The Nation's Health

It is with great pleasure that I can introduce MentalHealthCop as a guest blogger. After a question was posed to me by him on twitter my instant reaction was 'here goes the #no. 2 emergency service trying to palm work off on to us'. However, in the intrest of fair play we agreed to answer the same question on each others blog with a mind to provoke debate from service users and health care professionals alike. Whether we come to the same conclusions I don't know, you'll have to check out his blog for my response!

Why do the ambulance service not undertake “safe and well checks?”

I should explain, I operate a 'rule of thumb' that 'RAVE risks' are the cue for the police to become involved in supporting or temporarily leading health and social care matters, to mitigate risks and keep people safe. It is an operational mnemonic for 'Resistance, Aggression, Violence or Escape'. A far from perfect model, but helps to point the police in the right direction.
Health and social care functions, we'd all agree, are best left to people who know what they're doing, but where they would be exposed to risks, the police should either support them or temporarily lead a situation, until the risks are managed. Once mitigated or found not to exist, the police should begin to disengage and let the professionals take over.

For those who've not read my blog: I've been interested in how we police incidents involving mental health issues since I joined the police and as I've become more involved in it, I've found that frontline police officers like clarity around when a 'mental health job' is a police responsibility.
Egon Bittner (criminologist) said, "There is nothing which could not become the proper business of the police." Of course, this is not the same thing as saying that everything IS the proper business of the police! So where's the line; and who draws it?!

The start of my conversation is usually, "Is there a RAVE risk?" If not, using the police needs to be balanced off against the potential to stigmatise and criminalise the person concerned and it needs to be considered against other police priorities, because we are a finite resource and currently getting smaller.

This is important: the police are frequently accused - as am I personally - of perpetuating the myth that people with mental health problems are violent, when this mostly nonsense.
The police have a certain level of frustration with issues involving mental health: when one is asked to recover an AWOL patient from their home address, despite a Code of Practice saying that this should be done by a mental health professional (who does have legal authority to do so, regardless of what they may tell frontline cops who know no better!) it feels like the existence of the police as a generic 24/7 social service is being taken advantage of. That said, sometimes this frustration is inappropriately placed for if that AWOL patient has a history of aggression and violence, it may be quite appropriate for the police to do it.

So where's the line and who draws it?! And how do you bring about finality to that debate if it emerges that the police and the NHS have drawn their 'battle lines' at different places, leaving a gap between their expectations of each other?

So who should do a "quick safe and well" job? Such checks are often necessary and for a range of reasons: mental health services for community mental health patients who may have failed to attend an outpatient's appointment; general hospital patients or those who have attended A&E who left before treatment or self-discharged before proper explanation of the medical risks involved; other agencies such as education or children's social services asking the police to do checks for children absent from school or not seen.

So in theory, ambulance services could do it for the health situations as they are part of the NHS. For that matter, community mental health teams could do it and Crisis Teams could do it out-of-hours. The NHS is an employer of over 1 million people, working 24/7 and the numerous ways of addressing this issue. So why the police?

None of the scenarios necessarily involve what the public may regard as core police responsibilities: prevention of crime; detection of crime; protection of life and property and maintenance of the Queen's Peace. Especially in those first two scenarios - there are obvious links to health. If health action is required; if explanation of health risks is necessary, surely there can be no question that health professionals of one type or another would be are better suited than a police officer with a first-aid certificate? "But what about [RAVE risks]?" OK, the police should support this to keep you safe, but it remains a health issue at its core.

So I ask, if orientated around health concerns, why not ask the ambulance service to do it? I am being deliberatelyprovocative: apart from their obviously being part of the National Health Service, they are not necessarily any better placed to do this than the police. However outrageous it seems to me (and it does), the ambulance service have no more access to out of hours GPs, community mental health or health services than the police. I once heard a senior social care director within mental health shouting at an ambulance service mental health lead who wanted to do better for patients, "You will NEVER have direct referral access to crisis teams!" Not even, apparently, if the ambulance service knew they were dealing with a person who was currently open to that director's mental health services. I wouldn't have believed it if I hadn't been there. You would rather have a patient coerced by the police or taken by the ambulance to A&E - not a great place to be mentally ill - than have your Crisis Team respond to a mental health crisis involving a current patient?! Bonkers.

Where a safe and well checks leads either emergency service to find a person who is mentally ill in a private dwelling only three things can result:

• Whether Police or Ambulance - if a person found safe and well; messages can be passed or warnings conveyed but if they are capacitous and are left there or taken to A&E or back to hospital.
• Ambulance only - person found; not safe and well and especially if uncooperative and / or where capacity is questioned, the get called and then neither agency have a legal power to do anything about it at all (unless Mental Capacity Act can be applied, which will be rare.)
• Police only - person found; not safe / well and ambulance get called to this health situation and then same predicament: no powers to intervene.As such, NHS Commissioners need to plan for demands we KNOW we will face: how do you respond to spontaneous mental health crisis in a private dwelling where there is no criminal offence? Parliament says, healthcare professionals leading to MHA assessment by an AMHP / DR, if need be for admission under s4 MHA.

So it emerges asking for a "quick safe and well" is too simplistic a description of a fairly complex problem that neither police nor ambulance are necessarily best placed to solve. And so this post is not for paramedics and cops: it is for NHS Commissioners and Service Managers and for inpatient nurses who ask for this to be done.