Eight Dimensions to Street Triage

Here’s a postulation about mental health related police scenarios:  they are comprised of a mixture of legal and medical issues, which boil down to three crucial things when officers meet the public:

1. Whether someone needs mental health and possibly physical health care support immediately.
2. Whether the patient objects to a proposed course of action to get it.
3. Whether we are in a place to which the public has access.

If the answer to all three questions, above is “Yes!”, you can use s136 MHA and if there is an allegation of a criminal offence within the context of the incident, you can arrest for that.

You would not need to use section 136 if the answer to either of the first two questions were “No!” and you certainly can’t use it if the last answer is “No!”

So the main issues are:  will Street Triage create a “No” answer for either questions 1 or 2, where a police officer alone would have had to say “Yes” because mental health nurses have far greater skills and information on which to answer the questions?  And most crucially, what does a mental health nurse add to a situation where it was all going terribly well, until we hit upon the “No!” for question 3.  Against this, should the potential of street triage be judged.

These musing give rise to eight broad dimensions within which this decision-making must occur – four in public and four in private.  The point of this blog, is to go through them all, highlighting whether Street Triage schemes would make a difference to an operational police officers ability to resolve the situation properly, with reference only to the ambulance service as medical back-up.

PUBLIC PLACE SCENARIOS

Situation 1:  A cooperative person – in immediate need of care / control —– police officers would refer a person to health services, either by calling an ambulance to them or by referring or taking the person to A&E, as the only 24/7 health gateways available immediately.  Street triage factors — would open the possibility of the nurse providing the care themselves or by being able to access Community or Crisis mental health teams.  This could also occur outside Street Triage if ambulance and police had access to referral pathways in their area.

Situation 2: A cooperative person – not in immediate need of care / control —– police officers here would refer the person to attend either their GP, or to contact their CMHT or CrisisTeam or A&E, as they saw fit.  ST factors — opens the potential that for existing mental health patients the nurse could contact relevant teams for follow-up, either the next day or soon afterwards.  Currently this can’t easily happen if 999 services have contact with people, existing mental health patients or not, hence current referral practices.

Situation 3: An uncooperative person – in immediate need of care / control —– this is current Section 136 territory, where officers would have answered “Yes” to all three questions and be starting to think about detention.  ST factors —  I would imagine if the nurse present thinks the person does have a mental disorder, then we’re potentially off down that route; but we know for example, in Leicester that section 136 detentions have reduced by 40%, so this is the area where triage is having an impact in terms of reduction.  The nurse being able to offer something that a police officer can’t, which turns an apparent situation 3 into a situation 1 or 2.

NB: I will be interested to learn what happens if officers are dealing with those kinds of presentations we saw in Panorama where intoxication and resistance is involved.  Elsewhere on my blog, because of lessons learned in previous cases, I’m wary about what would happen with resistant, intoxicated patients.  Some suggestion that nurses are encouraging detention in cells when we know that’s the wrong thing to do, both legally and medically.   This is the scenario of my deepest fear.

Situation 4: An uncooperative person – not in immediate need of care / control —– this is a difficult kind of scenario for officers, when encountering someone you think may have a mental health problem, they don’t want to receive offers of help that you can make open to them and you don’t feel that the issues warrant use of s136. Currently, it would be a case of offer a view about areas from which help or support can be obtained and respect the autonomy of people to make their own decisions, however unwise you may think they are.  ST factors — individuals may react differently to a mental health nurse and perhaps that may make a difference, one way or the other.  It remains possible for the nurse to refer someone back to a service that may know them, whether that be their GP or a community mental health team, if known to them.  Those services could, if they chose, follow-up whatever referral took place at a later date.

PRIVATE PLACE SCENARIOS

Situation 5:  A cooperative patient, immediate need of care / control —– this is the same as situation 1, above.

Situation 6:– A cooperative patient, no immediate need of care / control —– this is the same as situation 2, above.

Situation 7: An uncooperative patient, immediate need of care / control —– this is the kind of situation that could demonstrate the futility of Street Triage in some respects.  The only variation from situation 3, is that being a private place, section 136 MHA is not an option.  The nurse adds little immediacy to this situation having no extra legal powers and I’ll be mischievous enough to wonder whether we’ll hear examples of nurses ‘wondering’ whether a person like some fresh air to make them feel better and a brief walk?! << Don't laugh: I've heard CrisisTeams inciting this false imprisonment before.  If the situation involved a genuine ability to arrest someone for an offence or to prevent a breach of the peace, then the immediate threat would be resolved this way, as it always has been.  This is the “Tyler” situation from Panorama.

Beyond the expediency offered by a criminal arrest, we are back to the “Sessey” dilemma.  How do you keep someone safe.  The judge in that case said you contact an AMHP and arrange a Mental Health Act assessment.  I would hope the involvement of a Street Triage nurse asking for it, meant it was taken more seriously and agreed to more often, than if a police officer asks for it?

Situation 8: An uncooperative patient, no immediate need of care / control —– this is the same as situation 4, above.

IMPACT ASSESSMENT

So, let’s see where that leaves us.  The first thing to say, is that situations 1, 2, 5, and 6 involve cooperative people.  So these situations for the police were always about signposting to the health system however quickly it may be required.  It may be a mental health nurse can do this more appropriately, but it doesn’t seem a situation that inherently requires a dual approach.

  • Situation 1, 2, 5 and 6 — these would get resolved roughly as they always did, with street triage possibly bringing faster, more appropriate referrals.  I wonder how many of these kinds of incidents come to police attention only because attempts to access the NHS have failed?  For example, by the kinds of demand deflection that we know we’ve seen increasing over the last year or more.
  • Situations 4 and 8 — again, like situations 1, 2, 5 and 6, these outcomes would be comparatively unaffected save for the promising potential that a nurse could make necessary referrals based upon something of a clinical assessment and based upon whatever knowledge of the person was available to them from medical records.
  • Situations 3 and 7 — these two either stand as they are or become other kinds of scenarios because of the nurses increased skill base and information.  Scenario 3 – the police will either still detain under section 136 unless the added value of the Street Triage nurse can either turn the situation into a 1 or 2; and Scenario 7 is still troubling, unless the nurse can be instrumental in bring together a fast Mental Health Act assessment.  It still leaves you the sticky question of scenario 7 where the nurse’s view or information may actually add to the urgency of MHA an intervention which may still be hard to manufacture with an AMHP and a DR and potentially the need for a s135(1) warrant.

Of course, we know that in terms of detentions by the police, ten times as many people are detained under arrest for an offence than we detain under section 136 of the Act.  So wherever any of those situations involves a lawfully ability to arrest for an offence, we see that as an expedient way to resolve something that can’t otherwise be resolved.  Of course, that dimension to things is unchanged.

SECURE TAXI SERVICE

I’m going to put this view out in the open: some have started to wonder whether Street Triage is a secure taxi-service?  One Assistant Chief Constable wondered why the police were giving a lift to a nurse to visit someone in their own home, who actively wanted NHS input.  Why could that call not go to or be diverted to the NHS and their traditional mechanisms?  This could have been to their GP or to a community or crisis mental health team – and this gets you back to the heart of a problem.  Accessibility of whatever is the “right” NHS service for that demand and the reaction to any demand which is subsequently deflected to the police.  We know from reactions to Panorama and other debate, that mental health crisis teams are not emergency services, running around to all manner of crisis situations.  Some officers don’t realise that they are there to be able to provide support which negates the need to bring about a hospital admission: not a reception team to triage demand that may be crisis related and may or may not be primarily about severe and enduring mental illness.

I wrote this blog to make me think through what would the police traditionally do without Street Triage and what would it add?  I can’t help but conclude from the above exercise, that it would alter fewer than half the scenarios and whilst welcoming a reduction in 136 usage for scenario 3, it also gives rise to extra pressures for that situation to go awry by doing the wrong thing.  It does nothing to resolve the “Sessey” problem which we see in scenario 7 and fails to address the Adebowale Deficit.  No-one could object to a scheme which brings about better or faster referrals than could emerge from scenarios 1, 2, and 4; 5, 6, and 8 – but I ask whether a nurse in a car with a cop is necessary to make that happen?  In some of those situations, available, accessible and responsive health services (whether that is a GP, a mental health community or crisis team or the ambulance service if we feel we should ring 999) could potentially achieve the same thing.  I also wonder whether it would achieve it at less cost?

There is something else relevant here, which will be in my next blog:  how do we get the police using section 136 correctly and consistently, because Street Triage pilots are about to start in areas that have significantly different usage of section 136, including some areas that must significantly over-use it.  That is as important as putting a nurse with a cop.  In fact, we know that some mental health professionals conceive Street Triage as important because it potentially allows them to stop or influence the police from doing the wrong thing by misusing the power in the first place.  It’s all “doing the wrong thing righter.”


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

Winner of the Mind Digital Media Award.


 

Advertisements

5 thoughts on “Eight Dimensions to Street Triage

  1. Scenario 7 is the one I seem to see the most and the one which is hardest to bring to a conclusion. It had led to some extremely dubious uses of various powers – always with the best intentions of getting someone the help they need. This is the one I think we need to fix. The only way I can see to fix it is quicker attendance by the MH team. Two hours is ‘within protocol’ where I work but you can’t wait two hours with someone who is clearly in crisis!

    I can’t see the triage thing working in my area as I just can’t see where that extra police officer to go in the triage car would come from. We don’t have enough MH jobs to justify it.

  2. Interesitng article. Wouldn’t a mental healht nurse be able to more adequately asess urgency of care/control need than a cop? Also, it’s quite strange that in the UK, only A&e is available for people to access care immediately themselves. In the Netherlands mental health crisis teams have 24/7 operating hours that you can be referred to.

    1. Astrid, the Crisis Team in our area only works with those already in secondary Mental Health Services. If you have not been assessed by a MH professional before, or revently, you would be asked in the first instance to go through an out of hours primary care service or GP depending on when it is…..

      I believe the key is scenario 3.
      A mh nurse is only likely to determine that an uncooperative individual in need of care and control is not experiencing a mh problem in the most straightforward cases because technically diagnosis is a medical responsibility. But this is what interests me. If someone is intoxicated and threatening with or without mh problems on the basis of previous comments it is likely to involve restraint and then becomes a ‘medical emergency’ – presumably on this premise any person who presents with problematic behavior and needs restraint will be reviewed in a+e and then the ST becomes pointless?

      Secondary MH services are rapidly withdrawing from some areas of work or reconfiguring how care is provided so that medical responsibility rests with the GP. I am wary of hearing that s136 is appropriate if it has a health outcome and self referral counts as a health outcome (given that that could be advice to just about any issue) and yet unfortunately at the same time this will increasingly be the answer to most MH crises as commissioners limit funding for much else.

      1. I’m not actually sayign that it’s appropriate if it has a health outcome — I would argue it was appropriate if the power was exercised by the officer in good faith believing that all criteria for using it are met. But presumably, despite a lack of training on the points I’m making here, that’s what most officers would say.

        So judging it by whether or not it achieves a health outcome is just one way of inferring things, along with whether it achieves an admission. Genuinely interested in how you think we should judge the appropriateness of its use?

      2. I actually think there is no genuine way to *measure* whether it is appropriate.

        There are many occasions when an AMHP and two doctors end up detaining someone in circumstances where professionals end up agreeing that a person derives no benefit from an inpatient stay so it is unrealistic to expect a police officer to ‘get it right’ as it were.

        It’s an internal thing – the reason for a decision is notoriously impossible to assess. There are occasions why I simply don’t understand why a person hasn’t been charged for an offense. There is a perception amongst colleagues that s136s are used to avoid paperwork but I don’t buy into that because I have spent time with officers who have been sat bored for hours and just want to go home.

        In general I think this will be determined by the cultural of a team/organization. What are ‘the management’ saying because my suspicion is that in a hierarchical organisation like the police there will be pressure and influence even though it is theoretically the decision of the person on the ground.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s