Health Service Focus

Street triage, stations and suicide

Mark Smith, head of suicide prevention and mental health at the British Transport Police, talks to NHE about a street triage partnership between the NHS and police.

While policing and health have clearly defined remits, their responsibility crosses over on certain key issues. This includes mental health, and people who are vulnerable to self-harm or suicide.

Often these people are identified by the police rather than the NHS, but specialist knowledge about the best place for referral, current services used by the patient, and about the type of risk they may pose has been unavailable to officers.

A new project seeks to bridge this gap by bringing together police forces and mental health nurses. Closer working and better communication has a significant role to play in improving treatment of people with mental health issues and ensuring this treatment is standardised across the country.

Police pilots

At the end of August, the Department of Health announced funding to extend this street triage scheme; bringing mental health nursing staff and police officers together to improve the management of vulnerable people.

It follows trials in Cleveland and Leicestershire and forms part of a larger DH and Home Office plan on policing and mental health. Five pilots were launched with the British Transport Police (BTP) and the Metropolitan, Thames Valley, West Midlands and West Yorkshire forces. They join existing pilots in Derbyshire, Devon & Cornwall, North Yorkshire and Sussex.

Announcing the fund, care minister Norman Lamb said: “In some areas the police already do an excellent job in terms of their handling of situations involving people with mental health problems and work well with health colleagues to make sure that mentally ill people in crisis get the care and attention they need, but we need to make that the reality everywhere.

“We are launching these pilots to make sure that people with mental health issues get the right care, at the right time and in the right place.

“We know the barriers often lie at the crossroads between police and health services. That is why we are working with the Home Office and leaders of the police to look at how we can improve services for the very vulnerable people involved.”

National relationships

The funding has allowed the BTP to extend an existing pilot in London, where officers have been working with community psychiatric nurses in Barnet, Enfield and Haringey Mental Health Trust. 

The team screens everyone brought into BTP custody suites and ensures any mental health issues are identified and picked up early.

The nurses help the BTP to make decisions around what happens to these people, and provides the police with an advocate in the health service.

NHE spoke to Mark Smith, head of suicide prevention at the BTP, about the need for closer working between policing and health. He said: “As a national police force, it’s not very easy to build one-to-one relationships on a geographical basis.

“If you’re a borough based police force, you’ve got borough based health services and you can form some good relationships. Trying to do that nationally is very difficult.”

Breaking through the brick wall

That national focus means the NHS staff are invaluable for the BTP team, providing up-to-date information about the risks people could pose, what services they are currently accessing and the best place to refer them.

“They provide that overview as well,” Smith said. “Sometimes we might be thinking about detaining [someone] under section 136 – the mental health professional’s view might be different, and they might give us some information about how to proceed.”

One BTP policy is to put anyone who comes to their notice for attempted suicide onto a plan to get professional support. But without the NHS link, they have been “hitting a bit of a brick wall” around data protection, and knowing the right place and right people to speak to.

“These individuals can do in minutes what it would previously take us days to do.

“It’s been highly successful in helping us to manage the risk in relation to the individuals who come to our notice, which is a considerable number.”

Force-specific support

With the street triage scheme, BTP aims to replicate the London partnership in the North West. The pilot will involve a referrals system, where nurses are available via telephone, as well as intervention in cases that need medical attention and coordinating with the NHS on the BTP’s behalf.

Other street triage pilots will see nurses out on patrol with officers, but Smith explained that BTP’s geographical spread made this unfeasible. Instead of restricting coverage to that accessible by car, a phone system will allow nurses to cover a wider area: “Manchester, Liverpool, Preston, Wigan: all of that area will be able to benefit from that service.”

The funding will allow the force to give “the same quality of service to people across the country rather than just a pocket in London where we’ve had the benefit of NHS staff working with us,” Smith said.

In London, the team consists of around six BTP staff with up to four nurses, and the workload is “quite high”. With around 80 fatalities a year, the demand for the service is clear. As the rail network shuts around 1am, it means the triage scheme can also be arranged around these hours as needed.

Right resources for known demand

The BTP has been working with Dr Geraldine Strathdee, NHS England national clinical director of mental health, to ensure the demand that transport infrastructure creates on local services is known to local commissioners and understood. The police must create relationships with local CCGs to ensure the right resources are available for demand for mental health services, and their data can help to identify this.

For example, Smith explained how some London boroughs actually “import” demand from other areas – people travelling by train before attempting suicide. Closer coordination with the BTP could help the NHS uncover this hidden demand.

He said: “We want to make sure that we [engage with] local Health and Wellbeing Boards where we can. I know it hasn’t been an especially easy task for police to get a foot in that area at the moment because of a lot of flux and change.  We want to get representation at a national level so that people understand the transport-related issues.”

Standardising good practice

Disproportionate numbers of people attempting suicide are connected to wider community-related issues, such as population, poverty and, crucially, health. In the boroughs of Ealing and Hillingdon, where this is a particular issue, BTP officers are working closely with the West London Mental Health NHS Trust to help promote preventative messages and care to people “before they come into crisis”.

This was an example of one of the “pockets of good work” that are going on, which must be standardised to provide access to quality care across the network.

“These two public protection units, in the north and the south, will be able to foster those relationships with the mental health trusts and the NHS,” Smith said.

Managing risk

In terms of training, there have been “some big strides forward on training our staff to recognise vulnerability”. While greater medical responsibilities for police, such as very basic assessments around mental capacity, could be a consideration for the future, Smith cautioned that this would involve significant issues around liability and quality of care.

One thing which could benefit from improvement would be resolving “a mismatch of understanding between police and health as to the application of the section 136.”

Smith explained that from a policing point of view, this is often the only power available to manage someone they have concerns about, who could be a risk to themselves or others.

“So we use it regularly. Then when we take people for assessment, more often than not, they are released without further detention or assessment. And then we have a problem; because they’re back with us and the risk remains.

“There needs to be a better understanding of where we’re both coming from on this. Police are looking to manage risk, health are looking to diagnose, and somewhere in the middle sometimes the risk element gets left out.”