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Cynulliad Cenedlaethol Cymru |
National Assembly for Wales |
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Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon |
Health, Social Care and Sport Committee |
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Ymchwiliad i iechyd meddwl yng nghyd-destun plismona a dalfa’r heddlu |
Inquiry into Mental health in Policing and Police Custody |
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HSCS(5) MHP14 |
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Ymateb gan Mind Cymru |
Evidence from Mind Cymru |
We wholeheartedly welcome this inquiry. Preventing mental health crisis and improving the help and support people receive during a crisis is a key priority for Mind Cymru, our beneficiaries and supporters. We continue to work proactively and in partnership with Welsh Government, health services, Police and other agencies to achieve this aim.
Providing excellent crisis care requires a resolute focus on the person experiencing crisis, recognising them as an individual in-need and responding in a person-centred way. As the Concordat makes clear, supporting individuals experiencing crisis is a multi-agency responsibility that requires a joined-up approach. Discussions that seek to identify who the responsible agency is in any given incident run the risk of detracting from the core principles of the Concordat and losing sight of the key issue; the needs of the person experiencing a mental health crisis.
Since 2016, the UK Home Office has collected and published detailed data on the use of Section 136 in Wales, including the number of detentions, type of place of safety used and method of transportation.[1] The most recent publication covers the financial year 2017-18.
Whilst there is limited evidence available prior to 2016, the National Police Chiefs’ Council previously published data on the number of detentions and type of place of safety used in 2014-15 & 2015-16[2]. Where possible the following tables collate data from both sources.
However, the datasets contain significant gaps, with high numbers of items recorded as ‘other’ or ‘not known’, which limits our ability to accurately understand the use of Section 136 in Wales. Better data collection going-forward is crucial to ensuring effective policy interventions. Moreover, priority must be given to understanding and acting upon the experiences of people detained under Section 136, many of whom will be experiencing a mental health crisis and in need of urgent and compassionate support, regardless of where they turn to for support.
The below table outlines the number of Section 136 detentions by police force area from 2014-18. Whilst the general trend is of increasing detentions, 2015-16 saw a significant reduction. This coincides with development and publication of the Crisis Care Concordat in December 2015 and provides evidence of the Concordat’s immediate success in reducing the overall use of Section 136 in Wales.
When taking into account population estimates for each police force area, it is clear that some forces account for a disproportionate number of detentions in relation to others. However, further evidence and analysis is required to identify the reasons behind the significant geographical variations.
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2014-15 |
2015-16 |
2016-17 |
2017-18 |
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Dyfed-Powys |
197 |
226 |
270 |
239 |
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Gwent |
310 |
266 |
287 |
237 |
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North Wales |
466 |
323 |
589 |
680 |
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South Wales |
749 |
710 |
679 |
799 |
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Total |
1,722 |
1,525 |
1,825 |
1,955 |
The use of police stations as places of safety has fallen significantly over the past four years. The publication of the Crisis Care Concordat in 2015 and subsequently the passage of the Policing and Crime Act in 2017 marked significant reductions in the use of police stations as places of safety, despite the general trend of rising Section 136 detentions. This reduction is to be welcomed and demonstrates the Police commitment to avoiding using police stations as places of safety wherever possible.
In the majority of cases, people detained under Section 136 are brought to a health-based place of safety. Evidence gaps for 2017-18, namely the significant number of ‘not known’ locations makes it impossible to accurately compare changes since 2016-17.
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Health-based Place of Safety |
Police Station |
A&E |
Private Home |
Other |
Not known |
Total |
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2014-15 |
1181 |
541 |
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|
|
|
1722 |
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2015-16 |
1189 |
336 |
|
|
|
|
1525 |
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2016-17 |
1536 |
117 |
41 |
29 |
6 |
96 |
1825 |
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2017-18 |
1333 |
53 |
96 |
0 |
2 |
471 |
1955 |
Since 2016-17 the UK Home Office has collected data on the reason why a police station was used as a place of safety. The available data shows that only a very small number of those taken to a police station following a Section 136 had been arrested for a substantive offence. The most frequent reason is the result of a joint risk assessment, followed by health-based places of safety refusing admission or lacking sufficient capacity. The latter, despite the available figures being small, demonstrates the need for greater capacity within health-based places of safety, be they statutory or third-sector commissioned alternatives.
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Joint risk assessment |
Health-based place of safety - no capacity |
Health-based Place of Safety refused admission |
Arrested for substantive offence |
Other |
Not known |
Total |
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2016-17 |
28 |
5 |
16 |
4 |
42 |
22 |
117 |
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2017-18 |
20 |
7 |
9 |
1 |
14 |
1 |
53 |
Data on the method of transportation used to convey a person to a place of safety has been collected since 2016-17. Despite a significant number of ‘not known’ methods, it is clear that in the vast majority of instances police vehicles are used. Ambulances and other health vehicles are rarely used by comparison.
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Ambulance |
Police vehicle |
Other health vehicle |
Other |
None (already at POS) |
Not known |
Total |
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2016-17 |
124 |
1314 |
10 |
20 |
3 |
354 |
1825 |
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2017-18 |
62 |
1166 |
13 |
5 |
6 |
703 |
1955 |
The available data suggests that the most frequent reason a police vehicle is used to convey a person to a place of safety is the result of a risk assessment. Followed by an ambulance not being requested or being unavailable within a reasonable timeframe. Previous difficulties in accessing ambulances may also be a factor in Police decisions not to request one.
Greater provision of other health vehicles should be prioritised to ensure people detained under Section 136 are conveyed to a place of safety in the most appropriate way, without creating additional pressures on ambulances.
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Ambulance not available within 30 minutes |
Ambulance not requested |
Risk assessment |
Ambulance crew refused to convey |
Ambulance re-tasked to higher priority call |
Not known |
Total |
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2016-17 |
226 |
367 |
493 |
17 |
46 |
165 |
1314 |
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2017-18 |
273 |
215 |
429 |
5 |
9 |
235 |
1166 |
The below table brings together data from the most recently available Welsh Government ‘Admission of patients to mental health facilities’ statistical releases, which contain information on the outcome of mental health assessments undertaken at hospitals following a detention under Section 136.[3] The majority of Section 136 assessments are undertaken at hospital - either in a health-based placed of safety, such as a designated Section 136 suite or in A&E – and this data provides a key insight into the use of Section 136 detentions in Wales.
Crucially, the majority of people detained under Section 136 are discharged following assessment. In 2016-17, for example, 68% of those assessed were not admitted to hospital for treatment, this accounted for two thirds of the overall number of Section 136 detentions that year. This could be for a number of reasons, including people experiencing high levels of distress or under the influence of alcohol or other substances, being detained under Section 136, who, following assessment, are not deemed to need urgent mental health inpatient treatment. Similarly, high thresholds for access to informal hospital treatment may be a factor, whilst this isn’t an issue in and of itself it is compounded by limited access to community-based services. Without greater evidence, both from a service and service-user perspective, it is impossible to fully understand the reasons why the majority of people detained under Section 136 are discharged following assessment and to develop policy interventions accordingly.
However, we know that the police only detain someone under Section 136 when they believe the person is experiencing a mental health crisis and needs immediate care for their own safety, or that of others. Moreover, where possible, a police officer will consult with a health professional for their views before a Section 136 is used. Clearly, those detained under Section 136, regardless of whether they are admitted to hospital following assessment, are in need of some form of help and support; be it short-term or longer-term interventions. Greater availability of other services, for example out-of-hours crisis support in the community or alcohol and substance misuse services, may help to ensure those discharged from Section 136 following assessment go on to receive the help and support they need. Ensuring processes for hospitals to record the support and/or signposting offered to those discharged from Section 136 following assessment would enable policy makers to target interventions most effectively. Similarly, better data collection could allow services to identify any individuals repeatedly detained under Section 136, this would provide an opportunity for learning and to ensure adequate preventative support is put in place for the individual.
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|
Discharged from Section 136 |
Informally admitted to hospital |
Detained under Section 2 |
Detained under Section 3 |
Other |
All outcomes |
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2014-15 |
861 |
292 |
209 |
16 |
20 |
1398 |
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2015-16 |
976 |
271 |
207 |
14 |
11 |
1479 |
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2016-17 |
1211 |
245 |
296 |
16 |
11 |
1779 |
We know that access to crisis care services in Wales is limited and geographically varied. In recent years the number of people referred for support from mental health crisis teams has risen sharply. FOI responses, outlined in the table below, demonstrate the increasing pressure on crisis teams across Wales, with a 17% increase in referrals over the four years to 2018.
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2014/15 |
15/16 |
16/17 |
17/18 |
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Total |
16508 |
17938 |
18079 |
19269 |
A recent report by Health Inspectorate Wales (HIW) and Care Inspectorate Wales (CIW), Joint Thematic Review of Community Mental Health Teams, published in February 2019, confirms the difficulties people often experience when trying to access crisis services. The report found variability across Wales in the response to people experiencing crisis and whilst some received immediate intervention others experienced delayed responses, including struggling to contact services out-of-hours or having to attend A&E for support on more than one occasion. Overall, the report found that people accessing services in a mental health crisis “cannot be assured that their needs are always responded to appropriately and in a timely manner.”
In preparing the report HIW/CIW surveyed current and former service-users and family members or carers. They received responses from over 150 current and former users of Community Mental Health services. Only two fifths (42%) of respondents who had contacted their Community mental Health team in a crisis in the previous 12 months got the help they needed. Similarly, less than half (45%) of family members or carers surveyed felt they got the help they needed when contacting their CMHT in a crisis or with a serious concern.
HIW/CIW also found that initial access to services required improvement across Wales. This is particularly significant for those who may not be known to services before coming into contact with Police. Specifically, the report identifies the need to simplify referral and assessment processes and suggests integrated single points of contact for mental health services as a means of improving processes. This was also highlighted by the recent Health, Social Care & Sport Committee report on suicide prevention, which recommends that a single point of access for specialist services be implemented with pace to ensure timely and appropriate access to support, urgent or otherwise. The inquiry also recommended that Welsh Government outline what more needs to be done to deliver a safe and cost-effective 24/7 crisis care service in all areas of Wales, how this will be done and by when; a recommendation we wholeheartedly support.
Improving access to crisis care services, particularly out-of-hours services, is crucial to both reducing the overall use of Section 136 and ensuring those discharged from Section 136 following assessment go on to receive adequate care and support in the community. Current service provision is inadequate and greater urgency is needed to ensure there are sufficient services in all areas of Wales.
As noted above, there is limited available evidence on the support provided to those discharged from Section 136 following assessment including to which services, if any, they are signposted. However, there is significant evidence available on the effectiveness of care & treatment planning; a key element of the Mental Health Measure 2010. Any person in receipt of secondary mental health services has a right to a Care and Treatment Plan (CTP). This means that anyone admitted to hospital for treatment following a Section 136 detention should receive an individualised CTP, if they do not already have one, which Local Health Boards (LHBs) and Local Authorities (LAs) have a joint duty to implement. Similarly, anyone discharged from Section 136 who goes on to receive support from secondary mental health services, such as a CMHT or CRHT, would also be entitled to a CTP.
CTPs have a specific section dedicated to crisis planning which should outline what action a person should take if they feel that their mental health is deteriorating to the point of crisis. An additional section outlines the signs and symptoms a person might experience if they are becoming more unwell, these are known as relapse signatures and are intended to support an individual to better recognise when their mental health is deteriorating with a view to preventing crisis.
However, there is clear evidence that care and treatment planning is not being conducted effectively. A national audit of the quality of care and treatment planning, published by NHS Wales Delivery unit in July 2018, found that whilst LHBs and LAs are meeting their statutory requirements to produce CTPs, their quality is “generally poor” across Wales. The report also found that “the Measure is not being used as the central document to coordinate and review treatment and care, nor are service users or carers being routinely engaged in the formulation of their CTP as the Measure intended.” In relation to crisis planning, the audit found that “the quality of crisis planning within CTPs was poor” and “where crisis plans were produced, in the vast majority of cases they contained no contingency planning or any clarification of the response the service user or their family might expect in a crisis.”
In preparing their report the Delivery Unit held focus groups to better understand patient and family or carer experiences of care and treatment planning, the findings of which were incorporated into the report alongside evidence from the national case note audit. However, there is still relatively limited evidence on people’s experiences of care and treatment planning. Whilst service users will regularly complete satisfaction surveys for care and treatment planning, the results of these surveys are not published. This is despite the Duty to Review post legislative assessment of the Measure, published in 2015, recommending that all health boards report on the findings of care and treatment planning satisfaction surveys annually from 2016. As such, there is no evidence that the results of these surveys are being used to improve services and inform national policy.
The report on CMHTs in Wales conducted by HIW/CIW, referred to earlier, supports the findings of the Delivery Unit Report. Particularly in relation to crisis planning, the HIW/CIW survey of current and former service-users found that half (51%) of respondents did not know how to contact the CMHT out-of-hours service. Similarly, less than two thirds (60%) of family members or carers said that they would know who to contact in the event of a crisis or serious concern. As part of our own work to improve crisis care services as Mind Cymru, we wanted to better understand the effectiveness of care and treatment planning for people who had experienced acute mental illness or a mental health crisis. We surveyed over 150 people who had been treated as a mental health inpatient either formally under the Mental Health Act or as a voluntary patient. More than half (52%) of respondents told us that their CTP did not set out how they could access support if their mental health deteriorated or they experienced crisis. In the following month after discharge from hospital, 1 in 10 (13%) of respondents attended A&E as a result of their mental health.
There is little evidence of the effectiveness of care and treatment planning that relates specifically to people detained under Section 136. However, there is overwhelming evidence both from services and service-users that multi-agency care planning for people with mental health problems is not being delivered effectively. In particular, care and treatment planning is not being used as an opportunity to effectively prevent crisis, as intended by the Measure. Improving the quality of CTPs would help prevent mental health crises occurring as well as reducing repeat detentions and the overall use of Section 136. We would recommend that staff receive regular training on producing quality CTPs and that LHB’s conduct regular audits with a view to improving processes.
As noted above, more evidence is needed to understand how people supported by police or at risk of detention under Section 136 feel about the support they receive. However, anecdotally, many of those we have consulted with have been grateful for the support they received from Police during crisis. This challenges the general assumption that people experiencing a mental health crisis have negative views of being detained by police.
Whilst being detained may feel stigmatising for some people, our experience is that many are simply grateful to receive the support they need; so long as it is handled appropriately and sensitively. However, we know that in some cases this is undermined by the lack of provision following assessment; particularly if the person is discharged and signposted back to services they have struggled to access previously.
Mind Cymru’s Blue Light Program, which was launched in Wales in 2017, offered support to emergency services staff and volunteers in the police and other services. The Program provided training to staff to help them manage the situations they face, as well as training for managers to offer support to their teams. As part of the program Mind Cymru also established a network of Blue Light Champions to support and advocate for colleagues, as well as a wider peer support network within the emergency services in Wales. Research published in 2018, which looked at the impact of the Blue Light Program on the public across England and Wales, highlighted evidence that providing training in mental health awareness in the workplace is helpful in reducing stigma and also in changing people’s attitudes. Those who completed training were shown to have increased knowledge in recognising signs of distress and attitudes shifted towards becoming more compassionate. Ensuring that police staff receive adequate mental health support and training alongside tackling mental health stigma will have the added benefit of enabling police to better support people experiencing a mental health crisis.
The Mental Health Crisis Care Concordat is an ambitious agreement between Welsh Government and partners to improve care and support for people experiencing or at risk of a mental health crisis. The Concordat is underpinned by the following four core principles and expected outcomes:
Effective access to support before crisis point
Urgent and emergency access to crisis care
Quality treatment and care when in crisis
Recovery and staying well
Mind Cymru has actively supported the work of the Concordat, in particular through having chaired its Task and Finish Group Board (on behalf of the Wales Alliance for Mental Health) and assisting in its coordination. The Group had a focused remit on tangible improvements that could be made in support of achieving the ambitions set-out in the Concordat, including reducing the use of police cells in favour of health-based places of safety. This initial approach rightly focused on the moment of crisis as this was where problems were most acute and inter-agency working wasn’t as effective as it could be. This contributed to some immediate successes, including vastly reducing the number of people detained in police cells during a mental health crisis and largely ending the practice for those under the age of 18. However, the use of Section 136 only makes up part of the Concordat agreement and significant improvements are still required to realise the overall commitments it sets out.
Mind Cymru have since further supported the delivery of the Concordat, in particular through having chaired the Welsh Government Crisis Care Concordat National Assurance Group, and through providing ongoing co-ordination support with Welsh Government funding. The Group is made up of representatives from local implementation groups and key partners including Welsh Government, Police and health services, and is responsible for ensuring joint-working and the overall delivery of the Concordat, reporting directly to the Minister for Health and Social Services. This work is now underpinned by a three year delivery plan, covering 2018-2021. The delivery plan is guided by the Concordats key principles and expected outcomes whilst adding a further two:
Securing better quality and more meaningful data, with effective analysis to better understand whether people’s needs are being met in a timely and effective manner
Maintaining and improving communications and partnerships between all agencies/organisations, encouraging ownership, and ensuring people receive seamless and coordinated care, support and treatment
Whilst progress has been made, a focused
approach and greater urgency is needed if we are to truly deliver
the Concordat in full and transform the way in which we help those
experiencing a mental health crisis. There continue to be issues at
the moment of crisis that require effective partnership working and
focus but crucially this must be matched by significant
improvements to prevention, follow-up support and recovery.
Conclusion
The use of Section 136 in Wales continues to rise in-line with increased pressures on mental health services. Further investigation is needed to understand the reasons underpinning the substantial regional variance in the numbers of people detained. Significant progress has been made in reducing the use of police stations as places of safety however, pressures on ambulances and the lack of alternative health vehicles means that police cars are most frequently used to convey people to a place of safety following detention.
Crucially, the majority of people detained under Section 136 are discharged from hospital following assessment. Understanding the reasons behind this and what signposting and support is provided to those discharged is central to reducing repeat detentions, the overall use of Section 136 and, most importantly, ensuring that those experiencing a mental health crisis get the help and support they need. Better data collection generally, and in particular in relation to those discharged from Section 136, will enable decision-makers to target interventions most effectively.
Moreover, priority must be given to understanding and acting upon the experiences of people who have experienced a mental health crisis. Citizen ‘voice’ is one of 10 National Principles in A Healthier Wales yet it is clear that the voice of those who experience crisis is not currently being heard effectively or used to inform services.
Access to mental health services, particularly out-of-hours, needs to be urgently improved. Recommendations for improving services have been made by both the Health, Social Care & Sport Committee and HIW/CIW and should be taken forward with pace. This includes the provision of a 24/7 crisis care service and single points of contact for mental health services. Greater resources are required to ensure that people who contact mental health services in a crisis receive timely care and support. Similarly, there is clear evidence that care and treatment planning is not being used as intended by the measure, particularly in relation to preventing crisis. Improving care and treatment planning must be urgently taken forward.
Responding to mental health crisis is a multi-agency issue that requires a multi-agency response. This should apply the principles of the Future Generations Act by placing the person in the centre of public services to provide the best support possible. Partnership-working must focus on how this is achieved and avoid detractive discussions that focus on which agency is most responsible.
The development of the Concordat and subsequent related work has been successful in reducing the use police cells, encouraging better partnership-working, increasing the priority afforded crisis care, securing additional funding and crucially, raising awareness of the key issues. The focus now must be on implementation and driving through the delivery of the Concordat.
Ultimately, delivering on the ambitious goals set-out in the Concordat requires transformative change to mental health services with a much greater focus on prevention, early-intervention and recovery. This will require innovation, partnership-working and adequate resourcing and in-turn will lead not only to reduced detentions under Section 136 but ensure compassionate and effective support is provided to anyone experiencing a mental health problem.
All partners to commit to the full delivery of the Crisis Care Concordat National Delivery Plan 2018-21
Improved data collection in relation to Section 136 including the signposting and support provided to those discharged following assessment
All partners to ensure that the voice of those who experience crisis is effectively captured and used to improve services
Welsh Government to outline a route-map and timeframe for the delivery of an effective 24/7 crisis care service across Wales.
Concordat Assurance group to develop plans to increase capacity of health-based or alternative places of safety and non-ambulance health vehicles for conveyancing
Local health Boards to implement with pace and in a uniform way across health boards a single point of access for specialist services and ensure timely and appropriate access to support, urgent or otherwise.
Mental Health Service staff to receive regular training on producing quality care and treatment plans and Local Health Boards conduct annual audit to provide assurance and with a view to improving practice
Mental Health Services to ensure that service-users know how to contact them in the event of a crisis
[1] https://www.gov.uk/government/statistics/police-powers-and-procedures-england-and-wales-year-ending-31-march-2017
[2] https://news.npcc.police.uk/releases/use-of-police-cells-for-those-in-mental-health-crisis-more-than-halves
[3] https://gov.wales/statistics-and-research/admission-patients-mental-health-facilities/?lang=en