“A Police State of Mind” – or “Systemically Created Emergency”

“The police service is being increasingly used as the service of last resort….and play too large a role in dealing with people with mental health problem”   State of Policing 2017” Sir Tom Winsor, Chief Inspector of Constabulary

A couple of decades ago, when clinical notes were bundles of papers piled up in the drawers of khaki cabinets arrayed along a damp asylum wall, a modest piece of research flashed a brief beam of light on the strange world of mental health.  It concluded that the clinical assessment and diagnosis of patients brought to emergency departments by worried relatives were largely superfluous because they had already made an accurate (if lay and jargon-free) diagnosis of the mental health problem they had been contending with.

Relatives know, just as immediate neighbours know - and often the people behind the till in the corner-shop know.  And, more important, they know it when the first flicker of mania or instability reveals itself and, almost immediately, begins again to undermine the foundations of their relationship, often introducing uncertainty, dilemma and fear.  

But they don’t know what to do and all round the UK a vignette of prevarication, delay and crisis begins to play itself out.  Family members recognise the signs of illness but dread what they portend. At first, they may hope they are wrong or that this time it will be different.  Their wishfulness is likely to be shared by their relative/patient who has not yet reached the stage of reluctant acceptance of the burden of illness so that an apparent return to normality, evidenced, perhaps, by a continuing ability to be a good-enough parent or employee, is welcomed and decisive intervention delayed.

Further incidents or behaviours will indicate that a well-known sequence is under way but different relationships interwoven with different levels of tolerance may create or simply feed into intra-familial conflict further postponing help-seeking.     Eventually, maybe months after the first, determining event, a family member – generally the one with a relationship uncluttered by too much emotion or transference – will go to the least inaccessible agency which deals with health problems, that is the local GP surgery.  At this point, new considerations will add further links in the chain of delay - for example, worries about confidentiality and the resulting expectation that the sufferer should go to see the doctor him- or herself.  The GP’s own past experience of or bias against the specialist, secondary mental health services to whom he or she should refer may have led to distorted or constricted channels of communication which impede or slow a referral onwards.

When eventually the pressure of acuity and risk leads a GP to refer on, a late-stage request for intervention meets a dense nexus of bias, reluctance, resistance and muddle about the objective task on the part of the receiving agency. An ingrained belief that GPs over-state urgency is likely to combine with an institutionalised instinct to restrict workload and, perhaps above all, a fear that intervention will not only increase workload (mainly in the form of unproductive, if less stressful, bureaucratic activity) but leave community mental health team staff, now so remote from the safer haven of a hospital ward, holding risk and anxiety without a solution. 

Thus there are powerful disincentives against action and perverse incentives to create reasons for inaction.  What should be the central, collective, institutional task – making sure that all patients receive the optimal treatment in the most appropriate place as promptly as possible – is, if it actually has a pulse anywhere in the organisation, shut out by local imperatives and concerns. Staff who are perhaps instinctively responsive and keen to intervene may be felt by colleagues to be letting the side down or creating a dangerous precedent by being too eager to take a case on. Thresholds or remits (so often vague in operational policies or procedures) may be manipulated to justify inaction. Or the excessive demarcation which is a product of the chopping up or de-integration of services (for example, along diagnostic lines, according to speed of response or likely length of treatment or age, and so on) which is so favoured by NHS Trusts at the moment leads to time-consuming wrangling at the boundary about whose vague or sometimes over-complex criteria the patient meets.

When the referral eventually penetrates the protective shield of the recipient service, logistical wrinkles take time to be ironed out.  Phone numbers are wrong or not supplied; there is uncertainty about the lead relative; an entry-phone to the block of flats is broken so the patient is now physically inaccessible as well as almost certainly psychologically inaccessible.

When there is a lack of focus on or interest in outcomes, outcomes will create themselves.   Thus the collective, almost collusive, now institutionalised delay judders towards its inevitable denouement.  The person of concern, no longer able to resist the current of mania or the instructions of imagined voices, will appear in the street or on the bus or even at the doctor’s surgery out of mind and out of control.  Agencies which can say no are now supplanted by the agency that can’t say no, namely the police.  Thus slowly emerging symptoms playing out under the passive surveillance of the agencies commissioned to treat them reach the manufactured emergency which obliges an agency set up to fulfil entirely different functions to intervene.

Research shows that patients and relatives are generally more satisfied with the actions of the police in a crisis than they are with those of clinical staff. Transference (that is, an underlying emotional response) to the police is cleaner and simpler than it is to those caught up in the tangle of muddled roles and confused expectations. Mostly, they are experienced as containing parent figures with an ultimate reserve power hedged in by the law and their emotional antennae switched off by role.  Uniform and the devices which are draped from it announce what the patient already knew but was too overwhelmed to concede – that things have gone too far.   

In fact there are few objective crises in mental health.  Occasionally, mania or delirium may strike, often induced by street drugs or even prescribed ones such as steroids, or a product of acute infection or brain abnormality. Suicidality may peak suddenly and mental illness around childbirth can develop quickly and dangerously. These relatively rare events apart, there is no direct equivalent in the mind of the heart attack, stroke, ruptured aneurysm or life-threatening accident.  Yet A+E has become the default destination for the disaffected, dejected and derailed as it has for those with a wide range of routine physical discomforts, over 40% of whom are sent home without any intervention at all.  It has become a good that we are entitled to, a source of witness, recognition and validation which we must not be denied. 

The majority of mental health visits to A+E and contacts with the police are indicative of clinical abdication or passivity induced by institutional folly and the perverse structures it gives rise to.  Unambitious but well-functioning generic mental health teams with a broad range of functions (intake, assessment, brief or long-term; low-key or intensive; frequent or occasional clinical contact etc) and long-serving staff who worked with relatively small constituencies and built up a productive and protective knowledge of patients and their networks were nuked by gurus with new ideas backed by questionable research and the concept, mistakenly imported from physical health, that services should be sliced into slivers of specious specialisms.

An unintended consequence of the paranoid fixation on risk is that A+E and the police have become the default resource in mental health work.  Instead of promoting resilience, self-sufficiency and the capacity of informal networks, staff exhort parents or other key relatives to involve the police, oblivious to the trauma of doing so, and plans of care explicitly encourage attendance at A+E which, if it happens, is now a reassuring sign of clinical success instead of being a source of shame for clinical staff. Thus, perversely, the last resort has actually become an integral, unexceptional part of the day-to-day service.

Big, glaring problems do not always need hefty remedies.  They are simple but the NHS does not do simple, a failing which will eventually seal its demise.

• Ditch the metaphor of embattled staff fending off the cohorts of illness at a mythical “front-line” with essential reinforcements being denied by reactionary leaders
• More can be done with less
• Line up incentives, imperatives and institutional goals and ensure they are the same for all parts of the service
• Inculcate the nature and primacy of the product: the best treatment as early as possible
• Disperse self-serving internal professional guilds
• Make sure secondary mental health services are the servant of GPs, patients and relatives, not the ring-master
• Prize structural simplicity, responsiveness, continuity, interaction not transaction (i.e. relationship v the interchangeability of staff) and accessibility
• Attend to the creation of un-patients as much as patients (i.e. guard against the invention and elasticity of mental disorder)
• Make sure the organisation is internally boundary-lite
• Build in spare capacity from the start instead of craving it when it is too late
• Base all activity on the truism that where there is no brake on demand supply will always be overwhelmed