Emergency response to patients in mental health crisis is substandard and worse than that for physical health emergencies (Mental Health Taskforce, 2016). Inadequate provision and an increase in suicides continue despite government initiatives such as New Horizons: a Shared Vision for Mental Health (HM Government, 2009), No Health without Mental Health (Department of Health and Social Care (DHSC), 2011) and The Five Year Forward View for Mental Health (Mental Health Taskforce, 2016). Ambulance services respond to numerous calls related to mental health and, because alternative services are limited, the most appropriate care delivery is often not achieved (Mental Health Taskforce, 2016; Duncan et al, 2019).
The role of the paramedic has developed considerably, with increasing responsibility for providing patients with the most appropriate treatment at their first contact with a health professional (College of Paramedics, 2018). The contemporary paramedic is an autonomous practitioner who has the knowledge and skills to assess, treat, diagnose, manage, discharge and refer patients in a range of urgent and emergency settings (College of Paramedics, 2018).
This article will discuss and evaluate alternative care pathways that are available for paramedics to make appropriate referrals for patients presenting with acute mental health crisis. Through reflection on a case study, common difficulties faced in paramedic practice will be identified, along with an evaluation of comparable working practices of paramedics internationally. Evidence discussed suggests that improvements are needed for collaborative working between ambulance service trusts and mental health services. Therefore, further improvement to existing pathways is proposed via a multi-agency response.
Method
A literature search was carried out using CINAHL, MEDLINE and PsycINFO databases, using key words: ‘ambulance’; ‘paramedic’; ‘pre hospital’; ‘emergency’ and ‘mental health’; ‘mental illness’; ‘mental disorder’; ‘mental health crisis’; ‘psychiatric’ and ‘alternative care pathway’; ‘referral’ and variations of each in a boolean search structure. The search was international in scope but confined to papers in the English language. The timeline encompassed papers published within the last 10 years. Additional articles were found using similar key words via websites, including those of the DHSC, the Samaritans, Mind and the National Institute for Health and Care Excellence (NICE). The strategy for selecting papers involved a database search followed by a screening of titles and abstracts. The review included papers that referred to prehospital mental health crisis response from paramedics. Papers that referred to mental health crisis in other settings or omitted paramedics were excluded. Based on these terms, 35 of 222 were selected.
The article focuses on south-west England and includes the South Western Ambulance Service Foundation Trust (SWASFT) and Avon and Wiltshire Mental Health Partnership (AWP).
Background
Every year, approximately one in four people experience a mental health problem (Mind, 2017). The Adult Psychiatric Morbidity Survey provides data from 1 January 1993 to 31 December 2014 (NHS Digital, 2016). While there has not been a significant change in the number of people diagnosed with common mental health problems during this period, the number of people who self-harm or have suicidal ideation has increased, which suggests that people are struggling to cope (NHS Digital, 2016).
Self-harm is defined as intentional self-poisoning or self-injury, irrespective of motive (NICE, 2011). Carroll et al (2016) suggest that a past history of suicidal behaviour or self-harm is one of the strongest predictors of death by suicide. Men account for 75% of suicides in the UK (Office for National Statistics, 2016), with socioeconomic disadvantage highlighted as a key risk factor for suicidal behaviour (Samaritans, 2016). When low socioeconomic status is coupled with poor physical health, life expectancy for people with severe mental health problems can be reduced by up to 25 years (NHS Confederation, 2016). A combination of factors, including the side effects of antipsychotic medication, lifestyle and difficulty in accessing mainstream health services can all contribute to decreased life expectancy (Mental Health Taskforce, 2016).
A person may request an ambulance for both physical and mental crises (Elliot and Brown, 2013). Information obtained under the Freedom of Information Act revealed a 14% rise in mental health calls received by SWASFT between 2016 and 2017 (SWASFT, 2018a) (Appendix A available online). Palmer (2011) explored the difficulties patients have in sourcing help and found that many called 999 in desperation.
Suicide is preventable; no civilised and caring society should tolerate this level of despair, hopelessness and avoidable tragedy (British Psychological Society, 2017). To realise the Samaritans' vision of fewer people dying by suicide, collaboration across central and local government, all local agencies, ambulance trusts and mental health services is required to help ensure early identification of suicidal behaviour and ensure that the right and most effective care is provided at the earliest opportunity (Palmer, 2011; Samaritans, 2016). It is therefore suggested that paramedics are well placed to achieve this.
Case description
The patient, John Smith (pseudonym), is a 36-year-old man, who is employed and living in a socially deprived area. Following a recent incident in his personal life, he began experiencing symptoms of anxiety and depression. After visiting his GP, he was referred to the community mental health team. Their assessment concluded that he was low risk and he was subsequently discharged.
During the weekend following discharge, Smith expressed suicidal ideation and the intention to harm himself. As this occurred out of hours, his GP was unavailable. His partner contacted the crisis team but they could only provide help over the phone. Smith had not responded well to this. In desperation, his partner called 999.
With compassion and reassurance, the ambulance crew encouraged Smith to talk with them, and gained informed consent for a medical assessment. Several superficial cuts were found on the anterior forearms. He intended to kill himself by slitting his wrists, and planned to do so imminently.
To support clinicians in determining the risk of suicide or self-harm, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) (2016) has provided a risk assessment tool (Appendix B available online). Using this method, Smith was assessed as being high risk. The crew liaised with the crisis team, who recommended that he should return to his GP after the weekend.
Once the crew had entered into a patient–carer relationship with Smith, they had a duty of care (Clarke et al, 2012). Based on the four principles of ethics, they were able to consider their decisions to ensure they acted in his best interests (Beauchamp and Childress, 2013). The crew decided that leaving him at home with no immediate support would be a breach of this duty; therefore, the only other option was conveyance to the emergency department (ED).
Fortunately, after persuasion, Smith agreed to attend the ED. If he had not, the crew would have had to determine capacity with reference to the ’ID A CURE test’ (Is there an Impairment or Disturbance of the mind which prevents the person from being able to ‘CURE’, plus a failure of one of the following factors: Communicate, Understand, Retain, Employ, means the person lacks capacity) which is detailed in Sections 2 and 3 of the Mental Capacity Act 2005. As a result of the sudden decline in his mental health, it could be argued, Smith was suffering from mental illness causing a temporary impairment of his mind. His consumption of alcohol was an additional contributor to this impairment. If assessed at this time, he would have been found to be incapacitated.
Because Smith was in his own home, the crew would have had to use the Mental Health Act 1983, to arrange for an approved mental health practitioner (AMHP) and doctor to attend, with a section 135(1) warrant if needed, to assess him in his home or remove him to a place of safety. The crew could not have relied solely upon the Mental Capacity Act 2005 to remove John, as questioned in the case of Sessay R (on the application of) v South London & Maudsley NHS Foundation Trust & Anor (2011).
Discussion
In England, the income of mental health trusts was lower during 2016–2017 than in 2011–2012 (Royal College of Psychiatrists, 2018). These reductions left 48% of people who should receive care from social services with nothing (Docherty and Thornicroft, 2015). As well as a lack of funding, there has been increased demand for mental health services, both of which have contributed to prolonged stays in the ED before formal admission (Roberts and Henderson, 2009).
Cutler et al (2013) argue that the ED is a safe environment for those experiencing an acute mental health crisis, with access to medication, security measures or simply space to observe the patient. While this may be true, Nicks and Manthey (2012) disagree; a high-stimulus environment can exacerbate symptoms such as anxiety and agitation, leading to increases in absconding rates and risks of self-harm and suicide.
EDs across the UK house liaison mental health teams, the majority of which report that they provide a 24/7 service; however, only 10% do so with a sufficient level of staffing, with weekend services being particularly poor (NHS England et al, 2016). The evidence-based treatment pathway recommended by NHS England et al (2016) states that the mental health liaison team should respond within 1 hour of the patient arriving at the ED, and complete a full biopsychosocial assessment or Mental Health Act 2007 assessment within 4 hours. In reality, patients often have to wait 6–8 hours before they receive an assessment (Home Affairs Committee, 2015). In this example, Smith waited in the corridor outside the ED for more than 6 hours before he was assessed.
Mental health charity, Mind, undertook an inquiry into crisis mental health care, and found that patients felt the ED was inappropriate because of long waits, often in a busy area (Mind, 2011). Patients want reassurance, stability, kindness, to be understood and not to be judged, with access to help 24 hours a day (Mind, 2011). Unfortunately, a report from the Care Quality Commission found fewer than 40% of people accessing the ED felt they were listened to, taken seriously and treated with compassion, citing GPs, ambulance staff and the police as more caring (Mental Health Taskforce, 2016). Heyland and Johnson (2017) established that many patients prefer alternative, non-hospital services such as crisis houses offering minimal coercion, maximum freedom, autonomy, safety and opportunities for peer support. Bristol Mental Health (BMH) provides crisis houses, which in Smith's case would have been suitable (BMH, 2014a). Eliminating the distress caused by attending an ED and providing immediate safety and care would have been a more appropriate and proactive outcome.
The treatment and psychological support provided by health professionals to someone who has self-harmed is invaluable (Conlon and O'Tuathail, 2012). It can have a profound effect on future acceptance of care; for example, a poor experience can result in aversion to emergency services (Ahl and Nyström, 2012). Shaban (2006) recognised that paramedics have an opportunity to make valuable contributions to crisis mental health care as they are often the first point of contact following self-harm and/or suicidal ideation. It is widely understood that talking, engaging and listening are of utmost importance, but the ED environment is often not conducive to this. In contrast, the ambulance provides a space to talk in private, one patient at a time (Rees et al, 2015). Paramedics therefore have an excellent, unique opportunity to provide holistic care.
Historically, training and education in mental health has been unsatisfactory, although it should be given the same consideration as physical illness (Roberts and Henderson, 2009). The qualitative study by Roberts and Henderson (2009) revealed that paramedics with more than 5 years' experience felt more adequately prepared than those who had recently qualified, suggesting that the majority of mental health education is gained through experience.
The idea that paramedics require additional training is being recognised. For example, the London Ambulance Service organised a mental health study day, delivered by the West London Mental Health Trust (WLMHT). It is thought that paramedics will gain clarity in their decision making by learning from experienced practitioners (WLMHT, 2016). SWASFT offers three courses relating to mental health awareness (SWASFT, 2018b) and the paramedic science BSc includes a module on psychosocial studies (University of the West of England, 2018).
Elliot and Brown's (2013) evidence-based case for a national mental health pathway for paramedic care found no other guidelines for the treatment of mental ill health approved for paramedics besides the general information guideline provided by JRCALC (2016). They argue, therefore, that there is a developmental need for a paramedic referral pathway but this may be challenging as every case of mental health crisis presents differently (NICE, 2016). The clinical decision-making process is influenced by factors including: limited education, time constraints and the perception that alternative treatment options are minimal or difficult. This is especially evident if the paramedic has previously experienced poor support from community mental health teams. In this case, John ended up at the ED despite attempts to avoid it, so it is likely that this crew will have been discouraged from attempting referrals in future.
While it would be preferable to have a streamlined, national approach, this is not achievable because services across the UK vary widely (NHS England et al, 2016). AWP provides an extensive range of community services, which are accessible only via GP referral and provide non-crisis support (AWP, 2018). Paramedics can refer patients to the crisis team, which operates 24 hours a day (BMH, 2014b). This was the intended pathway for Smith but the team was attending only high-priority calls because of staffing levels. Depending on the level of urgency, assessment with the crisis team should occur within 1 hour (BMH, 2014c).
When a person in mental health crisis appears not to meet the criteria for support, the system clearly fails in its duty to care for people who are arguably among the most vulnerable in our communities (Elliot and Brown, 2013). In this example, the crew expressed feelings of guilt following the incident because they felt they had failed to communicate their overwhelming concern for Smith. If he had not been in crisis, the crew would have provided a safety net by arranging further support via the GP. A more efficient route would be for paramedics to directly refer patients to services at AWP such as the Assessment and Recovery Service (BMH, 2014d), Psychological Therapies (BMH, 2014e) or Bristol Sanctuary—a safe space to attend when in crisis during the evenings from Friday to Monday (BMH, 2014f).
International comparison
In New South Wales (NSW), ambulance officers receive extended training that enables them to detain patients under the NSW Mental Health Act (2007). A quantitative study by Cutler et al (2013) found that only 27% of the patients detained by ambulance officers were admitted to a specialised unit, compared with 60% of those detained by an accredited mental health practitioner. This is a cause for concern because of the associated social stigma and legal implications of inappropriate detention (Cutler et al, 2013). In the UK, social workers, mental health and learning disabilities nurses, occupational therapists and practitioner psychologists can train to become AMHPs, who can act under the Mental Health Act 2007 (Health and Care Professions Council, 2013).
One benefit of allowing paramedics to train as AMHPs would be a reduction of delays, as they could assess and transport patients directly to mental health facilities (Bradley et al, 2015). Townsend and Luck (2009) suggest that paramedics would be better qualified than the police, who often have to be called upon by paramedics to assist in detention under the MHA 2007.
In contrast, Emond et al (2017) suggest having the power to impose treatment upon a person with mental illness who has decision-making capacity may encourage defensive practices. For example, a paramedic may feel they are legally and morally safer to transport a person against their will; however, if this power is used inappropriately, it goes against the fundamental principle of respect for autonomy (Beauchamp and Childress, 2013). Knott and Bannigan (2013) found that nurses undertaking the role of an AMHP were concerned it could have a detrimental effect on the therapeutic relationship between them and the patient; a similar situation could arise for paramedics. In crisis situations, the paramedic can best play the role of patient advocate; the College of Paramedics therefore contends that existing powers in terms of deprivation of liberties afforded under the Mental Capacity Act 2005 are sufficient (Berry, 2014).
Western Sydney has taken a collaborative approach to treating mental health patients in the community. Mental health-related calls are passed to a dedicated dispatcher, who sends out the mental health acute assessment team (Faddy et al, 2017). Staffed by an extended care paramedic providing physical assessment and a mental health nurse responsible for comprehensive mental health assessments, this team can arrange direct admission to specialised inpatient units (Faddy et al, 2017). In the Canadian province of Nova Scotia, partnerships between the police department and mental health services promote efficiency and better treatment (Kisely et al, 2010).
In the US, the police take a lead in crisis response. Officers receive additional training from mental health professionals and can choose to liaise with mental health services once on scene with a patient, thereby providing a more calm, humane approach (Oliva and Compton, 2008). While this appears to be a good initiative, liaison with mental health services is a secondary action. In the UK, adoption of the Mental Health Crisis Care Concordat (DHSC, 2014) was intended to improve collaborative approaches, including provision of funds for the Street Triage initiative (Home Affairs Committee, 2015). Either a mental health practitioner and police officer respond and assess the patient together or, similar to the US, a mental health practitioner is stationed in the police control room providing advice to officers on scene (Horspool et al, 2016).
Evidence to support the success of this scheme is limited, but initial results are promising. Sue Mountstevens, the police and crime commissioner for Avon and Somerset Police, stated that during 2015–2017, the triage team assisted on more than 2500 occasions, providing better care and avoiding unnecessary detention (Avon and Somerset Police, 2017). Street Triage has helped develop relationships between the participating agencies and, importantly, gives frontline staff access to both police and medical records so they can establish whether a care plan is already in place (Home Affairs Committee, 2015).
Suggested pathway
In the West Midlands, a successful collaborative model has been implemented. Deployed under the guidance of both police and ambulance control rooms, a police officer, a paramedic and a mental health nurse respond to assist patients believed to require immediate mental health support (Birmingham and Solihull Mental Health Foundation Trust (BSMHFT), 2018). During the first year, 1000 patients avoided ED because physical treatment was provided on scene, and there was a 50% reduction in the use of detention under section 136 of the Mental Health Act 2007 (BSMHFT, 2018). A similar holistic, problem-solving approach to operate over the Christmas period was adopted in Wales; however, it was only temporary (Ford, 2017).
Staffing of these multidisciplinary teams requires careful consideration. As previously discussed, people who self-harm want to be seen by empathetic health professionals who will listen, and be supportive and non-judgmental (Mind, 2011; Rees et al, 2015). The attributes identified by NICE in the guidelines for the management of self-harm were also found to be the top six desirable qualities in paramedics: patient-centred, caring, empathetic, valuing life, professionalism and non-judgemental/non-discriminatory (NICE, 2011; Rees et al, 2015). Not everyone has these attributes naturally, but those who do and have an interest in mental health could form a specialised mental health response unit (Rees et al, 2015).
Conclusion
Mentally ill patients comprise an ever-growing proportion of the paramedic workload. Mental health liaison teams in the ED are a necessary part of pathways for patients that self-present; however, patients attended by paramedics could be assessed at home. Evidence has shown that improved collaboration between emergency services and mental health trusts benefits both patients and services, saving time and money, reducing patient distress and avoiding ED overcrowding.
Extending detention powers to paramedics is unlikely to bring significant improvements to UK referral pathways, unlike holistic team approaches such as that adopted by the West Midlands Ambulance Service. Consisting of a paramedic, mental health nurse and police officer, a mental health assessment and treatment team (MHATT) provide support and treatment on scene, make referrals to local mental health services or arrange direct admission under the Mental Health Act 2007.
SWASFT (2018c) has said they are keen to work with partner organisations to understand how they can collaborate to deliver the right care in the right place at the right time. Further improvement could be achieved through a multi-agency response to provide this (SWASFT, 2018c).
Many UK ambulance trusts employ specialist paramedics who have an extended range of skills to treat physical aliments. In a similar vein, introducing a role of specialist mental health paramedic (SMHP) with extended mental health education is recommended. Each ambulance service area would ideally have one MHATT operating 24 hours a day. A team of SMHPs could rotate their duties to include exposure to other 999 calls to support clinical skills retention. The MHATT could be tasked by a dedicated dispatcher or respond to crew requests.
In this example, a MHATT would have benefited Smith because he would have avoided the ED and remained in a familiar, calm environment. Second, his wounds could have been treated by the paramedic. Third, a mental health nurse could have conducted a mental health assessment resulting in either detainment under the Mental Health Act 2007 if required or prompt referral to the home treatment team with access to crisis services in the interim. The ambulance service would also benefit because it is likely that the time on scene would be reduced, and the crew who attended would have felt better supported, thus protecting their own mental health. Referral via ED or MHATT both lead to a similar outcome but the latter is more efficient, supportive and patient centred.