It’s been said of the criminal justice system that it’s not really a system at all – the police, the Crown Prosecution Service, His Majesty’s Courts Service, the Prison Service and the Probation Service: they are all independent organisations whose collective efforts amount to a something of process through which people pass, handed from one organisation to the next but it’s not a single system, per se, with overarching governance. Even political oversight is split: the Home Secretary oversees the police service and the Secretary of State for Justice oversees the rest. Even some ‘health’ responsibilities sit with the Justice Secretary because the Ministry of Justice (MoJ) houses the Mental Health Unit, which takes decisions on behalf of the Secretary of State about mental health patients who have been sentenced to hospital by the criminal courts.
It is in this vein that I want to argue here that we have no ‘mental health system’ – not really. We have general practitioners who are providers of primary care services; we have the ambulance service who respond to all kinds of health calls, including plenty of mental health calls, we have Emergency Departments who find many of their patients have co-existing mental health problems and / or have turned up at ED purely because of the need to access support for mental health problems; we also have mental health trusts who provide certain specialist services in hospital and the community including crisis teams and community mental health teams, and then various specialist mental health services provided by NHS England. Additionally, there are various walk-in centres and minor injury units as well as 111 for a telephone triage system which may advise and of course, the private sector.
Nobody is solely in charge of this: integrated care boards commission and oversee the stuff done at local level by NHS organisations, but that doesn’t touch NHS England or the private sector. In addition, the managers of acute hospital trusts and of mental health trusts often take decisions which impact on each other without obvious evidence of consultation about impact. One of the reasons we’ve seen the emergence of ‘liaison teams’ in Emergency Departments is because of the extent to which people would turn up there for various reasons, when ED had little to offer them, beyond a safe space and access to clinicians trained in acute hospital care serious injury or illness.
What’s the purpose of pointing this all out you may quite reasonably wonder?
NOWHERE TO GO
Imagine you or a family member is experiencing mental health problems and felt you needed help – where would you go? You may remember a campaign some years ago by the NHS entitled #ChooseWell which attempted to ensure people present to the correct part of the NHS so as not to unnecessarily present to an Emergency Department when you could see you GP. After all, you wouldn’t go to ED for flu, unless something serious was happening because of it. The problem with that campaign was it didn’t mention mental health once! – in fairness, some more recent versions of #ChooseWell have, but it amounted to telling people to text a service which would provide a local helpline number, often a third-sector support.
So how do you know where to go when it could easily be argued from the last paragraph that the NHS itself doesn’t really know where people should go?
- We know over 80% of people with mental health problems are receiving care from their GP only – we also know this service is limited in what it can offer at 10pm on Tuesday if a patient rings up for unscheduled care because they’re struggling.
- We also know that some psychiatrists estimate around 75% of those of us living in distress because of our mental health receive no formal care at all and have unmet needs.
So where do they start?
Of course, the seriousness of the moment may influence things: if someone found themselves suicidal, then irrespective of whether they receive GP support or not, irrespective of whether they are known to mental health services or not, it’s probably best to access something and be supported or signposted appropriately things appearing have become acute or time critical. This is where emergency services come in and of course the NHS’s emergency system is the ambulance service and / or Emergency Departments. EDs often have psychiatric liaison services within and it’s a national standard. But it can be commonly found that people ringing 999 are put through to the police service, especially if they sound highly distressed or agitated.
We are currently seeing a lot of discussion about the police service picking up demand which they are not best suited to handle. Officers do have powers under the Mental Health Act 1983 but those powers are often not relevant to a situation – not everyone needs detention for their own safety and in any event, certain data in policing tells us that most calls which see officers attending are in private premises where police powers can’t be used anyway. But why do we continue to see the police being called and, arguably, why is this unlikely to change?
POLICING’S WHAT HAPPENS
The police have always played a role as a social stop-gap because it’s a flexibly deployable group of people, available in principle 24/7 — “policing’s what happens when something’s happening which ought not to be happening about which somebody ought to do something now”, said Bittner and this has been true throughout its history because even where something is not a policing responsibility at its core, “there is nothing that cannot become the legitimate business of policing” if things deteriorate enough.
One problem in recent years has been the extent to which the police have been deliberately relied upon for tasks which have not, in fact reached such a threshold, but also the difficulties which appear to be faced by other organisations in preventing situations from reaching those thresholds in the first place. People can take their own views about the extent to which that difficulty is to do with money, politics, culture or structure – it’s inevitably a complex combination of those factors and no doubt, of others.
But this remains true: there is no ‘mental health system’ and disparate health services represent something of a process through which people can pass, with various entry points. But until the NHS knows or decides how those of us in distress due to our mental health should present and where, it seems likely people will continue to bounce to the emergency system, including police, ambulance and emergency departments.
What other choice do we have?
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, 2023
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 – www.legislation.gov.uk
Mental Health Cop 