Policing and mental health - Home Affairs Contents

4  Police and health service collaboration

Street triage

36. Announced in June 2013, Street Triage is an initiative that sees mental health nurses accompany officers to incidents where police believe people need immediate mental health support. The scheme is funded by the Department of Health and supported by the Home Office. It started with two schemes in Cleveland and Leicestershire, later extended to another nine forces.[73] There are other, similar schemes that have been designed locally with local funding. The format of Street Triage differs according to local circumstances. In Leicestershire, a police officer and a trained mental health nurse in a patrol car are able to respond to any call with a mental health aspect. The Birmingham and Solihull version is similar but also includes a paramedic. In Devon, a team of mental health nurses based in the control centre give advice over the telephone to police officers at the scene. The nurses can, if need be, go out on call with a police officer.[74] They generally operate overnight when need is greatest and mental health services tend to be lacking.

37. The pilots are still being appraised but initial results are promising. Street Triage has helped to develop relationships and break down barriers between the participating agencies.[75] Importantly, the collaborative approach gives frontline staff access to both police records and medical records, giving them quick access to critical information on a person's pervious contact with the police, clinical history and medications, and whether a care plan is already in place.[76] There is also anecdotal evidence that the mental health nurses are less risk-averse than the police officers when it comes to dealing with patients with a history of mental illness. So a nurse might be more willing to leave someone in the community rather than detaining and this confidence in time will be transmitted to police officers working alongside them. This had led to fewer s. 136 detentions and, in some places, it has led to a fall in demand for ambulances.[77]

38. In Leicestershire, there has been a 30% to 40% reduction in the use of section 136 powers since 2013.[78] In Cheshire, there was an 80% reduction in the use of s. 136 in the first six months of Street Triage. Instead of being detained, people were referred to other care, for example, 15% were referred to substance misuse services. In Birmingham and Solihull, there was a reduction in the use of s. 136 by 50% over a 20-week period.[79] As a result of these preliminary successes, HMIC has recommended that all forces should carry out analysis to assess whether adopting such a programme would be cost-effective and beneficial in their particular areas by 31 March 2015, and if the analysis is positive, they should work with their local mental health trusts to introduce Street Triage by 1 September 2015.[80] We did receive some evidence that questioned how Street Triage was being appraised and whether it was cost effective.[81] We note that two of the earliest pilots were in Devon & Cornwall, and in Sussex, two forces that still detain high numbers of people under s. 136 in police cells.

39. Though early indications of the effectiveness of the Street Triage scheme are very positive, it is important that the scheme is fully appraised against a range of clear success criteria, including an analysis of the relative merits of different models of provision, and the results published. In particular, it will be important to understand why the number of s. 136 detentions has fallen in some areas but not to the same extent in others following the introduction of the scheme. That information will inform the analyses that HMIC has asked each force to produce with a view to adopting some form of Street Triage. We note that different forms of Street Triage are funded in different ways and that it is not clear what guarantees are in place to secure funding at the end of the pilots. We recommend that the Government give a clear commitment that funding will be made available for schemes which have been proven to be cost-effective.

Liaison and diversion

40. Liaison and diversion (L&D) is a scheme that places mental health experts within police custody suites and courts, to identify early when someone who has been arrested has a mental illness, and refer them to support.[82] This would include someone, of any age, who has one or more of the vulnerabilities associated with mental illness, drug and alcohol dependency, and learning disabilities.[83] There are currently ten trials funded by the NHS, at a total cost of £25 million, with a further nine expected to be announced soon.[84] NHS England plans for L&D services to be available in all police custody suites and all courts by April 2017.[85] L&D is not an alternative to prosecution or out-of-court disposal where a person has committed a crime. The schemes are aimed at reducing re-offending by recognising when someone is ill or has a learning difficulty, and improving the treatment they get when they enter the criminal justice system.[86]

41. Similar to Street Triage, Liaison and Diversion services are intended to ensure that a person with mental health problems who does come into contact with the police and the courts receives appropriate treatment. The prevalence of people with mental illness within the criminal justice system is a scandal and any initiative that addresses this should be welcomed. However, its success will clearly rely on the availability of appropriate mental health services to which clients can be referred.


42. The Codes of Practice for the Mental Health Act require that people taken to a health-based place of safety should be transported there by an ambulance or other health transport arranged by the police. The Royal College of Psychiatrists standards specify an ambulance as the preferred form of transport and the Crisis Care Concordat states that police cars or vans should be used only in exceptional circumstances. Transportation in a police car or van makes patients feel like they are being treated like a criminal, reinforces the negative stigma associated with mental health and adds to the stress of the situation.

43. The provision of ambulances to carry people to a place of safety varies widely. In 2013-14, 75% of those detained under s. 136 in the West Midlands were carried in an ambulance, whereas in London it was 30%, in Thames Valley it was 10%, and in Lancashire it was 5%.[87] For many parts of the country, no data is available. The table below shows the top five areas for the percentage of those detained under s. 136 and transported by ambulance.
% of those detained under s136 conveyed to hospital by ambulance
Police force
West Midlands
North Yorkshire
Warwickshire & West Mercia
Note: data is not available for all areas of England

44. Various reasons are given for this variety of performance: ever increasing 999 calls asking for an ambulance, a shortfall of between 2,500 and 3,000 paramedics, and the local relationship between the Ambulance service and the police.[88] The Government's review of the use of s. 136 found a polarised answer to transportation; the majority of respondents who were paramedics or ambulance staff said ambulances should not be used, while the majority of police respondents said police vehicles should not be used.[89] The Government has raised the option of using unmarked police vehicles instead of ambulances.[90]

45. People encountering a mental health crisis should be transported to hospital in an ambulance if an emergency services vehicle is needed. Transportation in a police car is shameful and in many cases adds to the distress. Those affected, and their families, are clear that they wish to see ambulances used as transport to hospital. It enables the patient's health to be monitored on the way and improves access to healthcare pathways.

46. Reliable data on the use of ambulances to transport people under s. 136 is poor, but it is clear that the use of ambulances in these circumstances varies across the country. The relationship between the police and ambulance service at the local level is pivotal to how this can be improved. Forums that enable each to understand the priorities, roles and responsibilities of the other, such as partnership working and Street Triage, have been shown to work. To get to a point, such as in the West Midlands where 75% of people are taken to hospital under s. 136 by ambulance, require the ambulance service and the police to develop that local relationship. The Government must examine what the barriers are to poor performance of those ambulance services with regard to transporting people to hospital under s. 136. It must work harder to make sure examples of best practice are spread throughout the country.

47. Improvements can be made in how mental health crisis calls are received and processed by the 999 call handler. Such improvements can reduce the use of s. 136 and in turn reduce the demand on ambulances.

48. We recognise that there is a huge demand on all 999 services at a time of restricted budgets but, fundamentally, mental health needs to be seen on a par with physical health, and local commissioning of health services, including ambulances, must reflect that.

Delays waiting for a mental health assessment


49. People brought to a hospital A&E place of safety often have to wait between six and eight hours before they receive a mental health assessment. We know of one example where officers were required to wait 52 hours.[91] The police officers who bring someone to hospital can be asked to remain until there can be a handover to NHS staff. The most common reason for delays was because an AMHP or a section 12 approved doctor was unavailable.[92] Although there is no obligation for the police to wait till the assessment has been carried out, the guidance does recommend that they remain until a handover has taken place at the place of safety. Royal College of Psychiatrists recommend assessments should start within three hours, and almost 75% of health-based places already operate their own three-hour target.[93] The chance of delay increases when a person is detained outside office hours, but people taken to a hospital are less likely to encounter delays in assessment than those detained in police custody.


50. HM Inspectorate of Constabulary has found that, for those assessed in police custody, the average length of time to wait for an assessment was just over 9½ hours. Most long waits involved people who had been detained outside office hours. A smaller number of delays were due to the person being intoxicated and unfit for assessment. All those detained received an assessment in the police station, or were moved to a health-based place of safety for assessment within 24 hours.[94] Our evidence told a similar story, with police telling us that people were risk-assessed on entry and, if necessary, kept under observation, which could require an officer to physically sit in the cell doorway for several hours.[95]

51. Section 136 allows for the police to detain a person for a maximum of 72 hours and there was broad support for reducing this time from 72 hours to 24 hours. This would bring it into line with the time allowed under the Police and Criminal Evidence Act 1984 to detain somebody who has been arrested. It is worth reiterating that people detained under s.136 have not necessarily broken the law. Simon Cole told us:

    It is absolutely outrageous that you can be detained for 72 hours for being ill and 24 hours for murdering somebody.[96]

52. We recommend that the Government bring forward an amendment to the Mental Health Act 1983 to provide that a person detained under section 136 may be detained for a maximum of 24 hours. In tandem with this change, we recommend that the Government introduce specific time targets within which mental health assessments must be carried out, whether in a hospital or a police station. We recommend a target of three hours, in line of the standard of the Royal College of Psychiatrists.

What happens after custody

53. We found a lack of reliable data on what happens to people following detention under s. 136. The criterion for exercising s. 136 powers—that the person is in immediate need of care or control—would not necessarily result in admission to hospital. Dominic Williamson of Revolving Doors said one study showed that only 17% of those detained under s. 136 in hospital are further detained under the Mental Health Act once the 72-hour period has elapsed. He said it was unclear what happened to the other 83%.[97] This does not mean that 83% of people detained under s. 136 are then found to be perfectly healthy and sent on their way. The AMHP has responsibility for making a decision as to their care, and this could include an application for admission to a hospital, but the person could also be referred to a mental health service such as Community Mental Health Team, CAMHS or The Early Intervention Service, they may enter hospital voluntarily, be referred to a drugs or alcohol dependency service, or to their GP.[98]

54. There is a need for better data on what happens to people following detention under s. 136 if they are not later admitted to hospital. The person could receive treatment in a variety of ways, and the treatment plan could involve several NHS or community agencies, so understanding if the person received the most appropriate care after contact with the police is difficult. If we are to move beyond using s. 136 as a measure of performance, there needs to be more information to determine if the person received the care they needed.

55. We met Anne Popow who told us what had happened with her nephew, William Barnard, who suffered from schizophrenia. Following treatment in hospital, William was released on condition that he received a fortnightly injection administered in his home by a Community Psychiatric Nurse. His aunt told us that, after several months, he was informed that if he decided he no longer wanted to have this injection, he would not be forced to have it. He started to refuse his injection in January 2009. Six months later he stabbed and killed his grandfather John McGrath. His grandmother was also stabbed but survived. There was police contact with William during this time as he was the prime suspect in an armed robbery involving a machete in a local park. The police had ample opportunities to intervene. The communication between the police and the mental health team was poor when it was known that William was ill, refusing medication and a danger to others. The police who came into contact with William were not trained in how to manage him.[99]

Joint working and the Concordat

56. The importance of joint working on mental health crisis care was a constant theme in our evidence. There is an acceptance that issues around policing and mental health will not be managed by the police themselves. Joint working builds relationships between individuals on the ground, helps each service understand more clearly what the other services do,[100] enabled greater sharing of information between agencies and improved access to different pathways of care.[101]

57. With specific regard to how the Mental Health Act operates, the Code of Practice require there to be local agreements as to how the relevant bodies work together. Michael Brown said that where these agreements are poor, the co-operation between the police and the NHS is often difficult. He said:

    I think the extent to which the NHS supports the police is to do with personal relationships and partnerships. It tends to be that, where you have senior police officers knowing their senior health colleagues, they tend to have well established procedures, meeting structures and so on. They have methods of debating what the difficulties are and resolving them. They put joint training in place for operational staff at all levels. It is where you do not have those personal relationships and partnerships that you tend to find the protocols are not quite as tight as they perhaps could be and where training does not happen and, therefore, where frontline staff come into conflict with each other.[102]

58. On 18 February 2014, the Home Office and Department of Health published the Mental Health Crisis Care Concordat, Improving outcomes for people experiencing mental health crisis, setting out "the standard of response that people suffering mental health crises and requiring urgent care should expect, and key principles around which local health and criminal justice partners should be organised."[103] The Concordat aims to focus on four main areas: Access to support before crisis point, urgent and emergency access to crisis care, the right quality of treatment and care when in crisis, and recovery and staying well, and preventing future crises.[104] There are two stages to the Concordat on a local level, signing up to the local declaration and submitting an action plan to deliver the aims set out in the declaration. All the local authorities in England have signed up to the first stage but there is notable pause in local authorities submitting their action plan. We have been told by Simon Cole that among the reasons for delay have been concerns that the local Ambulance Service will not be able to deliver on a single national protocol that set down response times of 30 minute.[105]

59. The coalition government has recognised the poor state of current mental health services and it has made a commitment to put mental health at the same level as physical health. In addition to resources, there is a clear need for improved coordination between the organisations that come into contact with mental health sufferers. The Concordat has shown potential for bringing the relevant organisations together. Its success will be measured by how effective it is in those areas of the country where such relationships are not well developed, where there is an absence of local leadership, and where the commitment to addressing the issues is absent.

Data problems

60. There is a lack of adequate data to help understand several issues around police and mental health.[106] This makes it difficult to assess the amount of time and resources the police spend on dealing with mental health issues. Understanding the level of unmet demand in mental health is important in determining priorities and improving access. Therefore, it is important that we have reliable data on the number of people detained under s. 136 and what kind of place of safety they are taken to. Many of those who end up in police cells are there because they were refused access to a health-based place of safety, but previous surveys have all found difficulty in establishing why people were turned away. The CQC found problems accessing basic data on how often people were excluded from health-based places of safety.[107] HMIC has recommended that custody sergeants document when someone is brought in under s. 136 to their cells after being turned away by a health facility, and the reason for refusal.[108] Custody Sergeant Ian Kressinger and Custody Sergeant Andy Shaw both told us that they had started recording that data and passing it up to senior officers.[109]

61. Data collection around the use of s. 136 must continue to improve. People who suffer a mental health crisis and come into contact with the police are receiving different care in different parts of the country. Reliable data is important to assess where issues remain and fed back into discussions about mental health priorities.

62. Quantifying the scale of this issue is made more difficult by police data and health service data being collected by different bodies.[110] The work of the Health and Social Care Information Centre, and the collaborative work by HMIC and the Care Quality Commission, have improved this significantly and helped highlight flaws in the system. The Care Quality Commission are continuing to carry out inspections of crisis care in mental health as one of their measures when assessing health trusts.[111] We welcome the work being carried out by HMIC and the Care Quality Commission in collecting data on policing and mental health, and in particular on the use of s. 136 to detain people in police cells. We fully support the Care Quality Commission decision to measure the performance of mental health care providers' care for people in mental health crisis.

63. Data is not collected by the Home Office on police sick leave as a result of mental health issues. The Chair asked the following written parliamentary question to the Home Office:

    To ask the Secretary of State for the Home Department, how many days have been lost to long-term sick leave (a) in total and (b) for reasons related to mental health in each police force in each of the last three years.

Mike Penning responded:

    The Home Office is currently undertaking work to improve the quality of statistics on the number of contracted hours lost to sickness absence. […] The Home Office does not collect breakdowns of this data by reason for sickness absence.

64. We recommend that data on police sickness absence due to mental health issues is collected better. This would enable more effective examination of whether the work undertaken by police has a significant impact on their mental health and would help efforts to respond to these health concerns.

73   Extending the street triage scheme: New patrols with nurses and the police, 20 August 2013. After Cleveland and Leicestershire, the next four were: North Yorkshire, Devon and Cornwall, Sussex, and Derbyshire, and the next five were the Metropolitan Police, British Transport Police, West Yorkshire Police, West Midlands Police and Thames Valley Police. Back

74   Q 164 Back

75   Royal College of Nursing (PMH0014); NHS England (PMH0055); Qq 258-259 and Q 268 Back

76   Q 29 Back

77   Q 140 Back

78   Q 248 Back

79   Q 140 Back

80   HMIC, Core Business: An Inspection into crime prevention, police attendance and the use of police time, September 2014 Back

81   The Police Foundation (PMH0028); Michael Brown supplementary (PMH0052) Back

82   The Bradley Report, April 2009; Royal College of Nursing (PMH0014) Back

83   NHS England (PMH0055); Q 33; Faculty of Forensic and Legal Medicine of the Royal College of Physicians (PMH0035)  Back

84   The ten trials are in Merseyside, London, Avon and Wiltshire, Leicester, Sussex, Dorset, Sunderland and Middlesbrough, Coventry, South Essex and Wakefield. Q 262 Back

85   NHS England (PMH0055); Q 33 [Williamson]; Q 283 [Lamb] Back

86   Q 283. See also Q 153; Q 125; NHS England (PMH0055) Back

87   Health and Social Care Information Centre, Inpatients formally detained in hospitals under the Mental Health Act 1983, and patients subject to supervised community treatment: Annual report, England, 2013/14, October 2014 Back

88   Qq 176-177; Q 145; College of Paramedics (PMH0047) Back

89   Department of Health and Home Office, Review of the Operation of Sections 135 and 136 of the Mental Health Act 1983, December 2014 Back

90   Q 309 Back

91   HMIC and Care Quality Commission, A Criminal Use of Police Cells Back

92   Care Quality Commission, A safer place to be, 4.2. A section 12 approved doctor is one who approved by the Secretary of State as having special experience in the diagnosis or treatment of mental disorder, for the purpose of making recommendations for compulsory admission to hospital or guardianship under Part II of the Mental Health Act. The Centre for mental health found evidence that police forces increasingly prefer to provide officers to support mental health staff in the 136 suite rather than use police cells. Back

93   Royal College of Psychiatrists, Guidance for commissioners: service provision for Section 136 of the Mental Health Act 1983, April 2013; Care Quality Commission, A safer place to be Back

94   HMIC and Care Quality Commission, A Criminal Use of Police Cells Back

95   Q 211 Back

96   Qq 276-277 Back

97   Q 19; See also Qq 191-192 Back

98   Mark Standing (PMH0046); Q 119; Q 120 Back

99   Paul Bacon (PMH0057) Back

100   Q 155; Q 63 Back

101   Q 157 Back

102   Q 91 Back

103   HC Deb, 28 November 2013, Col 159WH [Damian Green]; The Police Foundation (PMH0028);  Back

104   Department of Health, Mental Health Crisis Care Concordat, February 2014 Back

105   Chief Constable Simon Cole (PMH0053)  Back

106   Police Federation of England and Wales (PMH0036); See also Rt Hon Mike Penning MP, Minister for Policing, Criminal Justice and Victims (PMH0056)  Back

107   Care Quality Commission, A safer place to be, October 2014 Back

108   HMIC and Care Quality Commission, A Criminal Use of Police Cells Back

109   Qq 201-202 Back

110   Royal College of Psychiatrists (PMH0038); Police and Crime Commissioner for Cheshire (PMH0033) Back

111   Q 261 Back

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© Parliamentary copyright 2015
Prepared 6 February 2015