By Matt Bee
You’re a young police officer and it’s late at night. You’re called out to attend to a man in the street. He’s incoherent, crying, wandering, and passers-by have twice seen him almost run over. What do you do?
Until recently you’d have more than likely whisked him off to the nearest psychiatric unit under section 136 of the Mental Health Act for further assessment. He would have been assessed by someone like me, who, until recently, was a mental health social worker who spent his days waiting for his mobile to ring before springing into action along with an approved mental health professional (AMHP), a doctor and handfuls of paperwork.
Alternative to detention
But now there’s another choice. In most constabularies, at least, a police officer can call for the street triage team – a small group of mental health professionals who will come and attend right there and then. These nurses will have an informal chat with the person, make a decision on whether detention is absolutely necessary, and help them on their way if it isn’t.
What difference does that make? To the person in distress, probably a lot. It must be harrowing to find yourself caught in the crosshairs of psychiatrists and AMHPs. You just nipped out for a few drinks and now here you are, about to be locked up and certified. I’ve seen plenty of people in this situation and, yes, they may be mentally unwell, but they know only too well the significance of the questions being asked, the forms being completed, and their future being quietly decided for them.
Unequivocal success
So I’m happy to report that when the first street triage team, comprising three mental health nurses and a support worker, came into being in Cleveland in August 2012, it was an unequivocal success. The difference this team has made is hard to overstate. Within a year, section 136 detentions fell dramatically. Of the 371 people the team attended, almost all of them were helped right there in the street. Only 12 ever saw the inside of a psychiatric unit.
That really is incredible! And the benefits don’t stop there. In 2009, the Centre for Mental Health estimated that it cost £1,780 to detain and assess someone in custody. If, say, a further 300 of that 371 would have been detained but for the existence of the team, that represents a saving of some £500,000. With a team budget of £170,000 a year, by my rough calculations, then, for every £1 spent on the team, £3 was saved. Pilot schemes elsewhere were soon reporting similar successes.
Home secretary Theresa May was so impressed that in 2013 she announced a further nine pilot sites, and the idea has grown from there. These days most constabularies are now either operating a street triage service or seriously considering putting one in place.
Where it all started
But where did it all start? Quite simply it was the brainchild of PC Rob King, now retired but previously a mental health coordinator for Cleveland Police with a dual role at Tees, Esk and Wear Valleys NHS Foundation Trust. He explained to me that he’d seen similar models operating in America but over there the idea was to train officers themselves in mental health needs. PC King reasoned: why not just have the police work alongside people who are experts already? Why not have them working with nurses right there in the street?
He put the idea to the Department of Health, got the green light, and three years later here we are.
Street triage
But where we’re at now is some sort of crossroads. Because although everyone seems to agree the street triage service works, no-one can decide on the best model for running it. Some teams operate out of hospitals, others from police stations, one has a purpose-built vehicle with an assessment room inside it, another can only provide support by telephone.
And who pays for the service is also up for debate.
Hospitals, the police and social services all stand to gain but how best to pool their budgets is proving tough. In June, the BBC reported that this year the street triage service in Kent, a partnership between the police and the local mental health trust was being axed, a move blamed on a lack of police resources to fund it. This was despite figures obtained by Radio Kent showing a 30% reduction in detentions under the Mental Health Act. Kent Police said it was operating a call system where police officers could seek the advice of a mental health expert on a 24/7 basis, instead.
‘No brainer’
This does seem something of a tragedy. Running a street triage team, in the view of Gemma Handley, operational support manager for the Cleveland service these days, is a ‘no brainer.’ The benefits are clear – both to local services and the man in the street.
But will these teams still be here in ten years’ time? I put this to Gemma and she thinks awhile. ‘Yes,’ she replies, ‘but there needs to be a national model established. It’s all a bit piecemeal at the moment.’
And this is the key issue: turning all these local successes into some sort of single cohesive national strategy. Let’s hope someone takes a lead with this soon. Because, as a mental health professional myself, to me the benefits of this service couldn’t be clearer.
Matt Bee is a social worker based in the north east of England
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I don’t know where to start with this article, but it’s probably to acknowledge that street triage does bring benefits to people. Of course it does – it’s obvious. However, because of what I’m about to say that is intended mainly as a rebuttal of the hyperbole in this article, I’ll also acknowledge this point again at the end. I’m not saying that it’s all bad – very far from it. I intend to be balanced, but slightly slanting to the negative, because of what’s above. So here we go!
I’m amazed, quite literally stunned that you couldn’t find anything negative or concerning to say. All ideas on this scale will have an upside and a downside, so where’s the downside? You need to look harder – it could be, for example, that if you assess the models of triage beyond Cleveland, they work differently and that you cannot draw the same conclusions about outcomes about either money or time. In Cleveland, the nurse responds on their own to front line police officers at incidents; elsewhere we’ve seen the introduction of double-crewed (or triple-crewed) multi-agency vehicles. When you do the analysis of time invested (multiple examples available on request) what you discover is that some police forces are now spending roughly three times as much resource servicing the same workload in this new way. THREE TIMES!
Then let’s look at the work – accepting that areas vary and that I don’t know figures on these things for Cleveland. Having shadowed various street triage schemes, they are mostly undertaking work that the police should not have been involved in to be begin with. So street triage is fixing the wrong problem, in many respects. It is address *how* the police respond without questioning *why* the police respond. In many cases I’ve seen and much of the data that some areas have available, most people encountered by street triage are existing MH service users who have a care-coordinator and a crisis plan. So how has it failed to the extent that the Crisis Team have been unable to support that person and the police get called? In many areas, the same could have been said before about those detained s136: most were open to services.
It is worth wondering (because no-one has the data, from what I can tell) that those who now manage to avoid detention under s136 are most usually those who were already well known by mental health services
And of course you article, like street triage when they talk about their work, is mostly a focus on s136 and therefore on interventions which take place in public places. Yet we know that street triage is mostly operating in private premises where s136 cannot be possible. What is the impact of their work there? How do mental health nurses add something to that ‘Sir Paul BERESFORD MP’ situation where everyone is agreed that someone needs immediate detention but the MH adds no legal option that the officers don’t already have? What ends up happening, perhaps unsurprisingly, is civil liberties invasion, just like the police in the bad olds days. I’ve seen nurses tresspassing in premises (and I told one of them to leave before I removed them) and I’ve seen so many emails from ST nurses encouraging misuse of the Mental Capacity Act and of Breach of the Peace provisions in obvious demonstration of their lack of legal knowledge. I don’t even want to go to the disappointing territory of “Can’t you just get them outside and 136 them?!”
The £1,780 saved per detention is not hard cash you can spend on other stuff – it’s an opportunity cost. The police, AMHP and doctors now uninvolved in the non-detention are still being made for, it’s just that they’re now doing other stuff, or doing it in different ways. You could equally well have pointed out that if an area is going to post four or seven full-time equivalent police officers and four full-time equivalent nurses that represents a cost of well over £500,000 and you have to remember, other forces were not using s136 to the extent that Cleveland was, so there is less over-use to reduce.
And I’m going to stop with a final point about time: most areas approach their ST impact calculation by telling you how many 136 detentions have been avoided, tell you what that means they’ve saved. So, “We used to have 600, we now have 250 – each detention cost x2 officers x4hrs waiting in a PoS and most people were not further detained. Working like this means we’ve saved over 2,000hrs of police time (350x2x4), provided a less restrictive experience” etc., etc., as well as the AMHP / DR assessment saving. But in order to achieve that, many areas have invested between four and seven officers in making ST work. That’s between 8,000 and 14,000 hours of investment from which around 2,000 has been saved. Even if you take into account avoided referrals to A&E, you still get nowhere near and in many of these schemes, the police officer is just accompanying a nurse who is busy doing crisis team work. And I haven’t properly touched upon the work ST are dealing with that has been sent to the police purely becasue the police ‘now have triage’ – I’ve seen it for myself and it accounted for nearly half of everything they touched. ST has created the chance for more MH related work to go to the polcie and I’ve caught GPs, A&Es and Crisis Teams sending work to the police that they would never have sent, if ST didn’t exist.
But I did say – so that you can’t pretend I didn’t – street triage brings benefits. It’s how areas find a way of trading off the impact upon each other of different ways of working. Fundamentally, the effective part of it, is the communication and the information exchange and each service being ‘open’ to the other about being willing to support each other with resources. But no-one at any stage is wondering whether they can be achieved in other ways. If your police force are over-using s136, train them to stop and lead them appropriately. If demand is coming to the police leading to s136 detentions which MH services wish the officers weren’t making, then create open and accessible mental health services. Worth noting that in one area where ST seems to flourish according to those involved in it, they are doing it in an area where the Crisis Team now have on duty only 25% of the nursing support that they made available a decade or two ago. The only ‘no brainer’ here, is why ST has become seen as the solution: it is a way of off-loading yet more work to the police and of bringing more resources from policing into the landscape, to off-set the impact of other changes in health. It worked well in America because they have a fundamentally different policing and mental health system.
You need to research this stuff far more!