Cynulliad Cenedlaethol Cymru	National Assembly for Wales
Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon	Health, Social Care and Sport Committee
Ymchwiliad i iechyd meddwl yng nghyd-destun plismona a dalfa’r heddlu	Inquiry into Mental Health in Policing and Police Custody
HSCS(5) MHP02
Ymateb gan Goleg Nyrsio Brenhinol Cymru	Evidence from Royal College of Nursing

Response from the Royal College of Nursing Wales to the Health, Social Services & Sport Committee’s inquiry into mental health in policing and police custody

The Royal College of Nursing Wales is grateful for the opportunity to respond to this consultation and would like to raise a number of points in relation to the inquiry:

Whether there are sufficient services (i.e. health and social care services) available to support police officers in Wales to divert people with mental health problems away from police custody.

The RCN maintains that it is unacceptable to hold mentally ill individuals in police custody suites, and the practice of detaining people under section 136 of the Mental Health Act should only occur in exceptional circumstances. People in mental health crisis are amongst the most vulnerable in our society, and sufficient investment must be made in services to meet there needs. The inappropriate detention of people within a police custody suite, or people with mental health needs being drawn into the criminal justice system unnecessarily, must be avoided at all costs.

Effective workforce planning is essential to ensuring that there are sufficiently staffed services to divert people with mental health issues away from police custody. Registered Nurses play an important role in these services and thus need to be integral in the workforce planning. They also play a vital role in helping to divert people with mental health problems away from policy custody. There must be sufficient Criminal Justice Liaison Nurses working within Health Boards who can work to divert vulnerable people away from police custody, and also sufficient numbers of Mental Health Nurses employed to work directly with the police to triage, support and treat individuals.

RCN Wales suggests the Committee may wish to ask Welsh Government if and when they intend to extend the Nurse Staffing Levels (Wales) Act 2016 to mental health settings.

The availability of safe spaces for people in states of mental health crisis is also important. Whilst police cars and police stations are not the best place for mental health patients, the hospital environment, although often preferable, is not always ideal, particularly if it involves waiting in A&E. Anxiety, distress and disorientation can be exacerbated in these environment. Section 136 psychiatric suites for use by health practitioners and the police to hold people under the Mental Health Act should be available across Health Boards in Wales, and these suites must be staffed by appropriately qualified health professionals.

The Committee may want to ask Health Boards for data around the availability of 136 suites, and the instances in which those suites have not been available to the police.

Early intervention to avoid mental ill health reaching the point of crisis is crucial. For example, mental health support services such as talking therapies, counselling, and community mental health teams should be available to all those who need them. Having access to different treatments and therapies can prevent mental health issues becoming more severe. This applies also to children and young people, for whom the role of School Nurses, Learning Disability Nurses and Child and Adolescent Mental Health Services (CAMHS) are very important. 

Early intervention also includes investing in childhood services such as Health Visitors who are able to work closely with families and young children to identify and manage emerging issues, monitor cognitive and emotional development of babies and children, as well as empowering new parents to access specialised support including maternal mental health or domestic abuse services. There is overwhelming evidence that a supportive home environment is positively associated with children’s early achievements, attentiveness at school, and their physical and mental health.

Important to note is the prevalence of mental health issues occurring in police work. According to data collected across all Welsh police forces as part of Mental Health Demand Day in 2018, 200 mental health incidents requiring police involvement were recorded, representing 9.5% of all police incidents during the Demand Day period. Clearly this is a significant proportion of police time and resources, and it is vital that they are supported by appropriately qualified mental health professionals, such as Mental Health Nurses, in responding to those incidents.

Whether local authorities and health services are meeting their duties and complying fully with legislative requirements to provide appropriate places of safety to which the police may take people detained under section 136 of the Mental Health Act 1983.

Investing in and growing the workforce is essential. The need for safe staffing levels in order to best meet the needs of vulnerable people applies as much in responding to people in mental health crisis, as it does on hospital wards or in care homes. Appropriate qualified staff need to be employed in the right numbers and in the right settings in order to ensure that local authorities and health services are able to meet their duties and comply with legislation.

It is understood from information provided to us by our members, that a significant number of Custody Nurses working within custody suites in Wales are not specifically mental health trained. Mental Health Nurses are specifically trained to work with individuals with complex and severe mental health issues, and are ideally placed to identify how their needs can best be met. The Committee may want to consider whether a standardised all-Wales job description or competency framework for all new Custody Nurses may help improve consistency in this area.

It is also important to acknowledge that in some instances of mental health crisis or psychotic episodes, patients can become distressed, violent and abusive. This can be often be attributed as much to feelings of anger or fear as it can their mental condition. Specialist Mental Health Nurses will have knowledge and skills in de-escalation, which can help prevent verbal abuse developing into physical violence. These skills should be acknowledged and utilised for the benefit and safety of patients, staff and the general public.

The graph below shows the commissioning numbers for nurse education places in the field of Mental Health. The graph shows that whilst there has been an increase in the number of commissioned student places over the past few years, for 2019 these figures remained static. The RCN is very concerned that this will mean that the capacity of the workforce will not be sufficient to meet demand.

Adherence to the Code of Practice to the Mental Health Act 1983 which requires that people detained under that Act should always be conveyed to hospital in the manner most likely to protect their dignity and privacy – taking account of any risks (i.e. by ambulance which should be made available in a timely way, as opposed to police transport).

The RCN maintains that adherence to this Code is paramount, and an important part of delivering person-centred care in the right place at the right time. It is also important to recognise however the safety risks for healthcare workers and clinicians which can sometimes be involved in dealing with people severe mental health problems. Experiences of violence and aggression towards NHS workers is not uncommon. According to the NHS Staff survey conducted in Wales in 2016, 11% of all staff stated that they had experienced physical violence at work from patients/services users, their relatives or other members of the public. The data on assaults also shows that rates are much higher within mental health units compared with the acute sector.

Some types of violence encountered by nurses can be related to a psychotic condition, but anger or fear are just as likely to lead to violence in mental health settings. Not only is it important then that people are transported in a way that protects dignity and privacy, it is also important that training is provided to all professionals who may find themselves encountering physical violence and abuse. This applies not just to employees of Health Boards but to employees within police forces too, and Mental Health Nurses can play a role in delivering this training. Specialist Mental Health Nurses will also have knowledge and skills in de-escalation, which can help prevent verbal abuse developing into physical violence. These skills should be acknowledged and utilised and Mental Health Nurses should be sufficiently deployed across Wales to work directly with patients and the police.

How effectively police forces in Wales work with partners (such as health or social care services) to safeguard vulnerable people in police custody, and how well the police themselves identify and respond to vulnerable people detained in custody, specifically those arrested under section 136 of the Mental Health Act 1983.

Integrated mental health teams working directly with forces, in control rooms, custody suites and on the ground is hugely important, and nurses should be enabled to play strong roles within these multi-disciplinary and multi-agency teams. The police depend upon good nursing support and leadership to cover clinical needs. The November 2018 report ‘Policing and Mental Health: Picking Up the Pieces’ highlighted the value of mental health nurses working with police forces and being available for triage when police are responding to calls from people in crisis.

Dyfed Powys Police and Hywel Dda University Health Board have operated a mental health triage service since launching a pilot scheme 2014. Police officers work side-by-side with health professionals to ensure those suffering mental health distress get the right attention and support. This multi-agency approach enables access to patient records, information, intelligence, and specialist advice to enable better decision-making at the scene of incidents. It also means that there is a wider range of options available to police officers as alternatives to detentions under Section 136 of the Mental Health Act. The system has also improved communication between agencies.

Another example of partnership working can be seen in Aneurin Bevan Health Board which employs a Mental Health Nurse to work in emergency control rooms responding to 999 calls from people in mental distress. With access to medical records they are able to triage the patient over the phone and work with the police on the most appropriate next steps for the individual. Betsi Cadwaladr University Health Board are also looking to initiate the service.   

Other ways in which Mental Health Nurses can be involved includes having mental health nurses in control-rooms with access to medical records so that they can advise officers on the ground, or having helplines available 24/7 or at peak times, with access to specialist mental health nurses who can speak directly with people in need of specialist advice, support or referral.

RCN Wales suggests the Committee may want to ask how these areas of good practice are being rolled out across Wales and to what kind of timeframe.

The effectiveness of multi-agency care planning for people with mental health problems when leaving custody, specifically for those detained in police custody under section 136 of the Mental Health Act 1983 to help to prevent repeat detentions.

Police forces, Local Authorities and Health Boards working together is essential for ensuring that the health and care needs for people with mental health problems leaving custody are met. Effective care planning for those leaving custody is important not only for the welfare of the individual, but also to help avoid people being brought into police custody unnecessarily and to minimise hospital admissions.

The RCN believes that effective care planning is an area where further work is needed in order to better protect vulnerable people. For instance, there is no built-in mechanism in the existing system whereby multi-agency reviews are automatically triggered for individuals who are repeatedly referred by the police to mental health teams. This means that agencies are not always routinely working together with individuals to achieve the best outcomes for those with mental health problems, and that repeat detentions are not always avoided. Better mechanisms around multi-agency care planning should be developed and implemented across Wales in order to improve the experiences of people with mental health problems leaving custody.

Whether effective joint working arrangements are in place, with a specific focus on implementation of the Mental Health Crisis Care Concordat, including whether the Welsh Government is providing sufficient oversight and leadership.

One area working well is that within Health Boards and police forces, there are dedicated points of contact who lead on mental health crisis care. There are clear lines of communication between these dedicated points of contact and different agencies and this has improved partnership working.

Other issues not covered elsewhere

If the Mental Health Act is reformed by the UK Government, key stakeholders including nurses and service users in Wales must be engaged with and involved in developing options for reform. The impact on Welsh legislative frameworks and practices must be taken into account. Equally, if existing Welsh legislation and frameworks are revisited, the nursing workforce and those using and experiencing the service must be involved in developing any proposals for change.

About the Royal College of Nursing

The RCN is the world’s largest professional union of nurses, representing over 430,000 nurses, midwives, health visitors and nursing students, including over 25,000 members in Wales. The majority of RCN members work in the NHS with around a quarter working in the independent sector. The RCN works locally, nationally and internationally to promote standards of care and the interests of patients and nurses, and of nursing as a profession. The RCN is a UK-wide organisation, with its own National Boards for Wales, Scotland and Northern Ireland. The RCN is a major contributor to nursing practice, standards of care, and public policy as it affects health and nursing. The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.