4 Other services for drunk and incapable people
Introduction and description of evidence
4.1 This chapter will look briefly at other interventions which are used around the world to meet the immediate care needs of drunk and incapable people. These other interventions include transportation services and the provision of medical support within police custody suites (usually by custody nurses). It should be noted that the latter intervention does not divert drunk and incapable people from police cells. However, it may be argued that it does remove some of the pressure from the police in assessing the fitness of intoxicated individuals to be held in custody.
4.2 There was very little evidence available on these other interventions, and in the case of transportation services, this evidence has been gleaned from reports which have focused on the provision of other types of services (including sobering-up services). The mention of a dedicated free bus or van service has been mentioned almost in passing, although one study carried out for the City of Seattle provided detailed information on the use of the sobering van in that city over a five-year period. 104
4.3 Although there is little literature on the subject of providing support to alcohol-related detainees in police custody, the literature is of good quality and is based on formal research and evaluation, and published in peer-reviewed journal articles or through government research reports. This includes:
- An assessment of the Kent (England) Custody Nurse scheme undertaken for the Home Office (Gannon, 2002)
- A comparison of nursing and medical provision (by forensic medical examiners) in police custody suites in the north of England (Bond et al, 2007)
- Two investigations of the feasibility of forensic medical examiners providing brief interventions to drunken detainees in police custody in London (Deehan et al, 1998; and Best et al, 2002)
- Abstracts of older research undertaken in Melbourne (Australia) on the evaluation of a trial forensic nursing service (Evans & McGilvray 1996; and Young et al, 1994)
Transport services
4.4 There was a great deal of evidence from North America and Australia of transportation services working in conjunction with sobering-up services. These services may, or may not, be provided by the same agency that provides the sobering service itself.
Sobering centre transport vans in North America
4.5 Many sobering centres in America work in conjunction with transport vans which take clients free of charge to and from the service. There was evidence of vans operating in the cities of Seattle and Portland, and in Alameda County, California. 105 The transport van programme in Alameda County included several vans, all staffed with an Emergency Medical Technician ( EMT) and an outreach worker.
4.6 In Portland, the van patrols the city streets from 7.30am to 11.30pm seven days a week. In addition, the van may also be directed to intoxicated individuals by the police. Under Oregon state law, the van staff have the power to take people into civil custody. However, they don't have police powers and generally, they allow the police to handle violent or aggressive clients. 106
4.7 The vans are well-used. The sobering up van in Seattle recorded 13,433 call-outs in 2005. This was down by 1,300 from the previous year. 107
Sobering service vans and night patrols in Australia
4.8 There was also a great deal of evidence for the use of transportation services in Australia. There was evidence of vans operating in conjunction with sobering-up services in Ceduna, Canberra and Darwin. 108
4.9 In addition, the use of night patrols is common in Australia particularly in Aboriginal communities (including rural communities) which are affected by alcohol-related violence. The night patrol is a form of community policing which is designed to deal with alcohol-related trouble before it gets to a stage of requiring police intervention. 109 Patrols have been operating in some areas since the mid-1980s, and in 1999/2000, there were 69 patrols operating in locations throughout Australia. 110
4.10 One in-depth study of Australian night patrols reported that these interventions initially developed in response to alcohol-related violence endemic in some Aboriginal communities. The patrols use a community approach to resolve problems within the community. They work in co-operation with the police, and act as a buffer between the community and the criminal justice system. 111 In some cases, the night patrol involves people on foot, in other cases, it is a bus. Both men and women, young and old, may be members of a night patrol.
4.11 One report stated that on a typical night, a night patrol:
… may attend a domestic violence incident, find somebody drunk, take the drunk to the sobering-up shelter… refer people to the women's refuge, this hospital or the … medical service. 112
4.12 Night patrols also provide transport for intoxicated people to be taken to a safe place (either a sobering-up shelter, or home). However, one author pointed out that the purpose of the patrol was not to "assist in removing intoxicated persons from the streets", although the point was also made that there has been some misunderstanding with the police over this. The main aim of the night patrol is to reduce alcohol-related conflicts and harm -- to resolve problems in the community; to help "settle disputes when they begin and not after they have exploded". Where the police have to be called, the patrol assists the police and the community to communicate with each other. 113
4.13 There is variation in how these patrols operate in different areas. Some are operated entirely by volunteer members of the community working on a weekly roster system, while others are staffed by paid workers. 114 Where a night patrol is staffed by paid workers, the available funding can put restrictions on the number of nights the service is able to operate.
4.14 In the city of Darwin, the night patrol was staffed predominantly by Aboriginal people. This patrol is:
responsible for 'scouting' Aboriginal camps, talking to people and, with the consent of the person concerned, (they) bring that person back to the sobering up centre. 115
4.15 A report on the operation of the Darwin night patrol made the point that the requirement to get the person's consent often requires a mixture of coercion and cajolery.
4.16 There have been several evaluations of night patrols in Australia. The findings clearly indicate that, where night patrols operate, people generally rated the patrols as effective in reducing alcohol-related violence and getting intoxicated people off the streets. 116
Providing medical support in police custody suites
Background - the burden of alcohol-related arrests on police custody suites
4.17 In recent years, research has been carried out in the UK to analyse and quantify the burden on police custody suites of alcohol-related detentions. Two recent studies (funded by the Home Office) have investigated this issue.
4.18 One was an analysis of 1,575 custody records from three metropolitan police stations in England (carried out in February 2000). 117 This study found that alcohol was a factor in almost a third of arrests. In analysing this data, the researchers made a distinction between alcohol-specific offences (such as drunkenness or drink driving) and alcohol-related offences (where the detainee was drunk or had been drinking prior to the arrest). Alcohol-specific offences comprised 15% of arrests and alcohol-related offences comprised 16%. Both alcohol-related and alcohol-specific offences were most likely to occur at night - particular Friday and Saturday nights.
4.19 Alcohol-related detainees spent significantly longer in custody than other detainees (average of 8.7 hours and 6.9 hours respectively) mainly because of the need to sober up before interviewing and processing. Alcohol-specific detainees spent less time in custody (average 4.5 hours). Many alcohol-specific detainees were held to allow them to sober up in a supervised environment and then were released without any charges being brought. (It should be noted that there were similar findings from an observational study carried out by Deehan et al (2002).)
4.20 A forensic medical examiner ( FME) was called to examine about half (53%) of those arrested for alcohol-related offences and just over a third (36%) of those arrested for alcohol-specific offences. The FME recommended that custody staff closely observe about a quarter of these individuals while they were being held. Another quarter of these detainees required medical attention from the FME.
4.21 In addition, there was evidence from this study that police custody staff felt that dealing with drunken detainees was not a good use of police resources and resulted in unnecessary pressure on police cells. There was also some evidence that custody staff did not feel adequately trained to manage drunken detainees.
4.22 The researchers in this study questioned whether the custody suite was an appropriate place for alcohol-specific detainees - ie, those who were often held in custody simply to sober up in a supervised environment and then were released.
4.23 However, it was not seen to be appropriate to divert alcohol-related detainees from custody, since many had in fact, committed an offence. Nevertheless, individuals arrested for alcohol-related offences still posed a significant burden on the police compared with those who had not been drinking. The researchers recommended that consideration should be given to how detainees with alcohol problems, whether chronic or acute, can be effectively dealt with in the custody environment. The suggestion was that trained staff could screen detainees for alcohol problems and provide brief interventions, or refer the detainee into treatment as appropriate.
4.24 It is worth noting that other studies have shown that a large proportion of the work of forensic medical examiners involves intoxicated detainees, and much of this work is related to assessing individuals for their fitness to be detained. If an FME considers an arrestee fit to be detained, they usually request that custody staff make frequent checks - eg, in some cases, every 15 minutes - to ensure the well-being of the detainee. 118
4.25 Traditionally, forensic and medical services to detainees in police custody have been provided on an on-call basis by medical practitioners (usually part-time GPs with special training in forensic medicine). However, in recent years, there has been a growing trend (in the UK and elsewhere) to restructure services so that initial medical contacts are made by custody nurses.
The role of forensic medical examiners and custody nurses in managing the care needs of intoxicated arrestees
4.26 There have been two UK studies which have specifically investigated the role of the FME in addressing alcohol-related problems of drunken detainees in police custody - through screening and brief interventions. 119 However, neither of these studies looked specifically at the effectiveness of using FMEs to manage the care needs of drunk and incapable people in police custody.
4.27 Nevertheless, there were a few messages from these studies which are relevant to the aims of this review:
- First, a large part of the job of an FME involves assessing the fitness of alcohol-related detainees to be in custody.
- Second, one of the reasons for this may be that custody sergeants feel a certain level of anxiety about this group, who represent one of the most common groups to die in police custody.
- Third, although FMEs generally feel confident about caring for the needs of alcohol-related detainees, they question whether it should be part of their role to screen people for alcohol problems or to deliver brief interventions, and they question the effectiveness of such interventions being delivered in the context of a police cell when an individual is intoxicated.
4.28 Four studies were identified which examined the role of custody suite nurses. However, none of these studies concerned the specific role of nurses in meeting the needs of alcohol-related detainees. One of the studies was not relevant at all to the purposes of this review as it primarily concerned an exploration of the roles and boundaries of practice among custody nurses. 120
4.29 The main purpose of three of the studies (two in Melbourne, Australia and one in the north of England) was to evaluate the impact of providing nursing care in police custody suites in parallel with medical support from a forensic medical examiner. 121
4.30 In all three studies, nurses provided the initial contact and triage assessment of police detainees. Nurses were responsible for undertaking assessments, conducting clinical procedures and carrying out on-going monitoring of detainees' health and behaviour. Referrals were made to the FME or hospital where necessary. All studies found that the use of custody nurses can improve the operational efficiency of health care services offered in police custody suites. One study found that nurses had faster response times, comparable consultation times and were perceived by custody staff as more approachable than their medical colleagues in providing handover information. 122
4.31 It is perhaps worth mentioning that this same study analysed the time nurses spent on different tasks, and similar to the studies of FMEs described above, the vast majority of the work of the nurses (approximately 90%) involved assessing an individual's fitness to be detained and / or interviewed by the police.
Temporary places of safety, mobile units and SOS buses
4.32 Finally, a model of service which is being used increasingly to meet the needs of drunk and incapable people in the UK, involves the use of a mobile service or a specially adapted bus.
Mobile Medical Response Unit, Cardiff
4.33 The Mobile Medical Response Unit ( MMRU) in Cardiff is an example of the former. 123 This service comprises a triage vehicle staffed by a driver and paramedic, which is supported by a number of patient transportation vehicles provided by St John Ambulance Service and the Welsh Ambulance Trust. The MMRU has a police radio and can respond to 999 calls directly. On certain occasions of high demand, the service operates in conjunction with a temporary treatment centre (a first-aid post located in the Millennium Stadium), where people with minor injuries can be referred. Patients who require further treatment are referred to the local emergency department.
4.34 In its first year of operation (Dec 2004 - Dec 2005), the MMRU was available on 17 occasions, and the treatment centre also operated on eight of those occasions, during periods of peak demand such as during the festive season, bank holidays or sporting events. Alcohol was reported to be a factor in 96% of incidents dealt with by the service.
4.35 A formal evaluation of the service concluded that it provided patients with a rapid and effective means of dealing with minor injuries, while freeing up emergency resources (police, ambulance and emergency departments). It was estimated that the service saved a total of 360 hours of emergency department time. In financial terms, this represented an estimated £14,445 in doctor costs alone. In addition, the Wales Ambulance Service Trust estimated that the triage and transport arrangements that comprised the MMRU saved the trust £25,000 in its first year of operation, largely because of the ability to retain patients geographically in the city centre. This saved on transport time, and time spent by staff having to wait at the hospital to transfer patients to the emergency department.
4.36 The costs of delivering the service were able to be kept very low because much of the cost was borne directly by the agencies involved in planning and delivering the service. For example:
- The Millennium Stadium treatment centre was provided to the partnership free of charge
- The cost of the MMRU paramedic vehicle and support vehicle was met by the Ambulance Trust, and since the MMRU relieved other ambulance vehicles of a large proportion of city centre work, this was seen as a neutral cost
- The cost of medical supplies and sustenance for volunteers and staff was met by the NHS Trust
- A donation was made to the St John Ambulance Service of £300 each time the MMRU operated, for the vehicles they provide and the three volunteers; and a further donation of £500 each time the temporary treatment centre operated, for the medical volunteers (doctors, nurse practitioners and first-aiders) that the charity provided.
4.37 In its first year, the direct costs of the service on each occasion of operation were £310.05 for the MMRU (total £5,271 for 17 occasions), and £1,044 for the treatment centre (£8,352 for eight occasions). These costs do not include the costs of nursing staff or policing, which was available on some, but not all occasions.
Other mobile services
4.38 Like the MMRU, SOS buses provide immediate assistance to people who may be intoxicated, distressed or have minor injuries. 124 They offer first-aid (including, in some cases, social and emotional first-aid), and a place of safety for people until they are able to be taken home by a family member, friend or taxi.
4.39 There are SOS buses in Norwich (since 2000), Weston-Super-Mare (since 2005), Southend-on-Sea (since 2006) and Belfast (since 2007). In every city, the bus project is a multi-agency initiative involving the local authority, police, St John Ambulance, the local community, churches and charitable agencies.
4.40 The service works by parking the bus in a busy, prominent, city-centre location at night. A support vehicle (a van or mini-bus) is used to transport people to the bus from around the city, or from the bus to a hospital emergency department, if necessary. In some cases, the support vehicle may also take people home. In addition, clients may present themselves or be brought along by friends. In Norwich, the bus works together with a first-aid centre (located separately in a porta-cabin some distance away).
4.41 The buses generally operate at the weekends, although the Belfast SOS bus is also deployed at other times during the week for educational and community project work.
4.42 In general, the clients are young people on a night out. In Weston-Super-Mare, steps have been taken to prevent the service being used by homeless people, by providing alternative services and shelters when the bus is on the street. There is an average 30-minute turnaround time for all clients, and the different bus projects have reported assisting between 8-9 clients (Norwich) to 400 clients (Belfast) per night.
4.43 Several of the bus projects are run as charitable endeavours and have received substantial donations (including donations of the bus and / or support vehicles) from the local community. Some have also been supported financially and in-kind by local businesses, nightclubs and the licensed trade.
4.44 Costs of the projects have varied. The Belfast bus is significantly more expensive than the others partly because the Belfast bus is larger (it is a 60-foot 'bendy bus' purchased from The Netherlands), and partly because the Belfast Bus is deployed for other activities during the day.
- Norwich: annual running costs, £43,000
- Belfast: initial fitting-out costs, £350,000; annual running costs, £200,000.
- Southend-on-Sea: £150,000 initial costs; annual running costs, £50,000
- Weston-Super-Mare: £20,000 initial costs; running costs, £378/night + annual costs of £1,000 for MOT, repairs and fuel.
4.45 Although the primary purpose of the SOS buses has been to provide a place of safety to vulnerable people, evaluation of some of them has shown they have also been successful in diverting people who are intoxicated (and those with minor injuries) from emergency departments, ambulances and police cells.