Volume of included evidence
A total of 34 publications including qualitative evidence on PRMHT interventions were identified. Of these, nine publications related to interventions that were implemented in the UK.9,41,42,46,50–53 The characteristics of studies reporting non-UK qualitative data are presented in Appendix 9.
One publication was a 2016 report commissioned by NHS England (Reveruzzi and Pilling)9 that evaluated the nine street triage pilots originally funded by the DHSC in 2013. The remaining eight publications provided qualitative data on seven interventions, two of which51,52 were included in the Reveruzzi and Pilling9 report, and a further six publications provided qualitative data on five interventions which were not included.41,42,46,50,53
Themes from UK-relevant qualitative data
The rapid evidence synthesis presented here expands the themes and findings from Reveruzzi and Pilling’s9 evaluation of DHSC-funded pilots to incorporate the five additional UK interventions. These themes were:
organisational objectives
assessment and identification of service user needs
pathways through the care system
care co-ordination and effective interagency working
quality of care provided
attitudes to service users with mental health problems
availability of resources
staff support, supervision and training needs.
Quality and methods of included qualitative studies
summarises a brief CASP checklist evaluation for each study reporting UK qualitative data.
A CASP evaluation checklist of included UK qualitative studies
Reveruzzi and Pilling’s9 evaluation reviewed and synthesised qualitative data provided by pilot schemes in their individual reports. Each pilot scheme report provided data on the local experience of the services and presented a range of qualitative material, including comments received from service users, families, carers, community members, police officers, MHPs and senior colleagues. An inductive approach was used to identify codes and themes progressively throughout the analysis. The thematic framework developed by the NICE Service User Experience in Adult Mental Health: Improving the Experience of Care for People Using Adult NHS Mental Health Services guideline54 was adapted and used to index and organise all relevant themes and subthemes. Following initial analysis, the results were discussed with the research team and gaps were identified in the existing data in terms of understanding the implementation, objectives, outcomes and longevity of the pilot schemes from a senior organisational perspective. As a result, six additional senior stakeholder interviews, covering five schemes, were conducted with individuals directly involved with existing street triage schemes. A schema of questions was developed according to the set of themes identified in existing qualitative feedback; the results of these interviews were combined with qualitative data obtained from the pilot sites.
Six publications evaluated five further PRMHT schemes that were undertaken independently of the DHSC-funded pilot evaluations. These were conducted in Essex,46 Oldham,42 Northamptonshire,50 Cleveland41 and a service running PRMHT schemes in two unnamed locations.53 These were published in 2014 and 2016; four were evaluation reports (ranging from 22 to 92 pages in length)41,42,46,50 and two were journal articles.41,53 All the studies clearly stated their aims and collected data appropriate to those aims. However, the brevity of most reports meant that the collected data were rarely presented in detail, and few studies addressed concerns about reflexivity and rigour in the data collection and analysis procedures. Consequently, this synthesis relies on data and themes obtained from relatively few stakeholders, and the limited reporting of primary studies precludes a thorough interrogation of the underlying evidence.
Description of the intervention models and specific details
Full details of the nine pilots can be found in the 2016 evaluation report.9 Very little detail was reported on intervention objectives and procedures from the schemes that were not part of the DHSC-funded pilot programme. However, what little information was available for all included interventions is presented in . Although there was considerable variation in how the interventions were implemented in different regions, they could be broadly classified as co-response models, consultation models or a combination of the two. More specifically, interventions could be described in terms of the primary role and/or location of the MHPs. These were:
Characteristics of UK-based PRMHT intervention studies reporting qualitative data
co-response models in which MHPs partnered with police officers to jointly attend incidents
telephone-support-only consultation models in which MHPs stationed in either police control rooms or hospital premises handled tasks, such as advising officers, consulting health records, undertaking liaison and referrals, and making follow-up calls to service users
predominantly telephone support with the option of joining police officers at incidents when necessary
telephone support and/or attending incidents without the presence of police officers when considered appropriate.
Although these interventions were often referred to as street triage, in some models the dedicated MHP(s) were not deployed to the street. It was also apparent that triage-related decisions were sometimes made on private premises, which has important implications for the use of S136 (see the following section).
Thematic synthesis of UK qualitative data
The 2016 evaluation9 of the nine DHSC-funded pilots coded collected qualitative data according to eight identified themes:
organisational objectives
assessment and identification of service user needs
pathways through the care system
care co-ordination and effective interagency working
quality of care provided
attitudes to service users with mental health problems
availability of resources
staff support, supervision and training needs.
The results of each theme from the DHSC-funded pilots’ evaluation are summarised below, incorporating additional published qualitative data from the additional UK interventions identified during the current rapid evidence synthesis. Studies were inductively coded to identify subthemes that emerged within the eight original themes.
Organisational objectives
Section 136 rates and related objectives
The primary objective of most PRMHT interventions was to reduce the number of S136 detentions during which police custody was used as a place of safety, with the ultimate aim of reducing demands on the police service.9,50 Strong partnerships between police and health services were seen as crucial to achieving this objective, with co-location being described as one means of building trust, confidence and understanding within teams.9 The authors of the Northampton evaluation noted that other objectives held by individuals and their respective organisations could relate to service quality, longer-term resolution and reduction of ‘regular callers’.50
Shared information
A highly valued core characteristic of PRMHT interventions among police and MHPs was the ability to share information. This was seen to inform and improve the professional judgements of both police and mental health staff, thereby reducing reliance on S136.9,42,50 When S136 was used, access to information via telephone facilitated discussions about the preferred and appropriate place of safety.42
Role and location of mental health professionals
The most notable difference in terms of the service delivery model between the evaluated PRMHT interventions was the role and/or location of the MHP(s). In one study, opinions about how best to utilise mental health staff varied. Among control room staff, deployment with the mental health car was seen as being more closely linked with a successful resolution of the incident:
I’d like to see a bit more, I don’t know, resolution involved. ‘Cause it’s fine giving advice, I must admit I’d like to see them out more, deploy more.
Reproduced with permission from Callender and Cole.
50 © Institute for Public Safety, Crime and Justice, 2016.
© Institute for Public Safety, Crime and Justice
However, opinions among mental health staff were somewhat more varied. Some commented on how they would deploy to ‘see what they could do’; others saw their role as being more beneficial in the control room, where they have access to patient records and can advise officers on-scene.50
Challenges of and barriers to the delivery of organisational objectives
Challenges and barriers identified in the DHSC-funded pilots included clarifying the purpose of the scheme, educating local services about its function and clarifying police officers’ role in private premises.9 Although some schemes were characterised as street triage, many call-outs were to people who were not in a public place. This raised issues about the limits set to police power under S136, particularly when people were in their own homes and would not come voluntarily to hospital.46 Police officers considered it important that health professionals involved in PRMHT interventions are made aware of these limits. Conversely, concerns have been raised that control room staff may fail to request a PRMHT team to attend incidents in the home if the intervention had been promoted to them purely in terms of street triage.46
Barriers to evaluation against organisational objectives
A challenge to showing whether or not objectives had been met was collecting evidence on the impact of interventions beyond S136 rates or other simple measures. Even when data sets were predefined, a lack of administration funds meant that data collection was often incomplete9 or inaccurate.50 In another study, the mechanisms to identify measurable impact were suggested to be inefficient and tiring.50
Assessment and identification of service user needs
Immediate access to accurate health information
Police officers considered the ability to have immediate access to relevant information vital to making judgements about risk and potential courses of action.9 Information that mental health staff could provide from NHS systems [e.g. SystmOne (The Phoenix Partnership, Leeds, UK)] was seen as informing the dynamics of risk (e.g. the meaning and implications of specific mental illnesses within the context of an incident).50 Officers expressed greater confidence in decision-making as a result of being offered immediate reliable information, including summaries about an individual’s current circumstances, information on access to services and care planning, guidance and advice on options and alternatives available on the day, and advice about how to proceed.42 In one co-response scheme, MHPs felt pressure from control rooms to attend incidents first and a relative discomfort at this as it limited the amount of information they could ascertain before they arrived.46
Beneficial role of mental health professionals in user needs assessment
The involvement of a PRMHT team helped better identify the needs of service users and improve access to care, perhaps especially when decisions were not straightforward.9 In one study, MHPs described how their familiarity and knowledge of mental health conditions meant that their judgements differed from those of police officers, particularly in terms of risk. In such cases, officers often assessed an individual to be a higher risk than did the MHPs.50 A by-product of this approach was a sharing of knowledge about mental health with individual officers, which varied according to the officers’ levels of engagement and interest.50 Another study gave the example of someone threatening suicide as historically being enough for officers to use S136, because of a lack of alternatives and an emphasis on being risk-averse.46 Officers involved in this co-response intervention reported feeling uncomfortable leaving someone alone if they were threatening self-harm or suicide, but also that they had historically been ‘overcautious’ when using the power to section, resulting in it being used too frequently.46
Other perceived benefits of involving PRMHT teams in user needs assessments included increased time efficiency by freeing up other response officers while the PRMHT team dealt with mental health-specific issues (although this would not apply to forces where police officers retain ownership of an incident until its resolution), and increased knowledge and confidence regarding their available options.9 Some health staff felt that, in their absence, police officers would still be likely to use S136 to ensure quicker assessment.9
Service user feedback on needs assessment
Very little service user feedback was available across the studies. When this was reported in relation to the assessment of user needs, opinions were mixed. Although some service users expressed problems around communication (e.g. difficulties understanding the nurse or being told the same things that they had heard in the past – that no immediate help was available),9 some people who had previously been sectioned found the experience of street triage to be consistently better.46 Some individuals felt reassured and calmed by the nurse’s presence and appreciated the fact that the incident was often resolved in their own home without having to go to hospital or be held in custody.46
Identifying needs of new and repeat service users
Police-related mental health triage interventions raised implications for identifying the needs of both new and repeat service users. In some cases, street triage led to individuals being identified in the community who had previously not had input from services.46 Elsewhere, the demand on the control room caused by regular callers and missing persons was a continual cause of frustration, with the operation failing to resolve repeat cases.50 Although MHPs did report ongoing work with these individuals (demonstrating a willingness to develop a longer-term relationship with service users), this was done beyond the bounds of the operation.50 One telephone-based scheme deliberately identified individuals who frequently came into contact with services via the police in order to inform interagency responses and risk planning. When utilised effectively, this appeared to reduce re-presentation and significantly support more effective management of police time and resources.42 One co-response scheme developed a dedicated ‘Integrated Recovery Programme’ to address the high demand created by frequent service users who would regularly call the police and mental health services for support.53
Pathways through the care system
Establishing links with other relevant services
Positive changes in pathways to care were often reported.9 This included better police links with home treatment or crisis teams.9 The facilitation of a wider range of pathways to emergent incidents was considered critical to reducing the number of S136 arrests that are used unnecessarily:50
It’s about opening up the pathways and the communication and liaison between various services in support of each other, really, for the best of the client to ensure that pathway is timely and consistent.
MHP.
Reproduced with permission from Callender and Cole.
50 © Institute for Public Safety, Crime and Justice, 2016.
© Institute for Public Safety, Crime and Justice
Crisis teams’ fears of a deluge of potentially inappropriate calls were not realised, as better officer understanding meant that calls were appropriate.9 Other perceived improvements to pathways included follow-up of referrals where none had previously existed and better pathways for people who are unengaged or unknown to services.9
However, where crisis teams were the services originally responsible for responding to crisis situations, including calls from the police, the introduction of street triage could initially create confusion about the roles and responsibilities within the available pathways:
. . . and the police brought a gentleman . . . if you self-present, it’s like you see the crisis team but because the police had brought . . . the crisis team asked us . . . there’s nothing set in stone that because the police have brought him it has to be street triage. He’d actually self-presented and wanted to come here to see the crisis team because he thought he was in psychiatric crisis but [street triage] assessed him.
Street triage staff.
Reproduced with permission from Callender and Cole.
50 © Institute for Public Safety, Crime and Justice, 2016.
© Institute for Public Safety, Crime and Justice
Barriers to accessing other relevant services
Some views identified systemic barriers to desired outcomes because of factors that lay outside the PRMHT interventions. Owing to long waiting times, referrals did not necessarily mean that service users received the intended mental health care or treatment, so there was a limit to what the mental health workers could guarantee the patient would receive.53 Examples were given of some patients still getting ‘stuck’ at A&E and then being sent home after a long wait.46 PRMHT referrals also had the potential to cause an increased workload for other services.53
Wider strategic considerations around the role of police in mental health-care pathways
Senior staff alluded to strategic considerations around sustainability and longevity.9 The existing PRMHT arrangements were sometimes referred to as a ‘short-term fix’ or ‘sticking plaster’.9 Some police officers believed that they personally should be bypassed whenever possible when incidents are clearly health related.9 One police manager described a long-term aim of moving to a situation when a police response is only required in the presence of immediate safety concerns for a client or the public:53
So one of the objectives of [project name], is the long term, almost a generational piece of work, to actually place mental health risk, mental health responsibility, back into the NHS, because it has never been in the NHS, because culturally the wider thing is the police in the UK scoop up everything.
05, police, manager, location 1.
Reproduced from Horspool
et al.
53 © The Authors, 2016. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:
http://creativecommons.org/licenses/by/4.0/The Authors
One strategic mental health police lead described their aim of moulding ‘a single acute care pathway’ that takes account of L&D, triage, rapid assessment, intervention and discharge within a primary care health setting, while also looking at the S136 and S135 processes.9
Pathways for intoxicated individuals present a recurring issue in one study, with there being some deliberation as to the best place to support such individuals.46
Care co-ordination and effective interagency working
Benefits of interagency co-ordination
The most commonly reported themes related to perceived improvements in care planning, co-ordination and effective interagency relationships.9 Stakeholders in one scheme perceived that collaborative working at operational and managerial levels led to an improved understanding between the different organisations by dispelling misconceptions and building rapport between operational staff.53 Police officers in another scheme reflected that access to telephone support had improved mutual respect between police and psychiatric health staff, and increased reciprocal awareness of each other’s professional knowledge, skills and work pressures.42
The combination of police and MHPs within other schemes was viewed as being complementary, and enabled police to utilise different options to achieve positive incident outcomes when they may previously have exercised S136 powers.50,53 In one study, police officers were perceived to be less risk-averse when decision-making was shared,53 although, in another, officers felt that the responsibility for S136 cases was not fully shared, and despite taking the advice of the nurse, officers still felt that their ‘neck is on the line’, which can make them reluctant to not use S136.46 Nurses, nevertheless, reported improved partnership working with police and more appropriate use of S136.46
In one telephone support scheme, when S136 was initiated, handovers from police to health professionals were seen to be improved in terms of risk and potential harm, being better managed with assessments completed more speedily.42
Other perceived benefits of improved interagency working included improved responsiveness from hospitals when MHPs were involved,9 and triage nurses gaining a better understanding of the limits to police powers.9 The presence of MHPs was also thought to help calm situations when problems arose around police uniforms.9 It was recognised that mental health staff were perceived less confrontationally than police officers by people in need; the fluorescent jackets and stab vests worn by officers were viewed as both presenting a physical barrier and heightening anxiety within certain situations.50
Staffing and co-ordinated working
Staffing of the schemes was mentioned in terms of both facilitators of and barriers to successful implementation. In one case, it was strongly indicated that more consistent staffing arrangements would be welcomed, as it was recognised that staffing of the operation was irregular from both police and mental health perspectives.50 Consistent staffing on this scheme was considered to enable the formation of stronger relationships and result in better outcomes for individuals in need.50 Conversely, inconsistent staffing arrangements resulted in less effective utilisation of time, as expressed by police officers not knowing what to do or how to add value within the control room during quiet periods. This was equally the case during incidents when an assessment was being completed.50 The benefits of consistent staffing may be linked to the extent of police staff enthusiasm for mental health-related work, with clinicians in one scheme reporting a qualitative difference between officers who were motivated to learn about mental health and those who were attracted to the scheme as a result of overtime payments (which led to the police officer sometimes acting simply as a ‘chauffeur’).46 One study noted that a minority of police colleagues felt that mental health should be the responsibility of the health service. Thus, a less enthusiastic response from some officers may pose challenges to the implementation of PRMHT services.53
Information shared by police and health colleagues
Again, police officers noted the sharing of information as a key component of effective interagency working, increasing their confidence and knowledge around mental health-related incidents and awareness of appropriate outcomes for users.9 Officers in one study said that although the provision of advice and information from MHPs might simply be seen as a ‘nice-to-have’ resource, it was actually recognised to potentially make ‘the difference between life and death’ within certain incidents.50 Elsewhere, the ability of police and nurses to work together when presented with someone in distress was said to facilitate the ‘bigger picture’, ensuring that more accurate decisions were made around risk. Police could provide information on an individual’s offending history, risk of assault and use of weapons, while the nurse could provide information around medication, diagnosis and care plans.46 Police officers have expressed confidence and gratitude in receiving support from triage nurses.9
In one case, managerial staff highlighted how the establishment of a co-response scheme had initiated a review of local agreements related to collaborative working with MHPs, police and emergency care. This led to improvements, such as a new information-sharing agreement that clarified the types of information that could be shared, and enhanced access to information that was felt to improve police decision-making, both during and outside street triage hours.53
Barriers to effective interagency working
A number of challenges around joint working were also raised. Although police officers expressed a respect for the judgements of mental health staff, there was confusion (and sometimes tension) in relation to the decision-making processes around deployment. This was heightened when resources were scarce on the ground and control room staff saw the car/team as a deployable resource.50 One study noted occasional disagreements about the most appropriate place of safety, which significantly impeded and delayed the progress of assessments and ultimately the resolution of incidents. This seemed particularly the case when alcohol, drugs and/or risk of violent behaviour were significant, and there was disagreement about the level of risk presented and the appropriate setting for a person to be located at.42
One study raised the importance of establishing lines of accountability and responsibility for such decision-making. For instance, it is critical to consider who holds responsibility for the shared decision to withdraw officers from the scene of an incident (i.e. taking no further action) in which a person expressing suicidal thoughts then goes on to commit suicide. This type of dilemma directly relates to the gap in police powers between S135 and S136, an unplanned detention of an individual to a place of safety.50 Officers in one study felt more comfortable leaving an individual threatening self-harm or suicide if the nurse had conducted their assessment and felt that it was safe to do so.46
Poor co-ordination between external organisations was a noted challenge. For example, a ‘lack of join up’ between different NHS trusts led to delays in both patient care and the release of officers from incidents.9 In one scheme, police service boundaries encompassed many NHS trusts and police officers would need to identify which NHS trust was responsible for care when responding to a mental health incident.53 Staff on one scheme noted the difficulty of maintaining a complex set of inter- and intra-agency relationships, including those with police officers and mental health service providers in the voluntary and statutory sectors, as well as managing their own internal networks.50
Quality of care provided
Positive effects on quality of care
Police, health staff and service users all noted an improvement in the quality of care with PHMRT schemes.9 Participants in one study frequently emphasised the importance of the scheme in delivering a better-quality service to people in need, rather than simply freeing up resources.50 It was felt that individuals in need responded more positively to MHPs on the ground, with the MHPs’ communication skills being critical to the positive resolution of specific incidents.50
Elsewhere, the positive impact on service users was acknowledged by police officers:
. . . when the street triage team go, they get a better service. Certainly get better handling . . . wherever the person is at a time of crisis, and threatening to harm themselves, saying, I want to hang myself . . . I just want to kill myself, leave me alone . . . then giving them a bit of a brief intervention, talking to them, and making arrangements for them, their care, moving forward, to speak to their family has to be a good thing. For a mental health professional to be able to do that is fantastic because that person then does not go into detention, they do not end up in police cell or a hospital where they don’t want to be . . . whereas the police couldn’t make those sorts of judgement calls, so the service user often ends up in custody at the police station.
Police officer,
Reproduced from Dyer
et al.41 Mental Health Street Triage. Policing: A Journal of Policy and Practice, vol. 9, iss. 4, pp. 377–87, by permission of Oxford University Press.
© The Author
Officers noted that an asset of one telephone-based service was the ability, when appropriate, to pass their mobile phone to the person who was the subject of the call so that they could talk to the MHP.42 This was considered to have the following advantages:
The distressed person could immediately speak with a trained MHP, which tended to calm situations.
It demonstrated that the police officers were taking seriously both the person’s views and the difficulty of their circumstances.
Police officers were seen as more welfare focused.
Officers felt that they were more frequently trusted and that any proposed plans to take people to hospital were seen to be more believable.
42
Police-related mental health triage schemes were seen as generating a positive cultural change that has benefited users.9 One officer said that they would never previously have taken people home as they would have lost S136 powers on entering the premises, thereby potentially losing what had been seen as ‘the safest option’.9
An additional consequence of more contacts in private dwellings was that individuals’ families were more frequently included in the care pathway, instead of people being isolated.9 In particular, this was observed in the de-escalation of domestic situations, leading to fewer young people being seen in custody.9 The involvement of PRMHT was reported as reassuring for family or friends who were often at the scene, which was predominantly the service user’s home.46
Reports on the DHSC-funded schemes noted fewer S136 assessments presenting in hospitals.9 PRMHT nurses reported that this helps prevent service users from feeling criminalised for their mental health problem. Service users in one study felt reassured and calmed by the nurse’s presence and appreciated the fact that the incident was often resolved in their own home, without having to go to hospital or be held in custody.46 When issues could not be resolved in the home, other service users expressed relief at being taken to hospital instead of police custody, as this was less shameful.9
Service users generally (although not universally) commented that follow-up calls were valued.9
Attitudes to service users with mental health problems
Service users expressed negative experiences of being detained in police cells, with one person describing feeling degraded by having had to strip and change clothing.9 Some service users felt that the police needed to work on building trust,9 for example by ‘speaking the same language’ and not asking for personal details.9 Some service users also held negative views towards authority. This point was echoed by police officers, who particularly noted the impact of arriving in police uniform as a barrier.9 In one study, police officers reported how competent mental health staff were when communicating with service users, striking a balance between empathy and assertiveness in resolving incidents.50
Availability of resources
Resource savings
One study42 noted resource savings from a telephone support-based PRMHT intervention, with officers reporting that it had saved police time when responding to and dealing with calls when mental health challenges were present. This was particularly the case when an individual required hospital assistance. Prior to the PRMHT scheme, when S136 was used to remove someone to a designated place of safety (typically an A&E department), officers would have to wait a considerable amount of time until a medical doctor and a social worker were available to make an assessment and a decision.42
Unused resource
Another study, in which a qualitative researcher shadowed a co-response team, reported some apparent ‘down-time’ between jobs, alongside occasional long journeys to attend incidents.46 The presence or absence of such factors would need to be considered when planning for efficient PRMHT resource use. However, it was noted in the same study that individuals did not seem to mind waiting some time to be seen by the team. However, there were resource implications for the other officers on-scene who could not leave until the PRMHT team attended.46
Availability of mental health professionals
Police officers in two studies41,42 noted the importance of MHPs being immediately available through the PRMHT scheme. In one, the services offered by a PRMHT co-response team were considered to be different from those offered by existing services, such as the crisis team, because nurses based with police officers were available to immediately respond (providing that they were on duty) to police requests for assistance.41 The second study noted the particular importance of being able to call PRMHT telephone support in ‘real time’ at the scene of an incident (24 hours a day, 7 days a week).42 Although there were occasions when officers did not access support because the line was engaged or not answered, this was generally the exception and became less frequent over the final period of the pilot.42 A direct, dedicated PRMHT line was seen as a preferred route to bypass switchboards and non-emergency services and talk to a trained individual who had access to health records and quite often knew, or knew of, the person who was the subject of the call and could respond and advise quickly.42
Police officers considered the unavailability of PRMHT staff to be a significant barrier to access and felt that additional resources were needed to ensure that staff are available to respond when needed.9 There was some suggestion that the control room might be reluctant to deploy mental health staff to incidents because of the risk of them becoming unable to respond to other requests while deployed at the scene.9
One study reported related concerns about staff availability and a perceived rise in the number of people driven to the hospital by police officers and left at the front desk.41 Some police officers were suggested to have bypassed the PRMHT service when it was unavailable. Some police officers argued that it was easier and quicker to take a person directly to hospital if they agreed to attend on a voluntary basis, rather than wait for PRMHT staff to attend the scene; in other cases, the police officers disagreed with the advice given by the nurse.41
Both police and health staff expressed disappointment at PRMHT services not being available around the clock.9,41 A nurse noted the potential waste of resources in promoting a service that officers found not to be consistently available, leading to the risk that officers learn to ‘do without’ it.9
Allocation of staff resources to police-related mental health triage teams
Some respondents raised concerns about the reallocation of staff resources to PRMHT from elsewhere. In one study,50 some police response officers felt that they were letting down their Incident Resolution Team (e.g. exposing their colleagues to a greater degree of risk) when deployed to PRMHT duties, rather than adding wider, systemic value. From the mental health perspective, it was indicated that, more recently, ‘bank staff’ were increasingly assigned to the operation.50
When one co-response PRMHT service was adopted as ‘routine’, it was staffed by an officer from the regular shift.53 Some interviewees felt that, at busy times, losing one officer from the shift compromised their ability to respond to incoming police incidents.53 Managers were aware of this criticism but justified the decision with evidence suggesting that having one officer dedicated to mental health incidents would reduce the workload associated with mental health for other colleagues on the shift.53 Health staff also raised concerns about competing demands when people were reallocated from existing mental health teams to PRMHT.53 This was compounded by perceived additional demand created by PRMHT referrals.53
Technological resource considerations
One of the DHSC-funded teams highlighted that it was crucial to develop a means of sharing electronic information on different information technology (IT) platforms or within a single shared IT platform.9 One scheme developed models for effective record keeping and information exchange.42 Another developed new information-sharing agreements,53 but there remained examples of incompatible technology hampering the expansion of the service. Police interviewees who proposed minimising police involvement in mental health response acknowledged that transferring this workload to health-based services would be challenging for technological reasons, such as incompatible computer systems and limitations in the call transfer systems (but the key challenge would be the absence of additional funding for mental health services to do this work).53
Other technological considerations included the means of communication with remote mental health support. Police officers in one study expressed a preference for a dedicated mobile phone rather than contact via their radio sets.42 This was because (1) the mobile phone could be passed to a service user if they needed to speak directly with the mental health practitioner, without having to share the officer’s personal radio earpiece, and (2) allowed officers to safely retain their radio set in case they urgently needed to call for assistance from colleagues.42 However, some officers were unsure whether or not their use of personally owned mobile phones would be considered inappropriate and, in another scheme, limited local mobile signal coverage was reported as an occasional barrier to contact.53 One study of a co-response model suggested that portable electronic devices might allow nurses to record notes between jobs, rather than doing this without pay after the end of a shift.46
Staff support, supervision and training needs
Recruitment
Several respondents across the studies discussed recruitment considerations. One particular difficulty in this respect was recruitment delays caused by the strict police vetting process.9 The procedures for recruitment to PRMHT teams were rarely reported, except for one pilot, in which a senior nurse, police officer and paramedic were all involved in appointing people to the relevant roles.9
Both police and mental health respondents from one primarily telephone-based scheme said that they would welcome more consistent staffing arrangements, because irregular staffing adversely affected continuity.50 However, it was acknowledged that a downside of this might be that the benefits for staff, in terms of increased knowledge between the organisations, might be more isolated to a core set of individuals.50 Respondents in another study discussed the implications of making PRMHT involvement obligatory for all staff, expressing concern about a negative impact on motivation levels, while recognising the benefit of spreading knowledge about mental ill health more widely across the force.46
In terms of personal characteristics, stakeholders in one PRMHT scheme described the police and mental health staff as compassionate and motivated individuals who work on the service and described these attributes as being important to the success of the service.53
Learning and sharing of knowledge within police-related mental health triage teams
A number of comments around knowledge and learning were presented across the studies. In the case of co-response models, ongoing learning was developed through continual discussion and debriefing between the police officer and nurse sharing a response car for several hours.9
Another study53 noted the importance of PRMHT mental health staff having appropriate knowledge of, and access to, existing mental health services (e.g. community-based mental health teams). This was more easily facilitated if the MHPs were familiar with services because they had worked with them previously.
One scheme9 began work on a joint training initiative to address confusion around the powers and procedures of both police and health organisations (e.g. the limits to police powers to detain to a place of safety when most face-to-face assessments are made within private dwellings).
Other training and support issues
One study50 suggested that better communication about the PRMHT scheme to front-line officers would support how the scheme is perceived and valued within incident resolution teams.
Service users in one police force evaluation believed that police officers needed more face-to-face contact with service users and suggested on-the-job training.9
The idea of providing nurses with protective clothing received mixed views, with some concerned that it would affect the rapport that a lack of uniform provides.46 Others pointed out that although MHPs did not wear protective clothing in the course of their PRMHT duties, police officers sometimes felt concerned about operating as a single-crewed unit with a civilian on board.46
Recommendations for future implementation of police-related triage interventions
The evaluation of the government-funded pilot schemes made the following recommendations for practice:9
An extension of the hours of all street triage schemes should be considered, so that the schemes can provide a 24-hour service 7 days a week.
The role of street triage schemes should be reviewed in relation to referrals from, and contacts in, private settings.
A number of key functions appear to be associated with better outcomes and operation of the services; these functions should be considered when developing or extending street triage schemes, which includes:
joint ownership of the scheme at a senior management level to support the development of effective partnerships
regular reviews of joint working arrangements
clarity about the population to be served by street triage
effective information sharing between services; in particular, access to health information
provision of timely advice to police officers at the point of initial contact and during the assessment process
integration of street triage schemes with the health service-based crisis pathway
provision of information on agreed referral pathways to health and community services at the point of crisis or after its resolution
joint training programmes for street triage staff
improved recording of causes of crises so that this information can be presented to the local safeguarding board and be included in the Joint Strategic Needs Assessments chapters on mental health prevention.
Co-location of health and police staff (e.g. linked to a control room) or dedicated telephone line(s) appear to be an important component of effective street triage schemes and could support a cost-effective roll-out of the programme.
New and existing technologies to support effective information sharing could be used both within and between health and police services.
A national curriculum and associated training materials for street triage staff and enhanced mental health training for all police officers should be developed.
Primary evaluations of other UK-based PRMHT schemes also made implementation recommendations, some of which were more specific than those from the wider evaluation. These included:
Recommendations for future research from qualitative evidence
The evaluation of the government-funded pilot schemes made the following recommendations for research:9
A common data set should be developed, and the appropriate resources monitored to ensure that data are collected consistently and support a review of the cost-effectiveness of the scheme, which should be undertaken to provide evidence for its long-term sustainability.
The review could take the form of an evaluation based on routinely collected data. Alternatively, a formal research study that tests different models of PRMHT (e.g. control room-based models vs. community team-based models) could be undertaken.
Other studies highlighted the importance of improved data collection to support evaluation and other objectives. Specific recommendations were:
The review and streamlining of data-recording procedures. As part of this, clear formulation of the expectations and accountabilities for all parties in terms of documentation.
50Improve data capture for all S136s and PRMHT attendances, to allow for a more accurate and ongoing evaluation of the scheme’s impact.
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The recommendations from the included qualitative studies appeared to be appropriate and follow on from the presented evidence. This report provides a number of observations that emerged during the synthesis of these studies in Chapter 6.
