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“‘ello ‘ello ‘ello. What’s goin’ on ‘ere then?”

The last five years have seen a steady increase in the number of people subject to the provisions of the Mental Health Act 1983 (NHS Information Centre, 2011). This is in large part due to increases in the use of section 136, the police holding power.

There was a staggering 135% increase in s.136 detentions from 6,004 in 2006-7 to 14,111 in 2010-11. But why?

This could be a result of increased mental health awareness and better training of police officers. Increased awareness of symptoms of mental distress may increase detection rates and prompt officers to use s.136 as a means of bringing people to the attention of mental health services. However, two unpublished studies by experienced mental health social workers involved in mental health training of police officers found the opposite. One of these – a controlled study – found a decrease in the use of s.136 following mental health training of police officers in one area, in contrast to a neighbouring area which did not receive similar training. (We are hoping to publish this study soon to make this finding more widely available.)

It is possible that the increase in s.136 detentions could be a result of better recording. However, I have quoted the official figures collected by NHS Trusts and collated by the NHS Information Centre. It is unlikely that recording systems have radically improved over the last five years to produce this pattern.

Unfortunately, research studies don’t help us much either. Most studies of s.136 are local, with small samples and frequently contradictory findings. However, they consistently find that only a small proportion of section 136 detentions (about 25%) subsequently result in a formal detention in hospital.

A recent study of the use of s.136 in Trafford, Manchester, for example, found threats of self-harm (35%) and aggressive behaviour (22%) to be the most common reasons for detention (Sadiq et al., 2011). Of those known to mental health services only 4% had a diagnosis of psychotic disorder, with most having a diagnosis of mood disorder (22%), personality disorder (20%), or a drug and alcohol problem (18%). However, this study included only 45 s.136 detentions.

A large study of 887 s.136 detentions over 3 years across five south London Boroughs found an over-representation of people of Black British, Black African and Black Caribbean ethnic origin in s.136 statistics and in subsequent MHA detentions in hospital (Borschmann et al., 2010). Over 40% of all s.136 detentions resulted in a discharge with no subsequent hospital admission (formal of informal).

Older papers (see the reference list of the Borschmann paper for some more reading suggestions) have found a preponderance of young men with a diagnosis of schizophrenia amongst those detained under s.136. Although young men are still commonly found in s.136 statistics, this pattern appears to be changing with fewer people with a diagnosis of psychotic disorder being detained (although Sadiq et al.’s (2011) study needs to be treated with some caution due to its small sample). This could potentially indicate that Early Intervention in Psychosis services are effectively engaging with young people with that diagnosis, but further research is required to confirm this.

The potentially changing composition of those who are detained under s.136 cannot explain the unprecedented increase in its use. It is possible that it is mirroring the decline in psychiatric beds over the same period. Rising thresholds for psychiatric inpatient care, in order to rationalise demand for a shrinking resource, may be leaving some people suffering mental distress literally on the streets waiting to be picked up by the police. Mental health crisis services are unable to cope with the rising demand and have become mostly inaccessible to people not already known to mental health services.

Whatever the reason for this pattern, though, it is clear that people find it distressing to be detained under s.136 of the Mental Health Act 1983. In one study, detainees and their carers talked about their dissatisfaction with the quality of care and treatment from both the police and mental health professionals (Riley et al. 2011). They felt criminalised and suggested that police stations should only be used in exceptional circumstances for people experiencing mental distress.

Mental health services should either accept police officers in their ranks as allied mental health professionals and provide them with full support and training, or provide mental health crisis services which genuinely meet the needs of their local population.

References

Borschmann, R. D., Gillard, S., Turner, K., Lovell, K., Goodrich-Purnell, N. & Chambers, M. (2010) Demographic and referral patterns of people detained under Section 136 of the Mental Health Act (1983) in a south London Mental Health Trust from 2005 to 2008. Medicine, Science and the Law, 50, 15-18.

NHS Information Centre (2011) In-patients formally detained in hospitals under the Mental Health Act 1983 – and patients subject to supervised community treatment, Annual figures, England 2010/11. London, NHS Information Centre for Health and Social Care.

Riley, G., Freeman, E., Laidlaw, J. & Pugh, D. (2011) ‘A frightening experience': detainees’ and carers ‘experiences of being detained under Section 136 of the Mental Health Act. Medicine, Science and the Law, 51, 164-169.

Sadiq, K. T., Moghal, A. & Mahadun, P. (2011) Section 136 assessments in Trafford Borough of Manchester. Clinical Governance, 16, 29-34.

6 thoughts on ““‘ello ‘ello ‘ello. What’s goin’ on ‘ere then?”

  1. Nathan Constable says:

    Superb article. My theories for increase would echo yours but I think there are others
    Officers detaining people because there  is no other immediate intervention option – officer then fearful of walking away in case person dies, officer gets sued etc. 
    It might be interesting to find out whether this increase in 136 detentions correlates with the increase in community based care.
    By which I mean – is there more likelihood of an officer coming across a person in mental distress because they are not in hospitals? It is also fascinating that so few 136 detentions result in hospitalisation. Suggesting that clinical decisions are being made  on factors like available bed space. Or are these poor people REALLY not ill enough? Let’s not forget that a police officer has detained them because he felt that person needed “immediate care and control” because of some form of mental disturbance.
    An  increase in 136 detentions could indicate a lack of proper intervention before police get involved and poor management of patient.
    It could also suggest officers making the wrong call at the incident. Are they overusing the power?
    Are they misreading the signs of mental disturbance? 
    I would agree that there is a lack of training for officers as you suggest but something else is lacking.
    What is really lacking is the availability of other options when an officer does come across a person in mental distress.
    “Hello, Emergency Duty Team? Will you come out and deal with this ill person?”
    “No, there are only two of us.”

    I have also plenty of experience of incidents where this call has been made to an EDT, crisis team or mental hospital and the answer has been quite simple “arrest the person”

    This gives these services the luxury of not having to deal with it until later and makes it the police’s problem for hours. 

    There are many reasons for the increase – these are my thoughts based on many years of policing. 

  2. ermintrude2 says:

    Thank you so much for writing and publishing this. It’s really interesting. While I could venture a guess about some reasons, I think there’s probably a number of factors (I know, it’s an easy way out). I think it also begs a lot more questions about different practices in different parts of the country – urban v rural – relation to training/input/culture of different services and good (or poor) links and coordination between local NHS Trusts and police services.
    I’d also be interested in the different routes ‘through’ s136.

    But thanks again for sharing this – it’s something I can bring back to the AMHP forums locally for discussion!

  3. Jan Penny says:

    I am the force mental health lead for Thames Valley Police, one of the largest non metropolitan forces covering the Counties of Berkshire, Oxfordshire and Buckinghamshire including the Independent State of Milton Keynes! We currently detain on average 2.6 persons per day on a S136 which I believe is a consistent number over the 4 years since I took up this post. Certainly there is not a statistically significant increase. I put this down to improved joint working, training and access to information for our Officers and partners particularly when it comes to not using S136 on very intoxicated individuals but actually arresting for offences instead.

    What there is definitely not is an increase in access to emergency care for people in crisis. The difficulty is that there is no emergency service for mental crisis unless in a public place. Crisis Services and CMHT are not primary care services and so will always require a referral from a health professional. Emergency Departments at hospitals robustly resist taking in persons who “only” have a mental health problem. Many health professionals including CMHT, crisis services and GPs (particularly Out Of Hours services) assume that when someone is in mental crisis then the police should be the first service to call. I am aware of a number of incidents where OOH GP has asked a Police Officer to “pop someone along to the surgery” to avoid them having to come out and Officers sitting with patients in Dr waiting rooms to make sure they don’t run off.

    In what parallel universe does this make any sense? Clearly if there is a real and immediate need for a person to be restrained under the Mental Capacity Act or to prevent a Breach of the Peace. How do services know this in advance unless they are there as well? Not only that but the number of requests we get to do a “safe and well” check on a person who professionals believe may have deteriorating mental health is increasing exponentially. Typically these calls come in at 4.30pm on a Friday – take from that what you will!!

    Why on earth is this a Police responsibility? Can you imagine the effect on someone who is already feeling very unwell of having a Police Officer turn up unannounced at their front door, sometimes in the middle of the night, just to ask them how they are? Personally I believe this is a violation of Human Rights Article 8 – A right to a private and family life. Worst case scenario they end up with acute stress trauma on top of their existing condition believing the Police have arrived for some other reason.

    My point here is that while it is important for Police Officers to have a broad understanding of mental health issues and legislation, I would really oppose a “Super Cop” who has specialist training in mental health. We do not need significantly better trained cops; we need better access to acute services for mental health crisis so the cops won’t be needed. We need to commission and train the ambulance service in a different way so they are able to deal with this type of health crisis. The hospital A&E departments need to start taking responsibility for the “whole person”. Crisis services need to be just that and become a primary care service. This is not going to get any better. There is a recognised deterioration in society’s mental health – there are not going to be any more Police Officers out there, quite the opposite and according to the Home Secretary our job is to “Cut crime, no more, no less”.

    Stop using the Police to deal with health and social care matters. Thank you for listening!

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