New guidance from NHS England was published last week and it’s taken me some time to read it all – there’s the first issue: it is ABSOLUTELY MASSIVE, totalling over 26,000 words!
I’m afraid it’s one of those documents which is so massive, it might be considered by some to be somewhat impenetrable and even before I’d finished reading it, I’m hearing people telling me things about its content which I specifically tried to look up and found it hard to use to get to an answer without reading (or re-reading) substantial parts of it. Having looked to confirm those rumours, I didn’t find them but couldn’t help but wonder if I’d nevertheless missed something in my attempt to read 26,000 words looking for a “yes / no” on something specific.
So I do wonder how many people will truly spend a part of their lives they’ll never get back, actually reading it (all)?
I’m not going to give a summary of it as such, but merely a reaction to it with some highlights and some links which might help you use it more easily. I’ve set myself the mission of completing this in under 1,300 words – 5% of the document itself and I’ve already used about 15% of that so best crack on!
SEVEN THOUSAND WORDS
There are four sections in this guidance: you only really need the fourth of them if you’re using this to look at the nuts and bolts operations of who should be doing what and when, according to NHSE.
Sections one to three – introduction, principles and partnerships, totalling 7,000 words – are pretty standard stuff about the RCRP background, the legal and ethical framework and the necessity of partnership governance structures and so on. I’m not sure it tells me much. You’d probably guess most of it by applying some common sense about legal and ethical principles and and good partnerships between public agencies, including the need for good local protocols.
Section 4 is all about the four phases of RCRP and there are specific sub-sections on each –
- Mental health related concerns for welfare
- Hospital walkouts and AWOL patients –
- Conveyance
- Section 136 MHA Handovers.
The hyperlinks in those four bullet points take you to the NHSE Guidance itself so you can read each section you need, without having to navigate through the stuff that probably isn’t going to answer your questions. One thing about the five NHSE links which struck me: they do all focus on mental health where as others in policing are talking more widely than that and talking more widely than these four things – so there’s another issue for you: this is guidance from NHS England to Integrated Care Boards and providers on something narrower.
AMBULANCE
Section four is the bulk of this guidance on the four topics above, totalling over 19,000 words. The first thing I’d heard about this guidance before I started reading it was how the guidance apparently says all calls for mental health matters should firstly go to the ambulance service, unless that police threshold is met. We know the ambulance service in some areas are experiencing a significant uplift in demand because of demand deflected by the police for issues which mostly don’t need an ambulance, so this claim from a police officer is an important one.
I couldn’t find that and think the officer is referring to guidance on welfare checks in section 4.1.3 –
- Emergency situations: ambulance or ambulance and police, depending on whether the RCRP threshold is met and this would include mental health emergency and mental health plus physical healthcare emergency.
- Non-emergency situations (under community MH services): their usual mental health care service will normally lead the response. If unable to respond with sufficient urgency (including out of hours), then the Crisis Team will lead.
- Non-emergency situations (not known to services): but good evidence the concern relates to the person’s mental health: intensive home treatment/CRHTT will lead.
You’ll notice immediately, this doesn’t cover everything! – we have gaps in knowing what NHSE are expecting. I’m also not sure the areas I’m familiar with have CRHTTs which could do this and the guidance is silent on what should happen instead as a contingency until that capacity is generated. Are we back to police keep policing (RCRP forces have already started saying no) or ambulance even though their criteria for deployment are not met? We don’t know.
We hear more about the ambulance service in guidance on phase two (hospital walk outs / AWOL patients) where it reinforces the role of the ambulance service should be restricted to situations where the person’s location is known and where there is an emergency of the kind which influences phase one guidance on welfare checks. This is important to emphasise because of how often I hear of the police suggesting ambulances deploy to people whose location is not known – it’s weird to think anyone wants to send an ambulance to a missing person who hasn’t yet been found.
Where are we sending the ambulance, officer?!
HERE AND NOW
The big thing worth noting here is the NHSE guidance emerges almost eighteen months after the National Partnership Agreement, just at the point where the police service is talking about all forces now being ‘live’ with at least some aspects of RCRP. The police are ahead of health here – it seems an obvious there is a risk police forces will be expecting the NHS to be doing this stuff now it has been published. In reality, it is coming out as something new to NHS organisations and having been in a room of healthcare security staff yesterday who work across the NHS, many of them were not aware this guidance had been released.
The further reality check is it may take months or even years for NHS areas to be able to deliver on much of this. The guidance does remind us in section 1 (intro) that RCRP comes with no new funding or resources and we know MH services are thousands of mental health nurses short, for example and the new government believe the NHS is flat on its face, unable to stand (to paraphrase a metaphor from the Prime Minister used today).
I couldn’t help but feel whilst reading this that I’ve read many similar things before, including in commitment to do things in the Crisis Care Concordat (2014) which also didn’t really happen for us because of a lack of resources. Remember it was estimated the NHS would require £260m to plug the “RCRP gap” – so as you read this guidance and see things about commissioned, secure transport services or adequate Place of Safety provision, remember the resources reality check and the historic pace of change on these topics.
DESCRIPTIVE / PRESCRIPTIVE
The fact the guidance exists with aspirations doesn’t mean it will happen – and in absolute fairness to NHS England, much of that will be about what priority Integrated Care Boards are prepared to give to ensuring resource for the difficult aspects.
There are errors in the guidance which should have been picked up – para 4.5.1, to give just one example, talks about situations where the police remove someone under s135 MHA to a Place of Safety “once they have obtained a warrant”. There’s no mention here of the Approved Mental Health Professional who is the only professional who can obtain the warrant and it all creates the impression for healthcare staff reading guidance the police can obtain them on their own, which they can’t. Whilst we’ve also got police officer telling AMHPs to execute their own warrants, which they also can’t, it just reinforces the confusion.
So – good luck with it! It’s massive, it’s extremely wordy and it has some errors which need ironing out. It’s also describing a future we’re not yet in – as it should – rather than a reality which should already exist which is what the police may think now it’s published.
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 am not a police officer.
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
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