What’s The Question?

If street triage is the answer, then what is the question we are asking ourselves in order to achieve that answer?  I pose this dilemma because of today’s Radio Four programme You and Yours, which highlighted the work of the street triage team in Birmingham.  (You can listen to the programme on iPlayer or the BBC website – the relevant section begins at 8mins 30secs).  In particular, I pose the dilemma because the introductory context which led to discussion of the street triage team was focussed on the problem of over-reliance upon police cells as a place of safety for those detained under s136 of the Mental Health Act and this conflates two separate problems – place of safety provision for those detained and mechanisms which may see a reduction in the number of people detained.

These two subjects are related, make no mistake – where areas are struggling to ensure that police stations are used other than exceptionally for those of us in crisis, they either need to increase capacity in the NHS to assess people or reduce the number of people detained by ensuring seperate provision.  But the reason this BBC introduction is problematic is simple: Birmingham was not relying upon police stations to act as a Place of Safety to start with.  Neither are many other police force areas who have introduced triage.  The legal imperative to ensure custody is not used, other than exceptionally, exists whether you have triage or not and West Midlands Police, Merseyside Police and the Metropolitan Police got to that position without the use of triage.

If the answer is street triage, the question cannot be, “How can we reduce the number of people going to police custody?”  

People weren’t going to custody to begin with – triage must be about something else.

It links to other ideas that I’ve heard expressed: a senior police officer told me that triage was “about saving police time, full stop.”  Except that we know that some models of street triage don’t save police time.  Typical analysis of the impact of street triage on police time goes like this: “We used to have X number of s136 detentions, each one of which took Y officers Z hours.  Now we have significantly reduced the use of s136 we have saved all that time.”  Of course, but you’ve also staffed a street triage initiative that didn’t exist before so you have to take that commitment into account.  600 detentions a year, reduced to 350 because of triage could equal 2000hrs of time saved, but if you need over 4 officers committed to triage to make that happen, you’re spending over 8000hrs to achieve your saving.

If the answer is triage, the question cannot be, “How do we save police time in handling mental health related crisis demands?”  

Some schemes are costing police resources – so triage must be about something else.

Many have pointed out that the reduction in the use of s136 is a good thing in itself because it helps deliver better, less restrictive outcomes for those of us in distress and that where this occurs it should be welcomed even if people would have otherwise been taken to an NHS assessment facility and even if it costs the police extra resources – surely this is about the public and vulnerable people, ahead of organisations convenience and resources?  I actually understand that fully and I’ve said so on this BLOG before people were talking about triage. The problem here is, we know that some schemes said they were set up to reduce the use of section 136, full stop.  Then they went about attending a load of incidents where section 136 was never a possible outcome – those incidents that occur in private premises account for more than 50% of the work of many schemes.

If the answer is triage, the question cannot be, “How do we reduce the use of s136 of the Mental Health Act?”

Some schemes are mostly enaged in work that has no potential to achieve this – so triage must be about something else.

None of these observations mean triage isn’t a good thing or that it isn’t bringing benefits, it’s about understanding what we’re trying to achieve and what the various advantages and disadvantages are to the various ways in which this sort of thing can be done.  But whatever you think the question is, triage is not the only answer – it’s just one of several possible answers.  Other approaches could include on of more from this list –

  • Deliver proper training to police officers on use of s136 of the Mental Health Act 
  • Have accessible, flexible mental health services.
  • Then! – create sufficient Place of Safety provision to meet local demand.

There’s a thought!

HERETICAL THOUGHTS

I was in London a few weeks ago for a meeting and having arrived surprisingly early, I was killing time in a coffee shop when I was hit by two thoughts I can’t get out of my head.  I’ve been arguing for a while now that street triage (if we have to use that name!) is not, fundamentally, about the model of operation adopted in a particular area.  We know, for example, that in the West Midlands, they prefer a triple agency car crewed by a mental health nurse and a paramedic as well as the police officer; whereas in Leicestershire, they leave out the paramedic and in Lincolnshire, they leave out out the police officer.  Some areas don’t have a multi-agency vehicle at all, they place a mental health nurse in the police control room to support and advise control room supervisors or frontline officers, as required.  In those areas that do have a police officer and mental health nurse model, some police forces have those officers working on street triage full-time, covering 18hrs of the day whereas others work the ‘late’ shift – usually 3pm to 11pm or 4pm to midnight.

The officer who undertakes that function is abstracted from the response team and will end up working the triage car two or three times a month.  The first model means officers are more rapidly building knowledge of the NHS, mental health law and so on; the second is more cost effective, development is slower, but that the offices take those skills into their ‘early’ and ‘night’ shifts and make a wider difference by working alongsid their response team colleagues who don’t ever work on the triage car.  When you then add in various geographies across England from rural to urban areas as well as those with a mix, you can see how complicated it gets to work out what triage is trying to do, how it fits into existing local services and so on.

Anyway, here’s my main heretical thought:  I wondered whether the massive reductions seen in the use of s136 MHA since the introduction of triage indicate that areas we’re either overusing the power to begin with when the legal grounds weren’t actually met, or that they we are now somewhat fudging situations to contrive avoiding the use of it when it was perfectly necessary to do so?  I hinted at this in a BLOG a few weeks ago where I talked about a grey zone in the way that schemes often ask the frontline officers to manage a potential s136 situation without invoking the power until triage can get involved to advise.  I’m going to deliberately just float that idea and return to it in my next BLOG: large reductions in the use of the power either mean something was wrong, or is wrong – in reality it will be a combination of both. 


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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5 thoughts on “What’s The Question?

  1. So locally every Friday we’ve had a police officer, usually a probationer, attached to our crisis team for our shift.
    It’s quite problematic because not many people being referred for a crisis admission or a MHAA want an officer to tag along so often it has been a case of them listening to all the difficult telephone calls and just getting a feel for what the team does. That said when they do this there is an increased respect showed.
    We’ve talked about a reciprocal, arrangement but that seems difficult to arrange too.

    Unfortunately in the shires a Street Triage car is never going to be economically viable. We have one nurse and one AMHP covering the entire county overnight, ST would mean a 50% increase in NHS staffing and, in an areas where the police are very cagey about just how few officers are out and about of an evening I can’t imagine they can spare an officer or a car either. And, as you identify clearly, it might reduce s136 detentions but it won’t eliminate them.
    That’s a shame because I suspect each officer doing one shift a month or every 6 weeks, with a nurse or an AMHP would be an education for both parties and surely repair out increasingly fractured relationship. We are after all on the same side.

  2. Could the question be; how did we get here in the first place? I see recent communitycare.co.uk press lease suggests that the Care Quality Commission have submitted proposals for the CQC to regulate the AMHP’s teams throughout the country enabling them to hold councils to account on their statutory duty to provide sufficient services. Could this be a step towards providing the right help at the right time to the people who need it, instead of the current fudge we find ourselves with now.

  3. I haven’t any experience of street triage but have info from friends on use of s136. In all the cases I have heard of it seems to have been used appropriately ‘If a constable finds in a place to which the public have access a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons, remove that person to a place of safety within the meaning of section 135 above.’ Problems seem to be either when the above doesn’t actually apply but something needs to be done…..and the endless hours of waiting for an assessment which seem to occur following arrest. My big worry is that decisions about whether to detain end up being made by a nurse or paramedic with the person then being left in the middle of the night having lied about their intentions……

  4. May be being unfair, but in my experience there seems to be a failing in MH services that frequent what look like suicide attempts are just gestures. Meaning that peopel are likely to be dismisssed as not needning any additional help. Resulting potentially in more tragedies…

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