surreyofficersPolice are increasingly the first resort for people who are mentally ill and in crisis. With hundreds of mental health bed closures in recent years and the NHS facing unprecedented staffing pressures, it is no wonder that an estimated 15% of police calls have a mental health aspect, according to the Centre for Mental Health.

This trend has led to concerns that some forces are detaining too many vulnerable and ill people who are ending up in police cells.

It also poses a dilemma for officers on the beat. Valuable police time is taken up in attending cases where someone appears suicidal or in mental distress. Yet the police could be accountable if they fail to act – or even open to prosecution.

The Government’s response has been to launch the street triage scheme, a Department of Health initiative supported by the Home Office where mental health nurses join police on patrols.
Eleven forces including the British Transport Police, the Metropolitan Police and Sussex are now trialling or in the process of setting up this new approach where the NHS effectively partners with the police service with the aim of ensuring people get the medical attention they need as quickly as possible.

The latest pilots were announced in August 2013 by Care and Support Minister, Norman Lamb. But Leicestershire and Cleveland have been testing street triage since January 2013 and August 2012 respectively and the results appear promising.

Reducing custody use
The main aim of a nurse going out on patrol with a police officer in a car is to reduce the use of police custody. Police have powers under section 136 of the Mental Health Act to remove someone from a public place and take them to ‘a place of safety’ if they judge them to be a threat to themselves or others.

In 2012, police stations were used for one in three known Place of Safety Orders accounting for around 7,800 of the total 22,100, according to the Health and Social Care Information Centre. These figures do represent a fall but are still considered unacceptably high especially when you consider they include sick, vulnerable people who have committed no crime.

Mental health campaigners warn this can leave those suffering from conditions including as schizophrenia, bipolar, depression or even dementia feeling criminalised.

However, early evidence indicates street triage could help reduce police use of section 136. In Cleveland, only 12 (3.2%) out of 371 people assessed by street triage teams went on to be detained under the Mental Health people detained under section 136 in Leicestershire has reduced by 40% since the pilot began.

Welcome support
For PC Alex Crisp, a Leicestershire triage officer, the scheme means welcome support from mental health professionals. Also important is the access it gives to services that police officers themselves cannot refer patients to.

In Leicestershire, the force runs the triage in partnership with the probation service and mental health trust. A dedicated ‘triage car’ is staffed by an officer and mental health nurse seven days a week from 10am to 2am. The team of two only attends callouts – unless there is an emergency elsewhere – involving people suffering mental distress who need immediate help. Cases include people making suicide threats as well as self-harmers. The team also gives phone advice to colleagues across Leicester, Leicestershire and Rutland. They can access medical and police records to make more informed decisions and an accurate risk assessment about the person they are dealing with.

Street triage, PC Crisp points out, is very much a joint partnership where joint resolutions achieve the best results. “At the end of the day we are police officers and not mental health professionals but often people with mental illness will present to police instead of their GP or care team,” he says.

“We have a lot of poorly people who have failed to engage [with services] or been discharged. There is only so much we can do and that’s where the car holds its own.”

He does admit though that the service doesn’t need to last forever, “if service provision worked properly. “It’s about joined-up working. Realistically we still operate in silos.”

But the triage scheme is not a ‘one-size-fits-all’ model. What works in Leicestershire would not work in Devon and Cornwall, for example, where police have to travel huge geographical distances. So it remains to be seen how different forces will run the scheme in practice.

Street triage also has its downsides including cost. Leicestershire has funded it through grants worth £298,000 in taxpayer’s money for a year. PC Crisp argues though that it helps police and NHS to make “massive cost savings” by reducing police time and unnecessary interventions.

Then there is the question of what training mental health nurses have in pre-hospital medical care. This is highlighted by Michael Brown, an officer with West Midlands Police who has helped produce national mental health guidance.

In his blog, Inspector Brown writes: “It’s all very well turning up to a job where someone appears to need support for acute depression, but what if they’ve got a brain tumor [sic] instead?”

The police and the NHS also need to be “careful,” says Brown, about the reliance on telephone advice. “I’m wary… of telephone systems which may lead to remote-decisions [sic] being made.”

Others have given the scheme a cautious welcome. Lord Victor Adebowale, chief executive of social care organisation Turning Point, who chaired the Independent Commission on Mental Health and Policing, says it is a “partial” solution to a complex issue.

“Triage nursing means police will get instant support so they’re less likely to react with force,” he says. “But this should only be in addition to a proper NHS response and doesn’t get the NHS off the hook.”

The introduction of triage also “doesn’t mitigate against” the need for direct and appropriate crisis service from the ambulance service, he points out. “We need to be clear that a health emergency requires an emergency response [by the ambulance service], whatever the cause.”

Earlier work
Meanwhile, for Paula Reid, senior policy officer from charity Rethink Mental Illness, who has spent time with the Leicester triage team to see how it works on the ground, reducing A&E admissions and use of section 136 must be the main goal of street triage. This, she says, is because it is “scary and daunting” to be in the back of a police car just because “no one will take you on”.

The dilemma, believes Reid, is whether “we accept police are going to be responding to these calls anyway” or “we push back to the NHS”. Ideally, she says Rethink Mental Illness would like the NHS to do work earlier so people in crisis would never end up coming into contact with police.

“Police officers don’t want very sick people in cells,” says Reid, who has a Churchill Fellowship from the Winston Churchill Memorial Trust to look at mental health and the criminal justice system. “And it shouldn’t be about accepting the police as the de facto response. You can’t say two people in a car is going to solve everything.”

Bather P, Fitzpatrick R & Rutherford M (2008) Briefing 36: The police and mental health. London: Sainsbury Centre for Mental Health.
Health and Social Care Information Centre (2013) Mental Health Act detentions top 50,000 a year. London: HSCIC.
The 11 forces involved in the street triage trial are:
• Metropolitan Police
• British Transport Police
• West Yorkshire
• West Midlands
• Thames Valley
• North Yorkshire
• Sussex
• Derbyshire
• Devon and Cornwall
• Cleveland
• Leicestershire