I’m Really Sorry, but! …

I’m not trying to get on anyone’s nerves here, I’m really not. I just feel really passionately about this and we can probably agree that it is actually my job to keep chipping away at all aspects of policing and mental health issues. So with considerable regret, I must again raise the topic of street triage, something which I’ll admit I often go out of my way to avoid discussing, not least because it tends to go down like the proverbial balloon. So I’m really sorry and not I’m trying to bore anybody here, or to undermine hard-working professionals who no-one doubts are trying to make the world a better place by supporting vulnerable people. I have to just hope it can be understood, I’ve been given a job that is around the application of the law and newly developed guidelines which needs to sit within a culture of robust evaluation. I am also subject to the police service’s Code of Ethics, which makes it clear we have a duty to challenge, question and discuss. I do again, because I know from discussions yesterday that I’m not the only person with questions and with concerns. Others who said so yesterday, include psychiatrists, AMHPs and police officers.

An academic article was published yesterday in the BMJ-Open (NB: not in the BMJ itself!) about street triage in the North-East of England, operating in the Northumbria Police area alongside Northumberland, Tyne and Wear NHS Trust, undertaken by Newcastle University, a Russell group institution (no less). There have subsequently been several media pieces covering the highlights from this publication, most of them within professional online articles rather than in the mainstream and through the magic of social media further discussion by people who know of such collaborative approaches elsewhere in the country. On this occasion, the main highlight seems to be that ‘street triage’ cuts the use of police powers in half; it has brought about significant cost savings (estimated at around £1m for a large mental health trust like NTW) and improved outcomes for vulnerable people who now often experience a far less restrictive approach to their crisis care.

So far, so good, right – who could possibly object? My objection is not to street triage, per se, my whole point is we don’t know enough about it to know whether we should be objecting to it or not! My objection is to extremely partial evaluation that fails to even acknowledge, never mind address, very obvious issues that should influence any assessment of the risks versus the benefits. I keep hearing that street triage ‘works’, but no-one can tell me what it’s trying to do. I also hear some say, ‘it works for us’, to quickly sidestep the whole discussion about what’s for and what it’s doing.

I’ve suggested that this article would be a good thing to give to university MSc students looking at research methods: it would allow them considerable scope to think about what this article is NOT saying and what the authors have NOT considered as relevant to an evaluation of the scheme as a whole or the use of s136, for therein lies the interest for me. I note (from what I can tell by looking them up), that none of the authors of the article appear to be police officers or lawyers – yet the primary aim of their focus is an analysis of the use of particular legal power and it’s mainly the legal perspective that’s missing, for me. Although that’s not all that’s missing.

OFF THE TOP OF MY HEAD

So here’s a list of thoughts in no particular order –

  • Are we really surprised to discover that if the police can now take mental health services to vulnerable people, they have to take vulnerable people to mental health services far less often than they previously did?! I’m not sure we needed a two-year research study to tell us that would happen. I’m infinitely more interested in why the police are involved at all, accepting that they will always play just some role in our wider mental health system. I worry this is inappropriately expanding the role, increasing risk and stigma – see below.
  • As early as the second paragraph, I had to pause when it was claimed that “three broad outcomes” result from use of s136 – involuntary admission, voluntary admission or referral to community services. Of course, it fails to mention the fourth outcome which is ‘absolutely no follow-up whatsoever’ and which can occur for a variety of reasons. This is reflected to a degree, in NHS Digital data on the use of s136.
  • But what are the unintended consequences in terms of how this service fits in to the wider health economy? – we know from observing street triage teams more ethnographically, there are several unintended consequences and I’ve written about them before. They go unmentioned here but can include even more MH related demand being deflected to the emergency system via the police by GPs, community mental health services, etc.; and sometimes, it leads to later, not earlier, intervention for people seeking support. We don’t know the extent of this, precisely because no-one’s looking at it in the evaluations! That’s why I’ve spent about many nights in the back of street triage vehicles, watching what they do and it’s a mixed bag, in my limited experience.
  • We know that street triage does not mostly occur in the street: this is yet another academic article where the main focus of evaluation is the use of police powers under the MHA which can only occur in the public sphere – what is going on in the 50-odd plus percent of ST incidents which occur in places where use of s136 is not lawful? It’s barely mentioned, as UCL barely mentioned it in their evaluation of the nine so-called pilot schemes (that weren’t actually pilots at all – triage had been up and running in three police forces for quite a while by the time those nine began). Whilst we’re on the subject, co-responding by police and mental health services didn’t begin in the USA in the 1980s: “car 87” has been operating in Vancouver since the 1984 and co-responding with health in Canada goes back to the 1970s.
  • There is no reference to what we know about the use of other police powers – you can easily reduce the use of s136 by simply using other powers instead: did they? We know that police forces have different cultures around the use of powers, for a variety of reasons to do with training, history and partnerships. This is why Nottinghamshire Police and West Midlands Police were using s136 MHA about the same amount prior to instigating street triage schemes in 2013 despite the fact that West Midlands Police is three times the size, with three times the population.
  • What is the follow-up rate for all of the referrals that are being made – community mental health services in that part of the world told the Crisp Commission that they had seen a 100% increase in workload in the year to May 2015 with an attendant reduction in staff. We know from some triage teams that they put in referrals at 10pm when someone is in crisis, and they’re not followed up by CMHTs the following day.  I have no idea whether this is a rare or a frequent occurence, because no-one’s recording and evaluating it.
  • “ST teams typically comprise a Police Officer and Mental Health clinician working together to attend incidents” – except that they don’t, do they?! Several schemes involve putting the mental health professional in the police control room (Norfolk, Devon and Cornwall) and others involve the clinician responding alone to support front line officers attending incidents (Hampshire, Cleveland), but even in the Northumbria scheme and those like it which have a multi-agency vehicle, they report not physically attending most of the incidents they were contacted about. This was also true in Leicestershire and elsewhere. So any analysis of a particular scheme, especially where it is getting in to cost-benefit analysis, needs to acknowledge they have an expensive resource, in the form of a police officer, who is not physically attending incidents because other officers are there and a nurse is giving remote advice and information that could be given from anywhere. I would suggest that is important to understanding the whatever dynamics of inter-agency working you want to understand; and to any health economics that are being attempted as a result.
  • On my night out with street triage in this area, all of the incidents we attended were generated by the NHS which was unable to cope with a kind of demand that did not need the police: it needed mental health professionals who didn’t have the capacity to help. None of those calls were from members of the public asking the police for urgent help in a context you would recognise as a policing incident. Across my nights out with ST as a whole, just under a half of all incidents were like this and several were explicitly referred to triage where they would not have been if it hadn’t existed. Make your own mind up about what that means about the role of the police in mental health crisis care but one research question I’m interested in would be “To what extent does the existence of street triage cause the system to refer incidents relating only to health issues to the police service, because of the ability to deploy a mental health nurse who would otherwise be unavailable?” We know that the answer to this question is not “To no extent at all” so we need to know more what the answer is, far more precisely.
  • I have been a regular presenter at CPD for AMHPs in the North-East of England over the last few years and the last time I did this, they expressed concerns about ST-type approaches that are not reflected in the evaluation. It is AMHPs who become excluded from the public contact where s136 usage reduces, because the AMHP plays a formal role in the assessment. So what do this crucial professional group think – I suspect many don’t know what to think because they, like me, can’t find any full evaluations to read.
  • Why so little mention of other schemes who have NOT found these outcomes? – I know of three police forces who have started doing the kind of street triage being evaluated here, but have pulled away from it completely or substantially because notwithstanding an impact on the use of the s136 legal power they found other reasons to think it not worthwhile. In one case, that was because of a view by the police that they were being expected to burden excessive costs for benefits the health system welcomed but for which they were not prepared to pay. The authors in this example haven’t touched upon these matters so I’m wondering if they considered them, or knew?
  • The paper notes the research evaluation of Dr Margaret HESLIN et al from the Institute of Psychiatry in London who evaluated the Sussex street triage scheme. From a health economics point of view, they note that street triage was cost neutral but that it involved a significant transfer of cost around public service provision from health to policing. So a public policy question for you: “To what extent is it the responsibility of Chief Constables to pay for efficient healthcare pathways?” We know the answer to this is not, “Completely!”
  • What is the understanding of s136 MHA, on which so much of the analysis rests: it refers (without a footnote) to ‘inappropriate’ use of s136 – what does that actually mean in the minds of the authors?! … we don’t know.
  • Leading on from that point, we also see no overt consideration of what is happening legally whilst these incidents are being handled in a new way. Section 136 is a power whose need must be immediate, in order to be lawfully used – given that street triage in south of the Tyne is moving around in an unmarked van, without lights and sirens and can take up to 45mins to reach an incident, what is the status of vulnerable people encountered by the first-responders who call for triage?
  • Do the attending police officers point out to the encountered person that they are not detained and not obliged to remain with the officers? … or are they, in reality, detained pending triage’s arrival to make the decision?! From other schemes, on just some occasions, we know they are and this can be both ethically and legally dubious – informing people that they are not detained and free to leave is common and legally required during other kinds of police encounters in order to remove ambiguity. It should be here, too; not least because of the questions around vulnerability and mental capacity that aren’t always features of those other kinds of policing situations.
  • And the title of the piece: “Too much detention” – I presume the authors are unaware that Baroness HALE, the deputy President of the Supreme Court who often gives the lead judgment on mental health and capacity law rulings like Cheshire West (2014), argued in her 2010 textbook on mental health law that s136 is, quite probably, under-used overall. Paradoxical though this may sound, it is quite possible to reduce the use of something that was already under-used: it’s a logical fallacy to assume that because something can be reduced, it must have been over-used to start with. The police could arrest innumerable people for offences or Breach of the Peace instead of using s136 in order to reduce the use of the power: any decision to do so tells us nothing at all about use of s136 before or after that change of approach because it could be true that arrest powers were already over-used prior to their increase!
  • Finally, the costs savings of £1m or so – even allowing for acknowledgements of estimates being made and so on, the thing that seems to be missing from the economics of it all, is the issue around cost to policing. I’ve already mentioned the piece by HESLIN which is referenced in this article, and that showed a transfer of cost for less restrictive healthcare pathways shifting from the NHS to the police. In order to run this kind of street triage team, forces are contributing between four and seven police officers.
  • This amounts to between 8,000 and 14,000 hours of police time and between £200,000 and £350,000 a year of cost, which needs to be offset against all the other calculations of time and money whilst remembering that any comparison to what was previously occurring in an area needs to remember that it was a s136 pathway already over-reliant upon the police because of an under-commissioned PoS service where the police were, in effect, asked to staff the mental health unit, requiring 10hrs of resources per detention. This doesn’t happen everywhere and amounts to a different partnership context against which to evaluate the impact of an ST scheme.
  • I also can’t omit to mention the reference in the penultimate paragraph about the use of police custody “when clinically indicated” –  I notice that’s left hanging in the air, entirely undefined, as are the current proposals to define ‘exceptional circumstances’ for reliance upon police custody in the forthcoming revision of Mental Health Act. I’ve got no idea what it means and suspect that health guidelines suggest it will more or less never be ‘clinically indicated’.

AND BREATHE!

I could go on … and on. It remains my view that street triage is very under-evaluated, that nothing we’ve seen so far gets us close to having a clear under-standing of risks versus benefits and that this week’s publication is encouraging but an extremely partial view. And you’ll have to forgive me repeating this point: my objection is not to street triage – it is to limited evaluation of these new ways of working! We didn’t even mention deaths following contact with triage assessment, have we? … they need looking at, too.

That’s why when I see things like this and find that people claim it’s an obvious success that needs to happen everywhere on a 24/7 basis, it does get me fairly exercised because it’s put across as a self-evident truth, beyond discussion. In reality there are many professionals and services who say otherwise but then again, they haven’t fully analysed it either!  I’m far from alone in having unanswered questions, although it sometimes feels that way – I actively want someone to come and show me I needn’t worry, because I’d love to be convinced about all this, given the obvious upsides to a collaborative approach.

But I want loads of data, quantitative AND qualitative.  So whilst we’re on the subject: where are the patient’s and public’s voices in all of this?  Exactly.

Other posts touching on street triage and those aspects of s136 MHA referred to above –


IMG_0053IMG_0052Winner of the President’sMedal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


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17 thoughts on “I’m Really Sorry, but! …

  1. Thought I’d replied via mobile – not to be. Therefore this will be short and sweet: Realist Evaluation – Pawson and Tilley 1997 – this is the only approach to evaluating these kinds of services which will work. The Home Office used to have their own research unit who were well versed in this approach – I was taught it by someone who did some work there – Nick Bland. I wonder if the research unit is still there? If Street Triage are paid out of police budget would make sense to commission them to evaluate it properly. Getting Health Services to evaluate themselves is a like getting the police to do the same, or getting Turkey’s to vote for Christmas.

  2. Info I would love to see for ST is
    a) percentage of calls to private premises v calls to public places
    b) percentage of calls to people already under care of secondary services
    c) For calls to people in public places
    i) Time taken for ST to attend
    ii) Immediate outcome of incident
    iii) Outcome 2 weeks later

    Personally I don’t think there should be a need for an emergency service for people already under care of secondary services, if you are so unwell that you are likely to need one then you should be in hospital. ……I suspect not a popular view.

    1. It varies from scheme to scheme, obviously and not all schemes publish or even collect all of that data, but the answers are roughly –

      a) 55% private; 45% public
      b) most are current or recent secondary care patients who are “known or open to services” (which is in keeping with the s136 stats generally).
      c) i) Between 15-45mins where they attend, but in many areas ST don’t physically attend the majority of their calls.
      c) ii) Usually resolved without detention / arrest.
      c) iii) We don’t know – no-one collates that.

      So for example, I have unconfirmed reports that one ST scheme is about to stop because, in the words of a MH professional from that area, “they’re just doing CrisisTeam work with known patients.”

      1. Dear Mentalhealthcop,
        Thank you so much – yes, I am. I hope that you too are well and happy.
        We seem to be going through very turbulent times the like of which we have not seen before. Careful policing such as yours goes a very long way to give a true sense of perspective and purpose so that everyone can be included which is so important not to have people feeling that they are without hope.
        With best wishes
        Rosemary

  3. I understand your questions and comments are unlikely to be well received by MH professionals who believe they have good working partnerships with police & wish for better crisis intervention for their service users. That is not the same as being honest about understanding (through meaningful research) about finding out what actually works.
    I have often challenged the idea that reduced s136 = better, what is important is what happens after. I personally believe it is of value and we currently have NO idea nationally or locally what a reasonable level reflects actual need.
    I have also challenged the idea, even in the short-term, ( though it was obviously necessary in many instances) that the Police should initiate interventions to address Health & Social Care potentially criminal and certainly Immoral inadequacies. Even though they already were in other ways.
    In principle I have no objection to some form of Street Triage, as part of a whole MH strategy to address the “crisis” part of a service response. That’s NOT what has happened or how most services have arisen / developed /been disbanded. Where these projects or pilots have – in a variety of forms -have delivered benefits, those lessons should Not be lost or abandoned. Nor should assumptions be made about the current or future costs, whether they be financial, a failure to actually assess what Health, LA, Police need to do / commission. Or more importantly the effect / impact on the individual & their family of police involvement, stigma, reduced likelihood of future requests for support, further alienation from health AND POLICE services. We know that people suffering from MH issues are actually a significant proportion of victims of crime, how on earth can we expect them to report this if their experience of police has become negatively associated with MH crisis & requests for support?
    I agree much more support, BUT actually much more thought first, please.

  4. With respect you’re probably overthinking this. Most ST contacts are with people who are non psychotic – using substances,poor coping skills, difficult life ,awful relationships,poor etc. Reality is no-one really knows what the heck to do with this group and medicalising their life will often /usually make things worse for them. So unless the research looks properly at whether even having a health response is helpful at all or whether the medicalisation of distress has led to an exponential rise in these presentations we will continue to run round in circles trying to ‘fix’ people . If you doubt this, take a moment to think about the people who are repeat customers. Ps. I know this view will not be popular with the echo chamber of the twitterarti!

    1. Would love to see statistics for this – psychosis is not the only mental illness, nor even the one with the highest risk of suicide. Also diagnosis changes over time, so eupd, psychotic depression, schizophrenia as an example I know of. So the person you are marking down as a distressed inadequate person, may a couple of years later have what you consider to be a real mental illness. Also (and separately) if mental health services will only help people with a diagnosable mental illness, then perhaps mental health services should make that explicit, then we as a society could think about how to help people who don’t meet that threshold. As you find out more about services you gradually discover that there are all sort of thresholds that have to be met before you qualify for different/any level of care and it might help the debate if services went public with them.

  5. Anyone thought of having mental health ambulances with appropriately trained staff and perhaps even psychiatric version of A&E. Police would then only be needed if offences had been committed or if peolple in danger couldn’t be found. Suffolk Police have helped me to search for my daughter when she’s gone out with the intention of harming herself. They were professional, showed real concern and wonderfully kind but if Ishe had a crisis in our house what we need are health professionals.

    1. Seen on twitter last evening ‘Great end to the week seeing paramedic and mental health nurse working together in Crawley to treat patients and avoid A&E’ ‘they do home visits, assess support and access crisis team or MH bed as needed’ This would be in the SECAmb Surrey and Sussex area. This as a service user would be a preferable option

  6. I see that this blog has created a tad bit of controversy and I risk repeating myself here I think. I am a mental health service user who has many times been on a section 136 and to be fair most of those have resulted in a hospital admission either formal or informal. I have been on Section 2 or 3 x 8. I am classed as a mentally vulnerable person who can pose a risk to myself. I’ve had 2 occasions within the last 2 years where street triage has been suggested as an option. Once when I was in a public place but the triage car was not working that evening and the second time I was at home and the triage care was busy elsewhere. But neither time did I think that the presence of a triage service would have been beneficial. Most time I recognise when I am becoming unwell and need extra support yet that support is not available for whatever reason. For instance if I ring the crisis team it would be nice if they offered a home visit on the day not the next day It would be nice if my CPN was answering his phone during the day rather than at 4.30pm. In short there are many ways for someone who is already in contact with mental health services to be supported to not get to that point of crisis where police have to step in. Mental health services can also be pretty dismissive if they feel there is some element of ‘attention seeking’ going on with a service user so there is potential to be fobbed off by positive risk taking from the mental health professional in a triage car.
    Give me a mental health service where there is a bed available when I need one and for it to be a therapeutic environment on the ward, where the service is proactive and not reactive and then I might not get to the point where I end up in a suicidal situation.

    So please just put the money used on triage back into the mental health service.

    1. Great psot, couldn’t agree more. So much money is spent ‘gate-keeping’ and so much demand, which wouldn’t be there if beds were available is shuffled to ambulance, A&E and police…….

    1. So is it time for the Trusts and all the professionals to talk openly and honestly about what services they think are needed and how they can be provided. As a carer it often seems that so much effort is put into not providing services, and shuffling demand on to other services that is money just wasted. Care in the community seems to be just a matter of monitoring meds, not really needed if you are stable and have close family, nowhere near enough if you are unwell or don’t have close family. Hsopital stays are like gld dust and can be too short, especially for people who live alone…….

    2. Dear Tired Nurse. I get it I really do that mental health staff are under huge pressure and that u do your best mostly. I have on more than one occasion fought on the behalf of the staff. No one is putting the blame on the people on the ground. My CPN said last week that he was at a loss as he had nothing left to offer though he recogised I was desperately in need of more substantial help than he could provide. Yesterday I hit crisis point despite asking for help the previous day and I nearly died of my own selfdestructive actions. The police were not involved fortunately although they were used as a threat. I have ended up in hospital.

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