4 Police and health service collaboration
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.
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.
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.
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.
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.
38. In Leicestershire, there has been a 30% to 40%
reduction in the use of section 136 powers since 2013.
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.
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.
We did receive some evidence that questioned how Street Triage
was being appraised and whether it was cost effective.
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.
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.
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. NHS England
plans for L&D services to be available in all police custody
suites and all courts by April 2017.
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.
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%.
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
|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.
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.
The Government has raised the option of using unmarked police
vehicles instead of ambulances.
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
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
IN A HOSPITAL
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.
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.
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.
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.
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.
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.
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.
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 powersthat the person is in immediate
need of care or controlwould 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%.
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.
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.
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,
enabled greater sharing of information between agencies and improved
access to different pathways of care.
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
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."
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.
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.
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.
60. There is a lack of adequate data to help understand
several issues around police and mental health.
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.
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.
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.
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.
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.
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
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
Q 164 Back
Royal College of Nursing (PMH0014); NHS England (PMH0055); Qq
258-259 and Q 268 Back
Q 29 Back
Q 140 Back
Q 248 Back
Q 140 Back
HMIC, Core Business: An Inspection into crime prevention, police attendance and the use of police time,
September 2014 Back
The Police Foundation (PMH0028); Michael Brown supplementary (PMH0052) Back
The Bradley Report, April 2009; Royal College of Nursing (PMH0014) Back
NHS England (PMH0055); Q 33; Faculty of Forensic and Legal Medicine of the Royal College of Physicians (PMH0035)
The ten trials are in Merseyside, London, Avon and Wiltshire,
Leicester, Sussex, Dorset, Sunderland and Middlesbrough, Coventry,
South Essex and Wakefield. Q 262 Back
NHS England (PMH0055); Q 33 [Williamson]; Q 283 [Lamb] Back
Q 283. See also Q 153; Q 125; NHS England (PMH0055) Back
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
Qq 176-177; Q 145; College of Paramedics (PMH0047) Back
Department of Health and Home Office, Review of the Operation of Sections 135 and 136 of the Mental Health Act 1983,
December 2014 Back
Q 309 Back
HMIC and Care Quality Commission, A Criminal Use of Police Cells Back
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
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
HMIC and Care Quality Commission, A Criminal Use of Police Cells Back
Q 211 Back
Qq 276-277 Back
Q 19; See also Qq 191-192 Back
Mark Standing (PMH0046); Q 119; Q 120 Back
Paul Bacon (PMH0057) Back
Q 155; Q 63 Back
Q 157 Back
Q 91 Back
HC Deb, 28 November 2013, Col 159WH [Damian Green]; The Police Foundation (PMH0028);
Department of Health, Mental Health Crisis Care Concordat, February
Chief Constable Simon Cole (PMH0053) Back
Police Federation of England and Wales (PMH0036); See also Rt Hon Mike Penning MP, Minister for Policing, Criminal Justice and Victims (PMH0056)
Care Quality Commission, A safer place to be, October 2014 Back
HMIC and Care Quality Commission, A Criminal Use of Police Cells Back
Qq 201-202 Back
Royal College of Psychiatrists (PMH0038); Police and Crime Commissioner for Cheshire (PMH0033) Back
Q 261 Back