Oral evidence: Policing and mental health, HC 202Tuesday 21 October 2014

Oral evidence, 21 October 2014.

Witnesses

David Davis, College of Paramedics, Karla Wilson-Palmer, Royal College of Nursing, and Dr Mary Jane Tacchi, Royal College of Psychiatrists, gave evidence.

Chair

You have heard the previous evidence that has been given so we will not repeat the introduction that I normally repeat at the start of a session. I am very interested in the Crisis Care Concordat that was launched and the statement that was made, “We look forward to working together with others to ensure that the commitments made in the concordat become a reality as without this it is just a piece of paper.” Perhaps I can ask each one of you in turn, what is your assessment so far on what has been achieved? Mr Davis?

David Davis

Thank you. Good afternoon, representing the College of Paramedics. The Mental Health Concordat has been agreed with the Association of Ambulance Chief Executives, obviously they would be able to comment themselves. The College of Paramedics welcomes any initiative that focuses on the mental health needs of patients that present to the ambulance service, recognising that the numbers of patients who present, where mental health illness or psycho-social problems are a factor that needs to be considered as part of the clinical care provided, need to be given a greater priority. The matters relating to ambulance response time and so on are probably better placed towards AACE, as they call themselves.

Karla Wilson-Palmer

Hello, I am team manager for Devon liaison and diversion and the Devon street triage pilot projects. I am not in a position to be able to give a broader spectrum view of the crisis concordat and everything it means, all I can say it means for my services that we welcome the opportunity to work together to provide better services, more joined up services for those persons who find themselves in crisis.

Dr Tacchi

I think the concordat is an excellent start and what it has done is get all the parties together that are involved in mental health crises and get them to start talking and working together. But what we have to do is we have to not just talk about it, we have to work together. So I think it is the first time everyone has realised that it is all of our responsibilities to work together to make things better and that is a good starting point. For me the actual getting it on the ground and making it work is going to be the issue. There are an awful lot of people involved and each area you go to people are at different stages and have different services so there will be local implementation of the concordat, which will be the thing that will make things better.

Paul Flynn

We have seen these figures that suggest the number of deaths in custody are now at the highest level since 2005, I believe, it goes a long way back. Have you any ideas on how the number of deaths can be reduced? We have heard claims of inappropriate restraint being used on prisoner and a lack of understanding. Anything else you would like to enlarge on those and suggest ways in which this dreadful total can be reduced?

David Davis

We understand, the College of Paramedics and its members, that the leading cause of death in custody from restraint is positional asphyxia. As clinicians who are focused on the physical and mental health and well-being of patients, paramedics have a different focus to police officers. I might point out that police officers and paramedics work very closely together regularly and see ourselves operating as teams across the piece, but a paramedic brings a different perspective into looking at a different side of the welfare of the patient. So we believe that with the involvement of paramedics in these types of cases our focus on recognising, for example, someone who perhaps has a large abdomen being restrained on their front, we would be looking at matters relating to breathing and adequate oxygenation as a priority. So that level of clinical insight could bring some benefit. There is also some suggestion from around the world—certainly in New Zealand and Australia—that has been brought to the College of Paramedics that there could be some benefits in using chemical interventions, pharmacological interventions rather than just physical interventions. That is something that we would like to examine and understand. I know that the New Zealand medical director is coming to the UK later in the year and that is something that the college is going to be looking at.

Paul Flynn

Are the pharmacological interventions safe?

David Davis

It is a highly contentious area because, of course, the type of agents that are used are also the same agents used in sedation and anaesthesia. However it is our view that with the very advanced skills of critical care paramedics who specialise in that area of the business there is an opportunity to exam the opportunities to use those pharmacological interventions. It is something that as a professional body we do not want to be developing in isolation. Recently we met as part of a coalition of professional bodies where we can hopefully guide each other.

Paul Flynn

We heard of a young man, Herbert, from Bath Road in Wales, and there were a series of errors. It should have been recognised that he was somebody known to the police for his mental health difficulties and it was not; it was a hot day; he was restrained from behind; he was wearing a coat; he was carried a long distance to the hospital; and there did seem to be a whole chapter of accidents where he was let down throughout the lot, which contributed to his death. Is there evidence that lessons from cases like this have been learnt and there is a better understanding of the use of restraint?

Dr Tacchi

The work that has been done with Newcastle University and the Met with regard to screening for custody sergeants to screen out physical and mental ill-health and signposting custody sergeants to the appropriate places for people to be or to get help. A really useful tool has been developed together with the NHS and the police. I understand that it is going to be rolled out, it is a question of it being employed with the IT systems. You are talking about restraint but right from the very beginning making sure people are in the right place seems like a useful tool to use.

Paul Flynn

Most of these deaths are suicides and the graph is going up alarmingly. Have you any ideas why this should be and why there should be this continual increase?

David Davis

It is probably not possible to give accurate answers to that but one of the perceptions that members of the College of Paramedics have raised is that it feels very difficult to access crisis mental health services and it is felt, although again cannot be supported by evidence, that this results in members of the public who are suffering mental illness being unable to access crisis care, with a particular issue being drugs and alcohol being a barrier to accessing services. The anecdotal belief is that the consequence of having difficulty in accessing those services means that members of the public with these illnesses go and end up getting worse before they access services. But, as I say, anecdotal. Just coming back to the point you made about restraint. The members of the College of Paramedics are very keen to have greater knowledge and understanding about how to effectively manage restraint because it does not just apply to the Mental Health Act, it can apply to the Mental Capacity Act where it is necessary to treat patients where they lack capacity. The risks of death do not just happen in police custody, they can happen, as has sadly been the case in a couple of cases where patients have tried to jump out the back of a moving ambulance and lost their life as a result of that, which is the why the Mental Health Concordat and the joint working that we are seeing in a number of different areas provides some real potentials for benefit. An ambulance vehicle that can be appropriately locked, an unmarked vehicle that does not create the unwarranted attention or feelings of shame or embarrassment, and the ability for paramedics and police officers or mental health professionals and groups to be able to work together to complement the skills and competences that they have.

Paul Flynn

Do you think from the evidence we just heard that many policemen do not regard it as their job to look after those with mental health difficulties is a significant factor or is it a matter of resources? Is the training there? Do you think there is enough emphasis in police training because they seem to be the ones who first encounter people in distress in this way and are they properly trained? Have lessons been learnt?

Karla Wilson-Palmer

Can I answer that question? I think it is a whole big mixture of lots of different reasons. What I can see is I can see there are lots more training programmes, joint training programmes now available for police and health combined together. There are lots more health and police criminal justice teams working peaceably together, information sharing is improving, the roll-out of the national liaison and diversion programme, there is going to be better access for mental health services to pick up people at a much earlier stage and refer and signpost them on to the appropriate services and support criminal justice staff in being able to manage people more safely and effectively when they are going through criminal justice processes.

Paul Flynn

Can I say finally, we are aware that the crisis concordat was to encourage the police and health agencies to work closer together but is it happening? Is it all a plan or have you any examples where it has not been successful, or where measureable improvements have taken place?

Karla Wilson-Palmer

I am certainly aware of big changes, big positive changes, happening in the field of work that I am work in and I can see that being rolled out nationally. There is talk of ambulance services coming on board, the street triage pilots, that is certainly happening for us down in Devon. So I can see lots of positive changes. There is a long way to go yet for sure.

Michael Ellis

Do you think that police are currently doing things relating to mental health for which they were not trained, for which they are not equipped and should not be their responsibility? In other words, I speak to rank and file police officers who say quite frankly that they are not trained for some of the things that they have to do and that puts them under pressure. We sometimes seek to put them under pressure but they put themselves under pressure when they are not fully trained to deal with some of these difficult situations. Do you think there is a gap there and if there is a gap, surely it is more than just resources that is causing this gap, it is a skills shortage and there are other issue, aren’t there?

Dr Tacchi

I think it is very important that we are clear who has what roles and we cannot expect the police to become experts in the assessment of mental health, nor can we expect NHS services to become experts like the police. The only way forward is to work together so it has to be about collaboration. We are starting to see the street triage and people working together and you see quite quickly how just being even co-located, working together, having bases at the same place—where I work in Newcastle what the police do is they ring the local crisis team if they are thinking about a 136 and they have a discussion with a mental health professional. That is not in a policy, that is just what has grown up locally. It works and there are good relationships. However much training we do, I think that is great, but it is about relationships and collaboration and being very clear about what each of us does.

Michael Ellis

Sometimes police have to be medics, they have to be fire-fighters, they have to be mental health professionals, they have to be social workers; we expect them to deal with all types of emergencies and no doubt there are examples of good practice elsewhere in the country that can be replicated if they are known about. Did you have anything you wanted to add, Ms Wilson-Palmer? I am not forcing you to.

Karla Wilson-Palmer

I think there are lots of different models, as you correctly say, and they all do good work but they all work quite differently for lots of different reasons.

David Davis

If I may on your first question that asked about the view of whether police officers have sufficient knowledge, education and training in mental health issue, in the College of Paramedics’ survey, only 37% of paramedics felt that there was a good level of understanding among police officers in certain areas of the Mental Health Act, but it would be disingenuous—

Michael Ellis

How many police officers thought paramedics had a good understanding of policing? That is another matter.

David Davis

Quite. That is absolutely right, but it is clear from the joint working of lots of paramedics around the country that rank and file police officers feel that there is a significant lack of knowledge and understanding around this area but the same applies to paramedics too. As a college we are very keen to see an increase in education and training for all paramedics, whether with partners in other agencies or directly face-to-face with patients, because although we work in partnership with police officers and often ask them to come and help us—as a front-line paramedic myself I have regularly done that—skills of de-escalation, appropriate assessment and being able to assess pathways of care are things that are currently a problem and have been proven to be enhanced as a result of joint and collaborative working.

Mr Winnick

I have one or two questions, perhaps particularly to Ms Wilson-Palmer representing the Royal College of Nursing. As regards children being detained in police cells, that remains a problem?

Karla Wilson-Palmer

Nationally, there are still children being detained in police custody.

Mr Winnick

Do you have the feeling the numbers are fewer than before?

Karla Wilson-Palmer

I would not be able to answer that question, I am afraid.

Mr Winnick

But it certainly remains a problem?

Karla Wilson-Palmer

No children should be detained in police custody under any circumstance, and there are still children being detained for sure.

Mr Winnick

One or three, as the case may be, on the question of advice that the police should give to try to reduce the possibility of a teenager attempting suicide on their release, are the police updated on this as far as your professional bodies are concerned?

Karla Wilson-Palmer

Liaison and diversion and street triage are about having mental health practitioners working alongside police, including police custody. So if there was a situation whereby you had a young person detained in custody who is about to be discharged and there are concerns about that person’s vulnerability, they would have access to a mental health nurse who would be able to make an assessment on their mental health presentation, their vulnerabilities and risk factors. They would then be able to signpost that individual to the appropriate care or treatment and they would also be able to advise the police sergeant in the custody department how best to manage that situation, and what decisions they could potentially make.

Mr Winnick

But to try to prevent such a tragedy, a child taking his or her life, what I would really like to know from your two colleagues is if there is a sort of feeling that the police would be aware of it, if they have sufficient sensitivity and understanding that there could be a danger of a teenager committing suicide?

David Davis

One of the problems that we have is that as paramedics and police if we are called to a suicide or an attempted suicide, we are right there at the end of that journey and often children—because they are obviously under parental influence and guidance and, to some extent, control—may not necessarily present in the same way that an adult may to services. So the first time police and paramedics may see a child is at the point where unfortunately they have attempted suicide. However, there are warning signs and there are occasions when they present to our services, often mixed with drugs and alcohol, particularly in the teenage population where actually there are opportunities to be able to provide interventions, to divert them away. I know, speaking from personal experience, having seen the journey of a particular teenager from first presenting with an overdose of heroin to ending up very sadly a number of years later taking their own life, actually the biggest struggle was being able to access those services. But that was over a period of 10 years.

Dr Tacchi

You are asking are we increasing the awareness of the possibility and the need for assessment, and I think the concordat does that. So that means awareness among the police that these are issues that need to be addressed and the next thing is we need to make sure that the police have access to appropriate advice whenever they need it.

Mr Winnick

Thank you. Back to you, Ms Wilson-Palmer, I understand that you are involved in the scheme referred to in the evidence session just before you, the scheme operated in Devon and Cornwall, am I right?

Karla Wilson-Palmer

Just Devon.

Mr Winnick

How much time do you spend, or have the means to do so, in providing advice down the telephone compared to going out in a patrol car?

Karla Wilson-Palmer

You are talking specifically about street triage. Devon is a very large geographical patch and in order to provide a service to the whole of Devon, a street triage service, we have had to design a model that enables the police from all over Devon to access information and advice over the telephone, but also in the two main urban areas of Devon police are able to ask for us to be called out to attend and do face-to-face assessments, mental health assessments, just for the urban areas. Because it is such a big area there is no way we could be called out within the constraints of the budget to the whole of Devon for this pilot. So there is two ways.

Mr Winnick

How many are involved in Devon on this scheme?

Karla Wilson-Palmer

How many nurses?

Mr Winnick

Yes, how many nurses?

Karla Wilson-Palmer

I have nine nurses who are on a rota to cover four nights of the week at the moment but we are looking to increase the service to provide a day time service, Monday to Friday, as well. I have just realised I did not answer your first question. The vast majority of the work that we do in street triage is over the telephone, providing information, advice and support directly to the police response officers or to the radio operators themselves.

Mr Winnick

You do this in Devon, I said Devon and Cornwall. It would be two large counties to operate with the same team but presumably the same is happening next door in Cornwall?

Karla Wilson-Palmer

No, just in Devon at the moment. We provide the service to Devon and Cornwall Police who are one of the first four national forces to be identified to be funded for street triage.

Mr Winnick

Do you think Cornwall will follow?

Karla Wilson-Palmer

It is very complicated. Just Devon.

Mr Winnick

I see, okay.

Chair

Can you just clarify on which nights this happens and does it happen at weekends?

Karla Wilson-Palmer

It happens at weekends, it happens on Thursday night, Friday night, Saturday night and Sunday night between the hours of 8.00 pm and 6.00 am. Those were the hours that it was identified that the vast majority of section 136s occur, hence why we chose those hours. But, as I say, we have reviewed it and we are going to be increasing the service.

Dr Huppert

Can I put to you some of the issues that I raised with Lord Adebowale just before? Firstly, Dr Tacchi, in terms of people arriving at hospital, if somebody is very ill and perceived to be aggressive, how far should it be treated as a health matter for hospital staff to deal with rather than call the police?

Dr Tacchi

You are talking about people who are mentally unwell?

Dr Huppert

Yes.

Dr Tacchi

My experience of—

Dr Huppert

Sorry, let me clarify, somebody who is in the hospital setting and being aggressive, at what stage—because of course you do not know that they are necessarily mentally unwell right at the start, so presumably you have somebody who has the symptoms and presents in a certain way?

Dr Tacchi

I suppose it depends in what setting. If we are talking about an emergency department, so they are not an in-patient—

Dr Huppert

Yes.

Dr Tacchi

Yes, a lot of it would depend on the circumstances and the staff available but in a health setting, and I think David has alluded to this, the techniques of de-escalation and trying to avert aggression and violence are quite different from those used by the police often. So they will be the first port of call and then, relatively unusually, relying on the police, apart from when there are weapons involved or specific risks to both the person themselves and others. My experience is that the staff themselves, especially in mental health services, are fairly adept at managing that internally. It is only a matter of when we talk about violence to others, to the public, in a place like emergency departments where you might need extra help.

Dr Huppert

That is interesting. Do you think the situation at the moment is good enough that the police are not called inappropriately?

Dr Tacchi

I think the trouble is it is patchy so there are some areas where things are contained quite well within health and other places where they are not. My own experience is that it is quite unusual to call the police in those circumstances but I know that there is anecdotal evidence of the police feeling that they have been called inappropriately. Again, I keep saying this, it is about if we had really good relationships with each other then we would know what each other did and I think these things might not be so much of a problem. My own experience is that the police are extremely helpful in situations where there might be potential violence and will come and help you do your job in the community, not necessarily in the hospital.

Dr Huppert

Ms Wilson-Palmer, would you agree with all of that?

Karla Wilson-Palmer

Yes, I was thinking to myself there are quite a few assaults of members of staff in A&E departments and we cannot lose sight of that. People who assault staff in A&E come from all different walks of life. Some of them may have mental health problems, some of them might not. At the time they often have not had assessments, people do not know what they dealing with, so I think we have to think safety first. Most of the times I have been aware of it I have felt it very appropriate for police to be called when there have been threats to the staff, I am just thinking in A&E departments.

Dr Huppert

I should probably declare for the record I used to be ambulance technician with St John Ambulance, although I do not have anything like the same depth of experience. Mr Davis, it is a different setting that you are exposed to?

David Davis

It is, but we work very closely with colleagues within the A&E departments and I can think of a number of cases over the years where patients have ended up becoming violent. I think the key to managing these problems is to understand probably three issues: firstly, that acute A&E departments are not necessarily the right place of safety, in the same way that police cells absolutely are not an appropriate place of safety in our view. We know that patients tell us that when they go and sit with physically sick people and they are at the back of the queue and they are potentially low priority, it can be a very unsatisfactory environment and they may very well discharge and end up cycling around the system. So that is the first thing. The second thing is in order to avoid people ending up in A&E, violent because they have been restrained or because they have had their liberties taken away from them, the schemes that colleagues here have been involved in stop those cases and those patients presenting to A&E in first place. Then it is about understanding the drugs and alcohol component as well. There have been a number of schemes just looking at drugs and alcohol in isolation around the country where people have been able to dry out, so to speak, and be looked after and kept safe with people who are used to negotiating and de-escalating. But the police definitely have a role to play when physical safety becomes an issue because, like you say, everyone has multiple skills and competences and people who work in the generalist areas have to know a lot of things, but for physical restraint and keeping people safe, we rely on the police to do.

Dr Huppert

You were talking about training for paramedics that the college does, can I just check, do you also provide that to emergency care assistants and others that are within the ambulance family?

David Davis

Yes, so the College of Paramedics is the professional body as opposed to a college providing education and we set the curriculum for paramedics. However, our members are often involved in providing support to educate the ambulance technician and emergency care assistant grades, but it does not fit within our remit. AACE may best be spoken to.

Dr Huppert

Just to move on to this issue about places of safety, there have been a number of concerns. We have been told about the health-based place of safety, lack of beds, limited opening hours and so forth. I would just like to pick up, in particular, this practice of refusing patients that are brought to a health-based place of safety on the grounds of intoxication or other reasons. Are there other reasons that you have come across for hospital staff refusing to admit somebody brought under section 136?

Dr Tacchi

I think this has come about from misunderstandings from the past about what it is that we are doing in a 136. Historically there was a feeling that Mental Health Act did not cover people who were intoxicated and that might have been where the confusion has arisen. The Royal College of Psychiatrists have very clearly stated that people who are intoxicated and have a mental health problem are our business and it is our responsibility to look after them. So refusing people on the grounds of being intoxicated with a mental problem must not happen.

Dr Huppert

But it still does. We have had quite clear evidence about that.

Dr Tacchi

That is right, and we have to make sure that we have adequate facilities for people. One of the difficulties is you cannot really make an assessment until someone is sober, so that is the issue. What do you do for the period of time until the person sobers up? There is no place at the moment and that is what we need to have, somewhere safe, somewhere to be so that they can be safe and be assessed appropriately.

David Davis

The pilots that colleagues have spoken about around the country say that the refusals reduce significantly when the referrals are being made by a multi-professional team. In terms of the section 136 detaining, it is something as a college we would like to explore, potentially opening up the legislation to include paramedics as it is in areas of Australia and elsewhere in the world, recognising that it comes with very significant responsibilities so that it is not always a police issue. I know that perhaps you have also considered issues of detaining within the home, which again presents a real problem.

Chair

Final question from me. Lord Adebowale in his evidence to us said that the biggest reason for poor ambulance response, in London in particular, was the lack of recruitment for paramedics. As you represent the Royal College here, what can we do about that?

David Davis

It is well recognised that we have been facing a crisis in paramedic numbers. There are a couple of reasons for that. We have seen an unprecedented rise in demand in terms of 999 calls for ambulance service. It always used to be the police ahead of ambulance in terms of gross numbers of calls but I believe the ambulance service has taken over now. I was given a figure a couple of years ago that the annual increase in the numbers of 999 calls for the ambulance service now exceeds the total number of annual calls to the fire service. Not to say they don’t do a very important job, which they do. What are the numbers? That is difficult. We are currently working on a project with Health Education England jointly—

Chair

Who becomes a paramedic?

David Davis

Now? Historically, it used to be ambulance drivers who worked through the non-emergency vocational career to become paramedics in in-house training and education. That was the route that I took but predominantly—and this is the work that is being done with Health Education England—it is likely to become a solely graduate career, whether that is in-house vocational graduate education within ambulance services or students coming out of university. I think it is important to give you a sense of the numbers. There is a general acceptance that there are perhaps 2,500 to 3,000 too few paramedics. If we expand in developing specialist areas, as we wish to in mental health and supporting services such as 111, the numbers could be as high as 6,000, which is a very significant problem. It is something that we need to work in partnership to get through because it takes a good number of years—between two to four years—to train a paramedic.

Mr Winnick

Could you give some indication of salary for the position, on average?

David Davis

That is fairly easy. A registered paramedic is an agenda for change band 5 generally across the country.

Chair

How much is that?

David Davis

That would work out, including unsocial hours’ premium and the cost for working out of hours, between £25,000 to £32,000. Forgive me if I am not exactly right. Specialist paramedics would operate at band 6, which would range between £30,000 to £40,000-something; an advance paramedic would be around band 7, which would be between £35,000 to £50,000. The top end is after a number of years of having progressed through pay. The vast majority of paramedics sit in band 5.

Mr Winnick

You would not consider that to be a disincentive?

David Davis

We know that the biggest incentive to retain paramedics is by giving them a career structure and the opportunity to develop academically and in practice, which has been reflected in Sir Bruce Keogh’s recent report into urgent and emergency care that the role of specialist paramedics in primary care have a key role to play. As a college, we believe that the mental health arena is a key area that we need to develop advance practice. With that comes additional responsibility and the ability to earn additional money. One of the things that may impact on this area is the potential for independent prescribing. There is a business case currently going through NHS England in that regard.

Mr Winnick

We know the feelings, Ms Wilson-Palmer, of nurses, do we not, regarding salaries and the rest of it, and the concern that has been expressed very recently?

Karla Wilson-Palmer

Yes. Indeed.

Chair

Indeed. Indeed is a very good word to end this session. I thank all three of you, Mr Davis, Ms Wilson-Palmer and Dr Tacchi, for your evidence. We are coming to the end of our evidence sessions, not today but in the near future, if there is more that you think we should look at, let us know. We would love to have come to Devon and Cornwall—or perhaps Devon and not Cornwall—to have a look and see what you are doing but it is just time that is a problem for us now because we are keen to get this report ready. If there is anything we have missed out, please do not hesitate to write to us and we will include it in our evidence. Thank you.

Dr Tacchi

Thank you.

Chair

That concludes the formal session. Oral evidence: Policing and mental health, HC 202 18