Fighting for the right

It has been quite the week of highs and lows for mental health. The undoubted high was the second annual Time to Talk day run by anti-stigma campaign Time to Change on 5th February. People were encouraged to take 5 minutes to talk about mental health over a cuppa, make a quick call or send a text message. As I write this blog over 21 days’ worth of 5 minute conversations have been logged. #timetotalk trended throughout the day and the day culminated in Deputy Prime Minister Nick Clegg handing awards to 9 Mental Health Heroes, from a nomination list of 900. Radio talk shows, newspapers and websites were buzzing with positive mental health stories. It felt like progress was really being made in the fight against stigma and discrimination.

However there were also a number of significant lows this week. First, figures published by Norman Lamb MP showed that over 400 people were being sent more than 30 miles away for inpatient mental health treatment. The Care Quality Commission (CQC) then published a damning report into the use of the Mental Health Act in 2013/14, which has increased by 30% in the past decade. And the Home Affairs Select Committee published their inquiry into policing and mental health. The report highlighted many of the issues that have been covered in previous editions of this blog – local variation in responses, problems with transportation, challenges of local partnership between police and other health services and a lack of effective data about what is actually happening to people in crisis in contact with the police.

For me, these are all indicative of a complex range of issues facing the mental health system. These include stigma, funding, legislation, commissioning and, crucially, human rights. The Mental Health Act Code of Practice talks about the principle of treating people in the ‘least restrictive’ setting, but it is clear that this is not happening in many cases. Police involvement in mental health crisis situations is just one example. In the Home Affairs Select Committee report, Mike Penning MP, Minister of State at both MoJ and the Home Office states:

If you have a mental health issue, you will invariably come into contact with the police, as the professional involved…It is not the job of the police to be that first point of contact, they should be the last resort                                      (page 8)

Although the Minister is challenging this status quo, there is an inevitability to this scenario that is widely accepted. The report highlights that two thirds of people detained by police under s136 of the Mental Health Act are already known to mental health services. This makes the situation even more indefensible – if people are in contact with mental health services, there should be other systems in place to support them in a crisis. The fact that police are too often called to these scenarios shows the huge gaps in provision of mental health crisis care – an issue that needs to be acted on, and fast, by NHS commissioners. The Crisis Care Concordat is a hugely positive step in the right direction, but local areas need to see this is a priority in the coming months.

The CQC report paints an even bleaker picture. An 8% decrease in inpatient beds means that professionals are under pressure to detain people under the Mental Health Act in order to get them bed. This is a horrendous situation, not just for people needing a bed, but also for professionals put in this position. It flies in the face of a commitment to the ‘least restrictive’ setting and puts people under legal restrictions just to receive treatment. Where people are detained, over 20% don’t have their legal rights explained to them. Access to independent advocacy continues to be a concern for the CQC.

This is not to knock the positive work being undertaken by street triage pilots and liaison and diversion schemes. Within mental health services there are a large number of professionals committed to promoting recovery and autonomy for people using services. But this issue of people’s rights is not getting anywhere near the attention it deserves. It continues to get overshadowed by conversations about risk and funding pressures. The whole system needs to be rebalanced so that people’s rights are at the very centre of how we are measuring and improving care, not sitting at the periphery. This is surely one of the biggest forms of stigma we need to challenge.


End of year review

After another very long gap between blog posts, I thought I’d finish 2014 with a look at the Home Office/Department of Health review of sections 135 and 136 of the Mental Health Act. These two sections outline what powers the police have to detain people under the Mental Health Act. Under section 135 (s135), the police can apply to a magistrate for a  warrant to enter someone’s house if an Associated Mental Health Professional (AMHP) has concerns about their welfare. Under the Act, the police can then remove that person to a ‘place of safety’ (more on this later) for an assessment. Section 136 (s136) applies to public places or, more specifically, ‘a place to which the public have access’. This section of the Act allows the police to detain someone who might be a risk to themselves, or others, on the basis of their distress and bring them to a ‘place of safety’ for assessment.

Over the past few months, there has been a lot of focus on these aspects of the Mental Health Act, in particular s136 and the issue of a ‘place of safety’. Under the Act, this should ideally be in a health setting, with police custody being used in exceptional circumstances. However in practice, custody is frequently used – approximately 1/3 of people detained under s136 in 2011/12 were held in police cells. This is widely regarded as unacceptable and has received a lot of media attention, especially around young being people held in cells. This was one of the driving forces behind the review.

The review has two sets of recommendations – the first set would require some kind of legal change to implement them. This could only be done after further scrutiny and consultation, followed by the necessary parliamentary process. The second set are more about improving practice around s135 and s136 and could be implemented through guidance and robust partnership working. This post won’t be able to cover every recommendation in detail but will pick out a few of particular interest.

The headline points from the review are really around reducing the use of police cells as places of safety. It has been recommended that this is never the case for children and young people under the age of 18, and is only used for adults when their behaviour cannot be safely managed and supported in a health setting. Although this latter point will be open to debate – at what point is someone’s behaviour too challenging and who decides? – I don’t think anyone could argue with the former point about young people.

But young people are not currently held in police cells on the whim of police and mental health professionals. They are there because there is no health-based alternative. A CQC report earlier this year showed that 26% of mental health providers did not have any local ‘place of safety’ provision for under 16s. 16% do not have any provision for 16-17 year olds. So where does this leave everyone? We already know that children and adolescent mental health services are critically underfunded and young people are missing out on vital support. Just saying that it is now illegal to hold someone under 18 in a cell pending assessment will not solve this, it requires significant investment. The review does make recommendations about commissioners making sure provision matches need, but if the funding doesn’t follow this becomes meaningless. It also needs a significant improvement in the local data available so commissioners can make informed decisions.

The question of resources within the mental health and wider health system is raised in a number of other recommendations in the review. Reducing the amount of time someone can be held pending assessment from 72 to 24 hours (a very welcome move) is reliant on mental health professionals being available to do the assessment. Requiring the police to get health input before detaining someone under s136 , similar to the successful street triage pilots, means that health services need to make this resource available. While these recommendations are sensible – a health crisis should have a more health-based response – the realities of funding have to be acknowledged.

There is plenty more to chew over in the review and it’s well worth a read if you’re interested  in learning more about the existing challenges. I also recommend the Centre for Mental Health’s report which looked at how people experience s135 and s136 and was commissioned as part of the review. This is a key perspective that shouldn’t be lost in this debate.

Overall, the review certainly seems like a positive step for reforming these sections of the Act. There is great potential to improve practice, as well as legislation, and it’s encouraging to see the review highlighting this too. But we have to realise that we aren’t in the situation we are in because the police like putting people experiencing a mental health crisis in cells. We are here because there aren’t the resources in the system to adequately support people when they need it most. Initiatives like the Crisis Care Concordat and liaison and diversion pilots are trying to develop and disseminate best practice and are doing some great work. But without a serious injection of funding to improve both preventative and crisis services for people with mental illness, we’ll never fundamentally improve the support available.

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!

Mental Health Cop

We’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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