A person in mental health crisis arrives at A&E. Half the time, the crisis involves alcohol or another substance. They’ve been brought in under Section 136 of the Mental Health Act — the police’s emergency power to detain someone they assess as a risk to themselves or others.
These attendances make up 50% of all Section 136 presentations nationally. Half of all the times this country uses one of its most powerful pieces of mental health legislation, it’s in an A&E. Half of those use the act for someone in crisis with substances.
There are no 7-day-a-week crisis services commissioned for alcohol and substance use anywhere in this country.
Read that again.
Half the people the state is using emergency mental health legislation to detain are in crisis with substances. And the country has commissioned no crisis infrastructure for them. None.
When the system is asked to explain this, the answer is that mental health services are failing. Not the local authority public health teams who commission substance use services, which are not the NHS. Not the 2012 Health and Social Care Act that split mental health and substance use commissioning in the first place. Not the 10 Year Plan for the NHS, which is effectively silent on alcohol and addiction.
The blame lands on the mental health service that didn’t catch the person. Not on the structural decision that meant the substance use service the person actually needed never existed.
This is the architecture I argue in Episode 2 of the Layered Care podcast, which went live this week.
The episode is about neoliberalism — but it’s not really about Thatcher or markets. It’s about an ideology that has become so embedded in how we organise public services that it has made structural failure invisible. Every gap gets re-described as an individual choice. Every person who falls through gets re-described as someone who didn’t engage. Every commissioning decision that excluded them gets re-described as a service problem.
Carolyn Green’s post this week documented the empirical reality with rigour: the Section 136 statistic, the absent crisis commissioning, the blame misdirected at mental health services, the 10 Year Plan’s silence. The episode tries to explain why the empirical reality keeps reproducing itself.
The data and the philosophy are pointing at the same thing — and one without the other only gets you halfway. We need both: the structural critique to name what is happening, and the front-line evidence to show what it costs.
If you work in mental health, social care, public health, or commissioning, this matters because you’re working inside it. You see it every day. You may not have been given the language to name it. That’s what this season is trying to give you.
Episode 2 of Layered Care: The Invisible Architecture. Listen on Spotify →