Street Triage

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! –

MENTAL HEALTH 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?

TELEPHONE ADVICE

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.

PARAMEDICS

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 occured 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.

STREET TRIAGE

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?

  1. 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?
  2. 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.
  3. 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.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


 

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10 thoughts on “Street Triage

  1. Local ambulance service to me is in crisis in terms of staffing and meeting their response times. They are heavily dependent on CFRs (unpaid volunteers). I can’t even begin to imagine how they would resource your idea and yet it makes far more sense than a CPN. Most mental health nurses have very limited understanding of physical health problems and given the basic ‘kit’ you describe would be able to do little more than advise someone to go to their GP.

    Trouble is I think it’s quite widely known that under the recent changes t the NHS Ambulance Trusts are the most vulnerable to being privatised and effectively deregulated. I suspect we can expect less, rather than more, support from paramedic colleagues in future. Given the length of their training inserting more MH input shouldn’t be hard but would they be resourced to use it. I can’t over emphasize the benefit of joint training events where networking with otherrd promotes understanding and increases trust in other professions

    1. Why not remove the police from the situation altogether, except for violent situations?

      Police come into contact with a potential MH patient. They call an ambulance. The paramedic then takes over, decides if there is a physical or mental health issue. They hold a power of section similar to s136, applicable in both public and private places. They could then have powers to chemically or physically restrain – with police assistance if necessary.

      Some of these powers are already there under the MCA (to restrain and remove against someone’s will), and other exist in other countries (to section and restrain – see Australia).

      If we want to make mental illness a health issue, we need to stop having the police involved except as first contact and in extreme circumstances. A major part of doing this is improving community services so they react when called, are available at night, and are able to prevent crisis in the first place. Another part may well be treating mental health emergency as police do physical health emergency – call on the ambulance service and expect them to deal with it without police assistance (in the main).

      There are problems with this, not least the lamentable amount of mental health training and education in paramedic courses. There is discomfort in giving paramedics section powers – but similar powers are already there under the MCA, and Parliament is happy to give police s136 and nurses s5. So I don’t see insurmountable problems.

      (Disclaimer – I do not necessarily support all my points above – but I think it is an important debate to have as it is a logical end point of mental and physical health equality and reducing police involvement in MH)

  2. As a mental health nurse working in Criminal Justice Liaison, I too am not entirely convinced that the street triage idea will address any of the issues you raise. However, as it is generally accepted that 1 in 5 of police calls are mental health related, is there something else to be gained from this idea?

    Possible benefits could include:
    Improved communication and shared decision making
    Mental Health services taking more responsibility and being involved earlier in the process
    Better understanding of each others roles at an operational level which may reduce some of the frustrations and improve decision making
    A better pathway for the non 999 calls including AWOLs and welfare checks.

    I agree that the police are constantly left with issues which should be managed better by mental health services, but as a radical change of approach or increase in resources is unlikely, could this be a subtle opportunity to affect attitude and organisational culture.

    These are just the first thoughts that came to mind, feel free to challenge.

    1. Nothing to challenge as far as I’m concerned – I’m not sure that MH professionals working alongside the police adds much, beyond information provision. The kind of triage I want support with, is of the clinical kind after detention or arrest, to determine pathways into appropriate care.

      Everything you have written makes sense and I agree – but in some areas of the country, I get the impression that they are deploying CPNs with police to reduce s136 admissions. Fine if there are loads of inappropriate s136 detentions occuring – which is the case in just some police areas – but if the police are using the power well, what does the CPN add at the street-encounter stage?

      As you mention, there could be risidual benefits for AWOLs and welfare checks, which should include health professionals. All good debate.

      1. I think that the information provision element is a really important part of the process. In my experience the mental health professionals who are refusing to engage with the police and provide the service they are supposed to do are able to do so because an appropriate screening of risk has not been completed.

        This is because they can quite easily disengage by applying simple criteria for exclusion.

        If the MH staff in the 136 suite or Crisis/Assessment team were compelled to look at the mental health issues in context and consider the wider and more relevant risk associated with the presentation, it would be more difficult to justify exclusion.

        A good RMN or SW working with the police, who has access to information which they are able to apply there and then to influence decision making must have positive benefits.

        Knowledge is power 🙂

  3. If the decision was made to pair up a police officer and a paramedic with additional MH training, why not put them in an unmarked people-carrier, with all the ambulance kit to do a full assessment, 12-lead ECG etc, and a full set of paramedic drugs?
    For the majority of patients, I’d guess a people carrier would be ideal for getting them to the S136 PoS, they’d be being looked after by a paramedic, not taking an emergency ambulance off the streets, and have a police officer present – can the officer drive someone they have detained somewhere, or do they have to have an additional officer present?
    As above, the vehicle could be used as a response vehicle to other incidents as well when not doing MH work -maybe sudden death response and assaults?

  4. A few comments from an AMHP and EDT perspective. As MENTALHEALTHCOP has said this is all down to the will of those who decide where limited resources are most needed. There are always going to be individual police, crisis workers, CPN’s, social workers, paramedics who for whatever reason do not believe in fully engaging in joined up working. But with properly chanelled resources the elements are already in place to achieve what TM spoke about in her speech.
    When our Crisis team started in 2003 it had two members always on call overnight and regularly attended A & E to see Psychiatric presentations, often brought in by the Police. Patients were usually seen within 30 minutes and officers able to be back o the streets in perhaps 90 minutes assuming no restraint or conveyance issues, usually the case if the patient had agreed to come to A & E. Then cutbacks led to just one member of staff being on call but they would still attend A & E however now with longer delays while they waited for the on call Doctor to attend. Then they stopped the one member of staff attending at A & E as suicidal people were not having there crisis phone calls answered. For police officers this now means that if they take an apparently mentally ill person to A & E they are likely to be tied up for several hours. If there is an opportunity to place someone on a section 136 and take them to a local 136 suite i fully understand why the officers would use that. Unfortunately this does lead to inappropriate 136’s where we often find we are assessing people who have said they were quite happy to go to A & E and wait to be seen there or just wanted to go home.
    Where a section 136 is unavoidable we must make sure that the 136 suites are properly and expertly staffed with greater capacity as often suites are full just so that the patient can sober up leading to the use of police cells for subsequent detentions. I don’t believe that mental health staff should feel under pressure to assess as quickly as possible. Sometimes a better assessment and outcome can be achieved by waiting 24 or even the full 72 hours that the law allows.
    My ideal would be Crisis teams that have three permanent overnight staff, two CPN’s able to assess at A & E and make clinical decisions and a AMHP able to take Crisis calls, provide information for attending incidents on the individuals concerned and able to arrange Mental Health Act assessments rapidly. It would not be difficult to work out a protocol with EDT possibly sharing a AMHP if people wanted to do this and were willing to work together.
    In this model paramedics would be pretty much left out of the 136 process as is certainly the case in my area which i guess would suit them.
    I would like to see more inter agency contact between AMHP’s, hospital staff and the police regarding mental health work as it is virtually non existent here. Where there is regular joint meetings, for instance in our vulnerable persons meetings much more understanding has been reached about what each agency is able to do.
    Well i was never going to be able to fit that in a tweet.

  5. ‘doing the wrong thing righter’ is a wonderful phrase. You are so right that if mental health services were able to support their patients better and perhap there was more suicide prevention training to identify risky patients then then these issues (and possible solutions) wouldn’t even need to be thought about. In my local trust the ‘crisis’ element has been left out of the new structure so yes you can get extra support when heading for a crisis (can’t usually get a hospital bed) but this consists of pre planned appointments. If your crisis has the misfortune to be on a different day and a phone call doesn’t help then there is no where much else to turn.

    Yes I think paramedics should be trained in mental health although they seem to be pretty much clued up already just from experience in dealing with those of mental health issues. Not sure that there would be enough psych nurses available for street triage – they haven’t got enough to staff 136 suites quite often.

    Mind’s campaign about crisis and acute care highlights the failings across the country – where the service users are being let down all the time. A personal example here. I was being supported by the ‘crisis’ team (not their actual name as they have removed crisis from the title recently because of a suicide attempt. I rang first thing in the morning to say I was feeling at risk and was obviously in distress. I was offered an appointment for 3 days later. The police ended up having to search for me later that day with helicopter and many officers as I drove off to end my life. Had I been offered immediate face to face help then this all would have been prevented.

    They need to put more money into mental health services which should in the long term mean less burden on the police, ambulance service and A&E departments.

  6. Very interesting idea, as a mental health worker I would love to work with the police service, and definitely see a gap in the services and training and indeed powers. However, like you said I can see several flaws in the idea of street triage, I’m always shocked when I speak to police officers about the lack of training they receive yet they’re as much in the deep end of acute mental health as an acute ward or crisis team- even after 3 years I sitll get confused as to the powers for MHPs and police so god knows how police cope with such minimal training. Perhaps there is a roll in a few RMNs being employed with in each police service, perhaps with dual training as a police officer and mental health nurse? CPNs do eventually start to lack acute care skills (I cannot praise the good ones enough though for the care they give), maybe it would be more advisable to rota staff from acute wards / PICU?

    There definitely needs to be more money put into mental health care across the board, I’ve moved areas lately and am appalled at the lack of services/ services with small opening times and seeing how much the police do for us. I’ve had to give telephone advice in the past and whilst for some people it can be life saving it too has its own flaws and I’ve had shifts where the same person has called in more times than I can count and consequently people in crisis haven’t always been able to get through.

    I half agree that using MHPs instead of paramedics may only provide knowledge, however a GOOD MHP, especially of the nurse variety, should have first aid / wound care knowledge (although no where near that of a paramedic) and I would hope would have top notch communication skills, I’ve seen a few police officers with patients who just couldn’t care less/ have treated them as criminals instead of unwell, which really isn’t therapuetic ( although I’ve never worked in your line of work so I’m sure you could say therapuetic goes out the window). I also think that having some kind of MHP could perhaps be less intimidating for the person, I know if I was really unwell being picked up by the police would scare me to death! But again…you could just give paramedics more training and they’d probably end up just as competent as an RMN….

  7. The Adebowale and May recommendations are indeed laudable but need to be driven forward to be realised in practice. Having read the comments from the “professionals” above perhaps the following suggestions may assist?

    1. If the MHA and MCA were rewritten to meet the ideal street triage concept, what changes would be necessary and why?

    2. Would ready access to medical records be helpful in determining the course of action in each case? Eg – so that a 24/7 accessible (to the police) qualified mh advisor would be in a better position to decide whether to send an ambulance to detain and take to a place of safety for further mh assessment / care. Presumably the police would assist the paramedics if the “patient” was considered as likely to be violent.

    3. Would modern ICT (e.g. webcam and direct voice comms: police officer / “patient” / paramedic) be of any benefit provided the police could access 24/7 qualified medical advisor?

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