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Is mental health crisis care in crisis?

Police mental health guru Mental Health Cop posted an excellent response on his blog to my post on rates of police detentions under section 136 of the Mental Health Act 1983.

His main argument is that the figures are wrong. The increase I discussed is, he argues, the effect of better recording rather than a real increase in the use of s.136. The very low rates of s.136 detentions in the official figures contrast with local experience, which does suggest that something is awry. Without confidence in figures, it makes it difficult to construct arguments about what is going on.

He suggests that if there has been an increase in the use of s.136, additional contributing factors include the introduction of Supervised Community Treatment and Place of Safety providers accepting people who they previously may have excluded. He also argued – quite rightly in my opinion – that most people being detained under s.136 have unmet health care needs, whether or not they are subsequently admitted to hospital.

My response to his post was:

I’d be very happy for you to track me down and give me a big hug. After all, isn’t that what us social worker-types are good at? (Giving hugs, not tracking people down – that’s your job!)

I think you make some excellent points here which deserve further exploration.

Firstly, I agree about the under-reporting of s136 detentions in the official statistics. These figures do seem far too low to be believable. Perhaps they are the ones which come to the attention of the NHS? Possibly they reflect an increase in s.136 suites or places of safety located on NHS premises in latter years so that more are officially recorded. I do seriously doubt if they include use of custody suites. Whatever is going on, this merits further exploration to ensure that planning can be based on accurate figures.

Secondly, from the discussion my post provoked on twitter and previous experience, I think that it is wrong to describe an instance when someone is discharged from a s.136 with no admission to hospital or need for subsequent mental health care as an ‘inappropriate’ use of s.136. Quite frequently mental health crises can be short-lived and 72 hours are often sufficient for the worst to be over so that the person can return home and sort out the mess they were escaping from. If someone is distressed and in a public place, something needs to be done then and there to support that individual. If police powers are required for that person’s safety, or someone else’s, and if there is an appropriate place of safety, s.136 can be an appropriate means of providing that immediate care.

That brings me on to the point I made in my post which you highlight in yours. I think it is time to realise that the police are providing emergency mental health care and should receive proper training and support from the NHS to undertake this role. You may not be administering drugs or providing psychological interventions, but you are providing a crisis intervention nonetheless. This needs to be properly respected and supported by mental health professionals. There are studies indicating that people find being detained under s.136 a frightening experience. I can well imagine that. Being taken into custody whilst in a mental health crisis criminalises distress and is certain not to be received well.

Perhaps it is time for some joined up thinking to find ways to respond to crises more effectively and without the NHS washing its hands of them (see my twitter feed for some examples provided to me in the last couple of days). Crisis teams are not set up to work with the kinds of crises which result in the use of s.136. They require referrals and the people often need to be known to mental health services already. The police are effectively providing a crisis mental health service as crisis teams are not able to respond with the same immediacy. If specialist police officers were able to work as ex-officio members of crisis teams (in a similar way to police child protection officers working with social workers in children’s services), they would be able to access training and lead on mental health issues within their local force. A bit like you are doing, I think, except without the NHS connection!

A number of years ago I trained to be a Samaritan. I gave up after a short while because of other commitments, but that period of voluntary work opened my eyes to the role of the police in mental health care. When I arrived for one of my first shifts after I had completed the training, I was ushered upstairs to help a suicidal young woman who was hanging from the window ledge of a second floor window. Police officers were also there holding her arms and trying to pull her back through the window. I relieved one of the officers and helped to haul her back in through the window. We had saved her life (or certainly saved her from some broken limbs). I don’t know what happened to her after that – or whether she was successful with a subsequent suicide attempt – but we had intervened at the moment to prevent her from harming herself. This is the bread and butter of community policing, but it is not recognised as emergency mental health care.

Since I qualified as a social worker, I have come across countless situations when mental health professionals have said “it’s a matter for the police” in the case of some mental health emergencies. Mental health services are just not set up to deal with the real crises – that is left to the police. I know that many NHS Trusts have excellent working relationships with the police, but isn’t it time to take this a step further and assist the police in their provision of emergency care (even if that is only containment and control)?

I appreciate that we are a couple of bloggers airing our opinions and could be dismissed as such. However, I think your excellent blog highlights the important role that police play in mental health care and that a more holistic approach is required which encompasses a multi-agency approach involving the NHS, local authorities, police, housing associations and so on. With community mental health teams becoming less integrated – with social workers being pulled out to focus on ‘core’ social work tasks such as personalisation and safeguarding – and the Age of Austerity tightening eligibility criteria, I sense a greater demand for crisis services is just around the corner. I’m not certain that the leaner public services we will have over the next few years has the capacity to meet it. But that’s another issue…

Jan Penny, the mental health lead for Thames Valley Police, then entered the debate with a comment on both blogs (Click here for Mental Health Cop blog comments and here for comments on my original post). Jan argued that emergency care for people in a mental health crisis is lacking. Police should stuck to policing and mental health professionals should attend to people in a mental health crisis.

This echoed an earlier comment on my post by Nathan Constable who argued that s.136 is frequently used when there are no other options available to police officers as mental health services are either closed or don’t accept referrals direct from the police.

I concur with these comments. Although I have come across crisis teams which take referrals from the police, I am not aware of any evaluations of them or anecdotal comments how they are working. Perhaps someone with experience of this may like to share some thoughts?

This discussion illustrates a significant gap in crisis care for people in mental distress. With concern being expressed from both mental health professionals and the police, perhaps it is time for the Department of Health to consider an alternative approach to managing mental health crises.

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