MPA/NHS joint review of mental health and policing - terms of reference

Report: 5
Date: 12 November 2004
By: Clerk

Summary

This report sets out the draft terms of reference for the MPA/NHS joint review of mental health and policing. The terms of reference were considered by the Joint Review Project Board on 30 September 2004 and are submitted to Co-ordination and Policing Committee for formal approval. The terms of reference are attached as Appendix 1 to this report.

A. Recommendations

That members approve the terms of reference for the MPA/NHS joint review of mental health and policing with particular reference to membership, overall scope, expenditure, and timescales.

B. Supporting information

Background

1. On 29 July 2004, the Police Authority agreed to undertake a MPA/NHS joint review of mental health and policing in London. Richard Sumray was appointed Chair of the project board on a rotating basis with the Professor David Taylor, Chair of the Camden and Islington Mental Health and Social Care NHS Trust. The project board met formally for the first time on 30 September 2004.

Membership

2. The report considered by the police authority in July 2004 proposed a project board membership of six members, three of whom would be drawn from key stakeholder groups. It has been agreed that the project board will consist of:

• MPA Members: Richard Sumray (Co-Chair), Reshard Auladin, Kirsten Hearn
• NHS Members: Prof David Taylor (Chair Camden and Islington Mental Health and Social Care Trust), Alison Armstrong (Director London Wide Mental Health Programmes and Prison Health) and Stuart Bell (Chair of the London Mental Health Trust Chief Executives Group, also Chief Executive of the South London and the Maudsley Mental Health Trust)

It has been agreed that Linda van den Hende and Bruce Frenchum from the MPS and Peter Horn from the London Development Centre for Mental Health will act as advisors to the project board.

3. A reference group has also been established. This group consists of nineteen key stakeholders including academics, voluntary organisations, users/carers and service providers. Its terms of reference is to:

• To help the project board consider and challenge the policies, processes, management structures and services provided by organisations involved in policing mental health;
• To assist the project board in identifying gaps and inconsistencies in service provision and make suggestions on how to address the issues raised;
• To contribute to the development of an action plan that will deliver tangible benefits to the users of mental health services.

Overall scope

4. Draft terms of reference were prepared following an initial project board meeting in July 2004. This was then formally presented to the project board on 30 September 2004. The terms of reference are attached at Appendix 1 of this report.

5. The main focus of the joint review will to be to add value to the multi-agency response to mental health related problems, to develop closer links with partners working in this area and to provide an improved response to service users.

6. The objectives of the joint review are to:

• Identify potential improvements in current services and facilities delivered by the MPS, NHS and other stakeholders to improve the safety, security and quality of care provided to people with mental disorders. We will do this in part by using the findings of the MPS and mental health services mapping exercises, describe at all levels and in all contexts relevant to mental health care and public safety and well-being the policies, working arrangements and operational procedures used by the MPS, NHS, social services and other agencies in London in relation to services provided in response to mental health related problems.
• To identify communications channels and information gathering and exchange processes between agencies including any established protocols with a view to addressing how they could be improved
• To explore lessons learned from recent cases, which may not have been handled appropriately, as well as examples of innovative practice to develop recommendations for improvement.
• To identify areas in which changes in process or policy would benefit service users and eliminate discrimination, particularly for key groups such as young black men, who may be experiencing more problems accessing mental health services, particularly where dual diagnosis is an issue.
• To clarify the human rights issues relevant to both public protection and individual mental health service users.
• To elucidate the myths and realities around the predictability of behaviour and claims that a proportion of violent and related undesired events associated with mental health problems could be avoided proactively.
• To create an action plan to address the issues identified, using the suggestions for improvement developed through consultation, including identified leads, deadlines and completion measurements and a monitoring system to track improvements.

Costs/benefits

The cost of the joint review, in terms of MPA officer support, approximates to around one third of a full-time equivalent for one year. In line with practice developed in MPA scrutinies it is proposed to offer reasonable travel expenses to witnesses. Other funding requests will be presented to the chairs of the panel for approval prior to formally requesting funding from the relevant bodies.

Timescales

Research to meet a number of the objectives is already underway and will be complete by the end of January. Evidence hearings will commence at the end of January and continue during March to be followed by preparation of the final report and a period of consultation. The final report will be presented to Co-ordination and Policing Committee in June 2005. A programme of project board meetings is being set for the initial stages of the scrutiny.

C. Race and equality impact

The joint review project board acknowledges that prejudice towards people with mental health disorders continues to be an issue for all the service providers involved as well as for the public at large, not least when such individuals are from minority ethnic groups or have additional problems like those associated with illicit drug or alcohol use. The project board is aware of the difficulties faced by some groups, particularly young black men and refugees in accessing mental health services and is also aware of issues around contact with the police. While equality and diversity implications will be assessed as an integral part of the review, the project board will take steps to ensure that prejudice is not perpetuated in the work of the review. Recommendations arising from the review will concentrate on short, medium and long term solutions and will ensure that the responsibilities of all agencies under the Race Relations Amendment Act 2000 are considered throughout the review.

D. Financial implications

The scrutiny will be carried out within existing MPA resources.

E. Background papers

• Police Authority 29 July 2004: Report 49 (Mental Health and Policing Joint Review)

F. Contact details

Report author: Siobhan Coldwell, MPA

For more information contact:

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

Appendix 1: Mental health joint review: Terms of reference

Contents

• Introduction
• Background
• Objectives
• Structure
• Approach
• Plan
• Constraints
• Costs
• Annex 1: Scrutiny plan

Version history

1. Draft for approval by chairs: Sally Palmer, 30 July 2004
2. Draft for circulation to panel: Sally Palmer, 3September 2004
3. Draft for circulation to COP: Siobhan Coldwell, 20 October 2004

Introduction

In May 2004 the MPA’s Co-ordination and Policing Committee considered a paper on mental health and policing in informal session. The committee felt that the scope of the issue to be addressed was too broad to be managed within the MPA’s usual scrutiny process and would require the commitment of organisations outside the policing arena in order to make most impact. Members decided to commission a joint review of mental health and policing to be chaired by the MPA and NHS with the involvement of key stakeholders. The purpose of the joint review will be to consider the policies, procedures and management structures and services provided by organizations involved in proving services to Londoners with mental health problems and the wider communities in which they live. The review aims to identify gaps and inconsistencies in service delivery and to agree an action plan for improvement to be implemented by the key stakeholders.

Background

The problem

The recent report Mental Health and Social Exclusion published by the Social Exclusion Unit in the Office of the Deputy Prime Minister found that ‘Depression, anxiety and phobias can affect up to one in six of the population at any one time’ [1] although serious mental health problems such as schizophrenia only affect one in two hundred adults each year. The key piece of legislation in this area is the Mental Health Act 1983, which sets out four categories of mental disorder – mental illness, mental impairment, severe mental impairment and psychopathic disorder. The vast majority of people with mental disorders receive treatment voluntarily. Only around 10% are admitted to hospital on a compulsory basis under a ‘section’ of the Mental Health Act. [2] In London the rate of admissions is twice that of the rest of the country. There are a wide variety of mental health disorders ranging from mild depression, through learning difficulties to illnesses like bi-polar disorder and acute behavioral disorder which are more likely to lead to violence or contact with the police if left untreated.

A recent report completed by the Greater London Authority around the Availability of Mental Health Services in London published in 2003 found that the level of service provided to treat people with mental health disorders varied greatly across London:

‘The patient mix in London’s mental health services includes much higher numbers of patients from more deprived areas than the rest of England. It has higher proportions of patients with psychotic illness and alcohol related problems... Standardised admission levels vary considerably between boroughs.... There is significant variation in the level of resources put into mental health in different boroughs’. [3]

Some sections of the community experience particular difficulties in accessing mental health services. The report Inside Outside, found that ‘There are significant barriers to minority ethnic groups seeking and successfully accessing services...There is greater involvement of the criminal justice system, and in particular the police’. [4] Refugees are also over represented in the number of people using mental health services. In Ealing it was estimated that refugees make up 6-10% of service users compared to 3.9 – 4.5% of the population. [5] Language and translation services are seen as a key weakness within the health service. [6]

In addition, there is some evidence to suggest that drug and/or alcohol abuse may be related to underlying mental health problems and may play a role in triggering mental health disorder. [7] A study managed by the NHS Executive stated that ‘Approximately half of the people who are treated for drug and alcohol problems have a complicating mental health problem’ [8] A study carried out for the Home Office showed that people who are brought into police custody with alcohol related offences spent considerably longer in cells than other detainees. [9] This dual diagnosis potentially presents police with a situation in which people with alcohol related mental disorders are spending extended periods of time within police custody, rather than in a treatment facility.

Many different public sector bodies are involved in the care and treatment of mentally ill people including social services, primary and secondary care providers, charities and voluntary sector groups. Recent cases, such as that of Anthony Hardy have highlighted problems with information sharing and co-operation between the police and the NHS. These take many forms, but are perhaps particularly sensitive in the context of the release of potentially high-risk patients into the community.

The response - London

The front line response to people in mental distress is often provided by crisis team members, general practitioners, out patient department staff, police officers , social workers and members of the public. Other parts of the NHS are more frequently engaged later on in the treatment process. There are five Strategic Health Authorities (SHA) in London which develop strategies and performance manage the Primary Care Trusts (PCT). PCTs are given funding directly by the Department of Health to commission health services; PCTs also develop primary care services and are tasked to promote public health. Secondary services are, in the case of mental health care normally provided by Mental Health Trusts (MHT). These Trusts in the main cover more than one PCT area and provide services commissioned by the PCTs, which include those provided by community mental health teams. Social services provide social care for patients with mental health disorders. Key stakeholders for this review will be senior representatives from MHTs and the Chief Executives of the London SHAs, as well as leading members and staff from the MPA and MPS to ensure the project has commitment from all relevant organisations.

The police may be involved in dealing with people with a mental health disorder in a number of ways. Officers may be called by the Approved Social Worker (ASW) during a risk assessment, when deciding whether to undertake a Mental Health Act Assessment on private premises. In this case the police role will be to assist in entering premises with a warrant or where consent has been given and to assist other agencies in transporting the person to hospital, using police vehicles where violence is anticipated. The police may also be involved in locating and returning patients to hospital. Police officers also have a role in dealing with mentally ill people when they are in need of care in a public place including possibly transporting them to a place of safety.

The response – international

Not all countries treat people with mental health disorders in the same way. A specialised police response to people in mental health distress based on the creation of Crisis Intervention Teams was devised in Memphis, and developed elsewhere in the USA. The Memphis model was evaluated by the MPS restraint review project team, set up to consider restraint and mental health issues in the MPS. The police CIT programme relies on a five day training course for volunteer officers including specific training in de-escalation techniques, awareness training in the different types of disorder and the medication taken to treat each one and some time spent with the mentally ill. Around 200 of the 2000 Memphis officers are CIT trained and all dispatch [10] staff have also received a two day training course covering mental health issues.

One of the key innovations has been access to a mental health treatment facility known as ‘The Med’. This is a general hospital open continuously, which provides a psychiatric triage facility. No patient can be refused by the facility and police officers are able to commit patients to the care of ‘The Med’ and return to duty within around 15 minutes. The police CIT model has been adapted to fit local circumstances and has been credited with a reduction in the number of officer and civilian injuries as well as better services for users and greater partnership with mental health service providers. The MPS restraint review team has recommended that an adapted form of CIT is evaluated for use in a pilot site in London.

MPS action

The MPS recently appointed a Deputy Assistant Commissioner to take an overall lead for Mental Health. Responsibility for MPS policy around mental health rests with the Diversity Directorate (DCC4 (6)) although the Territorial Policing Directorate is responsible for offenders with mental disorders and the Specialist Crime units also have some involvement. Each borough has a Mental Health Liaison Officer but the time they have available to devote to mental health varies according to other duties, inclination and training. The MPS is currently reviewing the way it deals with people with a mental disorder. Although the formal MPS policy has not been amended since 1994 a set of partnership protocols have recently been developed by the London Mental Health Partnership Group and are currently being rolled out across London. The review of restraint, initiated following the death of Roger Sylvester, has recently explored aspects of mental health care in detail. The review has identified the handover of patients from police to medical staff as an area of tension, as well as the involvement of police in restraining or otherwise controlling individuals while in hospitals.

The MPS is committed to training officers to deal with the mentally disordered, as well as prosecuting when this is in the public interest. Many boroughs are currently agreeing protocols with local hospitals and social services for dealing with mentally ill people. The MPS’ current policy also undertakes to inform social services about people who may be a danger to others. The MPS has also jointly produced a booklet with the London Ambulance Service called ‘Admitting Mentally Ill Patients to Hospital’.

Other relevant policy documents include the advice to police and custody officers provided by the Independent Police Complaints Commission around the treatment of people with acute behavioral disorders. These people are thought to be most at risk of sudden death during restraint. Such people are to be treated as medical emergencies and are to be contained rather than restrained until an ambulance arrives to transport them to hospital. A number of MPS Notices have been produced to give guidance to officers in this area.

Objectives and scope

The joint review will seek to add value to the MPS and NHS response to mental health related problems and develop closer links with the partners working in this area. This will involve understanding the existing pattern of services across London and the relevant working arrangements and organisational cultures in place before deciding which areas to focus on for improvement. In agreeing the objectives outlined here all members of the joint review panel commit their organisations to share information for the purposes of the review and to progress the recommendations of the final report.

The initial objectives of the joint review will be as follows:

1. To identify potential improvements in current services and facilities delivered by the MPS, NHS and other stakeholders to improve the safety, security and quality of care provided to people with mental disorders.
   We will do this in part, by using the findings of the MPS and mental health services mapping exercises, describe at all levels and in all contexts relevant to mental health care and public safety and wellbeing the policies, working arrangements and operational procedures used by the MPS, NHS, social services and other agencies in London in relation to services provided in response to mental health related problems.
2. To identify communication channels and information gathering and exchange processes between agencies including any established protocols with a view to assessing how they could be improved.
3. To explore lessons learned from recent cases, which may not have been handled appropriately, as well as examples of innovative practice to develop recommendations for improvement.
4. To identify areas in which changes in process or policy would benefit service users and eliminate discrimination, particularly for key groups such as young black men, who may be experiencing more problems accessing mental health services, particularly where dual diagnosis is an issue.
5. To clarify the human rights issues relevant to both public protection and individual mental health service users.
6. To elucidate the myths and realities around the predictability of behaviour and claims that a proportion of violent and related undesired events associated with mental health problems could be avoided proactively.
7. To create an action plan to address the issues identified, using the suggestions for improvement developed through consultation, including identified leads, deadlines and completion measurements and a monitoring system to track improvements.

The review will take a flexible approach to the subject areas that need to be considered in more detail.

The joint review panel acknowledges that prejudice towards people with mental health disorders, not least when such individuals are from minority ethnic groups or have additional problems like those associated with illicit drug or alcohol use continues to be an issue for all the service providers involved as well as for the public at large. While equality and diversity implications will be assessed as an integral part of the review, the panel will take steps to ensure that prejudice is not perpetuated in the work of the review. Recommendations arising from the review will concentrate on short, medium and long term solutions, and will ensure that the responsibilities of all agencies under the Race Relations Amendment Act 2000 are considered throughout the review.

Key exclusions

The availability of mental health services in London will not be covered, as it has recently been the subject of a review by the GLA called Availability of Mental Health Services in London. In addition, the subject of housing and mental health was explored by the GLA in July 2003 in a report published as Getting a Move on - Addressing the housing and support issues facing Londoners with mental health needs. The protocols in place between the relevant stakeholders involved will be part of the scope of the review.

The subject of restraint will not be covered in depth as it has already been explored by an internal MPS review of restraint practices. The joint review will consider how the recommendations from the review in relation to mental health can best be implemented where these recommendations relate to the overall operation of services.

Key interfaces

The joint review will need to understand work currently underway in the mental health arena including the outcome of the MPS mapping exercise and similar work underway in the mental health field as well as ongoing in central government and agencies such as the London Development Centre for Mental Health, the Kings Fund, the Social Exclusion Unit and the Sainsbury Centre for Mental Health. Current work to develop a mental health strategy for London will be crucial, as well as Government proposals for the reform of the Mental Health Act.

Structure

Approach

The approach will follow elements of best practice as developed in previous MPA scrutinies in relation to consultation and gathering statements from witnesses. The joint review will include elements of the select panel process with the option of inviting witnesses from external organisations to set out their perspective. It is anticipated that the resources to carry out the joint review will be provided primarily by the MPA, with assistance from the MPS, the London Strategic Health Authorities and the London Development Centre for Mental Health. The joint review will be chaired by both the MPA and NHS on a rotating basis, with the remainder of the panel made up of key stakeholder and MPA members. Experience suggests that a panel of around six people would be most effective.

The review will use a mix of research, written consultation and statement gathering from witnesses. Other methods, including commissioning academic research may be used if considered appropriate by the panel. The review will engage and consult with service users who have had both positive and negative experiences of mental health services and the MPS.

The handling of media relations will be carried out on a joint basis with public relations units of all groups represented on the joint panel consulted during the publication of press releases and around the handling of the final report. A communications strategy will be prepared to support this terms of reference and will be approved by the joint review panel at the first meeting.

Panel meetings and statement gathering

Statements will be gathered from witnesses following research and written consultation and will be used to explore key issues in depth. ODPM guidelines and MPA experience suggests that meetings should reflect a number of principles:

• meetings can be confirmed and will be quorate if either of the chairs can attend plus three other panel members;
• statement gathering sessions would not be open to the public and press as a matter of course;
• members of the public and press may apply to attend statement gathering sessions and the panel will give consideration to allowing them to attend on a case by case basis;
• consideration would be given to (eg) using a smaller panel for specific sessions if the attendance of all members would be prejudicial to an effective hearing;
• witnesses would be provided with advance sight of the main areas of questions, protocols of member behaviour plus a written briefing on what to expect;
• witnesses would be provided with a summary of the hearing to ensure accuracy.

Plan

An outline plan for the joint review is attached at Annex 1. The plan is based on current MPA resource availability and committee structures and will need to be amended to take into account the requirements of other bodies. The plan assumes that a draft report will be produced by the end of March 2005 with a final report to be approved by June 2005. Panel meetings will be held on a monthly basis with no panel meetings will be scheduled for August 2004.

Deliverables

The joint review will deliver a written report setting out:

• what was reviewed and why;
• how the review was undertaken (including witness list);
• findings;
• conclusions;
• options (where applicable);
• recommendations for the MPS, NHS and/or others with rationale;
• next steps.

Constraints, assumptions and risks

Constraints

The completion of the review to time, budget and quality will be constrained by the availability of adequate resources within the MPA and the provision of additional resources from other organisations.

The size of the panel will need to be limited to a manageable number, despite the large number of stakeholders likely to be encompassed by the scope of the review.

Implementation of the review may be constrained by the co-operation of organisations not involved on the panel – for example, changes in legislation which can only be achieved with Government intervention.

Assumptions

COP Committee and the NHS decision making body will delegate authority to the joint review panel to approve minor amendments to the terms of reference and plan.

Where members of the panel hold critical differences of opinion the chairs’ views will be decisive.

Risks

The Government has published a revised Mental Health Bill, which will have a direct impact o the work of the review. The review will mitigate this risk by analysing the potential impact of the Bill on the areas covered by the scope of the project and will take steps to influence the new legislation as it passes through the relevant stages. The review will not be delayed pending the content of the Bill.

This is the first joint review carried out by the MPA and NHS partners. There are many organisations with an interest in the scope of the review and there is potential for expectations to grow beyond the capacity of the resources available to deliver. The decision of the joint chairs in terms of variations to the scope of the work conducted will be based on an appreciation of the impact on timetable, budget and quality and will be final.

There is a risk to the implementation of the joint review if the recommendations developed fall outside the remit of the MPA to deliver or monitor. A new mechanism to report back on delivery will need to be created when considering implementation as part of the final report.

Costs and benefits

Costs

The cost of the joint review, in terms of MPA officer support, approximates to around one third of a full-time equivalent for one year. In line with practice developed in scrutinies it is proposed to offer reasonable travel expenses to witnesses. Other funding requests will be presented to the chairs of the panel for approval prior to formally requesting finding from the relevant bodies.

Benefits

It is envisaged that the joint review will directly influence NHS, MPS and other stakeholder policies and procedures in supporting people with mental health problems. The review will map the overlaps between the different agencies involved and will put an action plan in place to improve processes and develop and revise protocols. The joint review should also highlight other areas where change, although beyond the direct control of the organisations involved in the review, might desirably be made to secure improvements in outcomes for individuals and the public generally

Annex 1: Scrutiny plan

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