Street Triage: A Diversion From the Real Problem?
It cannot have escaped your notice that I have some reservations about the Street Triage programme. I have blogged about them before here
My main problems with it are that it still relies on the police rather than a fully resourced and re-imagined “crisis team” (working with a much broader definition of ‘crisis’) and the fact that it does nothing to address the issues of training, legislation, restraint, bed spaces, transport, exclusion criteria, handover to the NHS or avoidance of cells for those who are detained.
I am concerned that it will be hailed as a success when it hasn’t really addressed any of the deeper seated problems. You know, the ones which lead to people dying because they are in the wrong place, being dealt with by people with the wrong equipment and the wrong training.
The chances of this happening again remain JUST as high with Street Triage as they have always done.
There has been some debate on Twitter about this again today but it seems to be mostly us cops who are raising the concerns and questions.
Which is why I am delighted that Dr Holmes (aka @northwestdoc) has written another superb blog for me to host.
This is the view of a serving FME and Section 12 doctor who works with the police all the time.
It seems I am not alone in having a few questions.
Over to you Doc.
I welcome street triage. I really do. I do so because I am lucky enough to work in a Force area where 9 -5 Monday to Friday I have a mental health nurse sitting in my busiest Custody Suite delivering real partnership working.
Police/FMEs/Custody Nurses/Courts all consult and have information freely shared with them to allow them to make decisions in real time about detainees who are under arrest and are open to Mental Health Services.
However within these discussions are a high proportion of cases who are triaged by mental health services as NOT needing their input. People who have in the past been diagnosed with conditions such as ‘Mental and behavioural disturbances due to Alcohol/Drugs’. Borderline/Emotionally Unstable Personality disorders. Mild anxiety and depression.
Some of these people are not open to services, others have been open but a mental health response is not deemed necessary: the diagnosis is made, reassessment not necessary and no follow up is offered.
Psychiatry is very fond of the term ‘gate keeping’. It’s not a term I’ve heard much in other services. Gate keeping is a pretty fierce process. It’s meant to identify who is appropriate for what service.
However in reality it’s a process of exclusion: who is not entering an inpatient bed/Crisis Team follow up/Secondary Mental Health Care etc.
Believe me it’s a hard process when you are within psychiatry to access services for patients. The thresholds for most services are very, very high.
The philosophy in mental health has also been to cut access to inpatient care dramatically.
The latest National Confidential Inquiry into Suicide and Homicide in Mental Health Patients presented by Professor Appleby in July 2013 at the Royal College of Psychiatrists International Congress hints at this.
There is an increase in suicides within Crisis Team caseloads as due to lack of beds some of the most risky people are managed at home instead of in hospital.
I like s136. It does what is says on the tin, giving Police Officers an alternative to arrest for someone in a distressed state.
It’s very difficult to exclude mental disorder in someone who is distressed and intoxicated and the ‘care and control’ provision is perfect.
It also doesn’t require Police Officers to make a definitive decision, rather to get the person somewhere safe, to see someone who can make the definitive decision.
In fact I think it should be extended to private dwellings as there are many situations perfect for sections 136 which occur in people’s homes.
When s136 works as it is supposed to it is a wonderful process. The Police detain and transport quickly to a health based place of safety. The HBPOS don’t apply exclusion criteria such as ‘too drunk’ or ‘no staff’. The person is taken in and handover takes place which incorporates a joint risk assessment between Health and Police.
If the risks are high (eg violence) the Police stay to support the process. In my experience skilled health care staff who approach 136s as their problem, not extra work generated by the Police, can deescalate and manage most s136s and the Police can leave.
In my area where the HBPOS is in Accident and Emergency there is a physical health screen. This is likely to involve a full assessment by a doctor, possibly bloods, an ECG etc.
A proportion of s136s will be health problems masquerading as mental disorder: head injury, hypoglycaemia and sepsis to name but a few.
There may be a period of ‘sobering up’ required. Assessment can begin but as you cannot definitively assess mental state and risk whilst a person is intoxicated and the final decisions may be delayed.
Once ‘medically fit’ a s12 doctor and an AMHP (Approved Mental Health Professional – usually a social worker) will assess. The skill levels of these two professionals should not be underestimated. Both will be very experienced in their fields and have had detailed training in the operation of the Mental Health Act. The Psychiatrist will have usually have completed the four parts of the Royal College of Psychiatrists’ difficult membership exam which only has a pass rate of about 50%.
Before we come we will have looked at the case files of the person to find out if they are open to mental health services, what the diagnosis is and what their treatment, follow up and engagement is like.
Much of the time we will form a view on the likely outcome before assessment and if admission is a possibility look for a bed. The emergency psychiatry assessment is a lengthy process of 1 -3 hours (including writing up) and we will form a joint view on diagnosis and the plan.
If we want to detain under the Mental Health Act we will need a further doctor to convince of the need. For all admissions, under section or voluntarily the Crisis Team will also need to be consulted as they ‘gate keep’ all beds.
If we don’t detain or admit voluntarily (and the pressure on inpatient beds is immense at present) we will perhaps ask Crisis Team to come and assess to see if a period of support at home is needed. This can involve visits 1, 2 or more times a day by mental health professionals to monitor mood, medication, risk etc. We can also make referrals to drug and alcohol services, psychology, community mental health teams, GPs etc.
There are very few people who leave the assessment process without some sort of a plan, even if it is just a chance to ventilate their feelings, liaise with families and write to the GP to suggest some counselling support.
The other beauty of s136 is there is a statutory duty on the AMHP to consider what the persons needs are in the context of the crisis. AMHPS are often very proactive in finding temporary accommodation, providing numbers for debt counselling and numerous other actions.
What sort of people end up as S136 detainees?
Borderline/Emotionally Unstable PDs make up a large number of those people who are detained on s136.
The theories around this type of personality disorder are that they have had neglectful, disordered childhoods. They have often experienced physical/sexual abuse and their emotional development is damaged as they have never experienced unconditional love from their parents. It leads to adults who struggle with rejection and abandonment. They self-harm both as a form of self-loathing and as a dramatic response to distress. They suffer extremely high levels of emotional distress and lack the inner resources to deal with it. When distressed they externalise their feelings and often engage in behaviours which prompt a concerned response from others.
The last s136 patient( who had this diagnosis) I saw I asked ‘How did you feel when there was a crowd of people, Police and Ambulance when you were threatening to jump off the bridge?’ The reply: ‘I felt glad someone had noticed I was upset’.
The philosophy of management of such patients is that inpatient care worsens their condition. Put simply what the person needs is a way to ‘self soothe’, regulate distressing emotions and this is best provided by intensive psychological therapies such as Dialectical Behaviour Therapy: an intense and expensive therapy lasting over a year.
Short term inpatient admissions are seen as unhelpful as it is validating the mal adaptive behaviours such patients exhibit in response to distress.
Other types of people who end up on s136 are people in social/emotional crisis. Intoxication from drugs and alcohol can also lead to behaviour which causes concern and ends up as a s136 detention.
If I have recently split from a partner, drink heavily and then go round to my ex partner’s house threatening to self-harm if they won’t have me back that may end up as a s136 detention when the Police are called
People threatening suicide or self-harming are also a large group detained on s136 and fit the ‘care and control ‘ criteria perfectly.
The risk of intentional self-harm in these groups is actually deceptively low in many cases; many deaths are thought to be accidental.
Most completed suicides are done in private with precautions taken against discovery. Hangings in empty houses or deep in woodland. Overdoses in bed. If people do commit suicide by jumping off buildings/in front of trains they do so quickly before anyone realises what is happening and could stop them. To get a Police response you first need to be noticed and then wait a period of time for it to arrive.
However I expect nothing less than the Police to exercise their s136 powers and get the person somewhere safe, keep the public safe and bring them to me where I, a s12 approved doctor, and an AMHP can fully assess their mental state and risk.
Although the suicidal intent may be low these are some of the most challenging assessments in psychiatry. If it is a patient with a borderline PD or an alcohol problem they do have an increased lifetime risk of suicide.
This may be unintentionally in a state of high distress or when they develop a depression due to the misery of unemployment and loneliness. They need skilled and detailed assessment to identify those who really are high risk.
Street Triage has been proposed as a solution to what is seen as an ‘inappropriate use of s136’ by the Police and a waste of staff hours.
The Police need to be dealing with crime and not babysitting s136 detentions.
Distressed mentally ill people should not be in Police cells on s136 detentions in areas where there are no or insufficient HBPOS. Mental Health Nurses will be able to guide the Police on alternative pathways.
In my area the excellent Mental Health Nurses see Street Triage as a natural extension of what they do well already.
They agree they need increased operational hours up to about 2300 at night. If it’s called Street Triage so be it but ultimately they will do more of what they do in daytime hours.
Street Triage will boost what is already an excellent Liaison and Diversion Service. I see the dangers being in Force areas where services are already poor as it will be a sticking plaster over a gaping wound.
If s136 operated as envisaged with adequately staffed HBPOS and properly commissioned pathways the Police need never be tied up for hours with 136 detentions.
All Force areas are supposed to have active s136 groups at managerial level and with representation from all the disciplines to review s136 detentions and look at alternatives. It’s already possible to flag up on the PNC that a person need not be detained repeatedly on s136 but that arrest may be preferable. But these decisions need to be made at a senior level and liaison done with Custody Healthcare teams to direct them on dealing with the person in Custody. These groups can also influence Commissioners to make sure the right facility with the right staffing is available.
There is definitely merit in working to reduce s136 detentions. However I believe this should be done in a planned way in advance via proactive s136 monitoring groups.
It will be very easy for the Street Triage Nurses to advise the Police not to detain a person on 136 by consulting the person’s records and discovering they are known for example to have an alcohol problem and the circumstances look like they fit with an episode of intoxication, not an acute mental health crisis. However that person will still need an assessment of their current physical health, mental state and risk.
Who takes over responsibility and what is the lawful basis for making sure the person cooperates with full assessment? A mental health nurse isn’t going to be able to assess the physical health: remember an episode of seemingly drunken behaviour may be hypoglycaemia or a bleed into the brain without signs of visible injury. The recommendation is likely to be ‘attend Accident and Emergency for a check-up’. What if the person won’t go? Call an ambulance and use the Mental Capacity Act? Get the Police to arrest for drunk and disorderly and take to the cells for the Custody Nurses to assess? It doesn’t sound to me as if the Police are going to be able to make a quick exit from the situation and get back to fighting crime.
If a person has a diagnosis of borderline PD then the Street Triage Nurse may quite reasonably feel that the diagnosis is known so there is no need for a s136 assessment. However that person still needs their mental health and risk assessed and if they are threatening to jump off a bridge how do we keep them safe and make the assessment happen?
The mental health assessment is a lengthy process of 1 -3 hours. Where will this take place? Will they expect the Police to stay to support the assessment? What if the person refuses to take part?
The statutory duty of the AMHP will also be lost. I am sure good Street Triage Nurses will work proactively with housing, third sector organisations etc to support the needs of the person apart from mental health. However is there really going to be the time in the model to do this properly?
The process of both making sure that the appropriate people access the appropriate services and also that inappropriate people are excluded from Mental Health Services? Any GP will tell you the thresholds for Mental Health Services are at an all-time high in this time of budgetary constraints. Mental Health Services are discharging more and more people back to primary care with significant diagnoses such as bipolar disorder who previously would have been followed up by a psychiatrist. My biggest fear with Street Triage is it will become another form of gatekeeping. It is a welcome addition and support. But in my view the main focus for the Police should be on insisting that s136 pathways operate in the way they should.
I would also like to draw your attention to two other great blogs on this subject.