Search Strategy
Electronic search was conducted on October 24th 2018 and November 2nd 2018, on five key databases (MEDLINE, PsychINFO, EMBASE, AMED and PUBMED). The search terms used in this study is detailed in Table 1 below.
Table 1
emergenc* OR Crisis OR crises OR Urgent Psychiatr* or mental health Unit* OR center* OR centre* OR model* OR service* United Kingdom OR Scotland OR England OR Great Britain Wales NOT south Ireland NOT republic "Street Triage" OR "section 136" OR “section 297” OR "place of safety" Liaison AND "emergency department" OR "Accident and Emergency" Assessment OR decision OR Triage |
Inclusion and Exclusion
Studies written in English and conducted within the United Kingdom which described a form of PES that fits the definition provided earlier were included in this study. Search was not limited by years and this is to help have a comprehensive overview as well as show changes over time of the various models of PES. Studies which did not meet any of the criteria detailed above were excluded.
Search Result
Search Flow for this study using the search term detailed above provided 59 results. Figure 1 below shows search outcomes.
In total, nine type of PES were identified. There were more papers describing Crisis Resolution Home Treatment (CRHT) services than the others. Four papers described both the use of Police Officer Intervention (POI) and Health Based Place of Safety (HBPOS) in their papers. Also, three described both the use of Street Triage and POI in their paper. Table 2 below gives an illustration of the numbers of papers describing each kind of PES identified.
Majority of the papers reported services in England. Six papers described PES both in England and Wales and only one was exclusively about a service in Wales. Three papers were found in Scotland, of which two were a longitudinal study, thus, classified as one. Furthermore, only one paper reported a service in Northern Ireland.
Table 2
Types of Psychiatric Emergency Service (PES) identified.
CRHT* | POS* | POI* | Street Triage | MHLS* | PAU* | IS* | VS* | Crisis House |
15 | 5 | 4 | 3 | 11 | 3 | 8 | 1 | 2 |
7 |
(CRHT*- Crisis Resolution and Home Treatment, POS*- Place of Safety, POI*- Police Officer Intervention, PAU*- Psychiatric Assessment Unit, MHLS*- Mental Health Liaison Services, IS*- Integrated service, VS*- Voluntary Sector) |
Methodological Qualities
Papers found were of diverse methodology. Majority of the papers were quantitative studies, mostly retrospective surveys to evaluate the effectiveness of the service. Both systematic and literature reviews are referred to as ‘review’. We classed newspaper report, commentaries or editorials as ‘reports’. Furthermore, ‘case studies’ are described as detailed description of a particular service or review of case notes, while proposal and protocols were called ‘proposal’ On some occasions, a second paper was then published detailing the impact of the service. We only found one Randomised Control Trials (RCT) [48] and a proposal for a RCT [39] to be carried out. However, the full study of the protocol was not found at the time of conducting this review. Figure 2 below shows search outcomes
Typology of Psychiatric Emergency Services
POLICE OFFICER INTERVENTION (POI) AND PLACE OF SAFETY (POS)
Police officers in the UK can detain an individual who is deemed to be in mental health crisis in a public place [8]. The term used to refer to this power as well as the code of practice for the duration of detention varies across the 4 countries in the UK [8–10].
The Police Officers Intervention (POI) services aims to keep individuals in mental health crisis detained in a safe environment in order to complete a comprehensive assessment by a mental health professional [10–12]. This safe environment is often referred to as “Place of Safety” (POS) and it could be a police station, hospital, residential home or mental health institution. Some authors refer to POS as S136 suites and some studies use both terms interchangeably [12–14]. This explains why it is quite common to find a paper that describes both services as one. Nearly all papers describing POI and/or POS were from England, three were from both England and Wales, with only one from Scotland.
Profile of the detainees is similar across the 4 countries as they often have previous mental health history, suicidal intent and/or self-harm with underline diagnosis of schizophrenia, drugs and substance induced psychosis, alcohol and drug misuse, mania and personality disorder [10–11, 15]. Reported socio-economic status and demographics of individual who utilise POI and POS are mostly those with no fixed abode, unemployed, men, black ethnicity [16–17]. The behaviour leading to arrest includes threatening or actual violence or self-harm, causing disturbances, drugs or alcohol misuse16.
Over the years, there have been controversies about POI and POS with studies highlighting its ethical and moral concerns. This has been attributed to inconsistencies in police officers judgement about detention, lack of training of police officers in mental health, the use of police stations as POS and conveying detainees in police vehicles [10–11, 18]. This explains why it was strongly recommended that police station should only be used in exceptional circumstances [19].
However, police stations are still in use as POS. it has been indicated that: absence/shortage of spaces at designated POS, shortage of mental health staff, person displaying or with previous history of violence and alcohol intoxication are the reasons why police stations are being used. Besides, Hampson [12] pointed out that the use of police stations is usually a pragmatic decision due to many of issues identified earlier.
A literature review by Apakama [13] identified four kinds of POS: police custody, A & E, Psychiatric Unit, and Intermediate Care Facilities’ (Sect. 136 suites). This author concluded that none of the POS described can be considered the most appropriate for all groups of patient who are detained under S136.
Overall, the use of POI to manage mental health crisis in public places is important yet not without complexities. Likewise, having a designated POS that caters for the needs of patients and equally acceptable to detainees, mental health professionals, and the police should be the ideal, but this might be far reaching. Thus, a systematic review of current POI and POS model within the UK to ascertain its effectiveness and cost-effectiveness is needed.
Street Triage (st)
Street Triage (ST) is a collaborative mental health service by the police and mental health professionals delivered to prevent unnecessary detention of an individual in mental health crisis [20–21]. These services have been developed in response to reviews and reports about mismanagement of individuals in crisis using POI and POS [21]. For instance, the Bradley report [22] and the Crisis Concordant [23] called for a more collaborative practice between organisations to work in partnership in order to adequately improve support and treatment for individuals in mental health crisis.
As a result of the close link between the criminal justice system and mental health services, it is quite common to find a paper about POI and street triage. Nearly all papers on ST or in combination with POI were from England with only one [24] which did not specify the region within the UK. Three models of ST, have been described and these are: specialist police officers response, specialist mental health professional response and a telephone triaging collaborative approach [24–25].
Most of the Street Triage in the UK is the specialist mental health professionals’ response type where a mental health professional (usually a nurse) is stationed within the police control rooms with the aim of referring an individual in crisis to existing mental health services [20, 24, 26]. The specialist police officer response model is one in which the police officer have received mental health training to respond to mental health crisis [24]. The telephone collaborative approach is one in which a mental health professional is available on the telephone to offer advice or give information to patrol officers [24].
All three approaches have recorded positive outcomes. These include: significant reduction in the use of POI and admission from POI detention, positive service users feedback, less police time and resources, improved communication and understanding between the police and mental health services and improved care pathway for dealing with mental health crisis [20–21, 24]. It has been identified that the success of ST can be majorly attributed to the expertise of the mental health staff.
The drawback with ST is majorly attributed to staffing arrangements for mental health and police mangers as the current shortage of staff from both services might impact on the effectiveness of ST [24]. Moreover, ST may not be saving money as indicated if service users are not directed to the right services. For example, Heslin [27] study noted that referrals were made to General Practitioners (GP) and the A & E.
Generally, ST is viewed as a PES with many benefits. However, Methodological evaluations of its impact are limited. Moreover, there is a need to conduct longitudinal studies to ascertain its effectiveness in the long run. Furthermore, a comparison of the three models of ST described above can be investigated to identify which of the models are the most effective and cost effective and also help address the drawbacks identified above.
Mental Health Liaison Service (mhls)
Mental Health Liaison Service (MHLS) aims to provide assessment and treatment for individuals in hospitals with co-morbid physical illness and mental health problems [28–29]. MHLS is not a new concept, and has been described in literature since the 1970s [30]. However, the increasing presentation of co-morbid physical and mental illness at A & E and inpatients have further drawn attention to this concept [29–30]. In fact, Plumridge and Reid [31] stated that 28% of acute inpatients have co-morbid mental health problems with physical illness, this number increases to 60% if older patients with delirium and dementia are included. Furthermore, the recognition that health care professionals may not be skilled enough to manage the needs of mental health patient has increased the need for MHLS [29].
We recognise that there are various models of MHLS and many hospitals have taken on board the recommendation by the Royal College of Psychiatrists [13] about mental health liaison as an essential service needed in all acute hospitals. However, In line with the definition of PES described earlier, only papers describing MHLS that deliver urgent and emergency care and support to individuals in crisis within 24 hours of presenting in the A & E were selected. Nearly all papers about MHLS are from England, with only one from Wales and one from an unspecified region of UK. In one study MHLS was referred to as Rapid Assessment interface and Discharge service [28].
Reported beneficial outcomes of MHLS are: reduction in patients’ readmission and length of stay in hospital, better patient satisfaction, reduce length of time at A & E, overall, saving cost to the local hospital [29—29, 32]. Little has been reported with regards to its drawbacks as most of the studies were cross-sectional studies that focused more on its beneficial impact. Thus, there is a need to conduct longitudinal studies that highlights both beneficial and negative impact of this service. This will result in a more balanced view of MHLS and also help recognise areas that require improvement with the aim of optimising its beneficial outcomes.
Voluntary Sector And Crisis House
Voluntary Sector (VS) are also known by other names such as the third sector, non-profit, or non-governmental. They provide a wide range of crisis support services which includes: peer/group support, crisis café, helplines, crisis house and other forms of alternative to inpatient care [33]. VS mental health services provision is often viewed as complementary to the already existing statutory ones [33]. MIND [34] made clear that they close the gaps brought about by failures in service provision by statutory organisations by providing better access, which is more service user-led and reaches out more to Black and Ethnic Minorities and others who are hard to reach [33].
In this review three papers were identified of which all were from England. Also, one was a proposal to evaluate voluntary sector provision of crisis services and the other two were studies on crisis houses delivered by statutory organisations. The authors recognise that many crisis house form part of statutory house. However, in this study both have been considered together. This is because on some occasion crisis House serve as alternative residential arrangement to inpatient care for individuals in crisis and are often provided by VS [33].
It has been reported that crisis house are usually much preferred due to its being less stigmatising and institutionalised than hospital based services [35–36]. Moreover, MILMIS project Group [37] also stated that crisis houses serves as a better option to inpatient service especially in areas noted for hospital bed shortage. However, there are limitations to individuals, who can be admitted to crisis house. For instance, persons detained under the Mental Health Act, as well as those regarded as being of violent behaviour, or individuals misusing drugs or alcohol which require detoxification [35–36].
It has been pointed out that the profile of individuals using voluntary services, crisis house and statutory service are very similar, yet VS does not have as much recognition in research. Usually, larger voluntary organisations profile indicates their active involvement in crisis management. However, little research demonstrates the extent of the crisis support services provided by smaller organisations [33]. Hence, more methodological evaluation of VS provision of crisis services need to be carried out and it will be suggested that all stakeholders views such as the service users, staff and management be explored to have a holistic perception.
Crisis Resolution Home Treatment (crht)
The Crisis Resolution Home Treatment (CRHT) service serves as a great alternative to inpatient care for individuals in mental health crisis with the aim of delivering rapid assessment, support and care for individuals in the context of home and family [38–41]. CRHT is one of the popular crisis services in England due to the mandatory declaration under the NHS plan in 2002 [42]. Although, it is no longer a mandatory one; but it still remains an essential service with guidelines and reports strongly recommending it [43].
Various terms have been used to refer to this service for instance: ‘crisis resolution’, ‘crisis assessment and treatment’ as well as ‘intensive home treatment’ [38]. Nevertheless, Morgan and Hunte [44] made clear that CRHT remains a more acceptable terms and the one mostly used in public report. All but two papers identified in this review about CRHT were from England, with one from an unspecified region of UK [45] and the other a collaborative effort between England and Norway [41].
The CRHT ideally provides 24 hours, 7 days a week, rapid emergency assessment within 1 hour, reviewing patients daily, with the intention of minimising disruption to the lives of individual over a period of 4–6 weeks [41, 46–47]. However, various models of CRHT currently exist, but it is expected that to be a multidisciplinary team offering home-based services. Besides, flexibility within each locality is acceptable [41]. Reported outcome include: reduce hospital admission subsequently saving cost and better user satisfaction [40–41, 48–49]. The success of this service has been attributed to it being a mobile service, home based and its strong emphasis on the importance of family and social network helping in the recovery process [41].
Nonetheless, one study indicated no reduction in hospital admission following its implementation [50]. These authors claimed that there was already a more proactive measure of reducing admission rate prior to conducting their study. Studies that have reported the negative impacts of CRHT are very limited [41]. This is not aimed at demeaning CRHT, rather it is to identify areas for further improvement and develop strategies on how to optimise its beneficial outcomes. Therefore, research on all possible outcomes of CRHT based on the various models being used is highly recommended. This will help policy makers identified evidence based strategy that is effective and cost-effective.
Psychiatric Assessment Unit (pau)
Psychiatric Assessment Unit (PAU) is one of the models of PES that emerge as a result based on the need to provide comprehensive assessment to individuals in Crisis [51–52]. The PAU is a dedicated 24-hour urgent assessment unit aimed at providing proper triaging for individuals in crisis. It is mostly run by mental health nurses and overseen by consultant psychiatrist. It prevents unnecessary hospitalization and could also offer comfort measures (food, shelter, shower, bed) and treatment usually up to 72 hours [52–53].
It has been documented that many of the referrals to this Unit is via the A & E as individuals with mental health crisis are most likely to present at the A & E [54–55]. There is evidence that the A & E is not an ideal environment for individuals who are in crisis and studies have emphasised its drawbacks on the patients, staff and facilities [54–55]. Reported drawbacks include: increased level of stress/crisis of patients, negative staff attitude, increased burden on resources of the facilities, inadequate or improper assessment of patients and many more.
We only identified 2 relevant papers via the electronic search, of which one was a conference paper and the other an editorial. We also discovered that three NHS trust are currently running this kind of service however, all three used different names to describe their service, such as: ‘mental health assessment unit’, ‘psychiatric decision unit’ and urgent psychiatric assessment service’.
Research on this kind of service is very scare, however, we found a poster by Birmingham and Solihull Foundation Trust which was recently developed into a full article [56] and an audit by Ul Haq et al [52] revealed similar results. They both reported a significant in-patient admission reduction and also lesser burden on the already stretched A & E department. However both studies were only carried out for a short period one and six month for Trethewey et al [56] and Ul Haq et al [52] respectively. Moreover, the views of stakeholders were not taken into cognisance. Thus, there is a need for more comprehensive evaluation of this kind of service and a holistic methodological approach is recommended that takes into cognisance all stakeholders views.
Integrated Services
An integrated service is one which incorporates two or more of the PES services described above in order to provide a holistic crisis intervention. Services describing POI and POS or both Street triage and POS in a single paper were not classed as an integrated service. This is because when individuals are seen by the police via the S136 or the Street Triage team, they are then taken to a POS; hence, there is a greater tendency to describe both services in a single paper.
We found no paper that truly meets our description of an integrated service. This is because majority of the papers either provided results of surveys or reviews of more than one service without necessarily being integrated. We found 8 papers describing more than one PES. There were more papers from England. Papers were also found from Northern Ireland and Scotland and one making comparison of available PES in UK and globally.
One paper described integration of two or more services [57]; however, it cannot be classed as an integrated PES. This is because this paper discussed three services, inpatient beds, CRHT, and Acute Day Care. Nevertheless, neither inpatient beds nor Acute Day care can be classed as a PES, because both type of services do not necessarily render crisis services in the first 24 hours as indicated in our definition of PES earlier.
Hence, there is a need to identify studies that incorporate at least two or more PES described above. Moreover, those services should be evaluated to see if it is more effective and cost-effective than single PES.