If policing is not the correct response to mental health crisis and people deserve or are entitled to the “right” care, what is the “right” care – and who determines it?
I’ve deliberately tried over the last twelve or more years or compiling this blog to avoid getting too abstract or philosophical about some of the non-police, non-legal stuff. The intention here is to be practical about how to improve police responses where they must occur and reduce the need for them, both in terms of crisis incidents and crime incidents. Those who’ve closely read the site throughout, though, may remember a few pieces where I’ve ventured in to what I want to highlight here: something about people’s rights and responsibilities to make their own healthcare decisions and the state’s relationship to all of that.
The police are not great at determining which aspect of the NHS is the “right” bit and I’ve used this example from the ambulance service before –
- Where the public ring 999 for an ambulance, 66% of patients are transported onward to an Emergency Department, 33% were discharged at the scene with some treatment and / or advice (to contact their GP, for example).
- Where the police ring 999 for an ambulance, 33% of patients are transported onward to an ED, 66% were discharged at the scene with treatment / advice.
- Disclaimer: these figures are a few years old and came from an informal discussion with a senior paramedic who mentioned this in passing.
Just think about that! –
Most people who find themselves attended on by paramedics because police officers decided it should happen, don’t really require paramedics and the public are better at determining the need for an ambulance on their own. So you might wonder, at one level, why do police officers make decisions to call an ambulance for some people involved in police incidents … why not just let people make their own decisions and be responsible for themselves and their healthcare? Answers usually include “well we have a duty of care” and even where that may be true, it doesn’t mean a duty can only be discharged by calling for our friends in green to rock up in a rolling intensive care unit on wheels because a guy in an RTC has a hurty shoulder after being jolted by his seat belt at the point of impact. If he’s a sober, conscious and adult man, he’s probably well-placed for himself to decide if he needs an ambulance or whether he’ll pop up the minor injuries later, or nothing at all. And even if you and I would get that checked out, it doesn’t mean he can’t be left to decide otherwise: the point is, for most people in most situations, the choice is theirs.
I was knocked off my bike a week before Christmas and suffered a hurty knee – I did not need an ambulance despite having been thrown over the bonnet of someone’s car and bouncing in to the road but some people were determined to ring one “to get checked out” and I had to stop them from doing it, because it simply wasn’t needed – and it’s my knee!
MENTAL HEALTH
But it’s all different with mental health, isn’t it? – because people in crisis can lack capacity to take decisions and are sometimes to distressed to see the injuries they may have experienced, etc.? Well yes, sometimes that is true – but not always. And the same legal principles apply: you must assume adults (ie, over 16yrs of age) have capacity to take their own decisions, including unwise decisions, unless you have good reason to think otherwise.
So what should happen if a person in crisis rings the police, for whatever reason they choose to do so? – well, there are two starters for ten: to determine whether there is a legal obligation on the police in that situation (crime, immediate risks, etc.,) and to reflect the fact people’s healthcare decisions are for them, except in situations where there is an established duty of care to act (ie, someone is under arrest in your custody, where they lack capacity to do so or where there is that immediate risk).
So imagine someone rings 999 for the police because they are having problems with their mental health. Assume that nothing indicates an immediate risk justifying a police response, who should the person be referred to or to whom should the police direct their referral that another agency should act. Well, we need to remember how complicated the NHS can be. All areas have Emergency Departments, ambulance services, 111-telephone services and in principle, every person should have a GP who will have some kind of out-of-hours service. In addition, all areas have a mental health trust providing “secondary” (ie, specialist) mental health care. But all of this needs a little untangling, to understand it properly.
NHS STRUCTURES
You will have variation across much of this, sometimes referred to as the “post-code lottery”. For example, if you ring 111 in Cambridgeshire you will hear a list of options where you “press one” for this and “press two” for that, etc.. Option two puts you through to a mental health-specific service and some other areas have this too – but not my home area. Mental health trusts also vary: most offer something we could call a “crisis team” and the name implies what it deals with. But crisis teams and crisis services vary. In some trusts like (the CQC “outstanding” rated) Cumbria, Northumberland, Tyne and Wear, they have a crisis telephone service which anyone can access, in principle. In other trusts, crisis services exist for those patients already receiving the specialist support of a mental health trust after being referred to them, but it’s not directly available to all.
Capacity within services vary: a crisis team in some areas is one nurse working out of hours so they are prevented from attending home addresses because of lone-working policies predicated understandably on staff safety, but in other areas they have more than one nurse and can go out to see patients. So what happens if a lone nurse believes someone needs to be seen in person? – well, sometimes calls end up going in to police or ambulance to conduct welfare checks and we’re back to the beginning of this: what is a police role and what is an example of the police filling in gaps for others?
But where the police conclude there’s no immediate role for them (see the ‘threshold’ outlined in the National Partnership Agreement), to which organisation do they then point the person or to whom do they refer? – you can necessarily say “ring the Crisis line”, because there may not be a generally accessible 24/7 service to allow for that; you can’t necessarily say “call an ambulance” because we know someone not requiring the police may not necessarily require an ambulance either (and remember: we know the police get that wrong a lot, see above) … so who is the “right” care? Well, to some extent, that’s none of the police’s business and it will vary by area and may even vary within a police force area. Some larger police forces cover two or more mental health trusts, two or more Integrated Care Board areas and have a multitude of non-identical services operating within their boundaries. Where no police duty to respond exists, it’s may almost be a case of advising people to ring their own GP or 111 if they don’t have one and be guided on the healthcare response by the healthcare professionals who should know in their area how it works.
Not by police guesswork about who they think should provide the response.
NONE OF YOUR BUSINESS
Going back to other pieces I wrote years ago: my healthcare is my business and it’s none of yours, unless I’m in your custody, vulnerable or lacking capacity to make my own decisions in a specific context due to illness, injury or age, etc.. Remember: we should presume people have capacity for their own decisions and an unwise decision is not necessarily evidence of any lack of capacity – if I don’t want hospital attention or an ambulance to be called for my hurty knee, that’s my decision even if you’d take a different one. This remains true of any mental health difficulties I may have unless, of course, I lack capacity to take decisions or am owed a duty of care by detention or immediate risk, etc.. Of course, mental health (like any number of so-called ‘physical’ health conditions) can mean someone lacks capacity, but it doesn’t always.
Mental health law is not just about capacity, so you need to know your legal onions – the MHA can sometimes still be applied to some people who have capacity to take decisions.
But in amidst all of this is a place for most of us where it’s simply not down to the police to make decisions about someone’s healthcare and even in those situations where there may be perceived an obligation to recommend or advise something, it would be usually be met by saying “I’d advise you to contact or consider contacting your GP or 111.”
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, 2024
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 