Channel Four News has used Freedom of Information laws to obtain data from Emergency Departments about delays for mental health patients. Their report from this week (25th October, broadcast on their 7pm news programme) highlights than mental health patients are waiting days, if not weeks in the emergency department, “guarded by hospital security” and often in a state of considerable distress. If you use X (formerly, Twitter), there is a good thread available with short videos, summarising this and it includes short interviews with staff from BHR Hospitals (Barking, Havering and Redbridge, in north-east London).
What I couldn’t help but note in the report, was the near-total absence of mention for the police service. It can’t be possible those patients all made their way to the ED on their own or via the ambulance service, there will have been examples where police accompanied individuals to ED or where section 136 of the Mental Health Act 1983, There is brief mention in one clip on the thread of a patient who was taken to ED by the police and had to wait two hours in the police van before then spending ten hours in the department. I will admit: I heard that and thought “only two hours and ten hours?” … sounds like you were quite lucky in some respects as that could have been a lot longer for both aspects, as the hospitals.
Much of what is summarised in the report is known already but it was refreshing to see it re-highlighted in the Channel Four report —
- That ED in that area is sometimes fifty percent occupied by mental health patients who are ‘waiting’ – either for specialist mental health assessments or admission.
- There were examples given of where distressed behaviours had involved patients hitting their head repeatedly off a wall, to the extent that it caused damage to the plaster board wall – hence, I assume, the need to reference patients being guarded by security (and no doubt, the police).
- It referenced the fact that the number of inpatient psychiatric beds in England has halved over the last twenty years – because of a policy preference that more care is provided in the community.
HOW DID WE GET HERE?
Various factors also play in to this, which probably need emaphsising to support the points Channel Four news is trying to make.
I’ve long wondered about the unintended consequences of the legal reforms of 2017 – that it would drive more people to end up in ED after police use of s136 MHA. Prior to 2017, if the police used this legal power to detain people, they could either remove someone to a mental health unit Place of Safety, or to the Emergency Department or a police station as a last resort. In local protocols, it was typically set out what criteria would trigger the need for ED and I’ve written about RED FLAGS on this blog, as a list of factors to consider and for the avoidance of doubt: the factors were conceived and written up by a Consultant in Emergency Medicine, Dr Tony Bleetman. Where someone detained is not presenting with a RED FLAG, the process should be they are removed to a mental health unit facility and if all else failed, custody was there as a last resort.
In 2017, this changed: because the government reformed the MHA to ensure that police station were used much less often. I don’t think anybody seriously thought that was a bad idea because we know how distressing removal to jail can be for those of us affected by our mental health, especially if we haven’t been accused of breaking any laws. So criteria were introduced to justify use of police custody and I wrote at the time of reform, that I personally would never authorise use of custody against those criteria (and I never, ever have). This meant, in reality, that unless mental health providers increased the capacity of mental health unit Places of Safety, ED was always going to end up being used more – because where else can you go?
- Imagine no mental health unit is unavailable because they are occupied by other people detained under s135/136 MHA by the police;
- Imagine the police station cannot be justified or authorised against the new criteria;
- Potential consideration could be given for whether an improvised solution could be found by taking someone home or to a relative’s home;
- But failing that —
- Can anyone think of another building which might be open 24/7, roughly connected to healthcare provision where someone could spend some time until an AMHP and DRs can convene an assessment and / or find an inpatient mental health bed, if required?
- I can’t think of anywhere other than ED, can you?
And since then, look at what’s changed in the world.
SHIFTING LANDSCAPE
Mental health beds have continued to be cut, police use of s136 MHA has continued to rise, we’ve since had a pandemic which threw the NHS in to a tailspin and ED was always busy environment before that and we changed the law in a way which meant unintended consequences – which were forewarned! – would be ED becomes the place of last resort where vulnerable people are not really welcomed. It should be borne in mind even prior to 2017, ED wasn’t considered by patients in crisis to be the most welcoming location to attend in surveys conducted by the Care Quality Commission. I can only imagine a repeat of such a survey would yield even worse results, for reasons which are not the fault of ED staff, either. They are not in control – indeed they cannot control – the variables that bring pressure to bear on their system.
- ED managers didn’t legislate in 2017 and did warn of consequences like this;
- ED managers cannot influence the rate at which police services use s136 MHA or necessarily ensure that their partner mental health trusts are ensuring adequate Place of Safety and other crisis accommodation for the population.
In the last years, I’ve known of major ED hospitals who, operating under considerable pressure of demand, have stated they will start to decline patients who are brought to their department by the police. Some forces have had to have meetings where they reality of such a decision would be laid bare – that people will end up waiting those hours or days in police cars or ambulances in a street or outside ED, because there is, on occasion, simply nowhere else to go, legally speaking.
The reaction to the Channel Four piece was to point out the investment in mental health services which has been made, including £150m for mental health ambulances. Such stock reactions often frustrate me, to be honest: because a mental health ambulance, however welcome, is simply not an answer to why some mental health patients needs to spend 10-days in an Emergency Department – it doesn’t create an inpatient mental health bed, or uplift the number of Approved Mental Health Professional who can undertake Mental Health Act assessments, for example.
OVER-RELIANCE
So I’m not sure I see the answers to over-reliance on the entire emergency system —
Timely, relevant and accessible mental health care and as I’ve written so many times before on their blog: our incredible ED staff, along with paramedics and police officers, are the agencies of last resort, towards whom vulnerable people end up deflected when the right care is not available in the right way, at the right time. It is within these contexts incidents arise like hospital walkouts, which we know from the Right Care, Right Person programme is an areas where the police are hoping to pull back from situations where there is no crime or immediate risk (to life / of serious injury).
It’s always been the case that long delays in ED for patients to be assessed and / or admitted to hospital under the MHA has been a source of such frustration, that people leave before completion of those processes. Notwithstanding emphasis in this new report about security ‘guarding’ patients, it remains obvious security officers have no legal powers to stop people leaving, especially where it’s not obvious there is an imminent risk (please note: an ‘immediate risk to life’ is not the same thing as an imminent risk – the first is legal phrase from human rights law, the second is just me using an adjective about something that will happen very soon).
So if you work in amongst any of this – whether it’s ED, police or paramedics – make sure you know what your legal position in and start preparing for the reality that you work in an environment where you need to be able to show you knew the law, operated within it and made legitimate request of other agencies where you felt it was right to do so – regardless of whether you’re confident they’ll give the response you’d hope to see. By not asking for what you know is needed, you accept responsibility for the outcome that follows – if you ask and are frustrated in achieving what you think is right, it’s for the others to explain themselves, if need be.
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 