Stepping on Toes

Over the last few years, we’ve seen a massive extension to ‘liaison’ work in mental health services. ‘Liaison psychiatry’ is now a sub-specialism for those psychiatrists who work in acute and other medical settings, giving specialist mental health support to those doctors in Emergency Departments, medical and surgical wards, for patients with co-morbid mental health problems. We see this in mental health nursing too. We’ve known for decades that many of us would like to see more mental health nurses based in police custody and as time has gone on it has increased and 70% of the population of England is now covered by Liaison and Diversion schemes. In just the last few years, we’ve seen this accelerate significantly:

We have mental health nurses in police cars doing ‘street triage’.
We have mental health nurses in ambulance vehicles working with paramedics doing ‘street triage’ without the police.
MH nurses are in police control rooms.
They are also in ambulance control rooms – indeed, they are in ambulance control rooms which cover forces where they are also in police control rooms; AND out doing street triage in police cars … or ambulance cars. Or both.
We see mental health nurses working in 111 call centres to give clinical advice to non-clinical call handlers and talking to patients.
In addition, of course, we still have crisis teams operating in each mental health trust, albeit many are much smaller than they were before – which probably won’t come as a shock after reading all that lot.

Just to emphasise how far the overlaps between agencies has gone, we also see police cooperation with ambulance services – and this adds to the mental health mix!

Some street triage initiatives are a three-person endeavour – a police officer, a mental health nurse and a paramedic.
In some areas, we have joint police-paramedic patrols, not specific to mental health, but involving such 999 calls.
We see paramedics in some forces in police control rooms, including forces where there are attempts to get MH nurses in the police control rooms.
If you look around you will see that paramedics are now able to apply to some private medical companies to work as healthcare professionals in police custody, alongside the MH nurses doing liaison and diversion.
They are also appearing occasionally in Emergency Departments.

CONFUSED LANDSCAPE

It begs even more questions, doesn’t it?! I had enough unresolved, unanswered questions about street triage before areas who swear by it also brought about the introduction of ambulance-flavoured street triage. It immediately made me wonder: if a 999 call came in about an agitated, distressed mental health patient who had taken an overdose and was threatening to harm himself with a weapon, would we send the police and the ambulance-triage car; or the police-triage car and a first-responder ambulance; or something else? And who decides? – the 999 operator?! They normally ask which service you need so would the answer be police or ambulance … or both?!

I also had questions about efficiency – if we have mental health nurses in call centres, whether that be 111, police control room or ambulance control room, do we really need them all when they’re broadly doing similar things, often at the same time. Advising non-specialist staff, sharing information from relevant health records and talking directly to prior to people. Do we need three nurses spread across this function or could #Team999 not just access the 111 nurse(s) for support and information? When calls come in which involve co-morbid mental health and physical healthcare issues, does the Force Control Room sergeant call upon the paramedic, the mental health nurse or both?!

The landscape here is getting increasingly cluttered – we’re stepping on each other’s toes a bit. It’s not that any of these initiatives is an appalling idea, but these various things are often being done in isolation, no doubt for genuine reasons, but in such an overlapping and confused way that it prompts to ask my favourite question of all: “What problem are we trying to solve” and my second- favourite, “Why is this the solution to that?” As an old superintendent of mine used to regularly say: form follows function – you work out what you’re trying to do, having understood your demand, and then you design a system to meet that demand. I can’t help but think that these initiatives are reactions to circumstances that were themselves unintended consequences of other decisions in the wider health system.

I’ll leave you to contemplate my point – I’m off to enjoy two weeks of annual leave in France. And my point is essentially an old one; and I’ve made it before – this is not a health system, in many important respects, it’s just a coincidence.

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