Ready to launch!

Today is the day! After months of talking and writing about it, my report has finally launched. Please do read and share it – I hope it can add to the current discussions about how the criminal justice system responds to people affected by mental illness.

I’m incredibly grateful to all the organisations that let me come and visit them for the project and all the passionate people I’ve met along the way. I also cannot thank the Winston Churchill Memorial Trust enough for giving me the opportunity to do this project. I really would encourage everyone to check out their website and consider applying.

Finally, huge thanks to my brilliant colleagues at Rethink Mental Illness, who kindly hosted a guest blog from me on their website to promote the report – I’ve posted the text below.


Paula from our policy team looks at what we can learn about mental health and criminal justice from the USA and Canada…

In the past few weeks we’ve seen a number of worrying reports about the state of mental health care in this country. An article this week in The Sunday Telegraph highlighted serious failures in care, while the former President of the Royal College of Psychiatrists recently described the system as a ‘car crash’.

Nowhere are those problems more evident than in the ever increasing number of people being detained under the Mental Health Act. Too many people are reaching crisis point because the support they need isn’t available in their local community.

Unfortunately, that often means people with mental illness end up in the criminal justice system. A third of people held under the Mental Health Act are brought to police cells, because there is no health-based ‘place of safety’ available in their local community. The police and other emergency services often have to respond to crisis situations with little support from mental health services.

Not only does this result in people being inappropriately held in police cells, it can also lead to dangerous use of restraint, and people in the criminal justice system often miss out on the support they need for their mental health.

What really struck me is that no one part of the system can solve this issue alone, and different agencies have to work together to address these problems.

So what can be done to tackle this issue? That’s a question that is being grappled with in many other parts of the world. Last year I was lucky enough to be awarded a travel grant from the Winston Churchill Memorial Trust, to travel to the USA and Canada and learn how they are dealing with these problems. I visited police forces, emergency departments, courts and mental health agencies to see what was working well and what we could learn from it.

What really struck me is that no one part of the system can solve this issue alone, and different agencies have to work together to address these problems. For example, crisis intervention team police officers in Memphis are trained by local mental health professionals and social workers, so they can understand how to get people in crisis support as quickly as possible. Case managers in New York courts work across local housing, welfare and mental health services to get people the personalised care they need. In Toronto, crisis houses offer community alternatives to hospital or jail for people with mental illness who end up in the criminal justice system. You can read more about what I learned here.

In a time of cuts and pressures on services, it is easy for different organisations to focus on their own roles and lose sight of how they could work with others to maximise their impact. But this is one issue on which we really can’t afford to have tunnel vision – the cost is too great for people with mental illness who are in the criminal justice system.

Thankfully, in the UK we have recently seen some genuine progress on this issue. In February, the Government published the Crisis Care Concordat, which sets out plans to improve care for people in crisis. That includes supporting people to help them avoid reaching crisis point in the first place, offering quality treatment to people who are in crisis, and helping them to recover and stay well afterwards.

The Government has also extended its liaison and diversion scheme, which aims to get the right treatment as quickly as possible to people who enter the justice system with mental health problems.

However we still have a long way to go, and for too long this issue has been marked as ‘too difficult’ to tackle. Now we need the Government, NHS, police and local authorities to work together to bring about real change in crisis care.

You can download a copy of the report here and join the discussion on Twitter using #mhjustice.

Rethink Mental Illness also provides practical advice and information around mental health and the criminal justice system. If you have any queries, please visit our criminal justice pagesfrom the Advice and Information Service, or call 0300 5000 927.

Emergency measures

Once again it’s been far too long since my last blog post as I put the final touches on my report – should only be a few weeks now. However I’ve decided to get back in the saddle after reading an article today in Mental Health Today. The article looked at dedicated psychiatric assessment units in emergency departments.

Central and North West London mental health trust (CNWL) has seen some really positive results since introducing this model earlier this year. The 24/7 unit, staffed by a specialty doctor, two nurses and supervised by a project manager and consultant psychiatrist, saw over a third of all liaison psychiatry referrals in the first four months of 2014. As a result, CNWL has seen shorter waiting times for psychiatric assessment, over 50% reduction in hospital admissions and decreased detention under the Mental Health Act. Crucially the unit is also reporting very high satisfaction rates from people affected by mental illness – 95% report that it has improved their experience of services.

Psychiatric emergency departments were something I came across a lot in my time in the USA and Canada. Many areas I visited, such as Memphis, had dedicated crisis assessment centres which acted as triage or assessment centres for people experiencing a mental health crisis. In other areas, such as Salt Lake City, Utah and Hamilton, Ontario, psychiatric assessment units are attached to A+E departments. These services are quite different to ‘places of safety’ under the Mental Health Act in the UK – they usually have no exclusion criteria and people don’t have to be detained to access them. They should have a number of referral routes open to them, ensuring the most appropriate support is available to anyone in crisis.

With community mental health services stretched, we know that people are increasingly coming into contact with services at crisis point. People affected by mental illness are twice as likely to use A+E and inpatient settings as the general population. Having services like these assessment units offer another opportunity to get people the support they need in a way they feel is positive. It’s great to hear the CNWL pilot has been expanded and I look forward to hearing more as the model develops.

Raising the bar

Today sees the launch of the long-awaited Mental Health Crisis Care Concordat. Part vision statement, part action plan, it sets out how agencies can work together to deliver high quality mental health crisis care to all those who need it. It’s a strong statement of intent and we have to hope that the funding will follow. I’m also pleased to see it echoes many of the good practice examples and recommendations I’ve included in my forthcoming report!

Although the proof will be in the delivery, one of the real strengths of this document is its whole-system approach. It doesn’t just focus on one agency or one intervention point. It talks about prevention, early intervention, alternatives to admission and recovery – concepts which can often get lost when the focus is on acute or crisis care. There is a strong emphasis on the rights and voice of the person in crisis through discussion of care planning and choice, where this is appropriate.

The document also focuses on the importance of local partnerships in bringing about change and delivering high quality services. Although the signatories of the Concordat are all national organisations, their hope is that the principles of the Concordat will be realised at a local level. This will be achieved through local Mental Health Crisis Declarations, jointly agreed across the NHS, local authorities and criminal justice agencies. These declarations should include a local action plan, a commitment to reduce the use of police cells as a place of safety and local governance arrangements. However it is important that this goes beyond words and plans – there has to be a real commitment of funding and buy-in of commissioners to support this.

For me, the real potential of this document is to raise expectations around mental health crisis care. Last year’s community mental health survey by the Care Quality Commission showed that only 61% of people had an out of hours number for their mental health team. Of those that had used the number, only half definitely felt they got the help they needed. If we are committed to parity between mental and physical health we have to demand better than this. A 50% satisfaction rate wouldn’t be acceptable in A&E and it’s not acceptable in mental health crisis care.

A series of statements at the beginning of the document show what people using mental health services want to see from a crisis care system. These are the core of the document and it’s important they don’t get forgotten as each stakeholder gets stuck in to their parts of the action plan. The ambition should be to reach the standard set by these statements, and then to keep on improving. A focus on mental health crisis care has been a long time coming – it’s important that we all keep up the pressure to maintain the momentum.

What’s in a sentence?

Yesterday was a good day, and not just because of a certain North London football result! Yesterday also saw a commitment from the Treasury to fund further liaison and diversion pilots in 10 areas. This will involve posting mental health staff in police custody suites and courts so that mental illness is identified at the earliest possible opportunity and the right support is offered.

Now the part of this proposal that predictably grabbed the headlines was the policing bit as this is the earliest, and often the most fraught, point of intervention. I have outlined in a number of earlier blogs why this is the case and some of the challenges facing police, especially when they come into contact with someone in crisis. A lack of appropriate referral routes and mental health support mean the police are often stuck between a rock and a hard place. I have also outlined some examples of the existing liaison and diversion work going on in the UK – street triage in Leicester and the use of community psychiatric nurses in custody suites in Cornwall. It’s important to note that liaison and diversion in itself isn’t new – what was announced yesterday was funding to pilot a core model informed by the pilots that have been running for the last few years. Liaison and diversion teams also don’t operate in a vacuum and having the right services available for them to divert people to will be key to their success.

What I wanted to do in this blog was really give a plug for the potential for the court side of this scheme. We all know the shockingly high statistics for mental health prevalence in prisons. 70% of people in prison are believed to have two or more mental health problems, though these are stats from 1998 and badly need updating. (As an aside we have to have a better understanding of the extent of mental health need in the criminal justice system and more robust data collection has a key role to play in this.). Courts and sentencing are a crucial juncture where better informed decision making could have a real impact on people’s lives.

Having mental health professionals able to offer advice and expertise at this stage is a really positive step. So many people get to court without any underlying mental health needs or other vulnerabilities being picked up. In some cases these people might already be known to mental health services, but no-one has joined the dots. These needs are therefore not taken into account at sentencing, where there is a real opportunity to divert people away from unnecessary, and expensive, prison sentences.

Community sentences with a Mental Health Treatment Requirement (MHTR), for example, could be used to ensure people get the treatment they need as part of their rehabilitation. These are currently grossly under-used compared to what we believe is the prevalence of mental health in the criminal justice system – 1% of all Community Orders has a MHTR. While there are multiple reasons for this, and not all of them will be fixed through liaison and diversion, a key part is information available at the point of sentencing. Mental health input at this point could therefore lead to better-informed sentencing and, hopefully, better outcomes in terms of health and reoffending.

The United States of America


Firstly, happy new year to everyone and sorry there’s been a bit of a lapse in the blog. I’m going to try and post more regularly over the next few weeks in the run up to publishing my report (out end of January, so watch this space…..)

I’ve also cheated a bit as my first blog of the year is not even my own. I’m borrowing it from the ever-interesting Mental Health Cop as it raises a few things that have been playing on my mind as I’ve been writing my report. This blog discusses the often very large differences between the USA and the UK and whether it is possible to translate their good practice here. It touches on the armed police in the US, the controversial DSM-V (the manual used to diagnose mental illness in the States) and the complexities of their health funding and insurance system. These are often at odds with how we view health and justice in the UK. Sometimes it was tough when I was away to separate things I disagreed with from the good stuff that was also going on.

However what really struck me when I visited programmes in the USA was the similarities in the challenges we’re both facing. People in crisis coming into contact with the police because they couldn’t access mental health services. Whether this was because they didn’t have the right insurance, or because that service is at capacity with a waiting list a mile long, the end result is the same. Poor community provision for people affected by mental illness and substance misuse. People not being able to access safe or stable housing. A reluctance from health services to take on people they felt were too high-risk, leaving the police with difficult decisions about how to best support that person. The systems responding to these challenges are undeniably different, but the principles underpinning some of the possible solutions are very transferrable. Greater mental health input into mental health crisis situations. Robust community partnerships involving health, criminal justice, housing etc. Having options available so you can support people in the least restrictive setting possible and with minimal criminal justice input. All these things are possible in either system, even if their implementation needs to be different. Or at least that’s what I’m hoping to highlight in my report!

Anyway, I’ll now hand over to Mental Health Cop’s post but I’d be really interested to what extent people think it is possible to learn from a system so different to the UK. And please, please do check out the rest of Mental Health Cop’s posts if you have an interest in this area – they are always thought-provoking and do not skirt around the tricky issues!

Originally posted on Mental Health Cop:

US FlagWe’ve been seeing interest in the US approach to policing and mental health for some while now – more recently, since these issues became a feature of interest in British policing and as part of the continuing interest that British policing generally has in American law enforcement.

There is much of interest in the United States and much I would like to see for myself, but there are certain reasons why I suspect a lot of it may not translate easily to the UK.  In 2013, two Winston Churchill Fellowships were awarded for travel to the US (and elsewhere) to examine mental health provision in policing and broader criminal justice.  I’m looking forward to reading the reports but I’m especially keen to understand whether potentially good ideas could shift across the pond.


Firstly, let’s focus on the US health system and their approach to mental health. …

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Two heads are better than one

Last week I spent a shift with PC Alex Crisp and members of the street triage team up in Leicestershire. A lot has been said about street triage – it has spawned many newspaper articles and Government announcements. I think some of this coverage has led to a slightly simplistic view of what the model is about so I was pleased to have the opportunity to go up and see it for myself.

The street triage model in Leicestershire is a co-response model – a police officer and a mental health nurse work together to respond to incidents. The key to this model is that decisions are informed by both the mental health and policing side, leading to more appropriate responses to people in crisis. The team was originally set up to reduce section 136 detentions and A+E admissions, although the work of the team has become more wide-ranging than that. They have taken ownership of repeat and complex cases in the area and are facilitating joint professional meetings to bring mental health and criminal justice professionals in the area together.

In Leicestershire the nurses who work in the team are all crisis nurses who rotate between shifts in the street triage car, custody suites, courts and probation. They therefore have a large amount of expertise of crisis assessments and the criminal justice system. The team don’t just offer support in person, they also are able to advise over the phone and via the police radio. The response officer in the team keeps an eye on the incoming police calls to see where support might be needed, and the nursing staff has access to mental health records for any information that might help inform decision-making and risk-management in these situations. If the street triage car does attend an incident, the nurses are able to do mental health assessments and make referrals to appropriate services there and then.

PC Crisp describes the street triage team as mental health tactical advisers – a ‘profession within a profession’. Frontline police have really welcomed the introduction of the street triage team to help support better decision-making in mental health incidents. One of the biggest advantages is a more positive attitude to risk – mental health staff and police handle risk in very different ways and there is a feeling that a joint approach has led to less intrusive resolutions to incidents.

Before I went up to Leicester, I have to say I was a little sceptical about some elements of the model. However having now seen it in action I think it’s a really positive initiative. It doesn’t solve every problem – I don’t think any of the models I’ve seen over the course of my travels do – but closer working between mental health professionals and police is clearly having a real impact. I’m really looking forward to seeing how PC Crisp’s plans for developing the model pan out!

How Many More?

In the past two weeks there have been two fatal incidents involving people with mental illness being detained by police. A lot has been written about this online – people are angry that these incidents continue to happen and lessons aren’t learnt, despite all the talk at a national level about this issue. Rather than adding to this I wanted to share this great blog, which sums up the frustration the police feel when these incidents occur. You should also check out Nathan’s other posts – he has a lot to say and it’s all very interesting…