Dr Chalmers: First, we welcome the focus on mental health crisis, following on from the excellent work that has been done by the concordat. The college is very much behind the principles that are driving the changes to legislation. Having said that, there are some very sensible changes. For example, there is the issue regarding clarification of a public place. My colleagues in the British Transport police and the healthcare workers who work alongside them have struggled with that issue. That is a very important change, because we know that the railway line is an important issue with suicide.
However, we have to step back and see section 136 in a much wider context of crisis care. I would be concerned that the legislation cart is coming before the horse. There have been significant changes in the past two years. Certainly, the number of people who are going to a health-based place of safety has increased. As you may know, the figures are variable, but it looks like about 80% of people, if not more, now go to these places. So there have been considerable improvements within the health services in their response to crisis.
We cannot do our job if we do not have the resources. Changes to the law could put pressure on the crisis services at a number of points, and I can expand on this if the Committee wishes. For example, there is the suggestion of changing the length of time to 24 hours. In principle that is an excellent idea. We want to reduce the time that people are subject to detention, particularly when that has been prompted by someone who is not a mental health professional. I think that 24 hours is a realistic timeframe in which to do that if the resources are in place. Generally, the areas that keep figures will tend to be the good areas. However, it is possible to meet people’s needs within a relatively short period of time, and do the assessment within several hours of presentation. That is perhaps not within the three hours that the college would set as the gold standard, but it is certainly within that longer period. It does become a problem if someone is intoxicated, or if they come in overnight when resources are less available and that gets passed on to the daytime services. There may be a knock-on effect.
The main problem that I see with the laudable aim of reducing the time for which people are subject to detention is when we come to the very small group of people who are subject to section 136 who need to be detained in hospital. As you have probably heard, approximately 20% of people need to come into hospital, and some of them will need to be detained under the Mental Health Act. If we cannot identify a bed for a person to go to, we might very quickly run up against this 24-hour time period. Then we—the AMHP, the approved mental health professional—are left in the most appalling situation. It is the job of the AMHP to make the recommendation for admission to hospital based on two medical recommendations. We have to say which hospital and which bed that person is going to. If we cannot identify that, then after 24 hours we will be in a position of acting unlawfully, because we have no way of detaining the person. I note that the Bill as it is currently written suggests that someone could be detained on clinical grounds. There is a lack of clarity around on what grounds we could extend.
I want to flag up to you the very important point that we may be in a situation where we cannot find a bed. That is not just me shroud-waving. The Committee will be aware that the Lord Crisp commission has highlighted the appalling situation where we are struggling to find beds. On occasions, we have to send people away, usually to independent hospitals. I will say a word about the difficulties there. Something like 500 people in a month have to travel more than 50 km to find a bed.
It sounds easy, “Let’s just find a bed in an independent hospital. Why wouldn’t they want to take somebody?” My team is in this position several times a month, where we will phone around several hospitals looking for a bed. Perhaps this sounds ungenerous, but sometimes it feels that if you have a choice you can cherry-pick the kind of patients you want to take. Often we think we are offered a bed, then we send the details and it is turned down. I am really concerned. Although I welcome it in principle, I just want to flag up the important resource issues that we might come up against with the 24-hour period.
Q Mr Kevan Jones:
Like you, I welcome the broad provision that has been put in place but I have this concern. What will happen is that people will not be taken to a police cell—which is what we are trying to avoid—but will likely be kept at home because that is now deemed as a place of safety.
Without statistics being published, we will see the number of people being referred to police stations going down, but we will not know what has happened to them. Do you think there should be in the Bill an onus on a local force to keep statistics of what happens to people under sections 135 and 136? Otherwise, we could get a situation whereby the problem just gets masked rather than solved.
Dr Chalmers: Your point is very well made. As early as 2011, the inter-agency group made a plea for good statistics. If you do not know what is happening we cannot track it.
If I could just take you back. I think we need to distinguish section 135 from section 136. Section 136 will never occur in a person’s home. What I think the Bill seeks to address is the lack of clarity about whether you could undertake the assessment in the patient’s home when you had entered with a warrant. It is the police who will administer, if you like, the warrant. They will act on the warrant accompanied by the AMHP and a doctor.
Up to now it has been unclear whether you could stay in that person’s home to undertake the assessment, or whether the Mental Health Act as written required you to remove a person to a place of safety. I have done many assessments in a person’s home, and I think that is probably better than removing them, particularly if it is not clear that you will actually detain somebody in hospital. It is important to clarify that.
Your point about data is particularly pertinent to section 135, where those are not collected nationally. Of course, there are two 135 warrants. There is the one to enter a person’s home to remove to a place of safety, and one to return them to hospital. We do need those data .
Dr Chalmers: My personal view is that that has slipped in. As far as I am aware, that was not consulted on. I do not necessarily know what the college position would be, other than to say it is always a good thing to talk. I would say that as a psychiatrist.
I just wonder whether that needs to be in legislation rather than in regulations or in the code of practice, because it is straying into an area of telling people what to do using the law, which I am not sure is particularly helpful. What we do know, based on evidence from the street triage projects, is that where people work together and there are conversations between police and healthcare professionals in some areas, it has led to significant reductions. If you include this provision, we are behind. The services are very patchy and variable. In some places it would work very well because police would have immediate access to somebody with authority to give advice. In other places, they would be foundering. Without bringing the resources alongside the law, there is the risk of setting people up to fail. Allowing things to develop in localities can find the best way of working, because there might be different pathways.
I have sidetracked your question, because I wonder whether we need to scrutinise whether that is a wise thing to have in statute rather than in regulation or within the code of practice.
Dr Chalmers: It would be a pragmatic response. There are pragmatic responses and principled responses. It is essential that people have good information explaining in easy, accessible language what is happening to them and their rights at that point. Nursing staff in section 136 suites are well placed to do that. Again, I would imagine that that is patchy, but it is something that should be built into the specifications and reviewed.
The pragmatic answer is that for people on longer-term sections, for whom there is a statutory right to advocacy, the responses are patchy, so we have not got it right for the people who already have a statutory right to advocacy. I think stretching it to 3 o’clock in the morning is going to be very difficult .
Q Jake Berry:
If I may address Sally: thank you for coming here today and for providing very detailed information about the journey you have been on with Maisie in advance of our meeting, for which we are all extremely grateful. As someone who has experienced the problems faced by yourself and Maisie at first hand, can you tell us a little about those experiences and what further you think we can do in the Bill to try to help parents who find themselves in the same situation ?
Sally Burke: I have to state that of all the agencies we have worked with in crises, the police have gone the furthest in improving how they are with Maisie and understanding her. I welcome the Bill for not putting children in a cell as a place of safety. Maisie has not been in that position—just the thought of it—I did not realise at the time the damaging effect it would have had on her.
As Maisie’s parent my main concern was to keep her safe, but I was in too much of a state seeing my child doing the things that she was doing to make a long-term decision. With hindsight, I was able to reflect on what the police need to do in that crisis. I am now more hardened to it, so if Maisie wraps something around her neck, I can say, “Take that off”. Before, I would be going to pieces asking, “Oh, what do I need to do? I need to find a pair of scissors, but everything is locked away in a safe, so find the keys”. It is an awful predicament to be in, but you do get hardened to it, as you know, and a lot of police officers are hardened to those scenarios.
You need to have officers who can talk about mental health to parents. The approach of a lot of the front-line officers who turn up depends on their view on mental health. An older generation chap would think, “It’s attention-seeking, this. What do we do with this girl?” But younger people who we have had out seem to be more sympathetic and have more of an empathy on mental health and can deal with Maisie on a much friendlier, teenage level, which brings her down. If you have somebody who has quite a negative view on mental health thinking that she is having a behaviour fit and wants some attention, trying to bring her down in that scenario is not as effective.
It is also important to help a parent make a decision about the best way forward and the best place to go for safety that will have the best impact on that child in the long run. That is really important. My confidence has grown massively over the past two years since we first went into crisis. The first time I went into crisis with Maisie, if somebody had told me they were taking her to the moon right now to keep her safe, I would have said yes, because it was so horrible. You just cannot comprehend how you feel, as a parent. So I think it is about educating the officers who go out to these calls.
I have helped our local police force. I have been to conferences there and have heard the mental health cop talk to the officers and say, “60% to 70% of our time is spent on mental health conditions, yet we get hardly any training; 6% to 7% of our time is on criminal offences, or crimes, and how much training do you get for those activities?” When you see it in the balance, I think that would really help families and youngsters in mental health crisis.
Also, if you could sew into that, with your magic wand, some training on autism and learning difficulties, because that comes across as a bit of a grey area. Some officers just do not know what autism is and how to treat a child with autism. When Maisie is in crisis, she does not like to be touched, but an officer will come up to her and say, “Come on, Maisie, it’s okay” and she will freak out because she does not want to be touched. So there needs to be some education around how best to approach a child in that crisis scenario.
Q Karen Bradley:
Sally, thank you very much. Your point about the amount of time police spend dealing with this is exactly why we want to do what we are doing in the Bill. It had been too easy, I think, for all agencies to let the police deal with this problem. It had become a police problem, but it never should have been. Police should always have been the last resort; it should always have been other agencies stepping in. You say you have not had the personal experience of a 136, but I wonder, as you have come into contact with police, whether you have had any experience of the mental health triage that I know many forces have rolled out as part of the crisis care concordat?
Well, the triage; so having mental health professionals with the police at the same time. Is that something you have experienced in your area?
Sally Burke: No; I wrote it down as Julie was talking. It is a postcode lottery, with the concordat and there being mental health staff available. As part of our campaign, just this January, we got a children’s mental health team as a wrap-around service, because we did not have anything. If Maisie went into crisis at a weekend or out of hours, there was no child and adolescent mental health services team available for her at all. It was, where do we put this child? As for concordat and triage, no.
In our experience of Maisie’s bespoke package, agencies say that they will work together, but it is actually worse for us as a family, because they will talk to one another, but they don’t listen. [Laughter.] No, they don’t. They each have their own system, and boxes that they need to tick, and they do not cross over for the child. It is not what is best for the child; different agencies have boxes that get ticked in their protocol and it does not fit across the board, so lots of things get left because nobody wants to be accountable for this child.
At the end of the day, Maisie gets sent to units all over the country and every professional who works with her says it is more damaging for that to happen, but nobody wants to take the responsibility. So at the end of the day, we have got a child who is going through lots of trauma and not getting the help because, on paper, it looks great that all these agencies are working together, but, certainly where we are, it is not working.
You could go and see where triage is taking place, outside your area so that you can experience that as well.
Sally Burke: I feel that the NHS has made so many cuts—especially in our area, with mental health—that the police have had to take the brunt of where to put these children. If you continue to show that that is their responsibility, they are never going to put the money back into children’s mental health and tick the areas.
Sally Burke: Maisie has got post-traumatic stress disorder, so she can go into crisis at any point—even from a song being played on the radio, if that takes her back to memories that are not very nice. It is about having somewhere that is safe and suitable. If she had a broken leg, you would not put her in a cell because the general hospital did not have a bed. It is about having a professional who is caring—the police do care, I do not mean that—and properly trained to deal with that, because it is a medical condition.
Dr Chalmers: Yes, local authority, health and social care—and it should be accountable. There are two things that the college would like to bring to your attention for consideration. One is that there should be reporting through CCGs to the Secretary of State about the state of crisis services in the area and how they are developing, or not, against the concordat aims. There is also an anomaly within the code of practice to the Mental Health Act, which requires people like me—section 12 doctors, AMHPs—to be bound by the good practice in the code, but requires commissioners to just take account of it. They should have a statutory obligation to work within the code of practice, because the principles underpinning the code of least restrictive option would work. We should focus that on our area—what we are doing in our area to provide services that could avert crisis and alternatives to the dreadful situations that everyone finds themselves in, where they have to do the least worse thing.
Q Mims Davies:
I want to ask Dr Chalmers about that place of safety and the work with CCGs and local authorities. I have experienced that in my patch: there is a kind of falling through the cracks, where the police do not want to use their cells as a place of safety. Do you feel that perhaps there should be some community hub, house or building? How would you term a place of safety? Is there some kind of crisis centre that we are missing, which CCGs could provide?
Dr Chalmers: I think we are always going to require the current, classic, hospital-based place of safety. In my ideal world that would be co-located with physical health services. In the use of section 136, among the problems that we see people presenting with, the problem of intoxication—not just with alcohol but now with so-called legal highs and synthetic cannabis—can cause people to crash very suddenly. Somebody who looks as though they are in crisis can become very physically unwell. There is an argument for having centres of excellence in urban areas, on the model of centres for stroke and cardiac emergencies, where the expertise is situated and you can move between one and the other.
For some people we also need some level of security. In its guidance the college specifies what a good section 136 suite looks like. I had the unfortunate news from a Health and Safety Executive investigator where someone was taken to a hospital-based place of safety where you could just open the door and walk out, and a tragedy ensued. For some people, there has to be a degree of security.
My colleagues in the child and adolescent faculty would highlight that a safe place for someone in crisis to be assessed is also necessary, particularly for children. The rough and ready survey that was done suggested that of the children who were picked up on a section 136, 30% do not have mental health needs and instead need social care and social responses. In an ideal setting, there would be a safe place for children to go that is age appropriate, too. Rooms have to be safe, so they look stark and sterile, but you can imagine a safe place for children where their families could come. Often with a section 136 suite there are no places for families to come and visit.
There is some evidence about alternative places before people are placed on a section 136, such as crisis houses. The crisis concordat is very good at flagging up areas of good practice. There was an initiative in Leeds that has been very successful. There was one using the Richmond Fellowship in Sussex, and that has been reported on. As I understand it—this may not be correct—the numbers were so small that they have expanded the resource to be a safe place to be in crisis. There is also the use of peer support. In London, users of service have provided safe places—they call them cafés—where people can go and be in a safe place with people to talk to.
I started by saying that you should not see 136 in isolation. I think you will get into trouble trying to fix one small part of the system; you will have knock-on effects and unintended consequences. You have to see it in the round of crisis responses.
It is now 27 minutes past four. We have got three minutes left and two Members who want to ask questions. I do not think it is possible to get answers to two questions in the time available.
Q Maria Caulfield (Lewes):
I am the MP for Lewes in Sussex, and we used to have one of the highest rates of patients with mental health problems being in police cells, but that is turning around. I want to highlight that it can work. Katy Bourne, the police and crime commissioner, has now allocated for mental health nurses to go out with the police. Is that something that you would like to see rolled out nationwide? It has certainly transformed care for patients in mental health crisis in Sussex.
Dr Chalmers: Certainly in my experience working in Oxfordshire—the city of Oxford was one of the nine pilot projects—we saw remarkable changes. There was a substantial reduction of, I think, 85% in the use of police cells as places of safety. Alongside that, there was a willingness among the commissioners and, in particular, the providers to increase the number of hospital-based places of safety. I would not be too prescriptive with the models, because there are a range of models. There is the nurse who goes out or there is someone in the control room. I think in the West Midlands they have all-singing, all-dancing ambulance, police and mental health all going together. If you give guiding principles, areas can perhaps decide what is best for them. I would hope that that would be driven by what is best for patients, rather than what is best for the budget.
Thank you very much. On behalf of the Committee, I thank both of you for bringing your great wealth of professional and personal experience to our attention. It is very helpful. If there are no further questions, which there are not, can we move on to the next witnesses? Thank you.