Impact of changes in the use of forensic medical examiners on custody provision

Report: 11
Date: 3 September 2009
By: T/AC Territorial Policing on behalf of the Commissioner

Summary

This report sets out the current position with regards to accessing healthcare provision within the MPS, taking account of the contractual changes in January 2009 and including the arrangements for clinical governance and specialist provision.

A. Recommendation

That members note the report.

B. Supporting information

1. A revised Contract for Services in respect of Forensic Medical Examiners (FMEs) was introduced on 12 January 2009. To date, 151 doctors have signed contracts and provide the majority of healthcare provision within the MPS.

2. Healthcare provision is currently provided by a structure which divides the MPS into 19 areas. Each day is covered by four six-hour sessions, meaning that there are 2280 sessions to be filled each month.

3. The number of sessions where cover is provided by FMEs under contract has increased month on month. For example, in April 2009, this represented 2061 (90%) of healthcare provision whilst by June, this had risen to 2126 (93%). This figure is expected to rise as further doctors are contracted to provide FME services to the MPS.

4. The small number of gaps in cover are filled with support from two agencies; Belvia Medical (Medteam) and G4S (formerly Essex Forensic Healthcare Services). This use is expected to decline as further doctors are contracted to the MPS.

5. Signed contracts for service delivery through the MPS have recently been returned from British Transport Police and are awaiting signature on behalf of the MPA. City of London Police has decided to outsource their provision to G4S Medical. There are no current plans for any other contracts within the criminal justice sector.

Clinical Governance

6. Clinical governance of healthcare provision will be in two parts; FMEs will be governed by a Medical Director and Custody Nurse Practitioners (CNPs) by a Nursing Director.

7. The process for filling both posts is well advanced. Job descriptions and role profiles have been created following extensive legal advice. The legal advice focused on whether the roles should be for employment or for contracts for services, with the outcome that the roles are those of employees and they will be advertised during August 2009.

8. Until the appointment of the medical director any matters requiring clinical expertise are referred, in confidence, to a senior FME who is an appointed member of the Commissioner’s Forensic Healthcare Advisory Panel.

9. Issues have been raised in respect of clinical governance. When the contract was changed, several FMEs expressed concern regarding the process to assess the professional competence of agency doctors. Two senior FMEs were invited to examine this issue and report their findings to the directorate. Their view was that agency doctors should be interviewed and undergo a period of workplace assessment before use within the MPS but they were not able to comment regarding suitability from a clinical perspective.

10. Although an interview process has been used in the past to select FMEs, this has led to criticism of the standards of some FMEs appointed in this way. Our assessment of the agency doctors involves ensuring that they are registered to practice medicine in the UK and have experience working within a custodial environment. We have clarified with the agencies that references have been provided and all the agency doctors have been security cleared.

11. The only other concern raised since the change in contract relates to a particular case in June where a FME raised a concern regarding another doctor’s clinical judgement. This doctor strenuously denies any wrongdoing. A senior FME has been asked to examine the circumstances and report back to the directorate later this month.

Accessing FME Services

12. As part of the planning process for the change in the contractual arrangements, Forensic Healthcare Services (FHS) (part of the Custody Directorate) examined the demand for healthcare across the MPS to inform a decision as to how healthcare services should be structured under the revised contractual arrangements. The current 19 areas were designed to offer the optimum coverage by FME groups, taking account of the geographical location, the capacity of custody suites and the views of FMEs. The current arrangement will be subject of review. The intention is to reduce the number of areas in line with the introduction of CNPs, to a total of 8 areas by 2012. The introduction of CNPs to BOCUs has been prioritised to take into account those areas where there is the longest delay in the arrival of FMEs.

13. During the early stages of the change to the contract, FHS created a 24/7 helpdesk to ensure that the correct level of healthcare was provided across the MPS. This has proved successful and the number of requests for assistance has decreased substantially.

Specialist Provision

14. The need for investigators to access forensic healthcare services in specific specialised cases outside or the normal arrangements has been identified. Two options have been identified. First, an ‘on-call’ retainer could be paid to FMEs, ensuring that they were therefore available to us exclusively if required. However, the suggested rate for the retainer of £80 per hour (to reflect payments to locum GPs) is not a viable financial option.

15. The second option is the provision of a larger cadre of ‘specialist’ FMEs who may be able to provide services within several disciplines such as witness protection, professional standards investigations, child abuse investigations and terrorism cases. These disciplines are all based around specialist work relating to recovery of forensic exhibits; all involve suspects who are potentially in need of enhanced assessment regarding the psychological pressures of the processes they are undergoing and all add to the development of specialist forensic healthcare skills.

16. The aim is to create a significant pool of doctors with many being multi-skilled. In this way it is envisaged that availability of FMEs for these specialist functions will be increased. It will also lead to enhanced forensic healthcare skills impacting positively on other areas of the service provision and will also impact on the overall attractiveness of the FME role and therefore our ability to attract and maintain the interest of the best doctors.

C. Race and equality impact

An equalities impact assessment was conducted and submitted together with the original report to the MPA on 7 February 2008. The situation regarding equalities impact is under constant review. Nothing within this report creates new issues in respect of race and equality impact.

D. Financial implications

With the introduction of Custody Nurse Practitioners under Project Herald (some of whom will be in place during this financial year) and the change to sessional rates, it is anticipated that the expenditure for FME services will reduce to £9.5m as compared to an annual budget of £13.1m (assuming no changes to the provision of FME services from 2008/09). This has been taken into account in the budget and forecast for Project Herald for the current financial year.

E. Legal implications

1. The provision of FME services is governed by the Police and Criminal Evidence Act (PACE) 1984, and Codes of Practice (Code). In a policing context, the care and treatment of detained persons is regulated by paragraph 9 of Code C. The requirements of PACE are explicit and in addition to the immediate medical needs of a person in custody, PACE also places obligations upon the custody officer to assess the fitness of detained persons for detention and interview, using FME support.

2. The Code was amended allowing clinical assessments to be undertaken by ‘Health Care Practitioners’, which included nurses and paramedics, in order that a more effective custody care could be provided by police forces. The term ‘health care professional (HCN)’ refers to a clinically qualified person, who is working within the scope of practice as determined by their relevant professional body. The HCN will also be registered with that body as competent to practice.

3. Section 9 A of the Code further states “whether a health care professional is ‘appropriate’ will depend on the circumstances of the duties they carry out at the time”. In respect of risk assessments and types of work the HCN will be involved with, the MPS has taken into account guidance set out in the Home Office circular 020/2003, and the National Protocol on Custody Care, which supplements the revised Code of Practice relating to PACE.

4. The change in structure of healthcare provision aims to deliver the most efficient, effective and economically advantageous solution, to an increasing demand for clinical assessments, representing best value to the Authority.

Lessons Learnt

5. A review focussing on the implementation of the revised contract has identified learning points: -

• If finances had been available, it would have been preferable to introduce CNPs before changing the healthcare provision provided by FMEs.
• Due to procurement rule restrictions, arrangements with agencies to provide FMEs were not put in place in advance of the changes to the contract in January. It would have been advantageous to have had such an arrangement whereby agencies undertook to provide FMEs should this need transpire.
• As part of the planning process and, in particular, during the period when the contract changed, the external communication of the MPS position could have been stronger.
• The 24/7 helpdesk has been an invaluable resource for MPS staff and FMEs and will therefore continue.

F. Background papers

• COP – 7 February 2008 – Project Herald, Changes to MPS Forensic Medical Provision

G. Contact details

Report author: David Imroth, Detective Superintendent, TP Emerald 

For information contact:

MPA general: 020 7202 0202
Media enquiries: 020 7202 0217/18

Abbreviations and Acronyms

BOCU

Borough Operational Command Unit

CNPs

Custody Nurse Practitioners

FHS

Forensic Healthcare Services

FMEs

Forensic Medical Examiners 

GPs

General Practitioners

HCN

Health Care Professional

PACE

Police and Criminal Evidence Act

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