Getting help in an emergency

‘Getting help in an emergency – the Mental Welfare Commission’s Review of Psychiatric Emergency Care Plans.’

Graham Morgan

3 February 2021

Hello thank you so much to Jim for asking me to give this presentation about our review of psychiatric emergency planning and to Tina for suggesting you might be interested in it.

My name is Graham Morgan, I work for the Mental Welfare Commission as an engagement and participation officer with lived experience of mental illness and would first like to set the scene for what I am going to talk about.

I will give some of the history that led to this document and then I will move onto how we created it and what we would like it to do.

Way back in 2016 we produced our report on place of safety. This was about those times that some of us are taken by the police to a place of safety because we have been found acting in a way in public that means they are worried about our mental health and our safety.

At the time we were concerned about the rising use of place of safety orders and the use of police cells to contain us when we are distressed, even though we are unlikely to have committed a crime. We were pleased to find that the use of police cells was now only used in a tiny minority of cases but wanted to follow up on the use of place of safety orders which we did with a report we published in 2018.

We found that most people detained under a place of safety order did not go on to be sectioned and, presumably, while they were very much distressed and needing help might have needed a different form of help to what they got. We also found out that there were circumstances where people got no help at all, for instance if they had been using drugs or alcohol to deal with their distress. One of the key things we found was the amount of police time spent with us when we are in crisis and the very varied way in which agencies responded to us and the police, when we are in crisis but not so ill that we are about to be sectioned or admitted to hospital.

This lead to further work in which we had another look at the psychiatric emergency plans that are meant to deal with the emergencies we get into and which each health board is meant to have.

This was an ideal project for me to be involved in because, when I worked with advocacy groups in the past, we frequently talked about our involvement with the police and the poverty of a meaningful response to our intense distress when in crisis.

I had become very tired of hearing of suicidal people –often diagnosed with EUPD being picked up by the police, when in the depths of despair, and taken to the local hospital which, in rural areas could sometimes be a few hours drive away, to be assessed and deemed not needing admission and therefore sent home again without support, only to be picked up again by the police.

I think some of the most distressing incidents I personally witnessed were when the police called me from home to travel twenty miles to the house of a person I worked with when I was part of HUG action for mental, because she was suicidal and drunk and mental health services were refusing to come to her or speak to her or admit her and the police were unable to do anything else and said it would be far better that I stayed with her rather than them having to arrest her for her own safety. On another occasion, admittedly ten years ago, when I was a patient in hospital, I encountered, with a friend of mine, a young woman. She looked like a teenager, she had just been admitted but had panicked at being in hospital and had been discharged at about ten at night. She was in skimpy party clothes, crying, suicidal, with no money and facing a five mile walk home in minus ten degrees or more.

Lastly I remember someone who escaped from hospital because she was so angry and so distressed. She contacted us and told us she was going to kill herself. We contacted the hospital who said they would do nothing as she didn’t mean it and was just being manipulative. An hour later the police came to where she was and prevented the suicide she was at that very moment trying to complete and which the hospital said wouldn’t happen. Despite this the NHS was still very, very, reluctant to take her back in as a patient and care for her.

Such things can get me angry and similar incidents that are still fresh in my memory still do.

As part of the original place of safety work I travelled around groups across Scotland talking about how people had found the police. We had wonderful and moving discussions which inevitably moved beyond the police and place of safety to how we are dealt with in crisis. I met about 170 people with lived experience or who were carers and produced a report on this wider topic.

In the second place of safety piece of work I also carried out one to one interviews with about 18 people, either family members or people with direct experience who had been involved with the police due to mental ill health, this informed the second place of safety report to some extent.

But it was the first report of lived experience around the police and crisis that had the biggest effect when we came to look at psychiatric emergency plans. We had a Specialist Registrar (Dr Anna Fletcher) on placement with us who did the main piece of work for this report. Between us we identified the key issues carers and people with lived experience had identified and this, combined with work she and our medical director at the time, carried out with Police Scotland, the Royal College of Psychiatrists, the Scottish ambulance service, the Health boards and the National distress interventions group led to a template of questions which we thought should underpin a modern psychiatric emergency plan.

The lovely thing about working in the Commission is that when we consult with people with lived experience about aspects of their lives, the subsequent reports can make a quick and important difference. The reason I say this is to mention that the report I compiled about lived experience was not particularly new; such issues have often been raised, for instance 30 years ago in Edinburgh with CAPS and on many occasions over the last 25 years with HUG (action for mental health) in the Highlands as well as by many other advocacy groups but sadly not to great effect, although admittedly, Edinburgh got a crisis house from the years of people with lived experience campaigning for its establishment.

Getting into the detail of what we looked at in the psychiatric emergency plans would I feel, just make this talk confusing but we selected fourteen themes ranging from:

Initial contact, to what a place of safety looks like, to transport when we are being taken somewhere for assessment or support, to information, young people and carers and aftercare and so on.

You can get to see the report easily by visiting the Mental Welfare Commission website, that is, if you have access to the internet.

To give a glimpse of the detail of this I will list some of questions we asked under the first theme of initial contact:

These included:

· “Is it clear who a first responder or a carer should contact if they discover a patient in a mental health crisis?”

· “Are there suitable services that a patient can self-refer to in crisis? Are there services where they can access face-to-face support when appropriate?”

· “Is there a description of a clear predictable response to crisis and evidence of crisis care planning?”

· “Is there appropriate triage and offer of appropriate support to address presenting problems which may not at their outset be diagnosable mental health presentations?”

· “Have services ways of responding to crisis that minimise the need for police intervention?”

· “Is there clear guidance on the role of police which minimises as far as possible the use of force and restraint and ensures they should keep a low profile and avoid criminalising the patient?”

· “Does the PEP emphasise sensitive and empathetic responses to patients in crisis? Does the PEP emphasise the need for compassionate non-judgemental care by all professionals involved?”

We then measured each Health board’s PEP against these questions. The final document describes the themes we developed, the questions we measured Health boards against and illustrates each of these questions with evidence we gained from people with lived experience and others when setting them. We then record how many Health boards actually addressed these questions in their PEP plans.

The number of Health Boards who met each of our criteria were very variable but this is perhaps not so surprising as, in this exercise, we were looking at emergency and crisis in a wider and more comprehensive fashion than had been looked at to date in psychiatric emergency plans.

We are very much hoping the Review of Psychiatric Emergency Plans which we produced in June of last year will influence how people like me and some of you, are supported when we are desperate in future and have already written to individual health boards with an analysis of their plans and hope this may influence them.

Initial reactions from Lived Experience Groups has been very positive, and I have to thank Tina who has been so passionate in pressing us to ensure that this document does not become a nice pipe dream of an ideal and actually serves to drive change.

Following some of her questions to us we will carry out the following actions and continue discussion about other ways in which our review can be used to act as a catalyst for improved services:

So we will

· Review the PEP plans of Health Boards against our ‘guidance’ on a regular basis and publish the results of these reviews.

· Consider the merit of asking the Scottish Mental Health Law Review to consider PEP’s in their discussions; especially when considering the right to health and alternatives to detention.

· When reviewing significant or critical incidents that have taken place , where relevant ,the MWC will review the PEP to check if health /social services have adhered to their own policies.

· Encourage Health Boards to listen to and act on the lived experience and carer voice and perception of their local reality it, just as we do via our engagement workers.

· We are aware that there is a rural dimension to PEP’s and the response to people in crisis and emergency. There are issues of transport, distance to specialist and in patient and assessment services as well as to places of safety. There is variation in the response of multidisciplinary teams and in triage and access to services that might divert from hospital admission or detention when people are in crisis in rural areas. There is also variation in the quality of the plans and in aftercare. We hope to incorporate this knowledge into our future work in rural areas in Scotland and in our interactions with Health Boards.

Thank you

For more information on the Mental Welfare Commission visit : https://www.mwcscot.org.uk/

(Photo: gutter in a storm in Cardross Feb 2021; Because this is what a crisis can feel like!)