Last year, the National Institute for Health and Care Excellence (NICE) published their Standards on the Mental Health of Adults in the Criminal Justice System. This involved NICE reviewing the best available evidence and practice around the contact that vulnerable adults have with the criminal justice system. Subsequently, NICE published what they call a â€˜quality standardâ€˜ â€“ this is the subject of a comment piece in the recently published issue of Progress in Neurology and Psychiatry (volume 22, 2018).
Iâ€™ve just spent a whole week in Cornwall (picture above), trying really hard to step away from work â€“ itâ€™s been quite a busy few months during which Iâ€™ve had to do things which are quite new to all the work Iâ€™ve ever done on policing and mental health. Iâ€™ve also been consumed in the recent months that the net effect of what weâ€™ve ended up doing to make the world a better place is merely making it worse. Not just slowing down how much worse itâ€™s getting â€“ but actually accelerating things in the wrong direction. I know itâ€™s not a view that many people share; Iâ€™m very aware of all the mantras that come out when these kinds of views are articulated â€“ that the only way to do things is in partnership, etc., etc.. So upon return from annual leave, I read the comment piece about the NICE Quality Standard and found, yet again, reason to question those kind of underlying assumptions and â€“ like the reports Iâ€™ve had to write in recent months for various legal processes after deaths in police custody â€“ I found myself wondering about attention to detail.
I need to repeat one more thing, about which Iâ€™m at risk of becoming really boring whilst I drip like a tap: if you think that the work to be done here is improving policing and criminal justice responses to the mental health demand that we face, youâ€™re fundamentally mis-identifying the problem. The problem here is not the police: it is the extent to which we deliberately rely upon the police to triage and gate-keep mental health demand that we increasingly decide should be criminalised. We rely too much and we need to work out how to stop because having just spent the last fifty or sixty years gradually and subliminally shifting institutionalised mental health demand from health to prisons and then regretting it; we need to make no mistake we are now seeing a similar shifting of crisis and community care from health to police and probation. And this Quality Standard and the arising expectations in comment pieces are just helping us reinforce this, in my own strictly personal opinion.
The comment piece claims that the Angiolini Report (2017) contains â€œ110 recommendations for improving the way that the police manage vulnerable people at the point of arrestâ€.
No, it didnâ€™t â€“ did the authors of the piece actually read the Angiolini report?! It contains 110 recommendations (see page 235 of the report â€“ theyâ€™re all laid out, one by open) and youâ€™llÂ notice the majority of them do not relate to the management of vulnerable people at the point of arrest or contact. Those which do relate to that, barely relate to the police â€“ they relate to the National Health Service and its need to improve accessibility and its interface with policing. Around 70 of the recommendations relate to processes after a death in police custody has occurred; processes connected to investigations carried out by the Independent Office for Police Conduct, to the whole coronial court process and certain specifics, such as a call for families who are bereaved after a death in custody to have access to Legal Aid.
If you look at the roughly 40 recommendations which do relate to how vulnerable people are managed, youâ€™ll see that fewer than 10 relate to matters over which the police have sole control. In other words, most of the â€˜Angiolini recommendationsâ€™ are about improvements in post-death procedures; less of it is about preventing deaths from happening in the first place and those which do have that bearing are about how accessible our NHS is.
The comment piece correctly states that Angiolini claims â€œPolice cells should not be used to hold those detained under mental health powers.â€ This is correct â€“ it does call for that. But it goes on, â€œThe NICE Quality Standard seems to accept that this sort of change will be a lengthy processâ€ and â€œthat procedures can be put in place in the interim, to keep people in custody safe and minimise any potential unnecessary harm.â€
No, no, and again, no â€“ history and evidence shows it cannot and it shows that moving to a position where areas do not rely upon police cells as a Place of Safety can occur in a relatively short period of time, given the will to achieve it. Areas without any Place of Safety provision at all have shown it is possible to get from nothing to working in a matter of weeks. Iâ€™ve been part of making this happen and these services still exist in the real world, where no-one is taken to police custody whilst detained under the MHA, ever. Yes, it will take careful multi-agency working and a commitment by Chief Constables to perhaps take more than a fair share of the resourcing in the interim transition period, but itâ€™s possible. See West Midlands Police, for details.
In the comment piece, little mention is made of prevention, yet this is the bedrock of most crime reduction and public health strategies: so how do we prevent vulnerable people from getting to police contact in the first place? You could be forgiven for thinking that the authors have assumed all CJ contact is unpredictable, unpreventable and unavoidable demand where the task, as outlined in the Quality Standard, is merely to better respond to what is happening, primarily through the medium of improved policing largely dependent upon improved training and competence. These are the standard traps to fall in to â€“ look at s136 data, look at street triage data, look at Liaison and Diversion or arrest data: those Iâ€™ve analysed show that most of the people in contact with the police are non-offending, known patients with requirements best satisfied by the NHS and which do not, for the main part, need the police at all. And of course, the fact that policing and criminal justice can be an anxiety aggravating, even pathologising process is left more or less untouched.
And as for â€˜acceptingâ€™ lengthy process: the Code of Practice to the MHA has called for the use of custody to be â€˜exceptionalâ€™ or a â€˜last resortâ€™ since at least 1999 â€“ is two decades enough to ensure that every area of England has a ligature proof room? Just think of how many far more complicated things weâ€™ve managed to sort in much less than two decades and then ask yourself whether the urgency of tectonic plate shift is inevitable.
There are four planks to this thing: my own view is that it reinforces that responsibility mainly rests with the police and it relies heavily on this mantra we repeatedly here in the UK and elsewhere: that the most important thing we can do is give the police more training. Itâ€™s as if policing is all thatâ€™s gone wrong here. â€œTraining for police officers to use non-contact and appropriate communication styles with disturbed individuals is clear available, but like the introduction of body-worn cameras, is probably not consistent or mandatory.â€ Iâ€™ll again be honest: the irony of NHS professionals highlighting inconsistency in policing is not lost on me after I learned that there are 27 different training courses in London alone,Â for restraint in mental health nursing. And of course, none of them are operating to a validated standard. Then add to that the 57 mental health trusts being commissioned by over 210 Clinical Commissioning Groups so that even one mentla helath care provider trust is not providing a consistent service across two different CCG areas and that this is because the NHS want it that way.
In policing, despite 43 different territorial police forces and a few other specialist ones, we have one personal safety training manual and all police forces operate to it. They may run their officer safety training in different ways, combine their OST with other things like first-aid in some forces, but not in others: but itâ€™s one national standard around the use of force and for all of my twenty years in policing, it has emphasised verbal communication and de-escalation.
A quick word on Liaison and Diversion teams, seen by Lord Bradley as key to whole diversion / criminalisation thing. Around 85% of the population of England is now served by a LaD scheme. Many of them operate on the basis of referrals made by the police to the nurses on duty in custody. Iâ€™ve known areas look for ways to improve the number of referrals made by the police, because of an ongoing suspicion that the police are â€˜missingâ€™ some vulnerable people in custody. Of course they are! â€“ they always were and they always will. Doctors with access to medical records get this stuff wrong when they have hours to assess someone, so Iâ€™m not sure what standard the police are being held to, if Iâ€™m honest, when they often have minutes to make decisions about who is vulnerable.
â€œThe true challenge is not knowing what to doâ€. I couldnâ€™t possibly disagree any more profoundly with this. I meet people regularly who do not know what to do â€“ have no idea of what is possible and think their problems insurmountable. But one thing I can agree with, is the commentâ€™s view that none of this stuff is new: they mention the Reed Report from 1992, and the Bradley Report from 2009. Weâ€™ve since had the Adebowale Report (2013), the Home Affairs Committee report (2015) and then the Angiolini Report (2017). In between all of those, weâ€™ve seen countless individual Coronerâ€™s inquiries, human rights cases, IOPC death in custody investigations, which all raise similar issues â€¦ over and over and over, again and again and again.
This would almost be boring if it werenâ€™t for the loss of dignity, safety and humanity â€“ the extent to which the learning is there to be had, but ignored. Â Instead, a preference of pushing an agenda that may help at the margins but doesnâ€™t address the core issue of why were are increasingly seeking to criminalise vulnerable people as a gateway to healthcare? We did it to prisons and probation and weâ€™re now doing it to the police. Until we stop just looking at the police, calling for ever greater levels of training and start looking at why vulnerable people come in to contact with the police in the first place, weâ€™re going to keep getting our analysis of this wrong. And of course, I would suggest we have Â for far too long.
So, weâ€™re off to a flying start to my return from leave! â€“ the mission for us all is to combat the covert criminalisation of vulnerable people which emerges from the unintended consequences of public policy being disaggregated, yet run on the pretence that we need to improve policing and police training which ultimately, at its best, is just an overly attractive half-truth. Â If you think otherwise, then I suspect weâ€™re trying to fix different problems.
Winner of the Presidentâ€™s Medal from
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award.