agencies now just refer people that way “because they have nurses now” and there is also concern that existing services are unable to cope with the new referrals they receive following Triage contact.
There are big issues with data sharing which are not overcome by having nurses sat in a police control room and there are actually significant medical risks with certain styles of triage schemes.
In short – I am even more worried about it than I was before I attended yesterday’s conference.
The good news is that it isn’t just me who thinks like this and I hope those attending yesterday left with a whole bunch of serious questions on their minds.
To conclude, I would like to echo Jenny Holmes call for a critical pause before any further triage schemes are introduced.
There needs to be some very detailed research undertaken and this needs to factor in the lessons learned so far, including near misses and deaths after triage contact.
I am aware of “miss-selling.” I have seen examples of where police officers have enthusiastically endorsed the work and advice of triage schemes where the advice was clearly wrong and police should have taken alternative action.
It needs to include real and direct service user feedback and ask the question “do you actually want the police turning up?”
It needs to look beyond the whole “reduce Section 136” objective and establish whether the use of Section 136 is actually a problem or whether it is a capacity issue in the NHS.
It needs to look at what work is being generated FOR triage schemes and BY triage teams and whether anyone is adequately well enough resourced to accept it.
It needs to look at what is happening in terms of follow up for those people who are not being detained.
It needs to look at an exit strategy for police and it needs to look at who is actually paying for what.
It needs proper, independent and critical review – not commissioned by NHS England or the College of Policing.
We need to stop conjuring figures, theoretical savings and supposed benefits out of thin air and establish exactly what it is going to achieve and how it is going to achieve it.
Is it effective? Is it lawful? Is it ethical? Is it value for money? Is it delivering something tangible and lasting? What is the next step?
So please – apply the brakes and look hard in the rear view mirror and at what has happened behind us. What is actually going on around us now. Where are we heading? Then ask whether we are really on the right path, can we reverse or has the Sat Nav sent us down a dead end dirt track with no way to turn around.