No matter what you think the problem is, there are only ever two solutions in policing and mental health —
All the emphasis is on the police here, isn’t it?! It’s almost as if the only thing we need to talk about going wrong or which is in need of improvement, is policing. It’s a part of a subtle narrative that is actually far more widespread than we realise, if we just look for it consciously. And it works because it’s highly intuitive: the police are not mental health experts and we’ve seen incidents where things go badly wrong when they come in to contact with vulnerable people … ergo, some expertise (achieved through training) would be good, but better still would be actual expertise (achieved through collaboration).
You can see the flaw with this, though, I’m sure – whilst the police are not perfect and no-one is pretending they are, whilst the police would undoubtedly benefit from real, good quality training on mental health (and on mental health law!); whilst the ability to call upon mental health professionals in real situations may well be of help – it’s just simply not enough because it’s not JUST the police who are causing the problems.
Let me pick you a real, high-profile example: the death in police custody of Sean Rigg.
MORE THAN MINIMALLY
Primarily cited in recent years as evidence of the need for improvements in policing, the tragic death of Sean Rigg is most usually referred to as a death in police custody. And it was – but it’s not often talked about in terms of the need to improve mental health services or the training or responses of the mental health professionals involved. This is highly curious, in my own view, because whilst the events following Sean’s contact with the police bothered me enormously and raised obvious questions, I was fundamentally as interested in why the Metropolitan Police needed to be called in the first place – and so was Her Majesty’s Coroner. The inquest jury returned a narrative verdict which outlined two things ‘more than minimally’ contributing to his death. Yes, one of them was the police response, restraint and reaction to him collapsing, but the first thing the jury highlighted was the earlier lack of care and reaction by mental health services. This included administering inadequate quantities of medication, a lack of care and crisis planning, a ten-day period in which they failed to escalate concerns after a clear sign of relapse and to call a Mental Health Act assessment. Systematic and individual problems!
Subsequent to those failures, the Metropolitan Police were called and yes, various things went badly wrong. Some of them were systematic issues for the organisation as a whole, others were individual matters for the officers involved – just like those for the trust. It was another of those police encounters where you might wonder why Sean was arrested rather than being detained under the Mental Health Act and removed to hospital. Notwithstanding that point, once the police detain someone and restrain them on the ground, a certain set of considerations need to follow to ensure the welfare of any detainee who has been subjected to such a high-intensity restraint event and in no world that I work does that involve removal to police custody without reference to NHS expertise about clinical welfare. The jury found that these issues also ‘more than minimally’ contributed to his tragic death.
But here’s the thing I can’t stop thinking: had the first set of short-comings by the South London and Maudsley not occured, we have to wonder whether Sean would have encountered the Metropolitan Police at all? — so is the ‘problem’ just about police training and police collaboration? Absolutely not – it is also about how our mental health services and / or our mental health professionals operate. It is for others to get in to specifics, but it’s not unfair of me to point this out when all we know here, years later, is about how this was a failure in policing that means we need far more training and more collaboration for the police.
That was an individual incident, but we could look at population level issues and make the exact same observation. We need to reduce s136 MHA, we are told – that is the publicly stated objective of many street triage schemes and indeed, many of the evaluations we’ve seen in to these initiatives have as their sole metric of interest, the impact of triage upon the use of the power. More than once, I’ve had to protest on social media about mental health trusts describing street triage as necessary to stop ‘inappropriate’ use of s136 MHA. Again, it’s the “police don’t know what they’re doing” narrative seeping out which is actually contradicted by data from within the NHS itself. It often suggests the opposite and it should be making us wonder about those same things raised by the London Coroner after Sean Rigg’s inquest.
Within s136 data and street triage encounters from some areas, the proportion of people who are currently open to specialist mental health services in their area is clear majority. In one example, 50% of people detained in a UK city under s136 MHA are known MH trust patients in that city and we’d have to assume that at least some of the others are known patients in adjacent areas, because around 20% of detainees were people who lived outside the policing and mental health trust area where they were detained. In another example, one area was concerned at high rates of usage by the local police and kept telling me that detentions included high numbers of tourists from outside the force area who came on holiday and were inappropriately detained for drunkenness and other shenanigans. A short ramble through the management board papers on the trust website revealed an internal report on s136 which included the nugget of information that 75% of those detained by the local police were local residents AND known to mental health services.
So how wrong are they getting it, these ill-informed police officers?!
Finally, in a recent discussion with one force about their control room triage scheme, which is still quite new, they sought a couple of us from the College of Policing to do a quick and dirty review of their first internal report looking at their scheme. One statistic they uncovered was that half of all the people at the centre of the ‘triage’ calls were known patients with the local mental health trust and a further third of patients were recently discharged or disengaged patients with that trust. In total, as few 12% of those encountered were entirely unknown to the local trust, but who knows how many of those were patients known to surrounding areas? Now all those people in these last three paragraphs were patients who had a crisis care plan and in theory, had access to a care coordinator and / or the trust crisis team. Why was that not sufficient or why did it not work for them?
My own experience over 20yrs has been police contact with known mental health patients includes a mix of things, both quite unavoidable and entirely preventable. I do wonder about how routinely forces and trusts are working together and sharing information to work out how much of each they have? And how do they use that to improve the police responses to the unpredictable stuff and to reduce the need for the police in the preventable stuff?! There is not only a risk to vulnerable people from inadequately trained police or police working in isolation; there is a risk to vulnerable people in criminalising them by over-normalising the police and this is where I think we need to look much more closely.
We need to work out why so many people, with care plans and theoretical access to services are coming to police attention in ever-greater numbers – and why, the mental health system is evolving in ways which encourage this. Quite frankly, it often relies on this – as when it is expected the police will unlawfully hang on to people for days whilst we frantically bed manages resources to ensure admissions. We don’t hear too much about the community mental health teams who say their workload has increased by 100% in 12 months; the CrisisTeams whose staffing is now 1/3rd the level it was about 10yrs ago; the fact that inpatient mental health beds have been reduced by 25% over the last few years, at a time when the number of people under the care of our mental health services is up nearly half a million patients. I could go on.
No-one doubts that the police need more training for the role they play and no-one, anywhere, is arguing that the police should play no role. However, accepting that there is a role, that we need more training to do it better, is not to accept that the police should be staffing mental health units for those detained under s136. It is accepting things like, the need to improve the way the officers respond to and investigate allegations of crime, to ensure that victims of crime with mental health problems are not discriminated against within the criminal justice system. It is about ensuring that police expertise in criminal investigation and offender management is brought to bear on mental lay unwell suspects, including through a model of liaison and diversion that actually thinks beyond health outcomes and addresses the question of when it is appropriate to prosecute a mentally disordered offender.
Policing has largely been motivated to look at mental health and improve its responses because of the legal fallout from serious untoward events. There aren’t many of them that don’t raise questions about how partnership organisations operated at the point where policing went badly wrong. It’s frequent quip of mine when presenting on this topic to joke that I still have just a few hours of training and that half of it was wrong. But I also remark that the other half of my training didn’t work in the real world because the real world doesn’t always look like the Mental Health Act or its Code of Practice. In 2014 we published a Crisis Care Concordat and this document merely reflected a load of problems that were well-known and reflected in other reports and inquiries. Three years later, the police have completed all its actions from the national action plan – but has the NHS?!
And yet somehow it’s still all about police training and police collaboration. This simply doesn’t add up, does it?!
Winner of the President’s Medal from
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award.