Conclusions and recommendations
1. Police
forces work with all members of the communities they serve. Working
with those with mental health problems will always be a core part
of that work. However, we are concerned by the extent to which
frontline officers are increasingly spending their time helping
people with mental health problems. For many people experiencing
an acute health crisis, a police officer is not the professional
best placed to help them, nor is dealing with acute health crises
the best use of police officers' time and skills. We believe that
the police should not be filling gaps in mental health services.
(Paragraph 6)
2. The use of section
136 of the Mental Health Act 1983 and reducing the detention of
people in police cells is widely seen as an indicator of a police
forces' performance in relation to mental health, and it has focussed
attention on the problem. We support the Government's commitment
in the Crisis Care Concordat to see the number of detentions in
police cells under section 136 halved in two years compared with
2011-12. (Paragraph 11)
3. We recommend that
the specific reference to a police station should be removed from
the definition of "places of safety" in s. 135(6) of
the Mental Health Act 1983. We recognise that there are concerns
over the lack of health-based places of safety that exist in some
parts of the country, particularly rural areas. However, this
proposal has been under discussion for some time now and commissioners
should have started commissioning appropriate place of safety
provision before now. All areas need to do so, and be able to
demonstrate that they have made progress by July 2015. The Government
should immediately re-issue guidance to police forces and health
trusts defining the exceptional circumstances in which police
cells may be used as places of safety. The presumption should
clearly be the health facility not the police cell. (Paragraph
15)
4. The Government's
own review of s. 136 recommended ensuring that police cells can
only be used as a place of safety for adults in situations where
the person's behaviour is so extreme they cannot otherwise be
safely managed. Following the general election a new government
should set out what they will do to ensure this happens if it
will not amend the Mental Health Act 1983. (Paragraph 16)
5. We commend the
work by Inspector Michael Brown, and others who have championed
the cause of mental health within the Police. His work online
has been particularly impressive. (Paragraph 19)
6. It is clear that
too many NHS Clinical Commissioning Groups are failing in their
duty to provide enough health-based places of safety that are
available 24 hours a day, seven days a week, and are adequately
staffed. CCGs must not only acknowledge local levels of demand
and commission suitable health-based places of safety, they must
also design local backup policies to deal with situations where
places are occupied. Relying on the police to fill the commissioning
gap not only imposes non-negotiable, external costs on forces,
but it increases the risk to highly vulnerable patients. We recommend
that the Department of Health, together with the Home Office,
issue clear guidance to CCGs about the appropriate number of health-based
place of safety places, having regard to local circumstances,
within three months. (Paragraph 20)
7. The NHS would not
turn away a patient with a physical illness just because they
were intoxicated. People with mental health problems have exactly
the same right to NHS care as everybody else and it is shocking
that patients are excluded from health-based places of safety
on the basis of informal exclusion criteria. The guidance that
people with mental health illness should be treated in a mental
health facility needs to be repeatedly reinforced. (Paragraph
24)
8. We note that the
Government review of sections 135 and 136 said they would explore
alternative places of safety. The fundamental reason for a place
of safety is to keep someone safe until they can have a mental
health assessment and a judgment can be made as to their future
treatment. Where there is a clear gap between demand and provision,
then we agree that alternatives should be considered. Anywhere
used as a place of safety must adhere to relevant guidance and
be able to secure the confidence of patients and their families.
In particular, the staff, especially if they might be called upon
to restrain someone, should receive validated training. (Paragraph
26)
9. We agree with the
proposal to amend the Mental Health Act so that the powers of
s. 136 could be used anywhere other than a private home. This
would give the police power to deal expeditiously with people
on railway lines and in high places to which the public do not
have access. We believe that extending the range of settings in
which the power could be used to include private homes would be
a step too far. Extending police powers must be done with caution,
as it is important that this does not reinforce the need for police
involvement in mental health cases, as we believe it is important
that it should be kept to a minimum. (Paragraph 30)
10. The fact that
children are still detained in police cells under section 136
reflects a clear failure of commissioning by NHS Clinical Commissioning
Groups. The de facto use of police cells as an alternative relieves
the pressure on CCGs to commission appropriate levels of provision
for children experiencing mental-health crisis. We support the
Government's proposals for a change in the law to ensure that
children can never be held in a police cell under section 136
of the Mental Health Act 1983, which we recommend should be included
in the next Queen's Speech. In the interim, guidance on the detention
of children in police cells under s. 136 must be made clear—that
it is unacceptable and must stop. This guidance needs to be distributed
to those working in the police and in the health service. (Paragraph
34)
11. The fact that
a place of safety is attached to an adult ward should not preclude
its use for children, particularly when the alternative is a prison
cell. The Mental Health Act Code of Practice is clear on this
point, and we recommend that the Department of Health draw this
to the attention of all providers of health-based places of safety.
(Paragraph 35)
12. 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. (Paragraph
39)
13. 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. (Paragraph 41)
14. 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. (Paragraph 45)
15. 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. (Paragraph 46)
16. 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. (Paragraph
47)
17. 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. (Paragraph
48)
18. 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.
(Paragraph 52)
19. 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. (Paragraph
54)
20. 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. (Paragraph 59)
21. 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. (Paragraph
61)
22. 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. (Paragraph 62)
23. 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. (Paragraph 64)
24. There is a need
to improve training for police officers and civilian staff in
identifying the signs that someone might be suffering from mental
illness. This should be mandatory for all front line officers
and include staff in the police control room. This is particularly
important for custody sergeants, who must be adequately equipped
with the skills to effectively deal with mental health patients
who come into custody suites. Police staff then need to be able
to get advice from a mental health professional—a social
worker, doctor, or nurse—who is better placed to recognise
medical conditions and illnesses, and is able to refer the person
for further treatment. Such advice needs to be available to the
police at all times, given that they operate 24 hours a day. (Paragraph
68)
25. Mental health
is clearly a large and growing element of modern police work.
The current amount of training for new recruits is not enough.
Some forces have developed their own training to address perceived
gaps. There needs to be a national strategy for mental health
training for all police. It needs to be updated on a regular basis.
As a minimum, it should include awareness of common mental health
illnesses, techniques in de-escalation, safe restraint, and awareness
of what mental health services are available locally. Mental health
awareness training should include a component that addresses why
some people who are ill might be perceived as violent, and how
these perceptions impact upon the BME community. (Paragraph
75)
26. This needs to
include joint training with mental health nurses, paramedics and
Approved Mental Health Professionals, and training involving mental
health charities and people who have been detained under s. 136.
We commend those police forces that already do this, including
Greater Manchester, West Yorkshire and Leicestershire. Joint training
should include de-escalation training, to make sure police officers
are familiar with the techniques taught in mental health services.
(Paragraph 76)
27. Restraint should
only be used in limited circumstances. Improved training should
be given to correctly identify the range of behaviour of someone
having a medical emergency rather than automatically presuming
that behaviour means they are violent. The training should be
aimed at reducing the presumption to use force and restraint on
someone who is ill. (Paragraph 77)
28. The best way to
reduce the number of people suffering from mental health issues
and who then die in custody is to reduce the number of people
with mental health problems entering custody. All that can be
done, needs to be done, to ensure that people going through a
medical emergency are treated like someone going through a medical
emergency. This includes providing sufficient resources to ensure
mental health crisis care is available 24 hours a day, seven days
a week. (Paragraph 79)
29. The recent increase
in suicides following custody is highly alarming. The police must
make sure that those who have been identified as vulnerable in
custody are notified to medical staff. There must be a formal
method by which this done and it must be followed. This will require
additional training for custody staff but it also requires improvements
in access to mental health nurses and doctors in the custody environment.
(Paragraph 82)
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