On Wednesday 7th February 2024 an evidence session was held at the London Assembly about Right Care, Right Person and you can view the entire session on YouTube.
A point of guidance on the session: the YouTube stream is three-hours long(!) and that’s reflected in the length of this post, so sorry for that! — it was a live-stream of proceedings and it doesn’t actually get going until thirty minutes in to what has been uploaded on YouTube. So don’t just watch from the start – scroll to just beyond 30-minutes if you want to watch it and I’d even say if you watched the first thirty minutes of the actual proceedings from that point, you’ll have captured the heart of what you might need to know coming out of this.
That all said, I’ve watched it for you! — you’re welcome. What follows is a summary and it doesn’t touch on everything I’d have liked to mention, with extensive quotations from those involved and there is also BBC News coverage if you just want to read a very short article. There was attendance from the Metropolitan Police, the London Ambulance Service, NHS England, the Royal College of Psychiatrists and the mental health charity Mind, amongst others. The chair of the meeting began by asking the organisation representatives to give their general perspectives on RCRP before then doing detail and discussion with Assembly members asking questions.
Nobody in the evidence session seemed to think there wasn’t a problem to fix or a balance to strike here but Dr Sarah Hughes from Mind set the tone for me by saying —
”The police have saved lives. When they’re the right people, the police have made a positive impact. For many people, when the police are involved, it hasn’t ended well. But sometimes the police are the right people, they just are – because of the powers that they have.”
So it’s about striking the right balance and in fairness to the Met, Commander Kevin Southworth had to keep reminding the session that RCRP is not about the police removing themselves completely from anything, but about attempting to better striking the balance. What follows may allow you to judge how the various organisations view the approach to getting that right.
POLICE
It began with the Police and Crime Committee chair, Caroline Russell AM asking Commander Southworth and Superintendent Alastair Vanner (Metropolitan Police) to talk about the background and why the scheme came about. They explained it was introduced in Humberside after the Picking Up the Pieces report (2018) and has since seen a reduction in the use of s136 of the Mental Health Act from over 700 a month to less than 400. The police characterised the past as “over-use” of the power, emblematic of over-reliance upon the police and in fairness to them, we heard later from others who believed 136 is over-used.
I’ve written about the ‘over-use’ argument before and I remain to be convinced that it is over-used, overall. I suspect it’s over-used and under-used as well as mis-used even mis-unused (is that even a word?) in most police forces around the country – all at the same time. People tend to look at 136 usage when determining their view on ‘over-usage’ question, but it’s not just about how it’s used: it’s about how it’s not used. If you want to see an example of non-misuse, look at the Northern Ireland inquest last year for repeated non-use of the power where a Coroner stated use would have affected “entirely preventable” homicides. It’s not the only example of non-use where fatal outcomes result, so I do have more examples if anyone wants to discsuss the observation. Then of course, how many people arrested for minor crime should have been detained under s136 MHA? – we have no idea, because no-one looks at it but again: coroners have entered that debate on occasion following deaths.
So I was immediately very interested in the data claim, not least because it was the main point made in the introducing about the scheme which is about so much more than 136 use. The latest Home Office data set for police use of s136 MHA was published very recently and Metropolitan police use of s136 increased slightly to 6093 for 2022/23, up from 5971 in 2021/22. In the context of this evidence session, it should be born in mind data reporting only covers to the end of March 2023, before the Met introduced RCRP in October. My substantive point in commenting on the data however is that 700 a month must have been something of an anomaly, perhaps for one or two months, if data supplied to the Home Office for publication is correct.
At 700 a month, we would expect annual reporting of 8,400 a year and it has never reached anything like that level. Average monthly use across the last two years (2022/23 and 2021/22) was just over 500. Of course, we may well be sitting here this time next year reflecting on 2023/24 data and seeing a significant downward shift because of RCRP’s introduction in this financial year but policing and mental health is about so much-more than s136 and the debates which result from it – as I was pleased to see the London Ambulance Service Chief Executive state at this meeting.
HEALTH
Martin Machray MBE (NHS England) spoke about a rise in admissions, assessments, contact. “We shouldn’t think of use of s136 MHA as a bad thing. It was set up as part of the Mental Health Act 1983 for a real purpose. The problem is it’s been over-used over time because of demand on services, not necessarily the right thing for the right person.” It actually wasn’t set up by the MHA 1983, but by the MHA 1959 but there we go again — taken as fact that s136 is over-used without any sense of how this view is reached by knowledge of how it’s mis-used and not used. We really do need to get beyond s136 because most mental health crisis incidents to which the place are or were called occur in private dwellings where s136 MHA cannot be enacted, even if they’re are immediate concerns for someone’s welfare.
We then heard from Dr Sarah Hughes (CEO of Mind) and Dr Lade Smith CBE (President, Royal College of Psychiatrists). They can more than capably speak themselves! —
“We support the principles of RCRP … it is striking that we got from 700 to 400. I do wonder where those three hundred people have gone? – that is the deep and profound concern we have. The police necessarily won’t know what is a mental health issue or not until they get there and are able to assess the situation. It’s difficult to assess whether things are life and death – if someone is at risk of suicide, you won’t know the risk until the person’s in front of you. There’s a bit of a gap between what we think the police should understand in relation to mental health and what is readily available for police on the ground. So that gap still exists and that gap is not going to be addressed by Right Care, Right Person. Whilst we agree with the principle there are some grave concerns about the roll out and the unintended consequences of this important policy. The only data that’s really being collected is from the police perspective, not from the system perspective.” — Dr Sarah Hughes (Mind)
“There is no doubt, the idea of trying to reduce police input is a good idea when it’s done properly – the difficulty that we have is the way in which this RCRP is being implemented. We know already … the state of of MH services across the country and in London are parlous, actually. We have had chronic under-resourcing, we have terrible workforce shortages, and since the pandemic there has been a 20% increase in need and demand. And that’s across the board, especially in children and young people. And before the pandemic, mental health services were meeting that demand despite everything and since the pandemic it’s gone up. That means there aren’t more people do the work and our waiting lists are higher and when people sit on waiting lists they’re more likely to go in to crisis. Unfortunately there are more people who are at home or in a public place who are so very unwell and unable to be safe that they need input. The Crisis Concordat was excellent was at identifying ways in which mental health services and ambulance services and the police could work together to provide a service for those people who may go in to crisis.” — Dr Lade Smith CBE (RCPsych).
Just reflecting on the claim that more people are likely to go in to crisis when they’re on waiting lists: the implication of this seems to be we may see a rise in calls for the police to intervene in situations which have become unsafe — fair enough. It’s interesting to note the reduced use of section 136 nationally and the slight increase in the Metropolitan Police area. So is the claim of more crisis not correct, or does the data reflect less police involvement? Inevitably, it will be multi-faceted and complicated.
ASPIRATION / IMPLEMENTATION
”There was a sudden cliff edge announcement that things were going to change … all of a sudden “right, we’re not going to do this any more” and there is a simplistic idea that somehow if someone has a mental health problem that they’re not going to need police input. There’s a whole branch of psychiatry that is about people who unfortunately develop a mental health problem and become violent or have to have contact with the criminal justice system and if you go any prison, 70% of people in prison have a co-morbid mental health problem.
We know people with mental health problems may well offend and there is a whole part of the Mental Health Act called Part III of the Mental Health Act which is about supporting people who fall foul of the criminal justice system. 136 and 135 is a part of that, we accept very much the idea there is far too much use of 136s – what we are concerned about is as a results of messaging and the way RCRP has been implemented, even when there hasn’t been all the partnership work that takes some years, bobbies on the beat and more senior police officers have decided to take matters in to their own hands and actually, the understanding and the learning and hte knowledge they have to do that is limited.” — Dr Lade Smith CBE (RCPsych).
Dr Smith used the issue of section 135 MHA (which is not actually any part of RCRP in terms of the four phases) to demonstrate a problem. Having pointed out how hard it is for an Approved Mental Health Professional to reach the point of securing a s135(1) warrant, she reports on the police saying “no, we can’t come because we don’t do mental health”. She points out the obvious error, because only the police can execute this kind of court warrant and it demonstrates in her view, the police haven’t got the knowledge they need to institute this programme. Those who’ve read this blog since it began know the whole point of it is predicated on that premise: that officers (and in all fairness, plenty of others!) don’t seem to know enough.
#TEAM999
The Chief Executive of the London Ambulance Service (LAS) had a very different take and he opened by saying so. He pointed out the LAS had placed their clincians in police control rooms leading up to the introduction of RCRP and a had helped the Met develop a script when assessing calls for potential health needs. If a call involved no obvious need for the police, it would be transferred by IT to the LAS who would then decide on whether it needed a 999 or a 111 response. Most needed 111 and as LAS run also run the 111 service in London, they are able to ensure the mental health component of that operates the way they want it to.
“We put some of our clinicians in to the police control room to find out “who are all these people and what are their needs?” and section 136 patients are actually quite a small volume of the total patients we are talking about. We receive around 200-250 referrals from the police a day. Nearly all of those people really are patients and it’s totally right that the police no longer send a police response to those people, but the NHS works out what is the right care. So what we have assembled is a team of our clinicians to triage those calls from the police and we then decided, is the person for the 999 system or a patient for the 111 system and nearly all of the people are patients for the 111 system.” — Daniel Elkeles (LAS)
It was very interesting to then hear from Alison Blakely (LAS) who described what happens after 111 receive a referral (whether from police or directly). She highlighted the introduction of six specialised mental health response cars run by the LAS with mental health clinicians and a paramedic. They attend crisis incidents following referral f rom the police or where someone has directly called 999 for LAS because of a mental health need. Since the launch of that service, successfully referred in to onwards care at home have increased. Before the programme, double crewed ambulances saw 70% people conveyed to an Emergency Department, with the joint response cars, it is 20%.
This sounds extremely positive but Dr Smith made a really important, under-made point in response to the LAS submission.
“What you’ve described is how the police and ambulance were responding to people in distress that isn’t mental illness. My concern is that understanding about mental health hasn’t translated in to understanding of mental illness. What you’ve just described to me, is a wonderful example of how you stopped dealing with complaints that are to with people who have mental distress who don’t have mental illness but I’m still concerned about how we manage people who have mental illness. — Lade Smith CBE (RCPsych).
Mental distress and mental illness are not the same thing — many people for a number of years have been observing how our broader debates about the importance of mental wellbeing are eclipsing necessary discussions about serious, enduring mental illness. Many calls to the police about ‘mental health’ are not calls about serious mental illness and when we see serious, adverse events of various kinds – like mental health homicides, deaths after police custody or contact – we’re actually talking about illness. It’s easy to lose that in the bigger picture of calls relating to distress borne of social and other, non-medical factors – and difficult to entangle that stuff over the phone and without input from NHS staff.
THE ADEBOWALE REPORT
I must admit, I loved the question about the Adebowale Report from 2013. I was interviewed by Lord Adebowale as part of that report and it was one of the toughest interviews I’ve known! As result of his deep-dive in to 55 fatal or serious incidents in London, he made 28 recommendations for improvement of policing and mental health in the capital. A London Assembly member asked how this background had influenced the Met in getting to where we now are, discussing RCRP. The answer reassured us that all the recommendations had been implemented.
The problem with this claim is that only nine of them were in the direct gift of the police to begin with.
The others were either about health or social care organisations or their interface with the police; or they were about governance of this stuff by the Mayor and the Assembly. Lord Adebowale went out of his way in his report to quote the Bradley Report (2009) that neither the mental health system nor the police can do this on their own and having been given a mandate to review policing from the (then) Metropolitan Police Commissioner, he had to depart from his mandate and examine health and social care factors which have bearing on policing – none of this stuff happens in isolation. I’d be amazed to learn he felt all 28 recommendations of his report were implemented, as intended – indeed, if they had been implemented you might wonder whether the Met would have reached a position of feeling RCRP was necessary at all?
There is much more to this session, but I’m now conscious of the length of the post and I’ll invite you to watch the rest of it for yourself, if you’re interested.
Two quotes from Dr Smith and Dr Hughes in conclusion, for all of us to note —
“We don’t know what we don’t know so in terms of the discussion and the examination of adverse effects, we already see from the Prevention of Future Death notices that there is a huge amount of lessons to be learnt that I’m not too sure have been translated into RCRP. Indeed Nottingham [NB: I think she meant to say Norfolk] have paused the roll-out of RCRP because of recent events. And so again, when we think about looking at examining adverse events that we know are happening within the system – they’re not anecdotes, they’re lived experience – it is about being able to collect that data. Equally, we might have to wait some times before we get outcomes from Coroners’ courts. Unless we have system-wide data then those adverse events are going to go under the radar.” — Dr Sarah Hughes (Mind).
“I have to say: there is long-standing societal discrimination against people with mental illness – and we have to be mindful of that. That is going to have an impact on the way any policy is implemented because there are already unconscious biases at play.” — Dr Lade Smith CBE (RCPsych).
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 