Safe spaces: scoping report

2. Support for Alternative Safes

2.1. HMICS Review of Mental Health and Policing

HMICS commenced a thematic review in December 2022 to assess the state, efficiency, and effectiveness of the force’s provision of mental health related policing services. While the final report^[1], published in October 2023, did not make any recommendations about alternative places specifically, it did find significant variations in the use of place of safety by police officers across Scotland and emphasised the need for consistency of approach in the use and recording of place of safety orders across Scotland, making recommendations to this effect.

There was also significant discussion in the report on the overreliance on police response to mental health and distress incidents, and the increasing demand on police time. The latter was particularly associated with time spent by police in ED settings often because no alternative is available. Similar concerns have been raised by other policing stakeholders.

2.2. Time, Space, Compassion

The Time, Space, Compassion principles recognise that space needs to be both physical and emotional, setting out that ‘the safe space will offer a physical space which is accessible, welcoming, and designed to meet the needs of people experiencing crisis who may have experienced trauma. Staff can create emotional safe spaces for individuals to share and feel heard, however transparency will be needed when there is a duty to share or report any information which is considered concerning’.

2.3. Mental Health Core Standards

The mental health core standards, published in September 2023, aim to improve the quality of mental health services and set out what good looks like. They include standard 1.7: “If I am experiencing crisis, I will be able to access the help I need at a time I need it, in an accessible and available space. I will be shown compassion by the people who provide my support.”

2.4. The Scottish Mental Health Law Review

The Scottish Mental Health Law Review Final Report[2], published in September 2022, noted the importance of periodic review of legislation, especially when there have been relevant changes in society and the law. It also noted numerous developments in culture, thinking, classification, and law in the field of mental health, including human rights. The review outlined over 200 recommendations for changes to these laws and to how the laws work in practice.

The review noted concerns about the definition of ‘mental disorder’ within the 2003 Act. The review recommended a change in the overall purpose for mental health and capacity legislation to ensure that all the human rights of people who need support under mental health legislation are respected, protected and fulfilled. On that basis, it recommended that the term ‘mental disorder’ no longer be used and that instead the law should apply to “persons with a mental or intellectual disability (and otherwise included under Adults with Incapacity legislation) whether short or long term”. This could include people with a diagnosis of mental illness, personality disorder, or learning disability. It could potentially apply to an autistic person, a person living with dementia, or a person without a diagnosis who is experiencing an emotional crisis. The review went on to say that the help a person should receive under the legislation will depend on their individual needs and the barriers they face, and that any diagnosis maybe highly relevant to determining that. Work is underway to consider this recommendation in relation to compulsory care and treatment and it will be important to consider how the use of place of safety powers can be used when considering a new definition.

The review also highlighted the importance of taking steps to provide a “breathing” or safe space in which to address the causes of a person's mental distress and to ascertain their genuine will and preferences in crisis situations, noting this could also address anxieties around having to give effect to an individual's wishes expressed in times of acute emergency. It recommended:

Through the mental health strategy, Scottish Government should:

• ensure adequate resourcing and multiagency training for detention in the
• community.
• work with health and care agencies to develop alternative places of safety.
• for people who are in distress and at risk, and whose needs are not met by in-patient psychiatric care.
• further develop approaches to recovery.
• develop person-centred safety planning, including joint crisis planning.

It also recommended the Scottish Government lead systemic reform of services available to children and young people experiencing acute mental distress, including the provision of safe and child-centred alternatives to admission to psychiatric care.

2.5. The Criminal Justice Committee

Following the publishing of the 4.4. The Scottish Mental Health Law Review, the Committee noted a formal response to the Review^[3]. They highlighted that there were some specific issues raised in evidence they would like to draw attention to and referred to the following recommendations outlined in the Review:

• “The Scottish Government should work with health and care agencies to develop alternative places of safety for people who are in distress and at risk, and whose needs are not met by in-patient psychiatric care”.
• “The Scottish Government should review whether the place of safety powers should extend beyond suspected mental or intellectual disability to other people who may be at serious risk.”

The Committee advised it would also be helpful to understand the options being considered by the Scottish Government as alternative places of safety for people who are in distress and at risk, and whether consideration is being given to introducing a ‘fourth emergency service’ whereby police officers can transfer the care of a distressed person to a more appropriate service, both during daytime and out-of-hours, following their initial response. The Minister for Social Care, Mental Wellbeing and Sport responded to the Committee^[4].

The Committee are also supportive of the recommendations made by the HMICS thematic review of Policing Mental Health.

2.6. Health Board Unscheduled Care providers

The Scottish Government held engagement sessions with all 14 health boards across Scotland in both August 2022 and 2023. The engagement sessions demonstrated progress toward meeting the Mental Health Unscheduled Care pathways objectives in each area. During these sessions health boards advised that having an alternative safe space to ED and urgent clinical assessment settings would significantly enhance their unplanned and unscheduled mental health and distress care response, but many noted the associated significant challenges of implementing such as an approach. This is explored further in chapter 6.

2.7. The National Confidential Inquiry into Suicide and Safety toolkit for specialist mental health services and primary care

This toolkit recommends that community mental health services should include a 24-hour crisis resolution and home treatment team (CRHT) with sufficiently experienced staff and staffing levels. CRHTs provide intensive support in the community to patients who are experiencing crisis, as an alternative to in-patient care. CRHT teams should be monitored to ensure that they are being used safely. Contact time with CRHTs should reflect the specialist and intensive nature of that role.

Both the King’s Fund Under Pressure report and the Independent Commission on Acute Adult Psychiatric Care referenced these recommendations in 2015 and emphasised the importance of CRHTTs operating efficiently as intensive specialist community-based alternatives to in-patient care rather than as generic crisis teams.

2.8. Mental Welfare Commission - Review of Psychiatric Emergency Plans

The Mental Welfare Commission (MWC) for Scotland carried out a review of Psychiatric Emergency Plans in Scotland. ^[5]The report, published in June 2020, notes that individuals are presenting in potentially highly distressed states and they may have to wait for some time in a place of safety during the assessment process. Therefore, the report highlighted the importance of ensuring that places of safety are comfortable and offer appropriate levels of privacy.

It outlined concerns from police regarding the perceived criminalisation of distress when they take a patient to a place of safety and must wait with them in public waiting areas, with the public often assuming the patient has committed a crime. The report also noted increasing concerns from Emergency Medicine Staff about over-medicalisation of distress and the need for appropriate triage and access to appropriate supports, including ‘persons of safety.’

The report highlighted that there are limited resources for substance affected individuals who are not at the time of the presentation eligible for mental health assessment and therefore require a safe space to wait until they are fit for assessment.

The MWC also published in November 2023 a review^[6] of repeated uses of police place of safety powers under the Act which highlighted instances where some people are repeatedly brought to the attention of mental health services by police services using the police powers under section 297 (place of safety) of the Act.

The report outlined the concerns of professionals that there appears to be nowhere else for people to go except for statutory places of safety – which tend to be hospitals. The data in the report demonstrates that most people are then not detained in hospital and that many are not admitted to hospital at all. It went on to outline that admission to any hospital carries risks and benefits, and recalled the concerns previously expressed about the inappropriate medicalisation of “mental unrest and emotional pain.”

2.9. Summary

While these reports and findings point to the need for additional safe spaces, it is often discussed as one homogeneous space that can be all things to all people, of all ages, ranging from alternative clinical settings to informal and comfortable community settings.

There is, however, consensus that they could be beneficial for people in crisis situations where: their needs can be better met outwith an ED setting, they do not require admission, and an alternative is required to keep a person safe or undertake further assessment in the short-term. This space would be beneficial for individuals who are in crisis or emotional distress and do not require any physical health concern to be addressed, to receive a tailored response to their presentation. Alternative spaces may also provide more timely specialist mental health support and advice as well as informal monitoring and supervision available over a limited period with escalation processes available, if required.

Alternatives to ED as a legal place of safety would also be beneficial, however; this statutory measure should only be used where people are not willing to engage with support on a voluntary basis and the criteria for statutory measures are satisfied. As such, when s297 is deployed, the alternative safe space must have the ability to support people who do not consent to engaging with their service.

As noted above, these examples are not necessarily exclusive of each other, there may be benefits of taking a mixed approach.