The Partnership Paradox

The more you ‘solve’ the short-term problem, with what might be considered a temporary or quick fix, the less incentive there is to solve the underlying long-term issue. I have been caused to think about this at least three times in the last week, following situations I’ve had to discuss at work or by email. Here’s a situation for you.

A man from Area A has been ‘sectioned’ to a hospital in Area B, over four hours away. He doesn’t like being away from home and hasn’t had very many visits from his friends and family, quite understandably, so he has absented himself from the hospital and returned to Area A. He goes to the hospital in Area A where he has been a patient before and asks to be admitted there, because he prefers the hospital and wants to be able to have visits every day from someone he knows. Unfortunately, it’s precisely because they do not have any available beds that he was admitted for far away to start with.  It’s a heartbreaking hypothesis, albeit very real for some patients in the UK – who could possibly fail to sympathise with this predicament when someone is so unwell?

However, legally speaking, this patient became ‘absent without leave’ (AWOL) under the Mental Health Act  (MHA) when he left Area B’s hospital and returned to present himself in Area A. So what do you do?!

Well, first thing, the police were mentioned in discussion of this situation, as the first response!  We really do need to think of the police as the last resort!  Yes, the police have powers under s18 MHA to re-detain any patient who is AWOL and to return him to the hospital in Area B, albeit it the Code of Practice says two things about this which are relevant.  Firstly, patients detained MHA should be conveyed by a non-police vehicle (see Chapter 17 of the Codes of Practice, MHA in both England and in Wales) and secondly, the return of patients is ultimately, in law, a matter for the hospital from which he’s missing, in this case, from Area B.

So are the police going to use s18 MHA and drive the eight-hour round trip to Area B with the patient?! Well, no police officers I supervise are going to do that. Let me explain why!

FIRST THINGS FIRST

M first reaction here is that he’s presented at Area A’s hospital asking for help and the police are not the only people with powers under s18 MHA. Approved Mental Health Professionals (AMHPs) and anyone authorised by the [Area B] hospital managers can use s18. So if the patient wants to come in, why not let him and put in a quick phone call to secure the authority to detain? Get him a cuppa to warm him up, and then explain what will have to happen at a relevant point. The police don’t need to be involved at all, unless the situation dramatically changes. So first things first: I’d decline to get immediately involved and encourage the NHS to use the powers available to them, which of course: they should already know! If they’ve reached straight away for the batphone, I think I’d mention that, too.

However, more generally in situations of AWOL patients going out of area or returning from out of area which did involve the police: upon discovering the AWOL status, I’d consider using s136 MHA to remove the person to (or keep them at) the local Place of Safety so the NHS could untangle it all. Nothing in law says I must use s18 MHA just because I can use it and if the circumstances allowed for it, I’d use s136 instead so local ambulance and NHS partners had to help me. If s18 was used because I couldn’t intervene quickly enough as duty inspector to ensure it wasn’t used, then there is a quick list in my head, I’d work my way through —

• I’d ask the local s136 PoS whether they’d be prepared to accommodate him whilst detained under s18 until such time as his hospital attended to collect him – many precedents for this are available, but cops attempting it should be aware that a) the PoS is under no legal obligation to agree to help in this way; and b) some people will (wrongly) insist that you can’t legally do that;

• If the PoS wouldn’t or couldn’t, I’d take him to the local police station, find somewhere comfortable for him to sit and wait for the hospital to attend – nothing in the MHA amendments from 2017 prevents a s18 detainee being held temporarily in a police station. It may well be ‘against the spirit’ of things: but it breaches neither the Act nor the Code at a point where simply getting on with the 8hr round trip would do so, and potentially put your detained person at risk (see below).

• If they suggested anything other than “we’re just putting those arrangements in place to set off” I’d mentioned their legal responsibilities and point out that the patient will be in the police station until such time as they collect him – however many hours or days or weeks that may take; and

• If that still didn’t work after about 2-4hrs, I’d tell them I was seeking legal advice from the Force Solicitor with a view to seeking a High Court injunction to get the hospital to give effect to their responsibilities.

PYHRIC VICTORIES

My own view is this: every, single, time the police undertake a (potentially reckless) eight-hour round trip, or similar, at a cost of thousands, it reinforces to the NHS and detaining hospitals they can afford (in more than one sense of the word) to continue with inadequate conveyance and returning arrangements because the police will just become quickly fed up of the idea of looking after someone and they’ll do it anyway because they’ll calculate the short-term resource-cost of getting on with it is less than the resource-cost of sitting it out. Someone will no doubt also focus “putting the patient” first as if the time spent sitting around or out of hopsital is the only consideration.

Let me outline the paradox of both of these points!

Firstly, yes: two cops undertaking the eight-hour drive may end up being less resource than that required to look after someone at a PoS or police station; in the short-term. But what we don’t know is how many times it would take for the police to front-up to that situation and decline to fill the conveyance gap and making strong representations afterwards about the resource-cost of inadequate arrangements to return patients. Every, single, time a duty supervisor authorises the short-term, quick fix and every time the police decline to seek a review of why such arrangements don’t exist, they risk pushing back the point at which adequate conveyance arrangements will be commissioned to prevent the problem.

Secondly, the “putting the patient” first argument isn’t as straight-forward as you think.  On the one hand, it may be true that the patient would be back to their bed in Area B if we “just cracked on with it”, as I was once asked to do as a PC returning a patient from Birmingham to York, along with another officer. But what if –

• there is an untoward incident on the motorway as the patient becomes distressed at being sent back to somewhere they obviously don’t want to be? – we know for a fact the IOPC have had to look at complaints and serious incidents like this;
• what if the patient then brings legal action against the Chief for conveyance by police vehicle? – we know that some have.
• it’s not as simple as just calculating the supposed resource-cost and the patient’s time spent sitting around. You’d need to know they’re medically fit to travel; you’d need information from the Area B hospital to risk assess things – if one officer is driving the car, is one more officer sufficient or would you need two? … or three?!

PARNTERSHIP PARADOX

This is one type of operational situation predicated upon a hypothetical situation, but these principles could be extended further to something else I was discussing at the Strategic Command Course last week – this is a course for senior leaders who will be the Chief Constables of the future. One delegate asked about the short-term versus long-term view of partnerships and it made me think of street-triage. In my own view, we see evidence that the determination to secure short-term benefits may be bringing us longer-term problems and that it’s difficult to ensure those looking at the schemes consider the long-term implications. I know that some Chief Constables have had to start thinking about this stuff because inevitably, their schemes evolve over time and not always in a way that suits.

Academics and mental health practitioners have commented that the introduction of street triage initiatives has coincided with a reduction in crisis services in some areas. Some parts of England no longer have overnight crisis team provision, because they’ve decided it’s no longer viable. I’m sure if we put it to them, they would say this decision is not directly related to the street triage scheme in their area, but it’s at least a massive coincidence. But what happens when the demand for crisis-type services exists? – someone needing to ring a service because they’re struggling with impulses to hurt themselves or end their life? Some of that type of demand is legitimately for 999, so whether or not there’s a street triage scheme; it’s going to go to the police or ambulance service.

However, we know for a fact that some such demand would be handled by community and crisis mental health services. So where do they send it and where do people drift to? – well, street triage is one option and I’ve seen this happen with my own eyes on nights out and later this week, I’m presenting a short ‘paper’ at a policing-ethnography conference in Newcastle highlighting this. Remember what I saw within that demand faced by street triage teams during many nights shadowing them across the length of England from the Tyne Bridge to Beachy Head, 46% of their demand was generated by the National health Service. This occurred because they couldn’t (or wouldn’t) absorb demand for their services and, in my own view, none of those incidents required the police, except for the one where an AMHP, a MH nurse and a mother decided to kidnap a young man to a hospital he didn’t want to be in and when he started to use reasonable force to prevent himself being assaulted and falsely imprisoned there, the police were called to help stop him from defending himself and to assist in unlawfully admitting him to hospital.

COST BENEFITS

This previous sentence is deliberately worded to reflect what was going on legally – I fully accept that morally, they were probably acting in good faith for good reasons, but if you want to force someone to hospital, Parliament were kind enough to write down in the MHA what must be done to ensure it’s done properly, in reflection of the rights of people not to be kidnapped, assaulted or falsely imprisoned and to ensure we respect their fundamental rights, something missing all too often for mental health patients. And the point I’m trying to make here is that we know so little about partnership initiatives like street triage, because they remain so spectacularly undervalued. Some police forces (or Police and Crime Commissioners) are now paying £250,000 or £400,000 a year for an initiative to assist with short-term pressures around policing and mental health, without knowing at all the other, coincidental or consequential decisions this is causing within the wider health service.

Many ST schemes operate in areas where it’s obvious this is not happening – it’s a genuine enhancement and compliment to other services already on offer. But too many police forces are seeing unintended consequences. Where now at the stage where multiple mental health nurses working on such schemes have said to me (or they’ve emailed, sometimes anonymously via this blog) to suggest there have been NHS meetings in their areas to further push crisis care demand towards policing “because the police have paid for nurses now”. So Chiefs would be wise to ensure they fully appreciate how the ST scheme or control room schemes fit in to local health economies. The risk is the police end up paying for community crisis services and providing them in such a way as to mean vulnerable receive their crisis care under the shadow of the criminal justice system and the implications of that should be obvious.

Short-term pain, long-term gain – if we really are serious about ‘working in partnership’, and serious about having “good partnerships”, then this cannot just mean that people get on with each other and are personable. No-one wants to come to work for difficult discussions, arguments or personality clashes, but there are some entirely unaddressed complex questions about partnerships between police and NHS managers that simply go un-had. I know we’re trying to operate out of our ‘silos’ but no matter how hard we do that and no matter the need to manage the overlaps between us, some things will remain police responsibilities and other things will remain NHS responsibilities and the gaps which compliment the overlaps are only gaps because sometimes, we don’t do our jobs properly or fully. This is as much about tactical decisions around incidents, like the Area A / Area B patient, above; and sometimes it’s about wider provision of initiatives like street triage.

OPERATIONAL AND STRATEGIC

And police officers of all ranks need to manage this paradox – only operational cops are going to get the ‘Area A / Area B’ stuff right as the Chief Constable and the Chief Superintendent will typically be in bed with their Ovaltine by then; but operational cops don’t sit in the partnership and strategic meetings to consider the spending of the big money on things like triage and they can’t commission proper research in to their demand, activity and effectiveness. We’ve a lot more work to do before we even understand this stuff to start the discussions.

I’d prefer to cut off my nose to spite my face – I’m a bit like that, frankly.  It’s important to me that we reinforce the principle that conveyance of patients over long distances is not an emergency issue for the police, it’s fraught with risk if they just “crack on” and it’s not a justification to breach the Code.  I’d sit it out until they collected him – and if not in the PoS, then in the police station.

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Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award

 

All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2019

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I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current.  Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.

Government legislation website – http://www.legislation.gov.uk

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