Monday 20 February 2012

Safe and Well?

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

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

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

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

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

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

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

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

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

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

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

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

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

We know that the police and ambulance service will be managing these things tonight - regardless of what day you're reading this. The answer is not necessarily 'police' or 'ambulance' and sending these professionals to safe and well checks creates exactly such a scenario. Even if you send them - maybe send the police to the RAVE risks, and the ambulance to the other jobs - they will still need necessary pathways available to them.

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

To read DiagnosisLOB's thoughts go and have a look @MentalHealthCop website!


  1. Excellent Blog!

  2. Brilliant interaction thank you both and all I have said on MHC blog applies here.
    Agree: "So it emerges asking for a "quick safe and well" is too simplistic a description of a fairly complex problem that neither police nor ambulance are necessarily best placed to solve.It is for NHS Commissioners and Service Managers and for inpatient nurses who ask for this to be done."
    Well said!

    1. Thank you for taking the time to read our posts. Very much appreciated!

      Ella x

  3. Fantastic Fantastic post from the both of you. It is so refreshing to see professionals from different services attempt to tackle contentious issues head on. Your blogs are two of the best blogs out there, i'm not kidding. They are both extremely well written with excellent content. I hope you both work together on future posts as it shows a solidarity between the services which carries some real weight behind it. Congratulations both of you for a job very well done.

    1. Please pass these comments on to MentalHealthCop. I was unable to post this message on his page too. Thank you again both of you.

    2. Thank you very much for you comment. I'll pass the message on to Mental Health Cop

      Ella x

  4. So refreshing to witness open and fair discussion Ella. I will post and comment to Mental Health Cop also. I feel you could both be part of a paradigm shift in behaviours with this subject, if only because you, and your respective readers are both able to circumvent the endless red-tape.
    I can share that ever-so-slowly, mental health providers are finally seeking to open up appropriate pathways and signposting via a 24/7 service 'staffed by mental health professionals'! This will start to provide the change in the current culture of 1- Everyone calling 999 for police/ambulance to mental health issues over which both are poorly equipped to deal. And 2- If 999 is called, a referral route for responders either via control or attendance to refer to appropriate agency hitherto unavailable.
    I think if you guys can continue to share your situations, frustrations and expectations - you can recover even more of the great relationship the police and ambulance used to enjoy - despite the cutbacks and operational pressures. Well done
    Brief bio - (Recently retired Paramedic and mental health lead - Currently mental health provider governor and counsellor in private practice)

  5. Thank you for taking the time to look at the problem of mental health. A lot of EMS blog skirt over or around the issue but i'm glad you have tackled it head on and done so with another service. You both gave very balanced and well argued views. I was a paramedic for 8 years and a technician for 11 years and with that experience I saw a lot of what you have. I also saw a number of staff go off sick with depression, anxiety, stress and even PTSD, so I would ask you, whilst you are dealing with patients with mental health problems how is the mental health of the service employees and is the support there if it is needed? Be interested to hear you thoughts on the issue. Thank you.

    1. Thanks for the positive comments, always good to hear. Regarding your question what I think I will do is write a blog on the issue. It is prevalent and should be highlighted. Watch this space!

      Ella x

  6. Sorry I am a bit late to the discussion! I have posted this to both blogs! This is my opinion from a service users perspective. I was brought up to see the emergency services as just that - for emergencies.

    My perception of the police (rightly or wrongly) is to be slightly scared of them. They are a body of authority and power and one that I have never wanted to mess with. As a child/teenager, if the police were ever mentioned, it put the fear of God in to me and immediately would behave! With those connotations, would I therefore want them turning up at my door? A resounding no!

    On the other hand, I see the ambulance service as, again, an emergency service. If it isn't life threatening then they shouldn't be there. There are many people who need them in the correct capacity to also add in non-urgent tasks (I know they get called to them all the time from time wasters, but it shouldn't be an added requirement of their role).

    So taking out the 2 options, who could be do the role? I obviously have no answer to that and don't know the workings of public sector organisations to be able to give an informed option. However, in my eyes, if social workers took that role, then it would free up the emergency services and I wouldn't feel as if I am taking a resource away from someone in more need than me (which is a huge thing where mental illness is concerned!!)


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