On Tuesday of this week, the College of Policing hosted a small workshop on street triage. It was an invitation only event to start gathering ideas about how to tackle a particular piece of work we’ve been set by Her Majesty’s of Constabulary and Fire and Rescue Services (HMIC). In their 2018 Picking Up the Pieces report, they asked the College and NPCC to come up with an ‘assessment framework’ for street triage. That’s what the workshop was aimed at starting to discuss. Some explanatory caveats or disclaimers are necessary before I outline what I want to say —
- Yes, this was an invitation only event – 43 police forces have at least one street triage scheme so an open invitation may have seen at least 43 requests to attend, and those forces work with 54 mental health trusts who may have wanted to accompany their forces because it’s a partnership initiative, by definition. We also needed to have some College of Policing managers and research / evaluation leads, academics and some others in the room; and most importantly of all, service user representation (see below). If it wasn’t invitation only, it would have ended up a massive exercise in crowd control, so we worked hard to balance the room with types of scheme, police / non-police attendees, England / Wales, all relevant types of MH professional to ST schemes in operation; senior people / front-line practitioners working on these things.
- There’s no point pretending that my views and use of social media around street triage haven’t caused some concern to the fact that the College is beginning this work, so let’s deal with it because you only need to read this BLOG regularly to know I’m skeptical about its overall value when we balance everything out. So the workshop was MC’d by my boss from the College – it was deliberately set up with more non-police than police; it was deliberately set up with more police who are known to value ST and champion it than those who are more skeptical and the research and evaluation lead from the College as well as academics were there to ensure that the discussion as evidence-based.
- We’ve deliberately tried to ensure my voice is no louder than anyone else’s and that it will be kept in check as work progresses. Whatever we produce to deliver this recommendation, it won’t just be written or produced by me and it won’t be published without loads of people more senior than me agreeing it is balanced and fair, after listening to others – we intend to publicly consult on the ideas as they develop, as work progresses and after we have fully involved partners of all kinds. That said, this is a product by the College / NPCC to assist Chief Constables in understanding, evaluating or developing their schemes in the context of partnerships which vary in nature and quality. But checks and balances against what I think are there, I would submit. And this is the BIG point for me personally: if my skepticism is unfair and unfounded, you only have to show me the evidence which demonstrates that. No-one has so far, but I’m genuinely open to it, believe it or not.
So, despite a few last-minute withdrawals, we had a productive day of discussion. It started off with a short explanation of what we’ve been asked to do; there was a half-hour open discussion for anyone to say, suggest or ask whatever the hell they like based on their various perspectives of what they thought was important about the schemes or the work we have to do; and then the College’s research and evaluation lead, Dr Paul Quinton outlined the difficulties with street triage evaluations seen so far – this is what gives rise to HMIC believing that work is needed to better understand all this stuff and that view is echoed by the National Institue for Health and Care Excellence (NICE) who found low and very low quality evaluations when they produced guidelines on the mental health of adults in the criminal justice system. Various views were given about the importance of partnerships, the background to various schemes, the perspectives that the attendees shared and what the future may hold. It’s obvious from that discussion (and we knew this already) that no two schemes are the same or can or should be compared because even the ones which look almost identical are trying to solve different problems in different contexts.
The rest of the day was given over to people in groups working through something called a ‘logic model’ which is just a structure for understanding how you go about defining problems you’re trying to fix, understanding how to think about interventions to fix those problems; and then looking at the outputs and outcomes you may want to understand in order to go about evaluating your scheme. Two headlines from that discussion, which again, we already knew —
- Street triage is often in existence without a clear understanding of what problem it is trying to fix, or why that solution is the best solution to fix that particular problem – for example, we know that some schemes were set up because the force / trust involved wanted to reduce the use of s136 MHA and reduce the use of police custody as a Place of Safety. So here are two questions: why do we think s136 is over-used and why is street triage the best way to reduce the use of custody, bearing in mind that several police forces have effectively eliminated the use of custody without a street triage scheme? Follow up questions: what if an inability to answer these questions means you’re reducing the use of a power that is already under-used and what if the ST initiative is a massively expensive way of doing something you could more easily and with fewer resources being spent? These are just some of the questions that arise from that particular problem.
- There are lots of myths, un-shared assumptions and even opposing views about ST, even between forces and trusts who work alongside each other – for example, we heard again how ST is aiming to reduce ‘inappropriate’ use of s136 MHA, but the police officers in the room asked what that meant and then constructively disagreed with healthcare professionals about what is and what is not appropriate. Whether I agree with them or not isn’t important: what’s important is that MH nurses and police officers disagreeing about what IS appropriate use means we probably have frontline cops and frontline MH nurses disagreeing about this stuff at jobs. Perhaps that’s why I saw an email early on in the life of ST where a MH nurses was fairly apoplectic because had used s136 MHA during an incident where they’d advised against it.
WORK TO DO
Now, the College of Policing are not going to resolve all this, or even try to. But what we obviously need to do is help forces understand some of this stuff and make their decisions about what’s important to them.
- Is the Chief Constable facing mental health demand and thinking ST will save resources? – what if doesn’t save resources, but it does improve experience and outcomes? To what extent should police funding and resources be spent improving healthcare outcomes? – we know the answer to that is not ‘never’, but there is presumably a point where spending to achieve those aims starts to affect the ability to catch criminals. Where’s the line?
- Is the Chief trying to improve timely access to mental health services? – what if ST is actually doing that, but at a cost (whether measured in time, resources or money) which is double or triple that previously experienced by working in partnership in other ways, but without a ST facility? Who is paying for ST – who benefits from ST and to what extent? What do service users in that area think of the particular ST service in that area?
And here’s the really big message, (which I’ve been arguing on this BLOG for years!) and it was rammed home again this week in the academic perspectives offered —
We simply don’t know anything like enough about what street actually does, how or why to answer many, if any, of these questions – especially because too many schemes don’t have identified objectives to measure them up against and they haven’t asked those on the receiving end what they think.
We cannot go back over the last six or seven years of ST and retrospectively find out the detail about incidents involving ST to better analyse what’s gone before. Much of what would need to be known is now undocumented history and we need to work out what we do in the future to better understand these phenomenon. I’ve recently taken to suggesting that we need to put forward ‘scientific’ hypotheses and consider whether we have the data (quantitative and qualitative) to prove or disprove them. You could write the same thing two different ways, and I would suggest we currently don’t have enough to prove or disprove either of them —
- Street triage saves police time, public money and resources whilst simultaneously improving access to services and health care outcomes for those in contact with that service.
- Street triage costs police time, public money and resources whilst simultaneously restricting access to services and affecting healthcare outcomes for those in contact with that service.
MOVING THIS ON
We’d all hope the first hypothesis could be proved – who wouldn’t? But what would it mean for public policy if we tried to do that and found we couldn’t substantiate it, but that we could substantiate the second one? As one person said during the workshop (and other academic mental health professionals have said this sort of thing previously), “We simply don’t know! – and we need to find out before it’s too late. It nearly is.”
I’ve emailed my various College of Policing and NPCC bosses to suggest a way forward with all of this. My suggestion would be to produce some documents that would assist in finding out more information that helps police forces answer the important questions in their local context, in partnership with the NHS. It’s not up to the College of Policing to say whether an area should have a street triage scheme, or which form it should take – but it is incumbent upon the College and NPCC to ensure police forces are equipped to ask the right questions and work out how to answer them. Chief Constables are accountable to Police and Crime Commissioners for their overall performance and we will ensure the PCC lead for MH, Matthew Scott from Kent, is closely involved in ensuring that what we produce can help PCCs do this by asking the right questions, also.
Once the bosses tell me what they think of the suggestion and it’s bashed in to some agreed shape, it will go to the people who were in the working group for their thoughts and I’ll then BLOG again to make that detail public and say more about how we will go about it, consult widely upon it and how police forces, partner professionals most importantly the public can get involved.
Standby for more!
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
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – http://www.legislation.gov.uk