Street triage ­- what, why and how?

Fiona Sweeney outlines an unusual role.

As I stepped out of the car and walked towards a house that was surrounded by ambulances and police cars, closing off an entire street, I believed I was becoming involved in some sort of military siege. Myself and a colleague were greeted by six police officers all looking somewhat stunned, being condemned as the ‘devil’s spawn’, unable to enter a family home. As we entered with trepidation, we were greeted by a service user known from some time ago, sitting in the family living room reciting prayers, rocking backwards and forwards ferociously, becoming increasingly agitated. She was in the grips of psychosis. Her family, equally distressed, clutching one another’s hands desperate for help, yet not knowing where or whom to turn to. This was to be my first of many shifts working on a street triage pilot, alongside the police.

Worryingly, although the police readily have contact with vulnerable individuals, they receive next to no training in mental health. I was surprised at the amount of calls the force control room receives that involve those in distress suffering from poor mental health. However, I was equally surprised at the responsibility both call handlers and police officers are expected to bear in relation to ensuring the safety of those suffering, with no supervision and limited knowledge of conditions. What I was not surprised at, however, was that these service users are at their most vulnerable, desperate for help, yet often receiving inappropriate care, with crises not always effectively managed due to this lack of training and understanding (see tinyurl.com/qgwcdo3).

One power that police officers possess as a way of ensuring those they believe to have mental health problems are assessed, is through a section 136 detention. These have been prominent in the news recently, more so for children and adolescents, and have been highlighted as potentially detrimental for an individual’s mental state, especially when police cells are used as places of safety (see, e.g. tinyurl.com/p6958xy and tinyurl.com/no8bvys). However, working within a Crisis Team I have witnessed that police officers’ and mental health professionals’ hands are sometimes tied, based on the limited number of Health Based Places of Safety. This being said, the readiness at which a section 136 detention is applied is unsurprising given that many police officers are unaware the mental health act code of practice states that professionals should make a decision using the least restrictive option. Therefore, someone should someone come into contact with services they should receive help and support in the community ideally, or be admitted to hospital without the constraints of being detained under the Mental Health Act.

There is yet to be a formal standardised measure to monitor the use of section 136 detentions, which raises concerns around the quality and completeness of the data. This being said, the Care Quality Commission reported 21,814 section 136 detentions in 2012/13, which is a fall from previous years. However, it has also been found that the percentage of individuals held on a section 136 who were subsequently detained further under the Mental Health Act 1983, has fallen to 17 per cent compared to 29 per cent in 2007/8. This may indicate that the detentions are not always appropriate. Unfortunately, subsequent data around the individuals that received mental health follow-up after being detained on a section 136 is scarcely reported.

What is street triage?
Street triage schemes were launched in 2013 by the Department of Health due to the increased involvement police forces were having with individuals suffering from poor mental health (see tinyurl.com/md8fe4s). They involve dedicated mental health professionals collaboratively working with police officers, attending scenes and offering more tailored interventions in order to ensure individuals receive the most appropriate care.

A typical working day… is not a working day on a street triage shift. We, much like the police, respond to many different incidents involving a variety of individuals of different ages and mental health issues. We usually start the day by attending a police briefing at the point when police officers hand over their shifts. We then continue the shift by listening to the police radios, and responding to incidents we, or the police force, feel may involve mental health. In some cases the individuals we go out to see are open to services, yet are in a time where they need additional support. Other cases involve those who have had no apparent involvement with mental health services, yet have reached crisis point.

As mental health professionals are readily available to advise police and to attend scenes, street triage has allowed individuals to received additional input from services, and also allowed those with no support to receive the help they so greatly want.

Current challenges
Due to many of the schemes still being appraised, little research has been conducted around the models of care the pilots have adopted and the service-user experience. At a time of mental health crises, service users can report feeling exposed, having to wear their heart on their sleeve, and relive painful memories, or engage in life-threatening behaviours, simply to be heard. In these instances, street triage schemes may prove beneficial, as it allows easy access to mental health care. However, police officers attend the scene first, and they are the ones to make a judgement of whether street triage assistance is required. Having joint working is beneficial. Nevertheless, I also feel that the police may be unaware of some ethical considerations mental health practitioners adhere to, a major one being consent.

People have the right to choose whether to engage with mental health services or not, and this decision may be influenced by many factors. However, with police presence, there is a concern that service users may feel somewhat obliged, or forced to speak to professionals in fear or doubt around what may result if they refuse. It is important for all those working on street triage schemes to be mindful of this, and not only educate officers around mental health presentations, but also the ethical considerations of working with these individuals.

Furthermore, at times of crises, timely intervention and support is imperative. Street triage aims to respond quickly. However, is there a risk of being moulded into an emergency response service? When presented with individuals in crisis, being calm and reflective is imperative. Projecting the feelings that are influenced by the autonomic nervous system with the external stimuli of blue lights flashing and sirens sounding, would only result in professional perceptions being impaired. It is these perceptions that impact upon the lives of the service user.

Although no formal research has yet been conducted around the schemes they have been hailed as a success, with West Midlands Police reporting a reduction in section 136 detentions (tinyurl.com/o9qnle9). Although this was the original intention, I feel they have done so much more. Becoming embedded in the police environment, including attending briefings, is completely alien to most working in mental health. Yet this gives us centre stage to spread the message that the police are not on their own in trying to resolve the distress of those with poor mental health, at least for now. It is also an opportunity for us to educate the police around different mental health presentations, debrief upon past issues, and create an openness for all around talking about mental health. Equally, I would not be alone in saying that mental health professionals like to talk. Therefore, this message is repeatedly spread.

In a time where NHS professionals are under much pressure, and there is significant financial doubt concerning the sustainability of certain services, it is easy for attention to be diverted away from patient care. After all, the NHS is considered to be a business. However, street triage has enabled me, and the clinicians I work with, to refocus upon the delivery of efficient and effective care within the community. It provides us with a constant reminder of why we chose to enter a caring profession – because we care. As a recent psychology graduate, being involved in a new initiative has been an exciting opportunity. One thing I feel that the street triage pilots have brought is openness, and willingness to speak out about mental health. There are instances now when at police briefings personal experiences of mental health are candidly spoken about. Encouraging this behaviour and enhancing individuals’ insights into a range of mental health problems in different professions will, I hope, increase understanding whilst decreasing stigma. The future of street triage schemes is uncertain, and whilst they have been found to be successful based on various measurements, I feel that there is still a long way to go in making sure high quality mental health care is delivered consistently to all individuals that require it. After all, lives are at stake.

Having the opportunity as a recent graduate to become involved in a new initiative has fed my ambition to become a Chartered Psychologist further. Fresh out of university, it is easy to become bogged down in the ever-increasing competition, and need to obtain relevant experience. It is easy to have the end goal in sight, yet become lost on the path to reach it. However, being a support worker or an allied health professional within secondary mental health services gives such valuable experience. Working within the Crisis Team has focused my attention upon reflecting on each experience whilst honing the skills learnt, and building the confidence to continually seek further challenges. This post has opened up many opportunities. I now begin a new challenge of facilitating group-based psychological interventions for offenders within the prison service. I hope to gain a place on a Doctorate in Clinical Psychology course in the near future, but continue to enjoy my journey of gaining experience on the way. I encourage anyone with a personal interest in mental health or psychology, looking to get their foot on the ladder, to take up a support role in the NHS. Innovation requires fresh ideas: ideas that new graduates can bring.

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