New money is making further investment in street triage schemes possible in many areas of the country and we have seen new schemes emerging in the early part of this year. Some NHS areas must be convinced of the value of them since they are funding them directly, without pilot funding from the department of health. In new extensions of the concept, we are starting to see variations on what street triage looks like and I know forces yet to go down this route are also thinking of even more variations on this theme.
For example, West Midlands Police is operating in trio with Birmingham and Solihull Mental Health Trust and West Midlands Ambulance Service – thereby enabling paramedics to have input into these 999 situations and we can easily see why this may be helpful. Immediate attention to physical health issues, including injuries from self-harm and the potential to identify presentations which may indicate A&E is required. In the Lincolnshire Police area, they are also including paramedics in the triage car itself, but they are not including police officers. Their arrangement is a pairing of a mental health nurse and a paramedic, able to respond instead or as well as the police when 999 calls are received.
There are (at least) two ways of looking at this: localism should allow for local leaders to make decisions about what suits their locality – what works in Newcastle may not work in Northumberland or vice versa because of geography and / or population density. So a “one size fits all” model may be futile. In furtherance of that same point, schemes starting in various areas are doing it against different backdrops: I heard a presentation last year by Cleveland Police about street triage and learned that officers in that force, prior to the commencement of triage, were using section 136 of the Mental Health Act around 500 times a year, which is high for the population of the area. In fact, it is roughly similar to the usage in Birmingham where the population is twice the size but in important respects, the outcomes were very, very different. Approximately 125 subsequent admissions in Cleveland after 136 assessment but around 225 in Birmingham – in other words, the number of MHA admissions correlates, at least roughly, to the population size, not to the use of s136. So schemes to match local need may vary for various reasons. Use of s136 in Cleveland is perceived by some others to be excessive and triage is seen as a way of helping to reduce this – we should also remember that per capita funding for mental health varies across the country, so certain things may be affordable in some places but not others.
Having said all of that, triage schemes in their various forms need, presumably, to be consistent to at least some degree on what, precisely,they are trying to achieve? I wonder how these intentions may be affected by approaches that see the police remaining outside the triage car – in other words, where frontline officers call upon a response from another professional agency who then either makes telephone contact to provide information / advice, or who turns up if they see a need to do so. I’m also wonder about whether it matters if the professional involved is not a mental health nurse? Original intentions in the schemes in Cleveland, Leicestershire and Sussex were to have nurse-led input into situations that the police could not legally manage anyway; and identification of situations where a legalised police response is not justified because of other less-restrictive interventions that a nurse can either provide or call upon.
How would those situations be handled by other health / social care professionals and what pathways would be open to them?
OTHER MODELS OF TRIAGE
One of the embryonic triage schemes I am aware of is looking at the deployment of a social worker, probably qualified as an AMHP, to act as the professional mental health advisor. The UK would not be the first country to do this: Portland in the United States has also looked at this approach, whereby emergency calls to the police that do not include suggestions of violence see a single agency, social work led response and calls involving threats and risks see the police supporting those professionals.
We only need to remember Panorama from last September to see how many of the “mental health issues” were in fact social, behavioural and substance abuse issues and who is to say that social workers, professionals in mental health are less-equipped than mental health nurses to undertake a triage function?
What about the use of a mental health nurse who is ALSO an AMHP, as in Sussex?
A qualified AMHP could certainly better gatekeep the legal considerations as to whether the MHA could be of application but it is interesting also for this reason: those qualified as AMHPs have very have few legal powers when acting alone, in their own right – those they do have would be of limited applicability to 999 calls to emergency services because they wouldn’t that add much to the legal authorities the police already have for themselves. So the ability of an AMHP to do legal things, would depend upon their ability to call upon a s12 Doctor and that varies from area to area.
I am aware of five police forces who have indicated that they do not wish to put a police officer in a car with a health or social care professional. Some argue that geography and demand renders it unjustifiable from a cost-benefit point of view to ring-fence officers to deal with nothing other than street triage calls. Others argue that a different model of response suits them better and that whilst they fully intend to close the ties between mental health and policing, it will probably not be in the format of a double or triple-crewed multi-agency vehicle. For clarity, these are not just rural forces covering large expanses of sparse population – they include some large forces covering major cities. They just prefer closer working ties where professionals call upon each other as required, all supported by better policies and improved (joint) training.
I’m not sure what Hampshire Police think of street triage as originally conceived (police officer + mental health nurse) but I do know that they have started a pilot whereby a mental health nurse is based in their control room and able to share information with police controllers to assist front-line officers in policing incidents. Bearing in mind that in Leicestershire, the street triage car does not deploy to 90% of the incidents where a street triage input is considered, a model that bases a mental health nurse in a control room achieves most of what street triage can do without having to ring-fence officers for the purpose, information-sharing being key. I know that in Kent, their model of street triage is firstly an information-sharing model, undertaken by telephone. It is secondarily, a model of deployment where a nurse can deploy to an incident, not from a double-crewed multi-agency car, but in support of the front line officers already there. That is how the Cleveland scheme works, too.
When you consider the eight-dimensions to street triage, we see that the attendance of a nurse at an incident may affect one quarter of the types of calls received – and even then, only where there is consent or cooperation from the person at the centre of the call or incident. Note: this is not one-quarter of calls, but one-quarter of the types of calls. We’re yet to fully understand the demands through formal evaluation and we’re yet to understand the impact of different models of working when compared to each other and when compared to what existed before.
WHAT ARE WE TRYING TO ACHIEVE?
I keep coming back to this point, whilst genuinely trying very hard indeed not to be negative or to just appear to be negative: the extent to which localism is leading to different improvisations of what street triage looks like, may be evidence in itself that we’re not sighted on a particular goal. Are we just hoping that we can “do something?” In one force, it is the privately stated ambition of MH services to “stop the police misusing 136”. In another, where little or no misuse occurs, it is to provide alternative pathways that negate the need for 136, even if it could have been legitimately used had a nurse not been present – there you have two schemes that are intent upon achieving very, very different things: all under the banner of street triage.
When we see consideration of the different kinds of MH professional that could be involved, we start to see that we’re not sure whether we are focussing upon assessment of clinical issues or broader assessment of social circumstances or the reduction of misuse. I admit to being interested in making sure that police officers detaining or referring people are not misunderstanding the presentation of someone as “behavioural” in nature, for something that is actually seriously pathological that places health at risk. Obviously, that cannot be a consideration in a model of street triage that employs an AMHP rather than a mental health nurse, and pre-hospital clinical capability is different again if a paramedic is involved. I still hear the debate ongoing about whether a mental health nurse should be undertaking pre-hospital screening of people in contact with the police whose identities and backgrounds may be unknown.
Given we can exemplify psychiatrists getting clinical presentations badly wrong, should we be putting mental health nurses in that position? Some of them say, no; others say yes. Even they can’t agree.
It was once joked admist a discussion on all of this, that maybe we should have a triage bus?! – something large enough to enable a police officer and a paramedic as well as an AMHP, a mental health nurse and a psychiatrist to travel in a together? A one-stop shop for all eventualities. Of course, such jest was quickly put to one side because we can imagine how enormously expensive that would be and how most of the time, most of the people in that bus would not be strictly necessary to the proper resolution of a particular call. Of course, that is true of current schemes to different extents in different formats.
The same principles of cost-benefit against a thoroughly understood demand profile have not yet been done – and I very much look forward to reading them in due course. When they’re undertaken, I also want to read something the legal and ethical issues involved because in the media material I keep seeing I just keep being told that it “helps”. Meanwhile, I remain concerned that the lack of proper emergency mental health law training for those involved – especially on the Mental Capacity Act 2005! – and the lack of vision around what to do when mental health emergency conflates with criminal law, may be leading to perverse outcomes. This needs addressing if we are to get convincing about the overall benefits. Just saying, “it helps” is very far from enough, without detailed answers to the understandable questions that arise.
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, 2019
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