One thing arising from the Home Secretary’s speech this week to the Police Federation conference was the idea of “street triage”. In short, this means a system whereby better health or mental health support is made quickly or immediately available to police officers who are often paired up with health professionals.
Now there are various ideas floating around about what street triage could mean. Different ideas in different places leading to various propositions. Indeed, to different ways of supporting the police at different times given that demand is greater at certain times of day, like “out-of-hours” periods of evenings and weekends. We’ve seen the idea of community psychiatric nurses being deployed with a police constable; of an officer having access to a telephone helpline and although I’m not aware of it happening in the real world, I’ve been involved in numerous discussions with paramedics over the years, about what might be possible if certain paramedics were given better clinical and legal training around mental health issues and were deployed with a 999 colleague from the police who had also been given better mental health awareness and legal training.
One point in principle before I get into different ideas: these schemes could be perceived as trying to “do the wrong thing righter”. Methods by which to better handle crisis events; or to better cover for other services. I’d prefer that we didn’t have crisis events in the first place and that services were responsive because they were fully resourced. I’ve written previously that in some areas of our country, CrisisTeams and other mental health support services including 24/7 helplines are deliberately pushing health demands to the police. Interestingly, they are doing this after meetings that took place in rooms into which the police were not invited. I’ve had healthcare professionals who were present in those meetings make this directly known to me. So before we start “doing the wrong thing righter”, let’s keep in view, what the right thing is, in terms of inpatient and community mental health care.
Finally, you can find these kinds of initiatives in other countries if you look. Vancouver pair up an officer and mental health nurse; Portland in the USA pair up an officer with a social worker. It’s clear there is no consensus and we’re all still feeling our way through this. This post, ultimately, argues for another option! –
NURSES POWERS AND TRAINING
This is a controversial point, so I floated this on Twitter to see what the reaction would be: psychiatric nurses are less frequently dual trained as adult nurses than they were in the past and they have no legal powers whatsoever. So if the police and a CPN turn up to a house where someone is self-harming we still have that “mental health crisis on private premises” dilemma. No-one has a power to act and although the CPN, if they felt it appropriate, would have a hotline to services who could potentially arrange a mental health or Mental Health Act assessment, what would the expectation be if the patient was under the influence of alcohol or drugs? Are we then back to “she’ll have to sober up first”, which doesn’t help us legally in terms of mitigating risks until an assessment or support can be given.
Secondly, if a mental health nurse and a police officer are deployed to a situation, whether it is in public or private, what kit are they deployed with? Is street triage going to be configured in such a way as to ensure proper triage of potentially physical causes of crisis events? It’s all very well turning up to a job where someone appears to need support for acute depression, but what if they’ve got a brain tumor instead? … or as well?! Will psychiatric nurses be carrying kit to do basic medical obs, like heart rate, blood pressure, temperature and blood sugar? What training have they got in pre-hospital medical care?
This is what we see paramedics doing when we detain people under s136 and we know that them doing it has led to discovery of underlying physical causation. Many psychiatrists and mental health nurses have told me that the first thing you do in a mental health assessment is a physical examination so unless CPNs are going to be carrying that kit we will just be drawing upon ambulances as well where people are being considered for detention?
I’m not attempting to disparage a single CPN with these observations – actually a fair few of them agreed with me during my twitter crowd-sourcing on this that we need to know more precisely what problem we are attempting to fix, before we move to a CPN-orientated solution. What is it, precisely, that we think the police can’t do or would be better done in tandem with a healthcare professional?
I think we need to be careful about telephone advice for a few reasons. Firstly, the person giving the advice is never doing so with the benefit of actually seeing that patient and on the back of talking to and examining them. We’ve seen forms of telephone advice or screening for years in areas where s136 protocols require the police to ring a PoS Co-ordinator to describe the patient and then be informed where the patient should go. What do we do if the person give advice and the police officer do not agree?! I can imagine telephone advice would be helpful in terms of quickly learning more information about someone – are they known to MH services; do they have a care coordinator; are there any risks associated with that individual, etc.. I’m wary, however, of telephone systems which may lead to remote-decisions being made. I’d actually go so far as to say that the only thing I want from a telephone system is information. The decisions would have to remain mine because I would be the one held accountable, regardless of the advice given – the advice giver would always have that get out of jail free card of, “Well I couldn’t see the person, I went off what I was told!”
By way of example, I’d point you all towards the Birmingham Place of Safety scheme – if an officer wanted advice or potentially some information, they can ring the place of safety itself and speak to staff there. However, this is not a pre-requisite to making a decision, including a decision to go there with someone who has been detained. The clinical input to that process is provided by the ambulance service who get a paramedic to the officers within minutes of a call following detention. This then allows the paramedic to help assess any urgent physical healthcare needs, against the RED FLAG criteria that were agreed with A&E. It also allows for decisions to be taken in person about urgent healthcare.
You may have worked out by now(!), I favour the idea of closer working relationships with paramedics; and if dual deployment is to be done, let’s pair up the 999 services!
This has already occurred in the north-east albeit, to address issues around the nighttime economy. I also think there is support for the idea in important places. Firstly, the Adebowale Report calls for far greater involvement of the London Ambulance Service in supporting the Metropolitan Police where they become involved in mental health emergencies. Secondly, paramedics and crews are highly trained in pre-hospital care. It was a paramedic who spotted the above ‘brain tumor’ example, after two doctors and an AMHP (mental health professionals!) had decided to section a patient during an assessment. Yes, I’ve heard reservations about the amount of mental health training that paramedics get – very little – but is that not a potentially easier problem to solve than the others mentioned around telephone advice models and CPN models?
Of course, paramedics do not always have access to certain MH pathways, like ease of referral to CrisisTeams, etc.. Here’s a radical idea: let’s open them up! Paramedics are trusted to make urgent clinical judgements about strokes and heart attacks along with the decision to take a particular patient either directly to very specialist cardiac services or to an Accident & Emergency service. With training, why would they get this wrong?
Here’s another thought about paramedics – they can be doing other NHS work when they are no mental health calls, because they are still paramedics. And if they were teamed with a police officer in a 999 response vehicle, they could also be jointly used for other reasons – like first responders to calls where ambulance would want police support or vice versa. It has the inherent advantage of flexibility, all subject to simply giving paramedics proper clinical and some legal training.
Despite my reservations – actually, despite my questions – it is beyond doubt that we need a better system of street triage to support police officers’ decision-making. I’m simply arguing that this should always be done in person, by people appropriately trained. CPNs lack training in acute pre-hospital care; paramedics lack it in mental health (emergency) care. Which of those two things is easier to fix and from where would you retain the most flexibility to use your resources?
Let’s remember as well, what problem are we trying to fix?
- Are we attempting to reduce s136 detentions? – we know that in some areas, such detentions are too numerous and some, if not many, are inappropriate. Is that not about better training for the police, rather than how we bolt on a healthcare professional?
- Is it about the health professional having access to pathways that are not available to the police or paramedics? – well let’s open the pathways and understand the nature and the variety of demand that our police and ambulance services are currently managing under the radar, because they all-too-often can’t access anything other than A&E, unless someone is detained or arrested.
- Or are we trying to improve on-street, clinical decision-making? – who is best placed to do this and after what training for the role? Whether we like it or not, Adebowale creates an imperative for ambulance services to be looking at this anyway. I don’t wonder whether “mental health paramedics”, be that a few with significant MH training, or more general MH training delivered to all – or both(!) – is ultimately a cheaper and more effective way forward, with access to advice lines from mental health services opened up.
Let us not forget that ultimately, the police officer in these types of situation is going to retain a legal right – actually, a legal duty – to make arrests for offences or detentions under the MHA where they believe the legal grounds are met. Either clinical need or legal duties arising from the Code of Practice to the Mental Health Act will demand that they call an ambulance anyway, notwithstanding the view of whichever healthcare professional is standing next to them. I have something of a nightmare in the back of my mind whereby health advice is not to detain someone who could have been detained or not to call an ambulance where one should have been called and in the subsequent inquiry it is pointed out to the officer, “the legal decision was yours to make, not theirs.” We need to bear this in mind, whatever it is that we decide to do!
And finally, all of this is about better response to mental health emergencies. Sounds like a good idea, doesn’t it? … who wouldn’t want such matters better handled, especially after the Adebowale Report gave us all a much required kick in the pants? But where is the discussion about how we got to this place – this is all “doing the wrong thing righter” because I want to see fewer mental health crisis events, notwithstanding the need to handle far more effectively, those that occur.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown OBE, 2019
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