Each type of PES will be described in terms of its structure, process, shortfalls and its perceived benefits.
POLICE OFFICER INTERVENTION (POI) AND PLACE OF SAFETY (POS)
Police officers in the UK have the power to detain an individual considered to be in mental health crisis in a public place in order to keep the individual and/or members of the public safe [8]. The term used to refer to this power, code of practice and 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 misuse [16].
A literature review by Apakama [13] identified four kinds of POS: police custody, A & E, Psychiatric Unit, and Intermediate Care Facilities’ (section 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.
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, conveying detainees in police vehicles and the use of police stations as POS [10-11, 18].
In the light of this, it has been strongly recommended that police station should only be used in exceptional circumstances [19]. It is hoped that this will allow patients feel less criminalised and mental health professionals carry out assessment and management promptly. However, police stations are still in use as POS based on pragmatic reasons such as: absence/shortage of spaces at designated POS, shortage of mental health staff, person displaying or with previous history of violence and alcohol intoxication [12].
Overall, the use of POI to manage mental health crisis in public places is important yet not without complexities. Likewise, having a designated POS suite or centre 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 that describes how POI services was initially used and then patient transferred to street triage. Nearly all papers on ST were from England and only one [24] did not specify the region where the study was conducted. We found three models of STs described and they 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 police 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 and mental illness [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 and physical illnesses and this number rises to 60% when 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 patients has increased the need for MHLS [29].
We recognise that there are various models of MHLS and many hospitals have taken on board the Royal College of Psychiatrists [13] recommendation 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) also known 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 gap brought about by failures in service provision by statutory organisations. For instance, they provide better access and more service user-led services that reach out 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 some crisis houses are also provided by statutory organisation. 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 mental health patients prefer crisis house to hospital based services because they perceive crisis houses as less stigmatising and institutionalised [35-36]. Moreover, MILMIS project Group [37] stated that crisis houses serve 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, these include, 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 and crisis house when compared with statutory services 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, only few researches demonstrate and document the extent crisis support services are provided by smaller VS 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 confines of their 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]. This is no longer a mandatory service but it remains an essential service with guidelines and reports strongly recommending it [43].
This kind of service has been called various names. 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 name 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 and also review patients daily, with the intention of minimising disruption to patients’ daily lives over a period of 4-6 weeks [41, 46-47]. However, various models of CRHT currently exist, but most CRHT are run by multidisciplinary team offering home-based services. It should be noted that there are variations in the structure of CRHT in different regions of the UK and these variations are based on local needs of patients within each region [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 its being a mobile service, home based and the strong emphasis on 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]. Such researches are valuable as they help develop strategies on how to optimise its beneficial outcomes and not to demean CRHT. 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 emerged based on the need to provide comprehensive assessment to individuals in crisis [51-52]. The PAU is a dedicated 24-hour mental health 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 hospitalisation and may 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 received are from A & E because mental health patients are more likely to present at the A & E during crisis [54-55]. There is evidence that the A & E is not an ideal environment for individuals in crisis and studies have highlighted these drawbacks to 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.
Research on this type of service is scarce. We found only 2 relevant papers via electronic database search, of which one was a conference paper and the other an editorial. When we carried out online search, we discovered three NHS Trusts 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’.
Furthermore, online internet search a poster by a NHS Trust which was later 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 of 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 longitudinal evaluation of this kind of service that takes into cognisance all stakeholders views.
INTEGRATED SERVICES
An integrated service is one which incorporates two or more PES services 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 POI or the Street Triage services, they are often taken to a POS; hence, there is a greater tendency to describe these types of services in a single paper.
We found 8 papers describing more than one kind PES; however, they do not meet our description of an integrated service. This is because majority of the papers provided results of surveys or reviews of more than one service without the services necessarily integrated. There were more papers from England. Papers were also found from Northern Ireland and Scotland and one made 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.