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NIHR Signal Closer links between police and health services can improve experiences for people in mental health crisis

Published on 27 August 2019

doi: 10.3310/signal-000809

Tighter working partnerships between health professionals and police services are likely to improve the care of people who come into contact with police during mental health crises.

People experiencing severe mental health episodes can present with extreme and unpredictable behaviour posing a danger to themselves and members of the public. Police are often the first to respond in these challenging situations.

New models are emerging of mental health staff working with police. This NIHR-funded review found limited UK-relevant evidence of mixed quality. Studies showed different models in use, from police and mental health staff responding to incidents together to health staff in police control rooms providing support and advice. There was little evidence on which approaches work best, but some research suggested a reduction in formal detentions although there were few outcome data reported.

Research shows potential for improving health outcomes for individuals in crisis by ensuring they are diverted to appropriate services, and in helping direct the appropriate use of police and NHS resources    

Share your views on the research.

Why was this study needed?

The growing volume of mental health-related emergency calls is an increasing challenge for police services. In London, in 2018 there were about 4,200 uses of ‘section 136’ that allow the police to take people with mental illness to a place of safety; for example, a hospital or emergency department. Lack of appropriate skills can result in inappropriate handling of such situations. Even when no crime has been committed, people experiencing a mental health crisis can often find themselves detained in police cells rather than being referred directly to relevant health care.

Police work in partnership with mental health professionals to manage these challenges using police-related mental health triage (PRMHT) known as street triage. This term describes a range of programmes and interventions including specialist police training and the use of on-call or on-site mental health professionals working with the police, although there are many variations in practice.

In the UK there is no universally accepted programme and little research data on the effects of this type of triage. This review assessed all the identified studies of triage interventions that have aimed to improve outcomes when police attend mental health-related incidents.

What did this study do?

The review looked at mixed study types, including 5 reviews and 16 primary studies, which were both quantitative and qualitative. These examined the effects, feasibility and implementation of PRMHT intervention models. The data synthesis focussed on a smaller number of these studies that were conducted only in England.

The studies were descriptive and mostly used data from police records and incident statistics alongside a small amount of qualitative evidence. Many did not include a comparison group, so were unable to conclude reliably how impactful police-related mental health triage interventions were.

This allowed for a qualitative assessment of what was provided but meant the review was unable to quantify the outcomes for police services, mental health services and the individual service users themselves. The study, however, provides a useful basis upon which further research can be planned.

What did it find?

  • Most police-related mental health triage schemes involved police officers working in partnership with mental health professionals but approaches varied from region to region.
  • Interventions included joint attendance at incidents by police and mental health professionals and the location of mental health professionals in police control rooms. They also included information-sharing agreements and 24/7 telephone advice led by mental health professionals.
  • Police officers appear to value PRMHT and when in receipt of relevant training were more likely to use health-based places of safety rather than police cells and to use the support of mental health professionals.
  • Schemes helped to reduce formal section 136-related police detentions, increase hospital admission rates to secure appropriate care and improve access to mental health services.
  • There is a lack of evidence around how PRMHT interventions directly benefit the service users, and stronger research is needed.

What does current guidance say on this issue?

Section 136 of the Mental Health Act authorises the transportation of a person who is in need of immediate care or control to a place of safety in order to assess their health needs. The Policing and Crime Act of 2017 mandates that where possible this should be to an appropriate health service rather than a police cell.

It is recognised within the Department of Health’s Mental health crisis care concordat that while dealing with mental health is a core police role this should not be done alone and should always involve the support of mental health professionals.

What are the implications?

Interventions fostering closer working partnerships between the police and mental health professionals can help the effective targeting of police and NHS resources, and improve patient outcomes. Well-developed lines of communication and information sharing are key in ensuring appropriate support and advice is available in the right place at the right time.

This study provides a useful and timely summary of intervention models that may help in achieving this. We do not have enough robust comparative information to know which approaches are most cost-effective. The findings help chart what is known and shape further research in this new field. This evidence is important for police and mental health services, and for ambulance staff who play a key role in transporting patients to relevant health care services.

Citation and Funding

Rodgers M, Thomas S, Dalton J, Harden M and Eastwood A. Police-related triage interventions for mental health-related incidents: a rapid evidence synthesis. Health Serv Deliv Res. 2019;7(20).

This research was funded by the NIHR Health Services and Delivery Research Programme (project number 13/182/14).

Bibliography

College of Policing. Memorandum of understanding: the police use of restraint in mental health and learning disability settings. Coventry: College of Policing. 2017.

Department of Health and Concordat signatories.  Mental health crisis care concordat. Improving outcomes for people experiencing mental health crisis. London: Department of Health; 2014.

HM Government. Policing and Crime Act 2017, part 4, chapter 4. London: The Stationery Office; 2017.

HM Government. Mental Health Act 1983, section 136. London: The Stationery Office; 1983.

Why was this study needed?

The growing volume of mental health-related emergency calls is an increasing challenge for police services. In London, in 2018 there were about 4,200 uses of ‘section 136’ that allow the police to take people with mental illness to a place of safety; for example, a hospital or emergency department. Lack of appropriate skills can result in inappropriate handling of such situations. Even when no crime has been committed, people experiencing a mental health crisis can often find themselves detained in police cells rather than being referred directly to relevant health care.

Police work in partnership with mental health professionals to manage these challenges using police-related mental health triage (PRMHT) known as street triage. This term describes a range of programmes and interventions including specialist police training and the use of on-call or on-site mental health professionals working with the police, although there are many variations in practice.

In the UK there is no universally accepted programme and little research data on the effects of this type of triage. This review assessed all the identified studies of triage interventions that have aimed to improve outcomes when police attend mental health-related incidents.

What did this study do?

The review looked at mixed study types, including 5 reviews and 16 primary studies, which were both quantitative and qualitative. These examined the effects, feasibility and implementation of PRMHT intervention models. The data synthesis focussed on a smaller number of these studies that were conducted only in England.

The studies were descriptive and mostly used data from police records and incident statistics alongside a small amount of qualitative evidence. Many did not include a comparison group, so were unable to conclude reliably how impactful police-related mental health triage interventions were.

This allowed for a qualitative assessment of what was provided but meant the review was unable to quantify the outcomes for police services, mental health services and the individual service users themselves. The study, however, provides a useful basis upon which further research can be planned.

What did it find?

  • Most police-related mental health triage schemes involved police officers working in partnership with mental health professionals but approaches varied from region to region.
  • Interventions included joint attendance at incidents by police and mental health professionals and the location of mental health professionals in police control rooms. They also included information-sharing agreements and 24/7 telephone advice led by mental health professionals.
  • Police officers appear to value PRMHT and when in receipt of relevant training were more likely to use health-based places of safety rather than police cells and to use the support of mental health professionals.
  • Schemes helped to reduce formal section 136-related police detentions, increase hospital admission rates to secure appropriate care and improve access to mental health services.
  • There is a lack of evidence around how PRMHT interventions directly benefit the service users, and stronger research is needed.

What does current guidance say on this issue?

Section 136 of the Mental Health Act authorises the transportation of a person who is in need of immediate care or control to a place of safety in order to assess their health needs. The Policing and Crime Act of 2017 mandates that where possible this should be to an appropriate health service rather than a police cell.

It is recognised within the Department of Health’s Mental health crisis care concordat that while dealing with mental health is a core police role this should not be done alone and should always involve the support of mental health professionals.

What are the implications?

Interventions fostering closer working partnerships between the police and mental health professionals can help the effective targeting of police and NHS resources, and improve patient outcomes. Well-developed lines of communication and information sharing are key in ensuring appropriate support and advice is available in the right place at the right time.

This study provides a useful and timely summary of intervention models that may help in achieving this. We do not have enough robust comparative information to know which approaches are most cost-effective. The findings help chart what is known and shape further research in this new field. This evidence is important for police and mental health services, and for ambulance staff who play a key role in transporting patients to relevant health care services.

Citation and Funding

Rodgers M, Thomas S, Dalton J, Harden M and Eastwood A. Police-related triage interventions for mental health-related incidents: a rapid evidence synthesis. Health Serv Deliv Res. 2019;7(20).

This research was funded by the NIHR Health Services and Delivery Research Programme (project number 13/182/14).

Bibliography

College of Policing. Memorandum of understanding: the police use of restraint in mental health and learning disability settings. Coventry: College of Policing. 2017.

Department of Health and Concordat signatories.  Mental health crisis care concordat. Improving outcomes for people experiencing mental health crisis. London: Department of Health; 2014.

HM Government. Policing and Crime Act 2017, part 4, chapter 4. London: The Stationery Office; 2017.

HM Government. Mental Health Act 1983, section 136. London: The Stationery Office; 1983.

Police-related triage interventions for mental health-related incidents: a rapid evidence synthesis

Published on 5 June 2019

Rodgers M, Thomas S, Dalton J, Harden M & Eastwood A.

Health Services and Delivery Research Volume 7 Issue 20 , 2019

Background Police officers are often the first responders to mental health-related incidents and, consequently, can become a common gateway to care. The volume of such calls is an increasing challenge. Objective What is the evidence base for models of police-related mental health triage (often referred to as ‘street triage’) interventions? Design Rapid evidence synthesis. Participants Individuals perceived to be experiencing mental ill health or in a mental health crisis. Interventions Police officers responding to calls involving individuals experiencing perceived mental ill health or a mental health crisis, in the absence of suspected criminality or a criminal charge. Main outcome measures Inclusion was not restricted by outcome. Data sources Eleven bibliographic databases (i.e. Applied Social Sciences Index and Abstracts, Criminal Justice Abstracts, EMBASE, MEDLINE, PAIS® Index, PsycINFO, Scopus, Social Care Online, Social Policy & Practice, Social Sciences Citation Index and Social Services Abstracts) and multiple online sources were searched for relevant systematic reviews and qualitative studies from inception to November 2017. Additional primary studies reporting quantitative data published from January 2016 were also sought. Review methods The three-part rapid evidence synthesis incorporated metasynthesis of the effects of street triage-type intervention models, rapid synthesis of UK-relevant qualitative evidence on implementation and the overall synthesis. Results Five systematic reviews, eight primary studies reporting quantitative data and eight primary studies reporting qualitative data were included. Most interventions involved police officers working in partnership with mental health professionals. These interventions were generally valued by staff and showed some positive effects on procedures (such as rates of detention) and resources, although these results were not entirely consistent and not all important outcomes were measured. Most of the evidence was at risk of multiple biases caused by design flaws and/or a lack of reporting of methods, which might affect the results. Limitations All primary research was conducted in England, so may not be generalisable to the whole of the UK. Discussion of health equity issues was largely absent from the evidence. Conclusions Most published evidence that aims to describe and evaluate various models of street triage interventions is limited in scope and methodologically weak. Several systematic reviews and recent studies have called for a prospective, comprehensive and streamlined collection of a wider variety of data to evaluate the impact of these interventions. This rapid evidence synthesis expands on these recommendations to outline detailed implications for research, which includes clearer articulation of the intervention’s objectives, measurement of quantitative outcomes beyond section 136 of the Mental Health Act 1983 [Great Britain. Mental Health Act 1983. Section 136. London: The Stationery Office; 1983 URL: www.legislation.gov.uk/ukpga/1983/20/section/136 (accessed October 2017)] (i.e. rates, places of safety and processing data) and outcomes that are most important to the police, mental health and social care services and service users. Evaluations should take into consideration shorter-, medium- and longer-term effects. Whenever possible, study designs should have an appropriate concurrent comparator, for example by comparing the pragmatic implementation of collaborative street triage models with models that emphasise specialist training of police officers. The collection of qualitative data should capture dissenting views as well as the views of advocates. Any future cost-effectiveness analysis of these interventions should evaluate the impact across police, health and social services. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

This evidence synthesis provides a rigorous and rich evaluation and description of the published evidence on police-related triage interventions for mental health-related incidents - often described as street triage.

It is encouraging to find these interventions were valued by staff, and some positive effects were shown. However, the limited scope and methodologically weak published evidence should be of concern, given the significant resources and efforts involved.

Policymakers, commissioners, police, clinicians and providers of services will benefit greatly from these findings and should support urgent calls for high-quality research exploring the efficiency, acceptability and effectiveness of such interventions.

Dr Nigel Rees, Head of Research & Innovation, Welsh Ambulance Service NHS Trust; Co-Injuries and Emergencies Specialty Lead, Health and Care Research Wales

The commentator declares no conflicting interests