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Cynulliad Cenedlaethol Cymru |
National Assembly for Wales |
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Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon |
Health, Social Care and Sport Committee |
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Ymchwiliad i iechyd meddwl yng nghyd-destun plismona a dalfa’r heddlu |
Inquiry into Mental health in Policing and Police Custody |
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HSCS(5) MHP23 |
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Ymateb gan Ymddiriedolaeth GIG Gwasanaeth Ambiwlans Cymru |
Evidence from Welsh Ambulance Services NHS Trust |
1. The Welsh Ambulance Services NHS Trust (WAST) welcomes the opportunity to submit evidence to the Committee’s inquiry into mental health in policing and police custody. We hope that this evidence supports the Committee in its inquiry and we would welcome the opportunity to provide further evidence in person should the Committee require it.
2. Our Mental Health Improvement Plan aims to improve our response to people in mental health crisis through better training of our people, developing better pathways for the public and improved mental wellbeing in our staff. We have already trained a fifth of front line staff in mental health interventions, we have rapid access to mental health intervention for our staff in place and we work in partnership with police colleagues to improve our response to people in crisis.
3. Our evidence will focus on our capacity to respond to people in crisis, the challenges of identifying mental health demand across the system, existing conveyance arrangements and our proposals for supporting and working towards a single crisis care model for Wales.
4. In October 2015, WAST changed the way it responds to 999 calls with the Clinical Response Model (CRM) in line with the five-step model for emergency services known as the Ambulance Service Care Pathway. This has not specifically impacted on our response to mental health calls.
5. This model aims to deliver a fit for purpose, safe and high quality clinical response that improves patient flow, outcomes and experiences of care, and supports the change to a clinically focused organisation that contributes to addressing the wider challenges facing the NHS Wales’ unscheduled care system.
6. A review of amber category calls undertaken by the Emergency Ambulance Service Committee (EASC), which includes the majority of mental health calls, identified that the “the overriding factor” in improving the response times for Amber incidents is “the availability of ambulance resources and not the categorisation of those patients as Amber.” Amber availability is the product of various factors: how much resource is available in the first place (levels of investment), unplanned abstractions from rosters e.g. sickness, post production lost hours e.g. vehicle defects and time lost at hospitals handing over patients or clearing for the next job.[1]
7. Across Wales from February 2018 to January 2019, 72,077 hours were lost to delays in handover of care from ambulances to hospitals compared to 59,965 hours in the same period the previous year. Improvements have been seen in winter months (2018/19) compared to last winter; however, the overall trend is increasing and the number of lost hours remains a significant concern.
8. WAST has been working with our partners across the system to reduce time lost at hospitals, which frees up more ambulance resources to respond to patients who are waiting in the community. The work involves reducing patients conveyed to major emergency departments, where it is clinically safe and appropriate to do so, and improving patient flow in hospitals.
9. It is challenging to get a full and accurate picture of mental health demand across the crisis care system in Wales.
10. In WAST, our approach to assessing demand in the 999 system relies on our prioritisation of calls and the category we assign to them. The two key mental health categories that can be assigned by 999 call takers are category 23 (overdose/poisoning) and category 25 (psychiatric/abnormal behaviour), but mental health conditions can be a contributory factor in many calls made to 999, and can be allocated to many other categories.
11. For example, if someone is having respiratory difficulty they will be allocated to protocol 6 - breathing problems, even if the source of their difficulty later transpires to be a panic attack. Whilst this ensures that we respond to the most serious and life threatening cases, it does mean that we cannot easily identify all mental health calls from our data.
12. Of the circa 470,000 calls to 999 that WAST responds to every year, at least 6% of these calls are allocated to codes 23 and 25 (roughly 3% each) i.e. have mental health as a primary concern. The EASC review of amber calls identified that around 3.3% of amber calls to WAST were in protocol 23—psychiatric/abnormal behaviour, which is broadly in line with the Trust`s estimates.
13. However, a 2013 study of the mental health demand in ambulance services looked at a random sample of WAST patient records and found that nearly 11% of calls where an ambulance was dispatched to an incident had a narrative relating to mental health problems.[2]
14. Looking at the wider crisis care system, a 2016 international study of emergency departments (including some UK EDs) estimates the total mental health demand to be circa 4% of all episodes in a year, with suicide and self-harm together comprising the largest categories.[3]
15. Her Majesty’s Inspectorate of Police and Fire & Rescue Services report “Picking up the Pieces” found that 3% of police incidents were logged as ‘mental health’ during a demand exercise that was completed by 22 police forces in England and Wales.[4] They also found that
“Overall, we found that many forces don’t have a clear picture of their mental health demand. […] Identifying the nature and scale of demand that the police face in dealing with mental ill-health is difficult. Many types of incidents that police attend can be mental health-related in some way.”
16. Some of the challenge arises from a lack of conceptual clarity e.g. being clear about what is (and what is not) a mental health presentation, how we record these cases and how we develop shared means of analysing and interpreting information. We also need to assess the level of co-response to demand e.g. where WAST and Police Services respond to calls jointly, or call on another service to respond instead. These issues are not new, and are not unique to Wales.
17. Developing a clear, system-wide picture of mental health demand is a priority, and we are exploring how we can approach this work with Welsh Government and EASC.
18. The Mental Health Crisis Care Concordat (CCC) is a shared statement of commitment from the crisis care system, with the aim of reducing use of Sections 135 and 136 of the Mental Health Act. Sections 135 and 136 are powers under the Act used to take people to a place of safety (section 135 from a private residence, section 136 from a public place). Section 136 is used by police if they think someone has a mental illness, and is in need of ‘care or control’.
19. The CCC states that:
Police vehicles will rarely be used to convey people in crisis save for the most violent of individuals and only exceptionally to transport people between NHS facilities. NHS Transport or other health vehicles (not necessarily an ambulance) should be commissioned to convey people to hospital who are in mental health crisis.[5]
20.The National Crisis Care Concordat Delivery Group, and several regional and local groups have been established to further define how this commitment would be delivered. As a national organisation, WAST is clear that a ‘once for Wales’ needs to be commissioned, with some local flexibility as required e.g. for rural areas. However, there continues to be significant variation across Wales.
21. The current crisis care model in Wales has developed organically over a number of years, and is based on traditional patterns of service and additional evidence, and has had some investment. This model is largely focused on meeting the needs of people who have a mental illness and are using or have used mental health services in the past. We believe that a focus on this group has led to some improvement over a number of years, though there is still some way to go to improve crisis services across Wales e.g. by having 24 hour crisis teams available to everyone who might need them.
22.We believe some of the police and WAST demand arises when people ‘fall through the cracks’ in these and other mental health services e.g. when services are ‘out of hours’. However, we also believe that there is probably a larger group of people who do not have a mental illness diagnosis, have not used mental health services or do not reach thresholds for access, but nonetheless end up in crisis and require a response.
23.There is no clearly defined pathway, or clear service offer and no ‘safety net’ for this group, leaving WAST, the Police Services, primary care, Emergency Departments and others to offer some form of crisis response. We acknowledge that the system’s response is not currently designed to help people to address the root cause of their crisis, or in preventing its recurrence.
24.In response to this, we have started discussions with Welsh Government, Commissioners, Health Boards, the Voluntary Sector and Police Services on developing a different model of crisis care that could offer different responses and approaches to people in crisis. We think it vital that there is a single, ‘once for Wales’ crisis care model (with local flexibility) so that there is equity of access across the country, and ease of navigation for the public wherever they might be.
25.This model needs to be stepped i.e. offer services at the right level for people when they need them, some of which could be by telephone, would include voluntary sector provision, would enable shared learning for police, ambulance and health board staff, and would seek to improve outcomes for everyone.
26.We see great potential for shared routine data collection that would help us to eliminate some of the issues identified earlier in this submission, and would help us to further target services at people who need them.
27.People in mental health crisis, and other forms of crisis, are an integral part of the population of Wales and deserve a timely response of our services as anyone else. However, we acknowledge the challenges in understanding the totality of the demand, and in ensuring that people receive the right response.
28.WAST is focused on improving outcomes for people in crisis through our mental health improvement plan. We are enhancing our practice and pathway development to respond better to people in crisis, however, system wide improvements are far more likely to be sustained and to deliver better outcomes and experiences for people in crisis.
29.We think that a single model of crisis care, with additional funding to establish it, support it and monitor its impact would be transformational and would ensure that people receive the services they need in a timely manner.
[1] EASC 2018 A review of calls to the Welsh Ambulance Service categorised as amber
[2] Whitfield et al 2013 Development of a pre-hospital mental health model-of-care for application and testing in the Support and assessment for Emergency Referral (SAFER 4) trial
[3] Barratt H et al. 2016 Epidemiology of Mental Health Attendances at Emergency Departments: Systematic Review and Meta-Analysis. PLoS ONE 11(4): e0154449. doi:10.1371/journal.pone.0154449
[4] HMICFRS 2019 Picking up the Pieces
[5] Welsh Government 2016 Mental Health Crisis Care Concordat