I blogged a few months ago about the Penrose Hypothesis – the idea that there is a correlation in society between any reduction in the inpatient bed provision and the subsequent incarceration in prison of mentally unwell defendants around a decade later. This hypothesis was first proposed by Professor Lionel Penrose in the 1930s but my recent post was motivated by more recent, further research which reaffirms his idea. Indeed, his theory has also been tested in other countries where we know cultures and legal systems can differ; yet the correlation was still there.
I know: correlation is not causation but so far so good for the point I want to make here: I’ve been wondering since that earlier post whether his idea goes further: if we can see that correlation in the inpatient provision and imprisonment, would we also see a correlation in community / crisis provision and the extent to which the police are deployed to so-called mental health crisis calls?
On one level this question is really easy to answer because the reality is we simply do not know. We don’t have anything like enough data and as far as I know and no-one’s tried to properly answer it. (PhD topic, anyone?!) It would require one hell of a project an analyse the factors involved and seek to establish a correlation and data quality may not even be good enough anyway. Which calls to the police are we labelling as ‘mental health related’ calls – what, precisely, are we counting? Then you have the similar problem in mental health services, how are you quantifying mental health provision and what kind of mental health provision are you counting or not counting?
Most mental health care is provided by GPs so are we included that or only more secondary care mental health services? You’d have to wrestle conceptually with all of that to validate your approach in any attempt to get this question off the ground.
HAVING A BASH
Fortunately, I’m not doing a PhD, I’m writing a blog post, so some speculation may be as permissible as it is unavoidable. There are various reasons why you might wonder about the question and invite real researchers to get interested in it. Here are some isolated issues to consider —
- Use of s136 Mental Health Act – the police response to MH crisis calls is often reflected in detention under the MHA for assessment. Use of that power has been rising more or less consistently for 30yrs. I don’t think anyone, anywhere is arguing that this is solely due to police officers getting better at spotting situations in which the power can be appropriately applied.
- Referrals to secondary mental health services – various sources suggest to us, that far more people are being referred to mental health service than ever before and are in receipt of services. We also know criteria for community MH care have changed at either end of the community mental health care spectrum. On the one hand, the diminishing number of psychiatric beds for an increasing number of people who meet the criteria for MHA admission are admitted and those who are admitted spend less time in hospital before being discharged back to community care. We also know some GPs have reported referrals to MH services are more often bounced back to them in primary care (at least in part because secondary care services are busy caring people in the community who may have been hospitalised 10 or 20yrs before, because of reduced number of beds).
- Arrests leading to assessment in police custody – numbers on this aren’t great at all. I did some detailed number-crunching around 2004/5 which suggested around 10-11% of those arrested were flagged for MH assessment of some kind and around half of those (5% of the total) were then assessed under the MHA. Those I know who work in custody now suggest those numbers are history and both percentages have risen to around 17-18% flagged and around 8% assessed. NB: those latter data are more speculative and anecdotal than my original sample where I literally read custody records and counted things.
- Triage calls – many police forces have had some kind of street triage or control room triage scheme for a number of years. No doubt, they have data over the periods of time they’ve operated as to whether demand has gone up or down, but I was always interested in some data that triage didn’t typically collect. (At least no scheme that I shadowed or read about in evaluations collected it.) Where did the demand come from that they were then involved in handling or support? Some of the narratives around partnership schemes were that the police are called by the public and then provide a sub-optimal response, so we need MH services to be present with them or in support of them, to improve the quality of the response. Unfortunately, that is only what happened in a small majority of cases.
There are no doubt plenty of things to consider: nurse recruitment and retention is key – services can only care for patients if they have staff, etc., etc.; politics and funding are also not entirely irrelevant (but or are they ultimately determinative of the point I’m hoping to imply).
YOU’LL PAY FOR IT ANYWAY
It was an early quip of mine on this blog that you can have as little policing of mental health crisis as you’re prepared to pay for; and that you’ll end up paying for it anyway in criminal justice costs of all kinds: policing, prosecution and prison. So given that you’re going to have to pay, what would you rather pay for, precisely? Of course, we know secure mental health care, typically required for those who are hospitalised via the criminal justice system, is profoundly more expensive than non-secure, direct, civil admission. Providing an emergency services’ response to mental health crisis is profoundly more expensive than community mental health care and so on. This is the basis of me speculative you’ll pay one way or the other so you might as well choose what you’d rather see for the money.
This has to be worth looking at: and not just because of cost. It’s also about what those of us who use mental health services say we want and need in our care, including crisis care: not being made to feel criminalised by invitation to ring the police or having the police called without consent. We’ve known for years that the impact of over-policing and it can, literally, be fatal. Oddly enough, some patients don’t like being criminalised and will go to considerable ends to avoid being made to feel that way when they’re already ill or in distress.
I submit this question needs looking at: can we extrapolate something from the ideas in the Penrose Hypothesis to understand other aspects of the mental health / criminal justice interface? Is there a correlation between the amount of community mental health care we choose to provide and the amount of crisis calls we expect our criminal justice and emergency systems to handle: I’ve always suspected there is and it ends up being more expensive as well as leading to outcomes which are less desirable for everyone.
I may be wrong: but I’d love to see this properly examined.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2022
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