Iain McKinnon

The impact of transforming care on the care and safety of patients with intellectual disabilities and forensic needs

NHS England recently published a national plan to develop community services for people with intellectual disabilities and autism who display challenging behaviour by using resources from the closure of a large number of hospital beds. An ambitious timescale has been set to implement this plan. The bed closure programme is moving ahead rapidly, but there has been little progress in developing community services to support it. This paper discusses the impact of the gap between policy and practice on the care and safety of patients with intellectual disabilities and forensic needs who form a distinct subgroup of the target population and are being disproportionately affected by this government policy.

Too much detention? Street Triage and detentions under Section 136 Mental Health Act in the North-East of England: a descriptive study of the effects of a Street Triage intervention

Objectives To describe the impact of Street Triage (ST) on the number and rate of Section 136 Mental Health Act (S136) detentions in one NHS Mental Health and Disability Trust (Northumberland, Tyne and Wear (NTW)). Design Comparative descriptive study of numbers and rates of S136 detentions prior to and following the introduction of ST in NTW. More detailed data were obtained from one local authority in the NTW area. Setting NTW, a secondary care NHS Foundation Trust providing mental health and disability services in the north-east of England, in conjunction with Northumbria Police Service. Participants People being detained under S136 Mental Health Act (MHA). Routine data on S136 detentions and ST interventions were obtained from NTW, Northumbria Police, Sunderland Hospitals NHS Foundation Trust and Sunderland Local Authority. Interventions Introduction of a ST service in NTW. The main outcome measures were routinely collected data on the number and rate of ST interventions as well as patterns of the numbers and rates of S136 detentions. These were collected retrospectively. Results The annual rate of S136 detentions reduced by 56% in the first year of ST (from 59.8 per 100 000 population to 26.4 per 100 000). There was a linear relationship between the rate of ST in each locality and the reduction in rate of S136 detentions. There were 1623 ST contacts in the first 3 localities to have a ST service during its first year; there were also 403 fewer S136 detentions. Data from Sunderland indicate a 78% reduction in S136 use and a significant reduction in the number and proportion of adult admissions that originated from S136 detentions. Conclusions There is evidence to support the hypothesis that ST decreases the rate of s136 detention. When operating across the whole of NTW, ST resulted in 50 fewer S136 detentions a month, which represents a substantial reduction.

Exploring the intersections between novel psychoactive substances (NPS) and other substance use in a police custody suite setting in the north east of England

Abstract Aims: Novel psychoactive substances (NPS), a range of plant-based/synthetic substances that mimic effects of other illicit substances (e.g. cannabis), are now illegal in the United Kingdom (May 2016) to produce/supply. Negative behavioural consequences of NPS use mean that users frequently transgress the law are arrested and detained in police custody suites. Evidence shows a link between traditional substance use and offending behaviour, with significant police time spent on alcohol-related incidents. We explore the intersections between NPS and other substances with police staff and users in custody; specifically the similarities and differences in treatment, management and policing of these substances. Methods: A qualitative study using semistructured interviews and thematic analysis. We recruited 15 police staff (4 women/11 men) and 25 NPS users (9 women/16 men). Results: Police staff perceived NPS users to be extremely volatile in custody and reported feeling less knowledgeable about how to manage and respond to their needs compared to other substance users (e.g. alcohol, heroin). Users rarely took NPS in isolation and often compared them to other illicit substances, balancing effects versus costs. Conclusion: NPS use has a striking effect on custody work, primarily because of unpredictable user behaviour, adding further pressure to already overstretched police staff.

Improving the detection of detainees with suspected intellectual disability in police custody

Purpose – The purpose of this paper is twofold. First to ascertain the efficacy of current police reception screening to detect detainees with intellectual disability (ID). Second to assess the validity of a short targeted screen for ID among police custody detainees. Design/methodology/approach – The study comprised three stages. First, 248 police custody detainees were assessed for a range of health morbidities, including a pragmatic clinical evaluation of ID. For those with suspected ID, the police custody screens were scrutinised for evidence that this had been detected. Second, a new police health screen, incorporating a short screen for ID, was piloted. Totally, 351 detainees were assessed in the same way as in part 1 with the new screens being scrutinised for evidence that ID had been detected where relevant. Third, the new police screen for ID was validated among a sample of 64 inpatients, some with ID and some without, from forensic inpatient services. Parts 1 and 2 were carried out in the Metrop...

Mental capacity to consent to research? Experiences of consenting adults with intellectual disabilities and/or autism to research

Accessible Summary The NHS Constitution states that all patients should have opportunity to take part in approved research This study asked clinical researchers how they include people with intellectual disabilities and/or autism in research Many barriers were identified that relate to making mental capacity judgements Many researchers agreed new resources that support consent and capacity judgements for research would be helpful and gave some ideas about what could help . AbstractBackground Adults with intellectual disabilities and/or autism are often excluded from participating in health and healthcare research. Understanding study information, which is an important aspect of demonstrating capacity to give informed consent, can be a particular challenge. This study surveyed clinical researchers to discover: (i) their experiences of assessing mental capacity for research; (ii) what methods they used to facilitate the inclusion of adults with intellectual disabilities and/or autism; and (iii) their views about a proposal to develop new resources to facilitate mental capacity judgements with adults with intellectual disabilities and/or autism for informed consent for research. Methods Clinical researchers in North East England who conduct research with NHS patients with intellectual disabilities and/or autism were invited to participate in a 22-item self-completed semi-structured questionnaire survey, either online or on paper. Results Twenty-one clinicians completed the survey (response rate 30.4%). Participants reported on 18 research studies which included people with intellectual disabilities and/or autism. In many studies people who lacked capacity to give informed consent were excluded, and often shortcuts were taken in judging capacity. Limited adaptations to support capacity were used. Respondents welcomed the proposal of developing assistive resources that could support capacity judgements and informed consent to research. Conclusions To improve access to research for people with intellectual disabilities and/or autism, researchers need robust methods to facilitate informed consent and mental capacity judgements. Future research should determine which assistive resources show potential to support informed consent and capacity decisions, and whether such resources could improve inclusion in research.

Changes in the Use of the Mental Health Act (1983) in England 1984/85 to 2015/16

BACKGROUND Concerns have been raised about the increase in the use of involuntary detentions under the Mental Health Act in England over a number of years, and whether this merits consideration of legislative change.AimsTo investigate changes in the rate of detentions under Part II (civil) and Part III (forensic) sections of the Mental Health Act in England between 1984 and 2016. METHOD Retrospective analysis of data on involuntary detentions from the National Archives and NHS Digital. Rates per 100 000 population were calculated with percentage changes. The odds of being formally admitted to a National Health Service hospital compared with a private hospital were calculated for each year. RESULTS Rates of detention have at least trebled since the 1980s and doubled since the 1990s. This has been because of a rise in Part II (civil) sections. Although the overall rate of detentions under Part III (forensic) sections did not rise, transfers from prison increased and detentions by the courts reduced. The odds of being detained in a private hospital increased fivefold. CONCLUSIONS The move to community-based mental health services in England has paradoxically led to an increase in the number of people being detained in hospital each year, and in particular an inexorable rise in involuntary admissions. This is likely to be partly because of improved case finding with an increased focus on treatment and risk management, and partly because of changes in legislation. An increasing proportion of this government-funded care is being provided by private hospitals.Declaration of interestNone.

Contextualising health screening risk assessments in police custody suites – qualitative evaluation from the HELP-PC study in London, UK

BackgroundIn the UK, police custody officers have a responsibility to screen for health morbidity and vulnerability among detainees. This study aimed to develop an understanding of the barriers to performing effective health screening in police custody suites, understand the impact of screening tools on practice within the custody suite, and to identify factors that could hinder or facilitate the future implementation of a new screening intervention in this environment.MethodsA qualitative study was conducted alongside a quantitative evaluation of a novel screening tool. Qualitative methods included observation of the custody environment, semi-structured interviews with police staff, and elicitation of comments from detainees about their experiences of screening. Data were analysed inductively using thematic analysis. Normalization Process Theory (NPT) was used to inform data collection and as a framework for higher level analysis of findings.ResultsFive overall constructs were identified that develop understanding of the integration of health screening within custody: the workability of risk assessment screening tools; the effect of the custody environment and the people therein; shifts in professional roles and interrelationships amongst staff; cultural responses to risk and liability in police work; how infrastructure, knowledge and skills can impact on detainee safety.ConclusionsHealth and risk assessment screening in police custody is a complex and demanding activity which extends beyond the delivery of a screening tool. Professional roles, the demanding environment and police culture impact on the overall process. Recommendations for improved integration of health and risk assessment screening in wider police custody practice are proposed.

Vitamin D in patients with intellectual and developmental disability in secure in-patient services in the North of England, UK

Aims and method To assess the benefits of the introduction of routine vitamin D serum sampling for all patients admitted to a secure in-patient hospital in the North of England providing medium security, low security and rehabilitation services for offenders with intellectual and developmental disability. The vitamin D levels of 100 patients were analysed at baseline. Those with insufficient or deficient levels were offered treatment and retested after 1 year. Vitamin D levels were analysed in the context of level of security, seasonality of test and co-prescription of psychotropic medications. Results Eighty-three per cent of patients had suboptimal vitamin D levels at initial test (41% deficient and 42% insufficient). This was seen among established patients and new admissions. Regression analysis of baseline vitamin D levels revealed no differences for levels of security, seasonality, whether patients were taking antipsychotic or anticonvulsant medication, or length of stay. Patients with deficiency or insufficiency were all offered supplementation. Those who opted in had significantly higher vitamin D levels at follow-up, compared with those who declined treatment. Clinical implications Established and newly admitted patients in our secure mental health services had substantial levels of vitamin D insufficiency. In the light of the morbidities that are associated with deficient vitamin D levels, routine screening and the offer of supplementation is advisable. Declaration of interest None.

Health characteristics of older police custody detainees in London, UK

Abstract The number of older adults involved in the criminal justice system is rising. Little is known about the state of health in older people who are arrested. This study compared characteristics and health care needs of older police custody detainees with their younger counterparts. The health characteristics of 57 police detainees aged over 50 were compared with 543 younger detainees. Older detainees had significantly higher rates of physical illness and risk of alcohol withdrawal. Although there were equivalent rates of mental disorder and drug taking compared with younger detainees, a higher proportion had presentations consistent with cognitive impairment due to possible dementing processes. Over 80% of older detainees were recommended to have a health assessment in police stations based on their presentation. Police detainees over 50 should be considered to have a health assessment as routine procedure. Further investigation should also be conducted into cognitive impairment in this group.

Mental Health: Suicide in the Criminal Justice System – Prevalence, Risk Factors, Prediction, and Prevention

At a population level suicide is rare; however, increased rates are observed in criminal justice populations. Suicide prediction and prevention among individuals in contact with the criminal justice system is notoriously difficult. The detailed investigation of deaths in prison and deaths in and following police custody are lengthy and seek to establish potential criminal liability for organizations and individuals. Therefore it is important that clinicians and custodial staff are skilled in the assessment of suicide risk. In this chapter we explore some of the challenges in these assessments and the known risk factors in these populations.