RCN position on the National Partnership Agreement: Right Care, Right Person (RCRP) – practice and workforce implications

Changes in ways of working

A policy paper was published in July 2023 outlining the challenges faced by police in England when responding to mental health crises against the backdrop of under-resourced and understaffed mental healthcare services. 

The Chief Constable of the metropolitan police has stated that officers spend, on average, 10-12 hours sitting with patients in ‘Places of Safety’ (i.e. A&E and 136 Suites) when the appropriate environment and qualified workforce are unavailable to assess the person’s needs. This delay in care is unacceptable to the person awaiting assessment while creating avoidable demands on police time.

Our members agree that people experiencing mental health crises should be able to access the right care at the right time, by the right person, and in the right place. In most cases, it is unlikely to be the police, and people would be better supported by specialist appropriately resourced mental health services.

The RCN has lobbied against using A&E as an appropriate Place of Safety under section 136 of the Mental Health Act (1983). This issue is a core contributor to the challenges outlined in the policing policy paper. The most appropriate place for this assessment is a specialist mental health facility with appropriately trained staff and an environment conducive to assessment.

The newly announced threshold for a police response to a mental health-related incident is:

• to investigate a crime that has occurred or is occurring; or
• to protect people when there is a real and immediate risk to the life of a person or of a person being subject to or at risk of serious harm

However, the police are granted statutory powers under the Mental Health Act (1983), unavailable to any other profession:

• Section 135(1) – Warrant to enter and remove to a place of safety.
• Section 135(2) – Warrant to enter and remove an absent patient Section 136 of the MHA – the power to remove a mentally disordered person without a warrant.
• Section 136 of the MHA – the power to remove a mentally disordered person from a public place without a warrant.
• Sections 35, 36 and 38 – Remand to hospital for report or treatment of the accused’s mental condition of patients subject to hospital orders by the court.

Although the policy states that police will continue to deliver their statutory duties under the Mental Health Act, our members are concerned that the ‘new threshold’ will further disenfranchise some vulnerable groups, such as those with complex emotional needs or a personality disorder diagnosis (historically referred to as ‘high-intensity users’).

Our members see parallels between this new policing position and the unintended outcomes that followed the national rollout of Serenity Integrated Mentoring (SIM) and other ‘high-intensity support’ models across England.

It is concerning that some individuals may feel compelled to contact the police when in distress due to a perceived lack of available mental health emergency or crisis services. This is particularly true for vulnerable people or people whose relatives or friends require assistance. However, it is essential to recognise that alternative resources and options may be available to help and support in these situations.

Individuals in a vulnerable state must receive adequate mental health care instead of being subjected to the criminal justice system. The government needs to reassure stakeholders and the public that individuals seeking assistance from emergency and crisis services will not face criminal consequences, particularly in situations where our health and care systems are underfunded and ill-equipped to cater to the needs of the most vulnerable members of society.

Despite the assurance within the policy to transition towards these new ways of working, our members have informed us that police forces across the country are already refusing to respond to mental health crises unless a crime is committed. These actions contradict the commitment to the policy and the statutory duties for police set out within the Mental Health Act.

We are concerned that such actions lack police monitoring, healthcare governance, and infrastructure to safely provide this vital public service. The move to withdraw police from responding to mental health crises, often as a last resort, without a clear transition, will increase pressure on already stretched mental health services. If done with haste, this will increase mental illness stigma, restrictive interventions, risk of harm to the public, and allow unnecessary convictions of people in mental health crises.

Evaluating the efficacy and structure of mental health services that cater to individuals with complex emotional needs is imperative. These services must align with the four domains of the Mental Health Crisis Care Concordat:

• Access to support before crisis point,
• Urgent and emergency access to crisis care,
• Quality of treatment and care when in crisis,
• Recovery and staying well.

Workforce challenges

Demand for mental health services has increased by 44% over the past five years. As outlined in the NHS England Long-Term Workforce plan, there will need to be a significant boost to the mental health workforce to meet current and expected future demand. Mental health nurses hold a unique role in assessing and formulating the needs of people experiencing a mental health crisis in acute hospital liaison, custody liaison and specialist mental health services.

Without adequate mental health nurses to assess people’s needs, including requesting a Mental Health Act assessment when indicated, the care pathway will continue to face delays and add pressure to already stretched police and emergency services. Increased workload leads to “burnout” of the remaining staff, contributing to a higher staff turnover rate and, therefore, more staff shortages in a vicious cycle.

There have been efforts to introduce new unregistered roles in mental healthcare due to a lack of registered mental health nurses. However, conducting proper workforce modelling and formally evaluating these roles is essential to determine their impact on patient outcomes and the existing workforce. The House of Commons Committee of Public Accounts (2023) has stated:

‘Medical and nursing staff made up 40% of the workforce in 2021-22, down from 47% in 2011-12, while therapy staff increased from 12% to 18% over the same period. The profile has also shifted to more junior roles across different staff groups. Given the increased complexity and severity of problems for people accessing services, the NHS must manage these changes carefully.’

The insufficient numbers of registered mental health nurses and the need for improvements in mental health nursing will take a further ten years to address. Failure to review and refocus workforce priorities on strengthening the number of registered mental health nurses will only prolong the necessary national and local time frame.

The UK Government must address the severe lack of registered mental health nurses and psychiatrists in mental health services with long-term investment in workforce planning. Statistics about successful workforce growth (presenting an overall increase of 22%) are often misleading and do not accurately represent the secondary mental health services staffing crisis. Immediate action must be taken to address the core staffing crisis. New workforce investment must prioritise recruiting and retaining registered mental health nurses.

The current global shortage of psychiatric-mental health nurses must be taken into consideration. The ICN's latest report underscores the unique challenges that an ever-growing number of these nurses face worldwide, reflecting the issues experienced in the UK. The reliance on international recruitment will not solve our challenges; the best option is to expand our domestic workforce quickly.

Recommendations

Healthcare professionals in England must consistently adapt and evolve to effectively meet the diverse needs of our communities. Mental health must be a top priority for all, regardless of their field of practice or workplace.

• There is a need for urgent evaluation of nursing and the broader community of emergency and crisis workers to determine the health and care professional’s capability and proficiency to support people with severe mental illness and complex emotional needs beyond the confines of traditional mental health services.
• Mental health services must design care pathways that work for the people in their care, which ensures a range of entry points and levels. Rather than continuing to create services designed to exclude rather than include the most vulnerable in society.
• The government must invest in hospital, custody, and court liaison and diversion models to provide mental health support instead of relying on the police. These services should be mandatory in every locality and staffed with professionals equipped to handle the complex needs of this vulnerable group. The focus must be on providing patient-centred care and ensuring patient safety. Cost savings should not take precedence over the well-being of service users.
• Mental health services must design care pathways that recognise and effectively mitigate the impact of the range of protected characteristics, as defined by the Equality Act 2010, on patient outcomes and experiences.
• To address the staffing shortages that affect the entire health service, including the safe care of individuals with severe mental health conditions, the government in England needs to commit to a law that outlines local and national accountability for workforce planning, funding, and investment. This should be done in conjunction with the workforce plan.
• Where vital emergency care (either by police or health and care agencies) is not provided to people in a mental health crisis that may warrant a Mental Health Act assessment, the RCN encourages members and the multidisciplinary team (including police and other emergency services) to formally record such incidents via their organisational incident reporting structures to uphold transparent multiagency governance and accountability.