The Garage, 14 Chapel Field North, Norwich. NR2 1NY

Programme

Time Topic Speaker / Facilitator

13.00 – 13.10 Welcome on behalf of governors Guenever Pachent (Lead Governor, NSFT)

13.10 – 13.20 Overview of event Barry Capon (Non-executive Director, NSFT)

13.20 – 14.20 What happens when someone is mentally unwell and needs urgent help in the community?

10 mins A service user’s experience of S.136 (Journal article summarised by Robert Nesbitt, Trust Secretary, NSFT)

15 mins Police perspectives including an overview of S.136

Insp Chris Galley (Suffolk Constabulary) Chief Insp Amanda Ellis (Norfolk Constabulary)

15 mins AMHP perspectives including an overview of S.135

Stephen Webster (Approve Mental Health Practitioner)

15 mins Transporting people safely, including new developments

Tim Hayes (East of England Ambulance Trust)

14.20 – 14.45 Questions and discussion from the audience Barry Capon (NSFT Non-executive Director)

14.45 – 15.00 Break for tea and networking

15.00 – 16.00 At the S.136 suite Helping people in acute distress to feel safe Assessment skills What happens next? Helping people who repeatedly present under S.136

Jenny Thurston (Modern Matron, NSFT) Stephen Webster (AMHP)

16.00 – 16.45 Questions and discussion from the audience

Barry Capon (NSFT Non-executive Director)

16.45 – 17.00 Thanks and closing comments

Barry Capon / Guenever Pachent

Policing and mental health 5th March 2014

Finding your way around the services flowchart…

Person with a mental health problem in acute distress and in

need of help

At home? In a public place?

S.136 of the

Mental Health Act (1983)

S.135 of the

Mental Health Act (1983)

Police take the person to a

place of safety – usually the

S.136 suite at the local mental

health hospital

At the S.136 suite the person

is assessed by a doctor and an

AMHP. They can be held for

up to 72 hours

Admission to hospital

Informally or under a section

of the Mental Health Act

Community support or no

further action

Magistrate hears evidence and

issues a warrant which allows

police, doctor and AMHP to enter

and see the person

The person is often then taken to

hospital to be assessed by a

doctor and AMHP. They can be

held for up to 72 hours.

Page 1 of 2

Policing and mental health event 5th March 2014

“Jargon Guide”

AMHP AMHP (pronounced AMP). Approved Mental Health Professional. This role used to be called an Approved Social Worker. Most AMHPs are still specially trained social workers but we can expect to see more AMHPs from other professions over time. When someone needs to be assessed to see whether then need to be detained and treated against their will ("sectioned") it is the AMHP who coordinates the assessment. They gather information; liaise with the care coordinator, psychiatrist, GP, police and ambulance. It is the AMHP who makes the application to section someone based on the recommendations of (normally) two doctors. They make sure that the person is assessed properly before a decision is made, that the section papers are properly completed if this is needed, and that arrangements are made for the person to get to hospital safely.

Informal admission

This is where someone decides that they want to be in a mental health hospital and to accept treatment there.

S.136 This refers to S.136 of the Mental Health Act (1983). When someone is in a public place (a place where the public normally have access) and they seem to be mentally unwell and in need of help, the police can use S.136. S.136 only applies when someone is in a public place. The person has to be vulnerable or present some risk to other people. Obviously, to intervene in this way as a citizen goes about their business is quite a big step and one that the police don't take lightly. The power allows the person to be detained for up to 72 hours in a place of safety so that an assessment by mental health professionals can take place. For many years the police station was often used as a place of safety. In the last decade there has been a growing understanding that for most people with mental health problems a police station is not the right place. We now have special S.136 suites at our main mental health inpatient units.

S.135 So what happens if the person is somewhere else, in a private place such as in their own home? This is where S.135 comes in. Forcing entry to someone's home is of course a very serious step and so a warrant is needed. S.135 applies when someone is in a private place. Normally the AMHP will present evidence to a magistrate explaining why the warrant is needed. There needs to be sufficient evidence not just that they are mentally unwell but also that there are risks. The warrant enables the police along with the AMHP and a doctor to force entry to the residence. They then make a decision as to whether the person needs to be taken to hospital for assessment. Again this is for up to 72 hours.

S.2 Often called an assessment section, allows someone to be detained and treated for up to 28 days.

S.3 Often called a treatment section, allows someone to be detained and treated for up to 6 months.

S.4 Often called an emergency section, allows someone to be admitted for up to 72 hours and the person is then admitted informally, or on a section 2 or 3, or discharged

1

This factsheet looks at section 135 of the Mental Health Act. It gives information on the professionals you might come across, when this section is used, how it is carried out, what your rights are and what could happen afterwards. This factsheet covers: 1. Professionals you might come across 2. When is this section used? 3. How is the section carried out? 4. How long will I be on this section? 5. What are my rights? 6. Can I be treated against my will? 7. What might happen after this section?

Section 135 The police taking you to a place of safety from a private place

• The Mental Health Act is the law which can be used to admit you to hospital for assessment and/or treatment for a mental illness.

• The police can use section 135 of the Mental Health Act to take you to a place of safety when you are in a private place. They can do this if they think you have a mental illness and are in need of care.

• A place of safety can be a hospital or a police station. The police can move you between places of safety.

• The police can keep you under this section for up to 72 hours. • During this time, mental health professionals can arrange a

Mental Health Act assessment for you. This will look at if you need to be in hospital because of your mental health.

• After being assessed, you might be sectioned using the Mental Health Act, or nothing further might happen and you could be free to leave.

• You have rights while under this section, such as getting legal advice, the police or hospital telling someone where you are and getting treatment from a healthcare professional.

1. Professionals you might come across

There are different professionals that might be involved in your care while detained under the Mental Health Act. We talk about some of these professionals in this factsheet:

Approved Clinician (AC) – an AC may be a doctor or another mental health professional such as a psychologist, nurse, occupational therapist and social worker who is allowed to use the Mental Health Act. For example, they can assess you for mental illness. Approved Mental Health Professional (AMHP) – this could be a social worker, psychologist, nurse or occupational therapist who is allowed to use the Mental Health Act. They can apply for you to be admitted to hospital under a section of the Mental Health Act. The AMHP needs to assess you and your situation to make sure that detention in hospital is the most appropriate way of providing the care and treatment you need. Police – they need to decide whether you meet the criteria for using section 135. They should take you to a place of safety either by calling an ambulance or in a police vehicle. Custody Sergeant - you might come across this person if you are taken to a police station as a place of safety. They are responsible for the safety of everyone at the police station, and to make sure you understand why you are there and your rights.

Top

2. When is this section used?

The police can use this section when you are in a private place (such as your home) and you are not able to care for yourself, or if you are living with someone and it is thought you are not being taken care of properly.

Top

3. How is the section carried out?

There needs to be evidence to suggest that a mental health care professional needs to assess you. For example, a friend or relative may have raised concerns about how you are. An Approved Mental Health Professional (AMHP) can then get a warrant from a magistrates’ court. This gives the police permission to access your property. Police can act as escorts for professionals who are taking you someone for an assessment or taking you to hospital. The AMHP would usually be in charge of the assessment and direct the police. The police should try and take you to a healthcare setting such as a psychiatric hospital or the Accident and Emergency part of a hospital. They can use a police station, but only in exceptional cases. Unfortunately sometimes there isn’t space in a healthcare setting. The police may also

take you to a police station if you may be a high risk to people in a healthcare setting.1 If you are taken to the police station, it doesn’t mean that you have done anything wrong. The police can arrange for you to be seen by a healthcare professional there. The police station doesn’t have to be the automatic second choice if a healthcare setting isn’t available. Other options could be a residential care home or a home of a friend or relative.2 The police can move you from one place to another, for example, from the police station to a hospital or from a hospital to a police station.

Top

4. How long will I be on this section? You can be on this section for up to 72 hours until an Approved Mental Health Professional (AMHP) and/or doctor sees you. If an AMHP thinks you should be sectioned using the Mental Health Act, two doctors need to assess you. You can get more information on ‘Detention under the Mental Health Act’ at www.rethink.org. Or call 0300 5000 927 and ask for a copy to be sent to you.

Top

5. What are my rights?

If you are in hospital, the hospital managers have to make sure you understand what this section means and how the Mental Health Act applies to you. 3 If the police take you to a police station, your rights are the same as if you were arrested. Remember that you have not done anything wrong and no criminal charges are being brought against you. You can:

• get the police to tell someone where you are and what’s happened • get free legal advice from a solicitor • get medical treatment from an appropriate healthcare professional

Top

6. Can I be treated against my will?

You cannot be forced to take medication or have any other treatment while under section 135.

Top

7. What might happen after this section?

After your section 135, three things could happen. These are:

• The Approved Mental Health Professional (AMHP) and doctors might decide that you need to be in hospital and section you using the Mental Health Act. You can get more information on ‘Detention under the Mental Health Act’ at www.rethink.org or call 0300 5000 927 and ask for a copy to be sent to you.

• The AMHP might decide that you do not need to be in hospital but that local healthcare services could give you more help. For example, they could refer you to your local Community Mental Health Team (CMHT) or contact your GP.

• The AMHP might decide that you do not have a mental illness or need any treatment. They could let you go from wherever you have been held.

Top

Go to www.rethink.org for specific information about - • Complaints About the Police • Detention Under the Mental Health Act • Getting Legal Advice and Assistance • What Happens at the Police Station

Or call 0300 5000 927 and ask for a copy to be sent to you. 1 Mental Health Act Codes of Practice, page 77, Places of Safety 2 As note 1, point 10.22, page 77 3 As note 1, section 132 The rest of the information in this factsheet is from: The Mental Health Act 1983. Section 135. Available from http://www.legislation.gov.uk/ukpga/1983/20/section/135 (accessed July 2013).

1

This factsheet looks at section 136 of the Mental Health Act. It gives information on the professionals you might come across, when this section is used, how it is carried out, what your rights are and what could happen afterwards.

This factsheet covers: 1. Professionals you might come across 2. When is this section used? 3. How is the section carried out? 4. How long will I be on this section? 5. What are my rights? 6. Can I be treated against my will? 7. What might happen after this section?

Section 136 The police taking you to a place of safety from a public place

• The Mental Health Act is the law which can be used to admit you to hospital for assessment and/or treatment for a mental illness.

• The police can use section 136 of the Mental Health Act to take you to a place of safety when you are in a public place. They can do this if they think you have a mental illness and are in need of care.

• A place of safety can be a hospital or a police station. The police can move you between places of safety.

• The police can keep you under this section for up to 72 hours. • During this time, mental health professionals can arrange a

Mental Health Act assessment for you. This will look at if you need to be in hospital because of your mental health.

• After being assessed, you might be sectioned using the Mental Health Act, or nothing further might happen and you could be free to leave.

• You have rights while under this section, such as getting legal advice, the police or hospital telling someone where you are and getting treatment from a healthcare professional.

1. Professionals you might come across

There are different professionals that might be involved in your care while detained under the Mental Health Act. We talk about some of these professionals in this factsheet:

Approved Clinician (AC) – an AC may be a doctor or another mental health professional such as a psychologist, nurse, occupational therapist and social worker who is allowed to use the Mental Health Act. For example, they can assess you for mental illness. Approved Mental Health Professional (AMHP) – this could be a social worker, psychologist, nurse or occupational therapist who is allowed to use the Mental Health Act. The AMHP needs to assess you and your situation to make sure that detention in hospital is the most appropriate way of providing the care and treatment you need. Police – they need to decide whether you meet the criteria for using section 136. They should take you to a place of safety either by calling an ambulance or in a police vehicle. Custody Sergeant - you might come across this person if you are taken to a police station as a place of safety. They are responsible for the safety of everyone at the police station, and to make sure you understand why you are there and your rights.

Top

2. When is this section used?

The police have the power to remove you from a public place if they think you have a mental illness and are in immediate need of care and control, for example, they might be worried about you because of your behaviour. The police do not need medical evidence before taking you to a place of safety. The police officer needs to reasonably think that you are mentally ill and they need to move you in the interests of yourself and other people.

The police cannot remove you from a private place under this section. Top

3. How is the section carried out?

The police must take you away from the public place to a place of safety. The police should try and take you to a healthcare setting such as a psychiatric hospital or the Accident and Emergency part of a hospital. Some hospitals have ‘section 136 suites’. The police can also use a police station, but only in exceptional cases. Unfortunately sometimes there isn’t space in a healthcare setting. The police may also take you to a police station if you may be a high risk to people in a healthcare setting.1 If you are taken to the police station, it doesn’t mean that you have done anything wrong. The police can arrange for you to be seen by a healthcare professional there.

The police station doesn’t have to be the automatic second choice if a healthcare setting isn’t available. Other options could be a residential care home or a home of a friend or relative.2 The police can move you from one place to another, for example, from the police station to a hospital or from a hospital to a police station.

Top

4. How long will I be on this section?

You can be on this section for up to 72 hours until an Approved Mental Health Professional (AMHP) and/or doctor sees you. If an AMHP thinks you should be sectioned using the Mental Health Act, two doctors need to assess you. You can get more information on ‘Detention under the Mental Health Act’ at www.rethink.org. Or call 0300 5000 927 and ask for a copy to be sent to you.

Top

5. What are my rights?

If you are in hospital, the hospital managers have to make sure you understand what this section means and how the Mental Health Act applies to you. 3 If the police take you to a police station, your rights are the same as if you were arrested. Remember that you have not done anything wrong and no criminal charges are being brought against you. You can:

• get the police to tell someone where you are and what’s happened • get free legal advice from a solicitor • get medical treatment from an appropriate healthcare professional

Top

6. Can I be treated against my will?

You cannot be forced to take medication or have any other treatment while under section 136.

Top

7. What are might happen after this section?

After your section 136, three things could happen. These are:

• The Approved Mental Health Professional (AMHP) and doctors might decide that you need to be in hospital and section you using the Mental Health Act. You can get more information on ‘Detention

under the Mental Health Act’ at www.rethink.org or call 0300 5000 927 and ask for a copy to be sent to you.

• The AMHP might decide that you do not need to be in hospital but that local healthcare services could give you more help. For example, they could refer you to your local Community Mental Health Team (CMHT) or contact your GP.

• The AMHP might decide that you do not have a mental illness or need any treatment. They could let you go from wherever you have been held.

Top

Go to www.rethink.org for specific information about - • Complaints About the Police • Detention Under the Mental Health Act • Getting Legal Advice and Assistance • What Happens at the Police Station

Or call 0300 5000 927 and ask for a copy to be sent to you.

1 Mental Health Act Codes of Practice, page 77, places of safety 2 As note 1, point 10.22, page 77 3 As note 1, section 132 The rest of the information in this factsheet is from: The Mental Health Act 1983. Section 136. Available from http://www.legislation.gov.uk/ukpga/1983/20/section/136 (accessed July 2013).

briefing

This month, the Department of Health published the Mental Health Crisis Care Concordat – Improving outcomes for people experiencing mental health crisis. The Concordat is a commitment from national organisations, as signatories to the document, to work together to support local system to achieve systematic and continuous improvements in crisis care for people with mental health problems across England.

This Briefing provides a summary of the key principles and commitments in the Concordat and highlights how stronger local partnerships can work together to deliver improved crisis care.

February 2014 Issue 270

Background A number of recent reports have demonstrated the need for health, social care and criminal justice agencies to work together to ensure that people with mental health problems get the care and treatment they need.

• An independent inquiry by Mind1 found variable access to crisis care services around the country.

• A criminal use of police cells2 highlighted the issue of people in crisis being detained by police officers and taken to custody cells, often because of a lack of capacity in the system.

• The Independent Commission on Mental Health and Policing3 made recommendations on how to prevent serious injury and deaths when police officers respond to incidents involving people with mental health conditions.

• There are continued high levels of detention of people from Black and Minority Ethnic (BME) communities, who are also over-represented on inpatient wards.4

• The Care Quality Commission’s (CQC) review of the Mental Health Act highlighted that the number of people detained or treated under the Act has risen by 12 per cent in the last five years.5

Key points•The Concordat is a joint

statement, written and agreed by its signatories, that describes what people experiencing a mental health crisis should be able to expect of the public services that respond to their needs.

•Local partnerships between the NHS, local authorities, and criminal justice system should work to embed the Concordat principles into service planning and delivery by agreeing and delivering their own mental health crisis declaration.

•Local agencies should all understand each other’s roles in responding to mental health crises.

•Local commissioners have a clear responsibility to put sufficient services in place to make sure there is 24/7 provision to meet local need.

Mental health and crisis care

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“We commit to work together to improve the system of care and support so people in crisis because of a mental

health condition are kept safe and helped to find the support they need – whatever the circumstances in which they first need

help – and from whichever service they turn to first.

We will work together, and with local organisations, to preventcrises happening, whenever possible through prevention and earlyintervention. We will make sure we meet the needs of vulnerablepeople in urgent situations. We will strive to make sure that all

relevant public services support someone who appears to have amental health problem to move towards recovery.

Jointly, we hold ourselves accountable for enabling thiscommitment to be delivered across England.”

Taken from the Mental Health Crisis Concordat.

• The economic case for early intervention in mental health conditions to reduce escalation to more serious or enduring problems is well established.6,7

Current service provisionIt was recently reported that over 1,700 mental health beds have been closed since April 2011.8 Funding for mental health trusts has dropped by 2.3 per cent in real terms since April 2011.9

During November and December 2013, the Mental Health Network (MHN) conducted a member survey on activity in crisis services. 20 per cent of our 64 member organisations responded. While the results therefore should be treated with some caution, 92 per cent of respondents reported an increase in demand for crisis services in the last 12 months. 55 per cent of respondents reported there was an 11–20 per cent increase.

The majority of respondents said that there was a problem with crisis care in their organisation.

Reasons varied; some were not clear about the causes of the rising demand, a number cited lack of resources, and others said there was a need to accelerate the service transformation agenda around prevention and improve whole-system understanding of how to respond to urgent mental health issues. Cost improvement targets for the year 2013/14 ranged from 4 to 7 per cent.

Policy contextThe NHS Mandate10 for 2014/15 sets out a number of objectives for the NHS to improve mental health crisis care. The Government expects:

• NHS England to make rapid progress, working with clinical commissioning groups (CCGs) and other commissioners, to ensure delivery of crisis services that are at all times as accessible, responsive and high quality as other health emergency services

• NHS England to ensure there are adequate liaison

psychiatry services in emergency departments

• every community to have plans to ensure no one in crisis will be turned away, based on the principles set out in the Concordat.

NHS England’s review of urgent and emergency care services recognises that the NHS urgent and emergency care system must be responsive to the needs of the most vulnerable people in society. This includes people suffering mental health crises. Aims of the ConcordatThe Mental Health Crisis Care Concordat – Improving outcomes for people experiencing mental health crisis outlines what needs to happen when people in mental health crisis need help. It establishes key principles of good practice that local services and partnerships should use to raise standards and strengthen working arrangements.

The Concordat is arranged around:

•access to support before crisis point

•urgent and emergency access to crisis care

•the right quality of treatment and care when in crisis

•recovery and staying well, and preventing future crises.

The Concordat contains an action plan and an annual ‘Concordat summit’ will take place to review progress and hold signatories to account on the delivery of the action plan.

briefing 270 Mental health and crisis care

03

Mental Health Crisis Care Concordat principlesThe principles include:

A. Access to support before crisis point

A1. Early intervention – protecting people whose circumstances make them vulnerable

B. Urgent and emergency access to crisis care

B1. People in crisis are vulnerable and must be kept safe, have their needs met appropriately and be helped to achieve recovery

B2. Equality of access

B3. Access and new models of working for children and young people

B4. All staff should have the right skills and training to respond to mental health crises appropriately

B5. People in crisis should expect an appropriate response and support when they need it

B6. People in crisis in the community where police officers are the first point of contact should expect them to provide appropriate help. But the police must be supported by health services, including mental health services, ambulance services and emergency departments

B7. When people in crisis appear (to health or social care professionals, or to the police) to need urgent assessment, the process should be prompt, efficiently organised, and carried out with respect

B8. People in crisis should expect that statutory services share essential ‘need to know’ information about their needs

B9. People in crisis who need to be supported in a health-based place of safety will not be excluded

B10. People in crisis who present in emergency departments should expect a safe place for their immediate care and effective liaison with mental health services to ensure they get the right ongoing support

B11. People in crisis who access the NHS via the 999 system can expect their need to be met appropriately

B12. People in crisis who need routine transport between NHS facilities or from the community to an NHS facility will be conveyed in a safe, appropriate and timely way

B13. People in crisis who are detained under Section 136 powers can expect that they will be conveyed by emergency transport from the community to a health-based place of safety in a safe, timely and appropriate way

C. Quality of treatment and care when in crisis

C1. People in crisis should expect local mental health services to meet their needs appropriately at all times

C2. People in crisis should expect that the services and quality of care they receive are subject to systematic review, regulation and reporting

C3. When restraint has to be used in health and care services, it is appropriate

C4. Quality and treatment and care for children and young people in crisis

D. Recovery and staying well / preventing future crises

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From April, NHS England will firstly carry out a gap analysis of current demand for services against available service provision. CCGs will use this to understand their baseline position and will then develop plans based on local needs and circumstances to move toward the Concordat.

Making it happenAcross England, local partnerships of health, criminal justice and local authority agencies are encouraged to agree and commit to:

• a jointly agreed local declaration that mirrors the key principles of the national Concordat – a commitment for local agencies to work together to continuously improve the experience of people in mental health crisis

• development of a shared action plan and a commitment to review, monitor and track improvements

• improving performance in the key area of using police stations as places of safety – by reducing the number of such uses, and by working towards a fast-track assessment process whenever a police cell is used

• evidence of sound local governance arrangements.

The Department of Health and the Home Office, together with Concordat signatories and other partners, are planning practical ways to support and promote the development of these local arrangements. A programme in support of implementation is being developed, including:

• the opportunity to register local declarations online

• convening a national steering group to assure the implementation of the Concordat and its effectiveness

• at least four regional events across England and an annual summit to assess progress

• communications support to enable participation by professionals working with people in crisis.

Effective commissioningDeveloping an effective local system that anticipates – and, where possible, prevents – crisis, and which ensures timely and supportive crisis care, is a commissioning responsibility. Local commissioners have a responsibility to ensure there is 24/7 provision sufficient to meet local need.

The Concordat supports a multi-agency approach to deliver excellence in commissioning. Health and wellbeing boards have a key role to play to bring health and social care commissioners together with the local community and wider partners.

Initiatives and interventions are planned to support commissioning arrangements locally. These include:

• the establishment of the Mental Health Information Network from April 2014 to ensure commissioners have the best possible information to support good decision-making about improvements to local services

• strengthening the social care contribution to commissioning

• support from NHS England to improve specialist leadership skills among CCGs

• working with pioneers in the integration of healthcare services for mental health, to demonstrate best practice and evaluate models of care.

There are also plans to support workforce development. This includes the development of NICE11 guidance on safe and efficient staffing levels in a range of NHS settings, including mental health inpatient and community units. Health Education England is setting up a Mental Health Advisory Board that will advise on policies, strategy and planning of the future workforce for mental health.

Police and local government also have a key role. The Home Office is scoping the development of a web portal to enable exchange of effective practice for police, health service and local authority partnerships. Close partnership working will be needed to translate the models of urgent and emergency care being developed by NHS England into local solutions that work for the demographic needs of local areas.

Core principles and outcomesThe Concordat sets out principles and statutory requirements that all services involved in responding to mental health crises should follow. These are detailed in the box on page 3.

briefing 270 Mental health and crisis care

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Access to support before crisis pointMental health services need to intervene early to prevent distress from escalating into crisis. Providers will want to consider:

• developing a single point of access to a multi-disciplinary mental health team, available to agencies across both the statutory and voluntary sectors

• delivering a joined-up response from services, for people of all ages, with strong links between agencies, for example social care teams and substance misuse services

• help at home services, including early intervention or crisis resolution/home treatment services

• respite away from home or a short stay in hospital as a voluntary patient

• peer support, including access to crisis houses or other safe places where people can receive attention and help

• access to liaison and diversion services for people with mental health problems who have been arrested for a criminal offence

and are in police custody or going through court proceedings

• suicide prevention – identifying those groups known to be at higher risk of suicide than the general population.

Each local area will need to decide the best combination of services that makes sense for their population.

Primary care, in partnership with others, has a key role to play in supporting people experiencing mental distress and in crisis. The Royal College of General Practitioners (RCGP) is leading work to support, develop and improve GPs’ knowledge and experience of managing people with mental illness and physical health. This includes proposals for extending GP training to include mental health, child health and dementia work-based modules. The RCGP is also currently working to support primary care services to work collaboratively with other services, facilitating and coordinating access to specialist expertise and a range of secondary care services, including crisis and substance misuse services.

From April 2014, the Home Office will begin scoping work with police forces to explore quantifying the demand for responses for people in mental health crisis, recording Mental Health Act Section 135/136 needs related to mental disorder or drug and alcohol intoxication.

Urgent and emergency access to crisis careBy October 2014, based on its review of urgent and emergency care, NHS England will describe models of care that work for people in mental health crisis, and will provide commissioning guidance. The Concordat has ambitions for mental health services to be available 24 hours a day, seven days a week.

Equality of accessThe Concordat supports Mind’s guidance on commissioning crisis care services for BME communities12 and recommends early engagement in the commissioning of services and person-centred care that takes cultural differences and needs into account, and access to advocacy services.

Initial steps for providersCurrent service provision should continue while the improvements envisaged in the document are put in place. However, providers can start to:

•strengthen local relationships with key partners, ensuring roles and responsibilities are agreed and understood around mental health crisis care

•consider the best combination of early interventions services that would support local need

•record the frequency and use of police custody as a place of safety and review the appropriateness of each use to inform use in the future

•ensure staff are properly trained in effective and appropriate use of restraint

•consider local plans to deliver 24/7 crisis care, seven days a week.

06

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The Department of Health plans to work with voluntary sector organisations to understand and respond to inequalities in access to mental health services, particularly for BME communities.

Children and young peopleChildren and young people should have access to crisis care. The Concordat asks local commissioners to take steps to commission mental health services that meet the particular needs of children and young people, and specifically states that police custody should not routinely be used as a place of safety just because health services are not available. It makes it clear that adult places of safety should be used if necessary.

The focus on the interface between specialist children and adolescent mental health services (CAMHS) and primary care needs to remain a central policy issue in CAMHS planning.

Staff training Local shared training policies and approaches should describe and identify who needs to do what, and how local systems fit together. Local agencies should all understand each other’s roles in responding to mental health crises. It is important that the training ensures that staff, from all agencies, receive consistent messages about locally agreed roles and responsibilities.

Appropriate and prompt response The Concordat recommends that commissioners and providers should work towards NICE Quality Standards13 so that:

• people in crisis who are referred

to mental health secondary care services are assessed face to face within four hours in a community location that best suits them

• service users and GPs have access to a local, 24-hour helpline staffed by mental health and social care professionals

• crisis resolution and home treatment teams are accessible 24 hours a day, seven days a week, regardless of diagnosis.

In addition, crisis beds, step-down and community services should be commissioned at a level to allow for crisis beds to be readily and locally available. Existing crisis plans and any advance statements should be followed, where possible.

Reducing the use of police cells as places of safetyNHS commissioners are required by the Mental Health Act to commission health-based places of safety so that any person a police officer believes is suffering from mental disorder, and who may cause harm to themselves or others, can be taken to a designated place of safety for assessment. It is essential that NHS places of safety are available and equipped to meet demand.

The College of Policing will be reviewing their curriculum to support frontline officers and staff receive sufficient mental health training. Improving recognition of vulnerability and risk will help the police decide whether individuals will be detained under Section 136, or whether they can be helped in some other way.

Providers and commissioners should record the frequency and reasons for using police

cells as places of safety. Local partnerships, while establishing local Mental Health Crisis Declarations, should improve performance in this area, reducing their use and set ambitions for fast-track assessments that minimise the time people spend in police custody because they are ill.

The Department of Health will monitor the national figures on the use of Section 136, and expects to see the use of police cells as places of safety to fall below 50 per cent of the 2011/12 figure by 2014/15.

The CQC is developing an approach to monitor the quality of health-based places of safety as part of future inspections.

An evaluation of the street triage pilot schemes is planned in 2014. These are partnerships between NHS organisations and the police, and involve mental health nurses providing advice to police officers to ensure people receive appropriate and timely care.

The Department of Health is updating the Mental Health Act Code of Practice. This will involve reviewing and updating local protocols on intoxication from alcohol and drugs. The Concordat states that intoxication should not be used as a basis for exclusion from places of safety, except when there are risks to the safety of an individual or staff.

Sharing need to know informationAll agencies, including police or ambulance staff, have a duty to share essential ‘need to know’ information for the good of the patient, so that the professionals

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or service dealing with a crisis know what is needed for managing a crisis and any associated risks to the distressed person or to others.14

Within the requirements of data protection legislation, a common sense and joint working approach should guide individual professional judgements. If the same person presents to police, ambulance or emergency department repeatedly, all agencies should have an interest in seeking to understand why and how to support that person appropriately to secure the best outcome.

Improving emergency department careClear responsibilities and protocols should be in place between emergency departments and other agencies and parts of the acute and mental health and substance misuse service, to ensure people receive treatment on a par with standards for physical health. The NHS Mandate requires NHS England

Case study: A new vision for urgent mental healthcare in North West LondonShaping Healthier Lives is North West London’s Mental Health Transformation Strategy, 2012–15. It involves collaborative work between eight CCGs and two mental health trusts.

The aim is to improve the experience of, and outcomes from, mental health urgent assessment and care. It provides the framework for improving mental health services across North West London, including increasing the management of the health and wellbeing of people with mental health problems in primary care. There is a need for rapid access to assessment and care for those in crisis, to be provided when and where the service user most needs it.

Initial approaches to improve crisis assessment and care include:

•roll out and embedding of a common Access and Care Standards Policy

•a review of the local skills mix, competency and training needs of staff

•progress to align mental health service to those in primary care – covering the period between 8am and 8pm as a minimum. Extension of home visiting for crisis resolution work providing 24/7 cover every day of the year

•simplification of the ‘way in’, with a single telephone number, available 24/7 every day of the year.

Taken from the Mental Health Crisis Concordat.

to ensure there are adequate liaison psychiatry services.

Local mental health partnership boards can support the development of agreement of protocols and escalation of issues around suicide, self-harm and people with co-morbid physical and mental health problems.

The College of Emergency Medicine will be conducting an audit of mental health assessment rooms in emergency departments during 2014, with a view to ensuring service users experience a safe and improved environment and that staff safety is improved.

Improving the 999 system for people in crisisThe Concordat proposals include:

• the provision of 24/7 advice from mental health professionals to or in each 999 ambulance control room

• enhanced levels of training for ambulance staff on the management of mental health patients

• ambulance trusts to work flexibly across boundaries to ensure that an individual’s safety (and treatment) is not compromised.

TransportationTo support parity of response to mental health emergencies with physical health urgent care, NHS ambulance services in England are planning to introduce a single national protocol for the transportation of Section 136 patients by April 2014. This aims to provide agreed response times and a standard specification for use by CCGs.

Regulating crisis careThe CQC will place a greater emphasis on inspecting and monitoring the care that people with mental health problems receive in the community,

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including during a crisis. The accessibility and responsiveness of services to support people through crisis and prevent hospital admission, and the number of people who are admitted to hospital far away from their home area because of local bed pressures, will be a focus.

The Department of Health and CQC will review the effectiveness of the current approach to monitoring approved mental health professional (AMHP) provision and whether the CQC requires additional powers to regulate AMHP services.

The CQC will continue to monitor the use of the Mental Health Act. The CQC will take account of this Concordat when inspecting and monitoring the support people receive from agencies in response to their crisis, including inter-agency working at key points in the care pathway. Evidence that the least restrictive care has been provided and that mental health legislation and codes of practice are complied with must be ensured.

RestraintThe Code of Practice requires the organisation to make sure staff are properly trained in the restraint of patients. Adequate staffing levels are also required.

The Department of Health and other partners are working on a programme to ensure the use of appropriate and effective restraint in health and care services.

It recommends that physical interventions should only be used as a last resort.

Recovery staying well/preventing future crisesFollowing a crisis, NICE recommends15 that people using mental health services and who may be at risk are offered a crisis plan. Advanced statements, detailing a person’s preferences for their treatment or care, can be drawn upon when a person in crisis cannot express their needs or existing arrangements.

The pathway of care between services should be integrated and organised around the patient. Health and wellbeing boards offer a forum for joining up local services and could coordinate the commissioning of services for people with multiple needs. Joined-up support is particularly important in criminal justice settings, and it is critical that the development of liaison and diversion schemes is closely tied in with existing custody based interventions, such as for drug misusing offenders to maximise their impact on this client group.

Mental Health Network viewpointWe welcome the publication of the Concordat, and the efforts of all those involved to make meaningful improvements to the care available to people in mental health crises.

As a national signatory, the MHN is keen to support our members

make improvements for people in mental health crisis and share good practice. Many organisations are working hard to improve services and make them more accessible to the people who need them. By working in closer collaboration with commissioners and other partners to develop local action plans, there is real scope to ensure people get timely care in a crisis and prevent mental health crises occurring and escalating.

We are pleased to see that commissioners, GPs and the police are looking to develop the support and training they receive to improve the understanding of mental health problems and to develop services.

Local agencies working together will go some way to support people get the right care, in the right place, at the right time. However, in order to achieve real improvements in crisis care, mental health must be genuinely put on a par with physical health. It is critical that the Government’s and NHS’s commitment to address long-term under-funding of mental health services is delivered, before the sector experiences an irreversible crisis itself.

For more information on the issues covered in this Briefing, please contact claire.mallett@nhsconfed.org

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References1. Mind (2011). Listening to experience: An independent inquiry into acute and crisis mental healthcare

2. Her Majesty’s Inspectorate of Constabulary, Care Quality Commission (2013). A criminal use of police cells? The use of police custody as a place of safety for people with mental health needs

3. Report by the Independent Commission on Mental Health and Policing (2013)

4. Health and Social Care Information Centre (2013). Mental health bulletin: Annual report from MHMDS returns – England, 2011–12

5. Care Quality Commission (2014). Annual review of the Mental Health Act

6. Mental Health Network (2011). Early intervention in psychosis services

7. Knapp, M., McDaid, D and Parsonage, M (2011). Mental health promotion and mental illness prevention: The economic case. Department of Health

8. Community Care (16/10/13). Patients at risk as ‘unsafe’ mental health services reach crisis point

9. Community Care (12/12/13). ‘We are firefighting’: the mental health funding shortage that’s hitting frontline care

10. Department of Health (2013). NHS Mandate 2014 to 2015

11. NICE (19/11/13). NICE to produce guidance on safe NHS staffing levels

12. Mind (2013). Mental health crisis care: commissioning excellence for black and minority ethnic groups

13. NICE (2011). Quality standard for service user experience in adult mental health. Quality statement 6, access to services.

14. Department of Health (2009). Information sharing and mental health: guidance to support information sharing by mental health services

15. NICE (2013). Quality standard on crisis planning

Signatories to the ConcordatAssociation of Ambulance Chief Executives

Association of Chief Police Officers

Association of Directors of Adult Social Services

Association of Directors of Children’s Services

Association of Police and Crime Commissioners

British Transport Police

Care Quality Commission

College of Emergency Medicine

College of Policing

The College of Social Work

Department of Health

Health Education England

Home Office

Local Government Association

Mental Health Network, NHS Confederation

Mind

NHS England

Public Health England

Royal College of General Practitioners

Royal College of Nursing

Royal College of Paediatrics and Child Health

Royal College of Psychiatrists

briefing 270 Mental health and crisis care

Mental Health NetworkThe NHS Confederation’s Mental Health Network is the voice for NHS funded mental health and learning disability service providers in England.

We work with Government, regulators, opinion formers, media and the wider NHS to promote excellence in mental health services and the importance of good mental health.

For more information about our work, please visit www.nhsconfed.org/mhn or email us at mentalhealthnetwork@nhsconfed.org

Further copies or alternative formats can be requested from: Tel 0870 444 5841 Email publications@nhsconfed.org or visit www.nhsconfed.org/publications© The NHS Confederation 2014. You may copy or distribute this work, but you must give the author credit, you may not use it for commercial purposes, and you may not alter, transform or build upon this work.

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briefing 270 Mental health and crisis care