1. NELFT Street Triage and Mental Direct Service
Wellington Makala – Deputy Director – Acute MHS & NELFT BME Ambassador

2. Crisis Care Concordat
In 2014 NHS England welcomed the mental health crisis care concordat as an important step forward in improving care and standards for people in a mental health crisis. The Concordat, launched by the Department of Health, is a joint agreement which describes how police, mental health services, social work services and ambulance professionals should work.
The Crisis Care Concordat published ‘Guidelines for Commissioning’ in 2015 which recommended the consideration of 24-hour telephone crisis lines and ‘St Triage’ police/mental health partnership working as part of a care pathway portfolio of Crisis response services.
In these schemes, mental health professionals provide on the spot advice to police officers who are dealing with people with possible mental health problems.

3. Why Is it necessary?
Policing Mental Health relates to about 20% of police time.
Home office, Department of Health and ministry of justice have identified a need to work more collaboratively.
Supports the drive described within the new MH concordat.
Police Federation raising concerns over the use of S136 MHA powers.
Reports outlining that custody is not a place of safety, we should not be criminalising persons suffering from mental ill health.
Prevent presentations to accident and emergency departments when a person has no physical health concerns.
The service will further enhance parity of esteem between mental health and physical health by ensuring mental health emergencies are treated with as much urgency and respect as if it were a physical health emergency.
The Crisis Care Concordat and other key national policy guidance documents including Crossing Boundaries 2013, London Mental Health Crisis Commissioning Guide 2014 and Achieving Better Access by 2020, all identify the importance of joint working, accelerated 4
Street Triage Business Case July 2015
access to services and an accessible crisis care pathway in providing support for those in crisis, their carers and their families.
In February 2014, 22 national bodies involved in health, policing, social care, housing, local government and the third sector came together and signed the Crisis Care Concordat. Since then five more bodies have signed the Concordat, making a total of 27 national signatories, giving focus to four main areas:
 Access to support before crisis point
 Urgent and emergency access to crisis care.
 Quality of treatment and care when in crisis
 Recovery and staying well
The Crisis Care Concordat published ‘Guidelines for Commissioning’ in 2015 which recommended the consideration of 24-hour telephone crisis lines and ‘St Triage’ police/mental health partnership working as part of a care pathway portfolio of Crisis response services.
Mental Health Direct (MHD)
MHD is a 24 hour Telephone crisis line and is an integral part of NELFT’s Crisis Care Pathway that includes Extended Hours Access Teams, Home Treatment Teams and the Emergency Duty Team.
This service has historically not had dedicated clinical or administrative staff, but rather has been run as a sub service of the Trusts switchboard. A pilot project has been running since January 2015, which has been funded from via a successful joint bid against monies that became available for Crisis services nationally over the winter period.
The additional funding obtained under the Crisis pilot has allowed NELFT to bolster this existing service with dedicated clinical staff so that the service can run robustly in regards to the volume of calls received and can provide the clinical skills required for complex crisis intervention. This has ensured that people, of all adult ages, including older persons, in crisis have direct contact with a clinician 24 hours a day, averting any unnecessary distress, escalation or admission.
Please see full evaluation of pilot, which accompanies this business case – Appendix 1
Street Triage (ST)
ST allows mental health professionals to provide on the spot advice to police officers who are dealing with people with possible mental health problems. This advice can include an opinion on a person’s condition, or appropriate information sharing about a person’s health history. The aim is, where possible, to help police officers make appropriate decisions, based on a clear understanding of the background to these situations. This should lead to people receiving appropriate care more quickly, leading to better outcomes, such as the reduction in the use of section 136, avoidance of unnecessary detention in police cells and reduction in the numbers of people being taken inappropriately to Accident and Emergency Departments.
It is estimated there are some 50 ST pilots or established services across England and Wales. These services differ significantly in their configuration; some feature staff based in police call centres themselves (a highly resource-intensive option for the NELFT patch due to the number of these centres locally), while others do not offer outreach assessment. They are mostly at the trial stage but all report significant impact in terms of reduction of S136 assessments and improvements in front-line police-NHS working,
The current three month ST pilot in NELFT was funded through crisis monies leading ot the service being launched in April The project has a senior clinician as project manager and an operational team comprising three Band 6 mental health professionals. This resource level allows 2 staff to be available from 5.00pm to 1.00am five evening per week (Mon to Fri) based at existing NELFT operational premises in Goodmayes and supports the seven police stations across the four boroughs of Barking and Dagenham, Havering, Redbridge and Waltham Forest.

4. NELFT MHS ACUTE CARE PATHWAY
Over the past few years NELFT Acute and Rehabilitation Directorate (ARD) have introduced a real focus on offering acute crisis care in the patients own home as an alternative to acute admission. This has been achieved through Home Treatment Teams who offer an alternative to acute admission. As an extension of that service NELFT have introduced Street Triage Pilot.
Street Triage Pilot was launched  on 7 April NELFT joined forces with MET Police to pilot a new project to ensure people with mental issues are prevented from detention under S136 of the Mental Health Act  ’83.
In April 2016 BHRW CCGs agreed to continued funding with the addition of LAS joining this collaboration. he Team covers all 4 NELFT boroughs.
Mental Health Direct was launched in January It has been funded from via a successful joint bid against monies that became available for Crisis services nationally over the winter period.

5. Street Triage Team
Dedicated phone line for MET/LAS officers
Three full time band 6 MH nurses.
Part time manager band 8a senior social worker.
Based at Block 8 Goodmayes hospital IG3 8XJ.
am.
Mental Health Direct
Dedicated phone line
Bank/Agency Band 6 mental health professionals Currently.
Hours 24/7.
Fulltime Band 8a Manager.

6. Mental Health Direct
Mental Health Direct is a dedicated out of hours crisis service staffed by qualified Mental Health professionals-CPNS/Social Workers. MHD is a 24 hour Telephone crisis line and is an integral part of NELFT’s Crisis Care Pathway that includes Extended Hours Access Teams, Home Treatment Teams and the Emergency Duty Team.
This service has historically not had dedicated clinical or administrative staff, but rather has been run as a sub service of the Trusts switchboard.  Available for people who are in crisis or wish to discuss issues regarding their mental health and their carers.
Signposting / referrals to appropriate health, social care or support services.
 Line management support.

7. Benefits Of MHD to date Access to support before crisis point
Urgent and emergency access to crisis care.
Quality of treatment and care when in crisis  
A reduction in the demand on A+ E departments.
A reduction in calls to the NHS 111 service by people experiencing mental health crisis.
Signposting to NHS 111 or General Hospital if the calls relate to physical health problems.
Less pressure on Home Treatment Teams to provide telephone support whilst out on visits or carrying out assessments.
Benefits to date
MHD provides direct advice and support not only to people in crisis but also their carers.
MHD has enabled a reduction in the demand on A+ E departments.
A reduction in calls to the NHS 111 service by people experiencing mental health crisis.
Availability of specialist mental health support provided in a timely fashion.
Signposting to NHS 111 or General Hospital if the calls relate to physical health problems.
Less pressure on Home Treatment Teams to provide telephone support whilst out on visits or
carrying out assessments.

8. Key outcomes
Reduced inappropriate or unnecessary use of Section 136 of the MHA.
Reduced time spent by MET/LAS officers dealing with those with mental health problems.
An improved experience for people who come into contact with the police through either detention under Section 136 or for other reasons related to their mental health.
Reduced inappropriate use of A&E as a place of safety.
Reviewed and Improved crisis, care and contingency plans for service users.
Reduced number of attendances in custody.
Improved multi-agency team work.
Reduced costs to health, criminal justice system, Ambulance service and Acute Trusts.

9. Key elements of the scheme
Dedicated phone line and telephone support available to service users experiencing crisis.
Dedicated phone line and telephone support available to the MET and LAS from 5pm to 12 midnight.
Sharing of information to enable informed decisions to be made by officers on the street/homes about the options available to them.
Face to face assessments where appropriate (on the street / people’s homes etc.)
Onward referrals to appropriate health, social care or support services of individuals who have come to the attention of the police.
7 day follow up those individuals referred on to other agencies.

10. Monitoring and Evaluation
All referrals are documented on a spreadsheets on shared drive and RIO.
Bi monthly meetings with the MET police and LAS leads of all for boroughs. Here we:
-Review case studies.
-Discuss what has and has not worked well.
-Review safeguarding cases.
Clinical and management supervision.
Feedback from service users, carers and our key stakeholders, uploaded onto Datix compliments.

11. Street Triage Service User Feedback

12. Street Triage Service User Feedback

13. Street Triage Service User Feedback

14. UNIQUE SOLUTIONS
Better engagement and improved crisis experience with our service users.
Less stigmatizing for our service user.
Stronger partnership and collaboration with key stakeholders :
Developing wider intelligence and information sharing Inc. A&E, GP’s.
Increasing trust between the MET and LAS to deliver a better service to the public.
Sharing information to inform MET decision making at the start of the process (“The more we know, the earlier, the better the decision!”)
Still retain the ability to provide a face to face assessment across the NELFT Boroughs.
Softer option in that police do not need to exercise power and control, this is in turn less stigmatising / intimidating/threatening to our service user.
The desired mode of conveyance being via LAS.

15. UNIQUE CHALLENGES Large geographical area/ response times/logistics.
Sections of extreme deprivation.
Transient population.
Limited funding resulting in restriction on our availability as ideally we would want to be 24/7 for the 365 days.
Some police officers/LAS still unaware of pilot. This is resulted in unnecessary s136 detentions and presentations to A&E at times.
Nationally the incidences of s136 have been consistently high.

16. Moving Forward
An integrated team model i.e. combined and dedicated team of Street Triage and Mental Health Direct Nurses working under the same management with one identity.
Single point of referral which would be less distressing to our service users.
Permanency - we believe this would have a direct impact in reducing s136 incidences.
Staff development and supervision to ensure good clinical governance and quality assurance.

17. Current Mental Health Crisis Service
We currently have a number of services providing the crisis and acute response for NELFT with different levels of funding. Some of the services are currently funded through the crisis concordant funds and one of them not funded therefore a cost pressure for NELFT.
Bleep Holding Team
Section 136
Switchboard
Enhanced Mental Health Liaison Service
Emergence Duty Team
Access Assessment & Brief Intervention Team
Emotional Wellbeing Out of Hours Service
Street Triage
Mental Health Direct
Acute Crisis Assessment Team (ACAT)

18. Fragmented Crisis Services
EMHLS
Switchboard
Street Triage
EDT
ACAT
Section 136
MHD
Home
Treatment
EWB OOH
Bleep
holding
AABIT

19. NELFT Integrated Acute Crisis Services
Street
Triage
MHD
EDT.
EMHLS
Section 136
Home
Treatment
ACAT
Bleep
Holding
EWB OOH
Switchboard
AABIT
New
Teams

20. BHR Integrated Acute Crisis Services
Inpatients
Police
Acute Crisis
Services
LAS
Voluntary
Sector
AABIT
New
Teams

21. Why integrated offer?
Single point for all the crisis services for NELFT which would mean doing the day first point of contact being Access Assessment and Brief Intervention (AABIT) and out of hours all referrals would go through the MHS Acute response services. This we believe would give a better service user experience for mental health patients during period of crisis.
The integrated offer would make it easy to develop a seamless care pathway for the LD cohort as per TCP programme, we are already providing as part of the integrated offer out of hour for Children and Young Persons in Essex which is funded by Essex.
This offers brings all crisis services under one management structure