A short post, because it’s just updated data on topics I’ve written about before, where the same issues prevail. NHS Protect issued its 2015/16 data for assaults on NHS staff and the headlines are –
Within the various sectors of the NHS –
I’ve written about this elsewhere and for detail, I’d encourage you to read the previous post. Suffice to say here, that medical factors are defined as relevant to an offence if “the person did not know what they were doing or did not know what they were doing was wrong, because of injury, illness or treatment.” This is, more or less, the legal definition of insanity, so it is quite a high threshold to meet – there are very few insanity findings in criminal courts in any given year. Yet the NHS records that more than 5 in every 7 of the assaults on their staff were at the hands of patients who meet that description. This seems unlikely to me – it strikes me as a massive over-representation given that we know from other sources that insanity pleas are few and far between. We also know from research for NICE Guidelines that fewer than 10% of people who offend whilst mentally ill are offending because they were mentally ill. There is little direct causal relationship between illness and offending, it seems.
Little appears to have changed in terms of certain inconsistencies that need pointing out, in order to promote debate about what they mean. Nottinghamshire Healthcare Trust and Oxleas NHS Foundation Trust (south-east London) both recorded that none of their assaults involved medical factors. No-one at all in those areas – not even one person – was so unwell because of illness or injury that they lacked all insight in to their actions. And yet just down the road from those two, in Derbyshire Healthcare NHS Foundation Trust and in West London Mental Health Trust, ALL of the patients were that unwell. I’ve worked as an operational police inspector in both Birmingham and in the Black Country: look at the figures for BSMHfT and the BCPT, above: one thinks that just over 20% of assaults were due to medical factors; the other thinks that just under 20% weren’t. I know Birmingham and the Black Country fiercely defend their cultural and various other differences but take it from as a neutral (a Geordie) who has lived and worked in both places for over twenty years overall, I can assure there is not that much difference!
It strikes me again, that neither of these extremes is likely to reflect the medical or legal realities in those areas. Just for completeness, there are two MH trusts data missing from the header image because of the page layout: I’ve highlighted them below because they also tell another story: why do MH trusts with a 1:2 ratio of staffing when compared to each other have roughly similar levels of assaults? You are twice as likely to be assaulted at work if you’re a mental health nurse in Ealing than if you work in Middlesbrough.
Of course, trusts differ in the services they provide – only some provide medium secure services; only some run learning disabilities or children’s mental health services; and only three trusts in England provide High Secure services and West London is one of them) … but it needs untangling if we are to make sense of data that is superficially confusing because it doesn’t compare apples with apples.
RISING LEVELS OF CRIME
What’s missing from these data are the reporting levels to local police services. One MH trust told me that they report around 15% or 1-in-8 assaults on the staff to the police, because their assessment of ‘medical factors’ and their consideration of victim’s views plus a guess at the public interest test for prosecution, is that a report is not needed 7 times out of 8. Yet in a recently developed MoU between NHS Protect and the police service, NHS are requesting trusts to report 100% of incidents recorded in these data to the police. With what purpose in mind? – of course, anyone who is assaulted is entitled to report that to the police, but I’m wondering what the motivation would be for doing so if the suspect was an 89yr old degenerative dementia patient who has pushed a nurse causing no injury during the provision of personal care?
This approach should be even more interesting in those trusts which report 100% ‘medical factors’ – because they are asking the police to criminal investigate the liability of someone that professionals themselves are already assessing as unlikely to be convicted, ever. That having been said, in those thankfully rarer cases of more serious crime, the potential that someone is unfit to stand trial or likely to be found not guilty by reason of insanity is not sufficient reason, in itself, not to prosecute. The criminal courts in this country have powers under the MHA that no doctors have to balance off the issues where treatment needs to be considered alongside public protection, so we. Do need that debate about when it is right to prosecute a very vulnerable person who has offended. We know the answer is not ‘never’, so it begs the question, ‘when?’
A rise of 2,500 reported assaults comes from greater recording of incidents previously not reported because of a lack of time to do so or a belief that nothing worthwhile would result; or from a genuine rise in the levels of crime … we don’t know. I’ve heard anecdote recently for each of those explanations and from professionals I know well and would trust; but it should be borne in mind the violent crime in society generally is rising and demand on the NHS is rising at a time when resources are being rationalised. It would not be unexpected if we saw numbers rising even just allowing for rising levels of offending. We need more data … much more data. We also need a clearer understanding of what ‘medical factors’ should mean and how this is being interpreted across the NHS. We need much more analysis and discussion of yet more data.
We don’t know what we’re doing so we don’t know whether what we’re doing is wrong.
This should be on our to-do list for 2017 — Happy New Year!
Winner of the President’s Medal from
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award.