Safe and Well?

<<< This is a guest blog from Ella Shaw – author of Diagnosis: LOB – who works for the ambulance service after a debate we had about the conduct of ‘safe and well’ checks for health situations.  I wondered aloud why the ambulance service don’t undertake these checks for NHS organisations when they are oriented around mental health or even broader health issues, supported by the police only where risks are involved?  To read my thoughts, you’ll have to read her blog which is a wonderful insight into the country’s 2nd best emergency service!  😉  >>>

Why do the ambulance service not undertake “safe and well checks?”

This is a question posed to me by @MentalHealthCop not only to prompt debate between the two of us but also in a hope of encouraging discussion and gathering opinions from all fields in the Police and NHS.  It is a good question and one which I have no doubt the police have repeatedly asked but as with every open question there will always be multiple answers.  As a result, we have agreed to write a blog and post it on each other’s site in a hope of offering a balanced answer from both sides of the fence.

I have spoken about problems around treatment for mental health patients at length in previous posts, most notably in Mental Health: No ones responsibility. There is a huge issue within the NHS surrounding mental health and the lack of access to good care. There are many barriers in place preventing easy access, moreover an apparent unwillingness by anyone to take a stand on the issue. It has become increasingly difficult for the ambulance service and the police to take people directly for assessment without having to go through A & E first which often leads to patients absconding and not getting the required treatment.  Unless the patient is under section the police have no powers to detain them in a hospital as the ‘place of safety’ requirement has been met. Hospitals in turn have neither the resources nor the inclination to detain a patient who doesn’t want to be there and they are subsequently reported as AWOL.  As a result, if the police find them, an ambulance is called because the patient may need to go to hospital again. Similarly if an ambulance comes across a patient, at the first sign of mental health the police are called ‘just in case.’ The question posed aims to look at the latter but in doing so may affect the former.

RAVE is a mnemonic for determining if the police are required based on various risk factors surrounding mental health:

  • Resistance
  • Aggression
  • Violence
  • Escape

If any are deemed likely the police are called. However, it is becoming increasingly common for them to be used to provide ‘safe and well’ checks for patients who have missed outpatient appointments, home visits or self discharged from hospital. When I initially read the question my initial response was “cheeky git, don’t palm your work on to us” but in all fairness is it a job for the police?  Is it even a job for the ambulance service? The purpose of these checks are to assess the patient for a possible return to hospital or to give a full explanation of risks regarding discharge.  On face value it doesn’t seem to be in the remit of the police, especially with the limitations of power within private dwellings.  Equally, is it the responsibility of an emergency ambulance crew who’s limited training on mental health patients makes them ill-equipped to properly deal with and advise the patient on his / her needs.  Surely this is something that can and should be carried out by community mental health services, not emergency ones?

The stigma surrounding mental health and the many ‘grey areas’ that exist around it mean we as an ambulance service are very wary of it. I have personally been seriously assaulted by a mental health patient when there were no red flags or RAVE risk factors on the patient’s name or address and therefore the police were not called.  As such, the thought of doing ‘safe and well’ checks poses a number of risks to crew safety.  At most we work as a crew of two, same-sex or mixed. It is more than possible that both members of said crew are inexperienced, with little or no dealings with mental health patients.  We also have little self-defence training (half day conflict resolution lecture) nor any means of personal protection, other than run, should things turn south.  Obviously RAVE is there to remove these risks as much as possible but, in instances where there are no RAVE risks and the situation becomes volatile, the police are better equipped to deal with it than us.  As such police are requested as standard by our control or ourselves as soon as we suspect it is a mental health job.  My point about the risk we face and staff needed to subdue said risk is often evident in the number of resources the police assign to one job. They have the security in numbers when needed which we do not. More often than not it’s a case of them not being required and leaving shortly after no risk is identified but we appreciate their presence all the same.

The other question that arises from this is “Are ‘safe and well’ checks an appropriate use of an Emergency Ambulance?” Obviously, the answer is no, it isn’t an emergency per se but this age-old debate isn’t only about mental health issues. We respond to a number of different calls that we shouldn’t, but with the way society is and the way the service is heading, perhaps these things should be in our remit.  It’s a question of what the public want from its ambulance service. In an era of health promotion and alternative care pathways, an ambulance could be used to assess a patient and refer on to mental health services directly, therefore negating the need for an A & E admission.  If this is the case, then perhaps this is a good use of an ambulance. Unfortunately, the idea of different health services working together and for each other is lost in our ‘each for their own’ society. Resourcing also plays a huge part. To say the ambulance service is stretched thin is a huge understatement.  There simply are not enough ambulances or staff to man them. In London alone 25-30 staff are leaving each month through natural wastage and these staff are not being replaced.  There simply isn’t the budget to replace them.  If ‘safe and well’ checks were part of our job something would have to be done to combat the increased work load.  Obviously in the big picture, the increased cost to us would be mirrored by a decrease in cost to the police and a decrease in hospital costs but I doubt ‘the brains behind the operation’ will see it that way.  Let us not forget, there are targets to meet!

For arguments sake, let’s say that we do take on some of the safe and well checks, what can we actually do?  We have no more powers than the police in a private dwelling, so we can’t force someone out of their home without going down the capacity route.  That in itself is very difficult to implement and prove, so is only done in extreme cases.  All we are left with are referrals to GPs or local mental health crisis teams.  But for anyone who has had experience of trying to contact either outside the hours of 9am and 5pm Monday to Friday will know the difficulties we face.  In reality we are in no better position than the police to assess or refer. It may be suggested that a paramedic or EMT are better placed to access but I’d have to disagree.  We have no training on it at all. Unless you count the two-hour PowerPoint presentation on ‘mental health disorders and the law.’  We are probably less actively involved in mental health than the police, so are not exposed to it unless there is a medical need.  The police will say it isn’t their job either to access a patient and it isn’t.  Surely it is something that should be done by Crisis Teams.  Again though, very elusive.  It seems that the attitude is very much ‘if we don’t answer, we don’t have to do.’  As a result the slack is picked up by us and the police.

Looking at the ambulance service’s ‘Vision and values‘ it appears these safe and well checks are indeed  as part of our job and I do agree with that.  We are there to meet the needs of our patients and the public, be it the trauma we all crave or the mental health we all fear.  You can’t be selective with what illnesses and ailments you go to. In terms of the police, the Met’s ‘Working together for a Safer London mission statement shoulders an equal responsibility to us by promising to work with all of its citizens and partners.  Mental Health is a huge problem and a huge cost to the country and be it medical need or in the interest of public safety, both the Police and Ambulance service share the burden.  There have been trials where a paramedic works alongside the police on weekend evenings with the purpose of reducing the need for an ambulance for minor injuries.  Perhaps a similar trial could happen with mental health policing? Unfortunately the powers that be seem to have their heads in the sand and are pretending mental health isn’t an issue that needs addressing, but it isn’t going away.  I think if common sense is used, the deployment of services can be cut down.  We don’t both need to be there all the time.  The officers and medics on the front line are more than capable but it’s a matter of attitude and policy change from above.  To do so, open and frank discussions between all services are necessary.  Where there are no RAVE risks the ambulance service could be involved and where there are the risks, the police will be involved.  I think we need to get away from calling the other when the need isn’t there.  As I said we are no better placed to refer on to appropriate care pathways than the police and they are in no better place to remove a patient from a private dwelling than we are.  It’s about education and knowing each other’s remits and limitations.

A huge part of it is also getting the already established mental health services more involved with our work and to take more responsibility for what is essentially their job.  Historically, mental health facilities and their staff have been very obstructive with dealing with other professionals, making for a hostile working relationship.  Gradually, as mental health is becoming widely accepted as a genuine medical and social problem, these barriers are being broken down and dialogue is becoming possible.  There is no reason they cannot have teams of their people doing the ‘safe and well’ checks where no RAVE risks exist.  If anything, they are the best placed to do so but exactly what they can and can’t do I’m not entirely sure.  If I’m honest, despite my interest in mental health, my knowledge of their services and powers are limited in part due to my lack of dealing with them but also the fact they don’t advertise what they can do.  If everyone is going to work together there needs to be more transparency and honesty about our roles. We all need to know what each other can and can’t do. We must know each other’s strengths, weaknesses and procedural limitations and, until then, there will be no progress at all.

In response to the question … why not indeed!  But let’s answer all the other questions that arise from that one first!  Let’s all get together and thrash it out.  Chance would be a fine thing …

To read @MentalHealthCop‘s thoughts on the same subject, you’ll have to read my blog!

Winner of the President’s Medal,
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2012

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8 thoughts on “Safe and Well?

  1. Chance would be a fine thing indeed. and AGREE: “The officers and medics on the front line are more than capable but it’s a matter of attitude and policy change from above. To do so, open and frank discussions between all services are necessary.”

    Trouble is dedicated clear thinking people like you and MHC will quickly identify what is needed and no doubt the fear will be that this will take additional resources.! (The cynical side of me recognizes the endless resource pool for management consultants et al) But after 7 years exploring NHS complaints, as I see it….. having (and paying for!) a whole load of layers that don’t work properly, If Health Select Committee and Parliament have found NHS Complaints “Not working and PHSO appeals process in need of a “complete overhaul”….NOW WHAT? Parliament too are still sitting on New Suicide Prevention Strategy (minus suicide indicators which were withdrawn in 2009)

    Seems all the pressure is put on front line staff! This pressure along with totally inadequate (so-called)”independent” investigations (when things do go wrong )and when families have the strength and tenacity to chase an explanation are the reason “lessons are never learnt” and front line staff are left dealing with endless crisis.
    If investigations are calling system failures “Service delivery issues” and not using Root Cause Analysis guidance Health Service Guidelines are not being implemented, in particular HSG(94)27 then we will never have a true picture of why we are constantly returning to this situation time and time again.
    Thank you for your input and great to read your suggestions to share info. Oooo result! a risk of some Joined Up Thinking!:o)
    “If everyone is going to work together there needs to be more transparency and honesty about our roles. ” Well said…couldn’t agree more!

  2. I think we would all agree, a definative answer about who’s job is it will never be easy however; the search for that answer is even harder in the more rural areas.

    Ella, when talking about ‘risk’ to ambulance crews said; “the risk we face and staff needed to subdue said risk is often evident in the number of resources the police assign to one job.”

    In areas like North Yorkshire it is not unusual for ‘Crisis Teams’, be they NHS AMHP or Social Services from the local authority, to be almost non existant outside of normal ‘office hours’.

    Add to this the already reduced Police and Ambulance resources, coupled with the vast geographic areas being covered requiring ‘travel time’ to be factored into the mix; it wouldn’t be beyond the realms of possibility for a single paramedic or 1st responder to be backed up by a single police officer.

    Time/distance is a major consideration especially when resources, from either service, can be 20-30mins travel time from each other and/or the incident… That’s a long time when you need some help!

  3. So refreshing to witness open and fair discussion. I have posted the main content of this comment to LOB also.
    I feel you could both be part of a paradigm shift in behaviours with this subject, if only because you, and your respective readers are both able to circumvent the endless red-tape.
    I can share that ever-so-slowly, mental health providers are finally seeking to open up appropriate pathways and signposting via a 24/7 service ‘staffed by mental health professionals’! This will start to provide the change in the current culture of 1- Everyone calling 999 for police/ambulance to mental health issues over which both are poorly equipped to deal. And 2- If 999 is called, a referral route for responders either via control or attendance to refer to appropriate agency hitherto unavailable.
    I think if you guys can continue to share your situations, frustrations and expectations – you can recover even more of the great relationship the police and ambulance used to enjoy – despite the cutbacks and operational pressures. Well done
    Brief bio – (Recently retired Paramedic and mental health lead – Currently mental health provider governor and counsellor in private practice)

  4. is there someone from a crisis team who could comment?!
    as a carer i have called the crisis team when i felt my partner was at risk because he left the house agitated and drunk – all signs of increased risk. in all of these cases we had their number because he had been on a&e for a recent self harm/suicide attempt. when i called they said there was nothing they could do because he hadn’t explicitly told me he was going to do anything to harm himself, but if i was worried to call the police to do a ‘safe and well’ check…
    sometimes i did, sometimes i didn’t. sometimes i went out looking for him. other times i left him to it. this happened more than once. sometimes he was ok. other times he wasn’t. usually it was myself that had to sort him out. sometimes i had to call an ambulance..
    in all these different situations, both the police and paramedics, were nothing but compassionate and helpful..
    but where was the specialist care and help when it was needed most…
    there has to be an approach that puts the patient first..

  5. Sorry I am a bit late to the discussion! I have posted this to both blogs! This is my opinion from a service users perspective. I was brought up to see the emergency services as just that – for emergencies.

    My perception of the police (rightly or wrongly) is to be slightly scared of them. They are a body of authority and power and one that I have never wanted to mess with. As a child/teenager, if the police were ever mentioned, it put the fear of God in to me and immediately would behave! With those connotations, would I therefore want them turning up at my door? A resounding no!

    On the other hand, I see the ambulance service as, again, an emergency service. If it isn’t life threatening then they shouldn’t be there. There are many people who need them in the correct capacity to also add in non-urgent tasks (I know they get called to them all the time from time wasters, but it shouldn’t be an added requirement of their role).

    So taking out the 2 options, who could be do the role? I obviously have no answer to that and don’t know the workings of public sector organisations to be able to give an informed option. However, in my eyes, if social workers took that role, then it would free up the emergency services and I wouldn’t feel as if I am taking a resource away from someone in more need than me (which is a huge thing where mental illness is concerned!!)

    1. I really like your response, to be honest. I think it’s measured and sensible – nothing at all, except willingness and possible an element of resources, prevents us having a social response to this stuff lead by people other than emergency services. We’ve just evolved a culture where it’s always been police, so why change it? That’s why I really like your response, because I think it shows that people just have a preference not to feel ‘pressured’ or ‘checked up on’ or ‘criminalised’ by having the police set upon them for being (potentially) ill.

  6. Late to the party, but just found this link:

    As a member of the ambulance service, I think this post is a bit misleading. I attend the majority of mental health patients I am dispatched to without even considering police attendance. I request police in the following circumstances, and think that this is justified:

    * Involvement of a weapon
    * Involvement of stated aggression / violence (although I have been known to go in anyway where there is evidence of particularly vulnerable people – children, the elderly – in the house)
    * I know the address as a dangerous one

    I attend many more ODs / suicidal thoughts / mental health problems without police than I ever do with them.

    I should add, however, that I have never been to, or heard of anyone else going to a “safe and well check” as described here where a patient has absconded from care, which suggests that the ambulance service here do not do them, and also suggests that either the police do not do them, or that they are invariably both safe and well!

    “Concern for welfare” calls around here generally involve someone calling either the ambulance service of the police because they’ve not been able to contact someone. If they called the ambulance service, the ambulance control room tends to call the police “in case they need to affect an entry” (secretly hoping the police will get there first and stand the ambulance down when the person is found to be well). If they called the police, the police control room tends to call the ambulance service “in case they’re injured or ill” (secretly hoping the ambulance will get there first and stand the police down if the patient answers the door).

    No-one ever thinks to look in the yellow pages for the phone number of a neighbour of the person there is concern about!

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