Frustrating Fragmentation

The following are locations or initiatives places where you can now find mental health nurses working on crisis care alongside other professionals from outside the mental health care system —

  • Police partnered triage schemes
  • Ambulance partnered triage schemes
  • Police control rooms
  • Ambulance control rooms
  • Police custody – in liaison and diversion programmes
  • Accident & Emergency – in liaison psychiatry
  • Mental health trust crisis teams.

Of course, that is in addition to the normal secondary care community mental health teams who support out patients like traditional, community mental health teams and those various versions and overlaps that use titles like home treatment team, assertive outreach teams.  There are also specialist community mental health teams like those operated by forensic services for patients who were previously in the secure mental health system and from place to place you may also find primary care liaison teams, working in GP surgeries or walk in centres, depending on your area.  One background to all of this stuff, is evidence that CrisisTeams have had their budgets cut by over 5% in the last few years at a time when demand for those services has gone up by 15%.  Where do you think the demand went?

The availability of mental health nurse-led services varies from area to area, but the point I want to make in this BLOG post is that about fragmentation, not variability.  I can think of several areas of the country where most of the things I’ve listed above exist in one form or another.  The problem is that they are often commissioned in isolation from each other – if they are formally commissioned at all – and this is done using distinct funding sources that are not necessarily sustainable.  Government funding for street triage is not long-term.  There are overlaps and gaps as a result of this: in one area, the liaison and diversion service runs for twelve hours during the working day and at weekends, but not at evening or at night when most people are first brought into police custody.  (I’ve always doubted whether the best can be achieved if liaison & diversion are coming into an investigation or detention many hours after it began.)  The practice of focussing street triage activity during the out-of-hours period certainly seems sensible but I wonder whether nurses available to share information, whether they are based in 999 control rooms or in deployable teams, could share information with custody sergeants as well as with frontline PCs at jobs?  Many custody areas are only booking in one or two people hour and it doesn’t take long to confirm whether someone is known to secondary care services.

Of course, like in all policing and health services, these teams come with remits and exclusions:  I remember when hospital psychiatric liaison services was introduced in Birmingham learning that the service would see anyone who was brought into A&E departments, except those who were under arrest by the police.  At a time when there were no health-based places of safety available it meant that someone detained under s136 who had taken an overdose or self-harmed would be taken to A&E, patched up and / or monitored in terms of their physical healthcare condition, but then not seen by the mental health professionals who were available at that time within that department.  The person would have to be transferred to police custody and seen by another team altogether who would take, on average, 11hrs to complete what probably could have been done in A&E in a couple of hours or so.  It is beyond doubt that some detainee’s detention was unnecessarily protracted because of this fragmentation.

CRISIS TEAMS

I was listening recently to a manager from the NHS 111 service – this is the telephone based service that replaced NHS Direct in England and offers an advice line.  In case you’re not aware, when you ring 111, you get through to a call handler trained in working their way through various algorithms for different aspects of care, to offer the correct advice.  In approximately one-third of calls that person will have to route the caller to a clinician with qualifications and far greater experience in order to offer the right advice.  I was fascinated to learn that where calls have mental health problems, 80% of calls to the 111 are then transferred to a clinician and 111 feel that there is an absence of primary care mental health services that they can signpost people to, hence they often are left with sign-posting someone to their our-of-hours GP or to A&E.  The only other option, is to involve the emergency services, if relevant thresholds are met or that 111 staff feel they must ‘do something!’  I’ve heard the same said of out-of-hours GPs.

I’ve always wondered about the early intervention concept we hear about in the health system – we hear it spoken about a lot, but various clues exist to suggest that it doesn’t translate easily into service provision.  We know that many detainees under s136 of the Mental Health Act are known secondary care patients – I shudder to think how many more must be in receipt of support from their GP for established mental health problems that are thought less serious.  We know that 15% or so of people arrested by the police and taken to custody are thought to have mental health problems and that those figures are based upon police identification of individuals.  I shudder to think how many must be people with known mental health histories who have chosen not to tell the police about their health during risk assessment questions.

We know that where a person comes into contact with the police, whether they will end up in contact with a mental health professional or whether the officers decision-making can be supported by mental health professionals will depend upon the arrest decision officers make.  We’ve known from criminological research about arrest decisions that officers are likely to be affected in their choices by the availability of support services that they think may be needed.  So for example, if you are an officer who works where they have L&D during the day and street triage at night, will this affect how you make an arrest decision at 2pm or 4pm, before street triage begins?  By arresting someone in distress for a public order offence, you can get them into police custody to be seen by a mental health nurse, but you can’t call upon triage support.  I say this again, we know from research that these things affect decisions and are therefore likely to be linked to whether or not someone is detained or criminalised.

CRISIS TEAMS

The evolving melange of initiatives, and the sheer variety of each of those initiatives may compound problems we have unless we control them carefully.  In some places, the triage nurses going out in police cars are part of crisis teams and the nurses take their turn staffing the car; elsewhere they are seconded from many other kinds of mental health nursing jobs for fixed periods to undertake this 999 triage work with the police.  In some areas, Liaison and Diversion is an 8hr a day endeavour and it doesn’t cover weekends; elsewhere it’s 12hrs a day and seven days a week.  This matters: we knew this would matter before we established these schemes.  I have received very many anecdotes in the last six months to suggest that the mental health nurses in these teams are pushing work in each other’s direction: street triage wondering why a community mental health team has asked for a police welfare check.  Is it because they now know that the police will involve the triage car?

So whilst this fragmentation is frustrating – because we know it is creating (at least some) work that didn’t previously exist – I also want to draw upon the other meaning of the title of this blog by arguing that it is possible to frustrate this tendency to fragment.  It sounds rather flippant, but doesn’t this all show that we need an overarching strategy for how those in mental health crisis can access services and assessment when needed – primary and secondary care?  I hate to think how much of the stuff I spend time debating on social media is just ‘failure demand’.  In other words, demand that exists because of a previous failure to do something or do something right for vulnerable people.  For what it’s worth, I suspect it is easily more than half.

Perhaps it is the definition of ‘crisis’ that we need to think about?  Wouldn’t we agree that someone with mental health problems who is arrested by the police is in need of unscheduled NHS services; someone who is ringing 999 threatening to kill themselves is in need of crisis mental health services, whether or not 999 services become involved.  Someone who self-presents to A&E is in need of crisis care mental health services, irrespective of whether there is also a dimension to their presentation that requires unscheduled acute hospital care.  We could go on and on.  I recently asked a GP about out of hours provision: what is your reaction when you are called about a patient with mental health problems?  If the patient is a secondary care patient, they would be signposted in that direction.  If they were not it comes down to whether they are actively suicidal that day and at immediate risk.  If risk of harm is acute, the GP would hope to provide some reassurance and possibly some medication that may help in that person reaching a point where they can see their own GP.  Otherwise, it’s about accessing emergency mental health services for assessment or emergency services if there is no time to wait for that.

So I was left wondering, if the money and resource flooding in to some local areas for these various emergency-999 related mental health pilots was consolidated with those services that already exist; and if supporting those in crisis or in contact with 999 services was all seen as different dimensions of similar kinds of work, could we not avoid both the fragmentation that is emerging and the unintended consequences of overly-functionalising teams who are ultimately dealing with the same patient groups.

Maybe we could call it a crisis team?  Just a thought.


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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4 thoughts on “Frustrating Fragmentation

  1. The reality is that crisis teams were originally set up to deal with acutely ill ppl who would otherwise be In one of the many thousand beds now cut. The groups you are talking about are usually far removed from this but of course may benefit from an assessment and possible signposting on to another service ( drug and alcohol; benefits specialist etc). If the funding is put in place most frontline MH profs wouldn’t have a problem with this but many would worry about the medicalisation of behaviours which others don’t know how to manage and feel uncomfortable with in the name of helping ( which often means someone else should be dealing with this!) Once seen, the argument that the person is ‘known to mental health services’ will be employed as though that statement in itself means anything. It doesn’t.

  2. Frustrating as it is the above is true. They re designed to treat people at home who would otherwise need to be admitted. Worked very well with relative who was refusing medication – they could defuse that problem twice a day and allow her to stay at home. They aren’t set up to deal with what might look more like a crisis – self harm, risky behaviour. suicidal ideation etc. The frustrations then arise because there isn’t anyone who’s job it is to cope with these things, so it’s back to family, police a and e etc. Part of the problem I have found is that services are bad at spelling out what they can and can’t do and what your options really are…… perhaps because it would be too depressing. Reality is that if you go to A and E you will wait hours, be seen by a nurse to see if you should be sent home or assessed, if the decision is that you should be assessed you will then wait hours for that and then probably be sent home…..

  3. Where I live you cannot self refer to the crisis team, nor can primary care services like GPs refer you. Referrals are only taken from the CMHT, or the hospital, so you either need to already be linked in with the CMHT and have a 9-5 crisis, ideally at the time of your regular, scheduled appointment, or be at the hospital. Most mental health crises don’t happen in this way. It’s hard not to think that the criteria and barriers for referral are for the convenience of the crisis team and to facilitate their preferred workload, rather than being patient centred and engaging with the messy reality of mental health crisis.

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