Police-related triage interventions for mental health-related incidents: a rapid evidence synthesis

Population

Reviews and studies were included if they evaluated interventions relating to individuals who are perceived (by themselves, by others or by police officers) to be experiencing mental ill health or a mental health crisis and who come into contact with the police.

Interventions

Reviews and studies were included if they described interventions that met the following definition of PRMHT:

• Police officers responding to calls involving individuals perceived to be suffering from mental ill health or a mental health crisis.

• A judgement about the most appropriate route of care for the person concerned is made in the absence of suspected criminality or a criminal charge (e.g. the use of L&D services to assess and refer individuals to an appropriate non-CJS treatment or support service, would be relevant; L&D services related to out of court disposals, case management and sentencing would not be relevant).

Study design and comparators

Reviews/evidence syntheses and recent relevant primary studies (those that were published after the search dates of included evidence syntheses) were included. Emphasis was placed on reviews that use transparent or reproducible methods [as determined by the Database of Abstracts of Reviews of Effects (DARE) criteria]. 31 It is mandatory that reviews demonstrated adequate inclusion and exclusion criteria, a literature search and a synthesis. In addition, a formal quality assessment of primary studies and/or sufficient study details must have been reported. Further details of the assessment are available from the review authors. Reviews that failed to meet these standards were tabulated and referenced. For recent primary studies, inclusion was restricted to quantitative evaluative methods, either as a stand-alone methodology or as a discrete part of a larger mixed-method study. Non-evaluative descriptive publications were excluded but recorded for information; details can be found in Appendix 2. Ongoing studies are listed in Appendix 3.

Outcomes

Inclusion was not restricted by outcome. Outcomes of interest were the:

• rate of utilisation of police cells in relation to S135 and S136

• quality and timeliness of assessment, referral and treatment

• mental health outcomes

• demand on police resources and police officer time

• demand for community mental health services

• rates of hospitalisation via A&E or acute mental health services

• level of service engagement

• rates of reoffending or arrest

• changes in case-finding and access to health services (e.g. mental health, substance misuse, sexual health and contraception)

• experience of services for service users

• experiences of police and mental health staff (including future staff training needs) and other relevant stakeholders

• costs to health and police services.

Settings

Inclusion was not restricted by country or setting.

Population

Studies were included if they reported data on interventions relating to individuals who are perceived (by themselves, by others or by police officers) to be suffering from mental ill health or a mental health crisis and who come into contact with the police.

Interventions

Studies were included if they described interventions that met the following definition of PRMHT:

• Police officers responding to calls involving individuals perceived to be suffering from mental ill health or a mental health crisis.

• A judgement about the most appropriate route of care for the person concerned is made in the absence of suspected criminality or a criminal charge (e.g. the use of L&D services to assess and refer individuals to an appropriate non-CJS treatment or support service would be relevant; L&D services related to out of court disposals, case management and sentencing would not be relevant).

Study design

Inclusion was restricted to well-reported qualitative studies that collected data using specific qualitative techniques (such as unstructured interviews, semistructured interviews or focus groups, either as a stand-alone methodology or as a discrete part of a larger mixed-method study) and from which the data were analysed qualitatively (e.g. using thematic analysis, content analysis or other recognised qualitative method). Studies that collected data using qualitative methods but then analysed these data using quantitative methods were excluded.

Outcomes

Inclusion was not restricted by outcome. Outcomes of interest included stakeholder (including service users’ and providers’) perspectives on the acceptability and feasibility of PRMHT, with specific reference to:

• attitudes, beliefs and experiences about the use of the intervention

• perceived facilitators of and barriers to implementation (e.g. willingness, capability and capacity of both police and mental health workforces, organisational and procedural factors)

• health equity issues [e.g for black, Asian and minority ethnic (BAME) communities, people without English as their first language, people with neurodevelopmental disabilities]

Settings

Given the unique governance arrangements for delivering a mental health triage service in the UK, as well as important differences in social context and the delivery of health and criminal justice services between countries, inclusion was restricted to qualitative data on interventions that were undertaken in the UK.

Pre-arrest diversion

Control room call-handlers identify incidents when people are in a mental health crisis and to which they can despatch unaccompanied police officers with special mental health training who can then refer to mental health services [e.g. CIT or a Mental Health Intervention Team (MHIT)]. 11,12,14,15,39,40

Co-response

Co-response includes front-line police officers being supported by a MHP as a joint, on-scene response (hours may be restricted, i.e. co-response with MHPs may be operated only during night shifts) and/or a MHP in a control room [e.g. street triage teams in the UK11,12,14,15 or a police, ambulance and clinical early response (PACER) in Australia]. 12 The Parker et al. 14 scoping review described interventions in which the MHP exclusively provided advice from a separate location (e.g. via telephone) as befitting a ‘consultation’ model.

Service integration models

This intervention was described in the scoping review of models of interagency collaborations. 14 The model describes multiagency integrated services to create a network to bridge gaps between services, decrease arrest, decrease violence, improve educational attendance and completion, and reduce symptoms of mental ill health and psychological distress. These may typically involve a network co-ordinator (often a MHP), a personalised action plan for individuals in mental distress and active follow-up with signposting to the relevant agency. This is somewhat broader than the focus of the current review as it encompasses far more than triage and/or crisis work.

Training programmes and resources

Training and resources were described for the various PRMHT interventions, which had either a specific or a broad mental health focus. 39

Kane et al. (2017)

The most recently published systematic review, by Kane et al. ,11,12 included studies that reported on-street triage and CIT, plus one study that compared three different approaches with police involvement.

As a result of street triage co-response interventions, a quicker and more appropriate response by the teams was reported overall. Reductions were reported in single studies for formal detentions, an increased use of HBPOS and a reduction in time spent on-scene by the team.

Kane et al. 11,12 also reported findings for comparisons between CIT-trained officers and non-trained officers. Trained officers were more likely than non-trained officers to direct people with mental ill health to mental health services, but this depended on local services available. Trained officers also demonstrated different approaches to people with mental ill health. Although it should be noted that police officers self-selected for training, that might indicate an existing difference between trained and non-trained officers, which could have an impact on approaches and attitudes.

One study in Kane et al. 11,12 reported on a comparison of three different models operating in the USA, including civilian police employees with additional training to assist police officers in mental health emergencies, a CIT unit and a mobile crisis unit. Authors reported that ‘the dispositions of cases handled by the specialised response personnel were found to be related to the programme type’12 (no further details reported), although all three models reported an average rate of arrests of 7%. Factors reported to be related to success were the existence of a psychiatric triage or drop-off centre to which the police could transport individuals in crisis, and community partnerships in which police response is part of a wider response involving relevant agencies.

Taheri (2016)

Taheri40 reported that there were no statistically significant effects of CIT interventions, between CIT-trained and non-trained officers, on official or officer-reported accounts of arrests of people with mental ill health. However, the studies were heterogeneous and reported conflicting results. 40

Paton et al. (2016)

The review by Paton et al. 15 evaluated on-scene co-response or telephone triage by health or social care professionals in collaboration with police officers (some of whom were in receipt of CIT training). 15 These included various collaborative partnerships. One UK study of a street triage intervention, in which officers received telephone triage, was associated with a reduction in S136 detentions and a number of calls were successfully converted to hospital admissions. 42 There were also improvements in police time on the scene of a suicide call, and improvements in engagement with outpatient treatment by service users, although these findings were reported only in one or two studies.

Paton et al. 15 also reported the effects of police officers receiving training in mental health. The interventions included CIT-trained officers and a MHIT. In one study, training seemed to result in higher levels of verbal engagement and negotiation, and more referrals to and transport for treatment. Lower arrest rates and reduced referrals to intensive psychiatric services were also reported in one study. In another study, a MHIT intervention found no significant differences in the use of force before and after training, and no perceived improvement in the quality of the relationship between officers receiving training and health-care staff. Trained officers spent less time dealing with events that related to the Mental Health Act 1983. 2

Booth et al. (2017)

A review of mental health training of service providers reported findings across several interventions. 39 The review found that CIT training may be effective in connecting people with mental ill health with appropriate psychiatric services via police officers. The training may also have had an effect on officers’ attitudes, knowledge and beliefs. However, the review authors state that these findings were based on limited- and poor-quality studies. No comparison groups were reported in the primary studies.

Education, awareness training and anti-stigma courses aimed at a range of trainees including police officers, MHPs, teachers, public health officials and voluntary sector staff reported various successes following training, including positive changes in awareness, knowledge and attitudes.

A study of the training for MHIT teams of front-line police officers in Australia found no substantial changes in practice or relationship quality compared with no training. There were also no significant differences in skills.

A number of other training programmes, not directly aimed at PRMHT, were also reported in the paper.

Parker et al. (2018)

The scoping review by Parker et al. 14 did not report any findings from primary studies.

Joint on-scene response with police officers (five studies)

Mental health professionals were partnered with police officers to jointly attend incidents. Schemes varied across the studies, with police officers attending in uniform and teams arriving in marked or unmarked police vehicles or community vehicles. Hours of operation varied and were often limited to ‘peak response’ hours. Outside the hours of street triage operation, ‘usual response’ from police officers and access to mental health services continued. 9,43,45,46 One study reported a telephone line also being made available during peak hours to provide support to officers. 46 In one study, joint on-scene attendance of MHPs and police officers in one county in England was compared with telephone support only from a mental health nurse in another county. 44 In this intervention, a police unit would be on-scene before the street triage team arrive to assess the risk and confirm the need for the street triage car. This is to ensure that risk assessments are carried out before MHPs arrive at the scene, as police have a duty of care towards colleagues who have not had the same degree of training in conflict management, and who do not have the clothing and/or equipment to manage such situations. The studies covered a number of areas across England including parts of Derbyshire, Essex, Northumberland, Tyne and Wear, Norfolk, Suffolk, Sussex, Thames Valley and the West Midlands.

Telephone support alone (one study)

A model in which telephone support was provided by a MHP from a police control room was employed by the British Transport Police (BTP) service, which covers large parts of England across many health trust and police service boundaries. 9 The study by Jenkins et al. 44 compared the joint on-scene response of MHP and police officers in Ipswich, Suffolk, with telephone support only from a mental health nurse in Norwich, Norfolk.

Joint on-scene response and telephone support (one study)

A dissertation by Brace49 evaluated a street triage scheme in England (area not reported) that consisted of a MHP working in the police control room as well as a joint MHP and police officer on-scene response, both overnight. The aim was to provide an out-of-hours service because during office hours a service is provided by police officers and the mental health crisis team.

Telephone advice to on-scene officers and attend if necessary (two studies)

Two studies9,50 used this model of intervention in which MHPs did not routinely attend incidents but were available to do so if required. One study, covering part of Northamptonshire, was not clearly reported in terms of the intervention but appeared to involve police officers, a MHP and control room staff over certain periods of operation each week (details not reported). 50 The other study covered parts of Devon and Cornwall, where the MHP was based in the control room, and also the area covered by the Metropolitan Police Service, where the MHP was based in a mental health trust. 9

Telephone and/or on-scene response without police presence (one study)

A telephone and/or on-scene response without police presence was reported in two pilot evaluations. MHPs were situated in a local hospital (North Yorkshire) or a Crisis Assessment Service (West Yorkshire). 9

Training programme for police officers (one study)

The RCT by Scantlebury et al. 47 evaluated a training programme conducted in North Yorkshire that was aimed at front-line police officers who come into contact with people with mental health problems. A qualified and experienced MHP delivered the 1-day face-to-face mental health training in addition to routine police training.

Number and rates of section 136 detentions under the Mental Health Act 1983 (four studies)

It should be noted that some authors indicated that these data were gathered at the incident level, not the individual level. Therefore, one individual may have received more than one S136 detention.

Reveruzzi and Pilling9 evaluated the nine pilot areas of various models of street triage implemented in England. Street triage schemes in the West Midlands, Derbyshire and Thames Valley (all joint co-response schemes) saw the largest reductions in S136 detentions, with decreases of 27.5%, 25.3% and 22.7%, respectively. Significant reductions in S136 detentions were also found in West Yorkshire of 19.8% (MHP telephone and/or on-scene response without police presence), in Sussex of 18.3% (joint on-scene co-response scheme) and in Devon and Cornwall of 15.5% (MHP telephone advice to on-scene officers). The Metropolitan Police Service (MHP telephone advice to officers and attend if necessary) and North Yorkshire (MHP telephone and/or on-scene response without police presence) increased S136 detentions by 15.1% and 19.4%, respectively. BTP (MHP telephone support only) results were not included in these figures.

There were significantly fewer S136 detentions after the introduction of the street triage intervention (joint on-scene co-response) in Eastbourne and Sussex than before the intervention. 43 However, the authors noted that in only 6% of cases people were detained under S136 by street triage teams, whereas the remaining cases were made by officers during shifts when the street triage team was unavailable. The authors also noted that across the rest of Sussex S136 detentions increased, although this was not statistically significant. This study evaluates the area of Eastbourne, an area that was also included in Reveruzzi and Pilling9 as reported above, although some figures differ. This may be because each study referred to different years of census data to calculate some findings.

Two street triage schemes were compared by Jenkins et al. 44 The team in Ipswich, Suffolk, was a joint on-scene co-response team intervention, compared with a MHP telephone support-only scheme in Norwich, Norfolk. 44 Over the total evaluation time period (pre and post intervention), the telephone support team had statistically significantly fewer S136 assessments per 100,000 people than the joint on-scene co-response team (p = 0.01). The difference was statistically significantly greater between the areas in the pre-intervention period (p < 0.01). Post intervention there was a small, non-significant increase in those detained under S136 in the telephone support-only area but a large reduction in S136 assessments in the co-response team area (p = 0.01).

There was a 60% reduction in the rate of S136 detentions in the first year of a street triage scheme (joint on-scene co-response) reported by Keown et al. 45 in areas of Northumberland, Tyne and Wear. The greater the rate of street triage in an area, the greater the reduction in the rate of S136 detentions in the same area (p = 0.003). Data across three of the areas (Gateshead, South Tyneside and Sunderland) that first introduced a street triage scheme showed a statistically significant progressive reduction in the number of S136 detentions during each subsequent 3-month period in the first year of the street triage scheme compared with the previous year. This resulted in a 65% reduction in the first 3 months, 73% reduction at 6 months, 83% reduction at 9 months and 88% reduction at 12 months (p = 0.001). Additional data for Sunderland were available and authors reported a 78% average monthly reduction in S136 assessments following the introduction of street triage.

Number of assessments/detentions taking place in police stations (two studies)

Keown et al. 45 reported that only a small number of assessments were conducted in police stations both before and after the introduction of a street triage scheme (joint on-scene co-response) in one area of the intervention (Sunderland).

In Eastbourne, Sussex, there were significantly fewer detentions in custody after the introduction of a street triage (joint on-scene co-response) than the usual response before street triage (p < 0.05), as reported by Heslin et al. 43 Although because the street triage hours of operation were limited, a number of the detentions in custody during this period were by usual response.

Number of assessments in hospital (one study)

Keown et al. 45 reported that most S136 assessments were conducted in a dedicated S136 suite in a psychiatric hospital in Sunderland (just one area reported in the study), as they had been before the introduction of a street triage scheme (joint on-scene response). There were also no significant changes in the proportion of individuals detained in hospital, voluntarily admitted or with no admission after the intervention.

Detentions taking place in hospital (one study)

There were fewer detentions in hospital after the introduction of a street triage scheme (joint co-response) in Eastbourne, Sussex (reported in Heslin et al. 43), than before the intervention, but this difference was not statistically significant. Across the rest of the county, the number of people detained in hospital increased but this was not statistically significant. As reported above, because the street triage hours of operation were limited, a number of the detentions during this period were by usual response.

Number of admissions to hospital as a result of a section 136 assessment (one study)

There were no significant differences in admissions to hospital following S136 assessment reported in Jenkins et al. 44 before the introduction of street triage schemes in Ipswich, Suffolk, and Norwich, Norfolk. After the implementation of street triage, there was a statistically significant higher conversion to admissions for a joint on-scene co-response in Ipswich than pre intervention (p = 0.01), but there were no significant differences for admissions before and after the telephone support-only scheme in Norwich. After the interventions, there was also a significantly higher admission rate following S136 assessment in Ipswich than in Norwich (p = 0.04).

The same study also reported that the proportion of individuals who were not admitted to hospital following a S136 assessment but had at least one subsequent S136 assessment in the following 4 weeks decreased in both street triage schemes, but the decrease was only statistically significant for the telephone support-only scheme in Norwich (p = 0.01 vs. p = 0.14). The authors reported that there were more individuals in Norwich who had some contact with community mental health services in the 2 weeks prior to a S136 assessment than there were in Ipswich, and that there were more individuals in Norwich who had some contact with community mental health services before the introduction of a street triage intervention as opposed to after this introduction than there were in Ipswich (p = 0.01). Whereas, in Ipswich, there were no statistically significant differences between contact before or after the street triage intervention. There was also no evidence to suggest that individuals assessed in Ipswich were more likely to have been deemed to have ‘no mental illness’44 before the introduction of street triage than after, but in Norwich there was evidence to the contrary (p < 0.01).

Contact with community mental health teams or follow-up services (one study)

There was some evidence in Jenkins et al. 44 to suggest that if people in Ipswich were not admitted to hospital, they were more likely to be offered follow-up from secondary mental health services after the introduction of a street triage scheme (joint on-scene co-response) than before the intervention (p = 0.04). If follow-up was offered in Ipswich, there was evidence to suggest that the first follow-up appointment was more likely to be kept after the street triage scheme than before (p < 0.01). In Norwich, evidence from the street triage scheme (telephone support only) suggested that a person was more likely to be offered a follow-up before as opposed to after the intervention (p = 0.02), but there was no evidence of any difference between compliance rates before or after street triage implementation.

Costs (two studies)

Senker and Scott46 reported costs of a street triage scheme that had both a joint on-scene response unit and MHP telephone support in Essex. The authors reported potential annual benefits from street triage preventing the use of S136 and the wider impact of its use. These potential annual benefits included gross realisable savings for NHS trusts or Clinical Commissioning Groups of £347,200, with benefit to the value of £99,650 for the Essex police force in terms of reduced use of custody and reduced officer time attending S136 incidents, which realised a gross benefit value estimate of £446,850 and a net benefit of £179,758 when accounting for costs of running the street triage scheme.

Over the period of a street triage (joint on-scene co-response) evaluation of 26 weeks in Eastbourne by Heslin et al. ,43 the total cost of the scheme was estimated to be £148,785. The street triage team attended a total of 233 incidents, giving an estimated unit cost of £630 per incident attended.

The study calculated average costs to payers resulting in £1043 per person for street triage and £1077 for usual response; CJS: £470 for street triage and £559 for usual response (representing a cost saving of £31,862 over a 6-month period); and NHS: £574 for street triage and £517 for usual response (an additional cost of £20,406 over a 6-month period to the NHS for the street triage arm).

Other outcomes (one study)

After a 1-day bespoke training programme for front-line officers, Scantlebury47,48 reported that there were no significant differences in the number of incidents requiring a police response between those police stations receiving officer training and those police stations that did not. There was also no significant difference between the intervention and control arm stations in the number of people with mental health warning markers on their record. However, there was evidence that incidents at stations randomised to the intervention arm were more likely to have a mental health tag (applied by officers to indicate that mental health is a factor in an incident) applied than incidents assigned to control arm stations (p = 0.001).

Section 136 rates and related objectives

The primary objective of most PRMHT interventions was to reduce the number of S136 detentions during which police custody was used as a place of safety, with the ultimate aim of reducing demands on the police service. 9,50 Strong partnerships between police and health services were seen as crucial to achieving this objective, with co-location being described as one means of building trust, confidence and understanding within teams. 9 The authors of the Northampton evaluation noted that other objectives held by individuals and their respective organisations could relate to service quality, longer-term resolution and reduction of ‘regular callers’. 50

Shared information

A highly valued core characteristic of PRMHT interventions among police and MHPs was the ability to share information. This was seen to inform and improve the professional judgements of both police and mental health staff, thereby reducing reliance on S136. 9,42,50 When S136 was used, access to information via telephone facilitated discussions about the preferred and appropriate place of safety. 42

Role and location of mental health professionals

The most notable difference in terms of the service delivery model between the evaluated PRMHT interventions was the role and/or location of the MHP(s). In one study, opinions about how best to utilise mental health staff varied. Among control room staff, deployment with the mental health car was seen as being more closely linked with a successful resolution of the incident:

I’d like to see a bit more, I don’t know, resolution involved. ‘Cause it’s fine giving advice, I must admit I’d like to see them out more, deploy more.

Reproduced with permission from Callender and Cole. 50 © Institute for Public Safety, Crime and Justice, 2016

However, opinions among mental health staff were somewhat more varied. Some commented on how they would deploy to ‘see what they could do’; others saw their role as being more beneficial in the control room, where they have access to patient records and can advise officers on-scene. 50

Challenges of and barriers to the delivery of organisational objectives

Challenges and barriers identified in the DHSC-funded pilots included clarifying the purpose of the scheme, educating local services about its function and clarifying police officers’ role in private premises. 9 Although some schemes were characterised as street triage, many call-outs were to people who were not in a public place. This raised issues about the limits set to police power under S136, particularly when people were in their own homes and would not come voluntarily to hospital. 46 Police officers considered it important that health professionals involved in PRMHT interventions are made aware of these limits. Conversely, concerns have been raised that control room staff may fail to request a PRMHT team to attend incidents in the home if the intervention had been promoted to them purely in terms of street triage. 46

Barriers to evaluation against organisational objectives

A challenge to showing whether or not objectives had been met was collecting evidence on the impact of interventions beyond S136 rates or other simple measures. Even when data sets were predefined, a lack of administration funds meant that data collection was often incomplete9 or inaccurate. 50 In another study, the mechanisms to identify measurable impact were suggested to be inefficient and tiring. 50

Immediate access to accurate health information

Police officers considered the ability to have immediate access to relevant information vital to making judgements about risk and potential courses of action. 9 Information that mental health staff could provide from NHS systems [e.g. SystmOne (The Phoenix Partnership, Leeds, UK)] was seen as informing the dynamics of risk (e.g. the meaning and implications of specific mental illnesses within the context of an incident). 50 Officers expressed greater confidence in decision-making as a result of being offered immediate reliable information, including summaries about an individual’s current circumstances, information on access to services and care planning, guidance and advice on options and alternatives available on the day, and advice about how to proceed. 42 In one co-response scheme, MHPs felt pressure from control rooms to attend incidents first and a relative discomfort at this as it limited the amount of information they could ascertain before they arrived. 46

Beneficial role of mental health professionals in user needs assessment

The involvement of a PRMHT team helped better identify the needs of service users and improve access to care, perhaps especially when decisions were not straightforward. 9 In one study, MHPs described how their familiarity and knowledge of mental health conditions meant that their judgements differed from those of police officers, particularly in terms of risk. In such cases, officers often assessed an individual to be a higher risk than did the MHPs. 50 A by-product of this approach was a sharing of knowledge about mental health with individual officers, which varied according to the officers’ levels of engagement and interest. 50 Another study gave the example of someone threatening suicide as historically being enough for officers to use S136, because of a lack of alternatives and an emphasis on being risk-averse. 46 Officers involved in this co-response intervention reported feeling uncomfortable leaving someone alone if they were threatening self-harm or suicide, but also that they had historically been ‘overcautious’ when using the power to section, resulting in it being used too frequently. 46

Other perceived benefits of involving PRMHT teams in user needs assessments included increased time efficiency by freeing up other response officers while the PRMHT team dealt with mental health-specific issues (although this would not apply to forces where police officers retain ownership of an incident until its resolution), and increased knowledge and confidence regarding their available options. 9 Some health staff felt that, in their absence, police officers would still be likely to use S136 to ensure quicker assessment. 9

Service user feedback on needs assessment

Very little service user feedback was available across the studies. When this was reported in relation to the assessment of user needs, opinions were mixed. Although some service users expressed problems around communication (e.g. difficulties understanding the nurse or being told the same things that they had heard in the past – that no immediate help was available),9 some people who had previously been sectioned found the experience of street triage to be consistently better. 46 Some individuals felt reassured and calmed by the nurse’s presence and appreciated the fact that the incident was often resolved in their own home without having to go to hospital or be held in custody. 46

Identifying needs of new and repeat service users

Police-related mental health triage interventions raised implications for identifying the needs of both new and repeat service users. In some cases, street triage led to individuals being identified in the community who had previously not had input from services. 46 Elsewhere, the demand on the control room caused by regular callers and missing persons was a continual cause of frustration, with the operation failing to resolve repeat cases. 50 Although MHPs did report ongoing work with these individuals (demonstrating a willingness to develop a longer-term relationship with service users), this was done beyond the bounds of the operation. 50 One telephone-based scheme deliberately identified individuals who frequently came into contact with services via the police in order to inform interagency responses and risk planning. When utilised effectively, this appeared to reduce re-presentation and significantly support more effective management of police time and resources. 42 One co-response scheme developed a dedicated ‘Integrated Recovery Programme’ to address the high demand created by frequent service users who would regularly call the police and mental health services for support. 53

Establishing links with other relevant services

Positive changes in pathways to care were often reported. 9 This included better police links with home treatment or crisis teams. 9 The facilitation of a wider range of pathways to emergent incidents was considered critical to reducing the number of S136 arrests that are used unnecessarily:50

It’s about opening up the pathways and the communication and liaison between various services in support of each other, really, for the best of the client to ensure that pathway is timely and consistent.

MHP.

Reproduced with permission from Callender and Cole. 50 © Institute for Public Safety, Crime and Justice, 2016

Crisis teams’ fears of a deluge of potentially inappropriate calls were not realised, as better officer understanding meant that calls were appropriate. 9 Other perceived improvements to pathways included follow-up of referrals where none had previously existed and better pathways for people who are unengaged or unknown to services. 9

However, where crisis teams were the services originally responsible for responding to crisis situations, including calls from the police, the introduction of street triage could initially create confusion about the roles and responsibilities within the available pathways:

. . . and the police brought a gentleman . . . if you self-present, it’s like you see the crisis team but because the police had brought . . . the crisis team asked us . . . there’s nothing set in stone that because the police have brought him it has to be street triage. He’d actually self-presented and wanted to come here to see the crisis team because he thought he was in psychiatric crisis but [street triage] assessed him.

Street triage staff.

Reproduced with permission from Callender and Cole. 50 © Institute for Public Safety, Crime and Justice, 2016

Barriers to accessing other relevant services

Some views identified systemic barriers to desired outcomes because of factors that lay outside the PRMHT interventions. Owing to long waiting times, referrals did not necessarily mean that service users received the intended mental health care or treatment, so there was a limit to what the mental health workers could guarantee the patient would receive. 53 Examples were given of some patients still getting ‘stuck’ at A&E and then being sent home after a long wait. 46 PRMHT referrals also had the potential to cause an increased workload for other services. 53

Wider strategic considerations around the role of police in mental health-care pathways

Senior staff alluded to strategic considerations around sustainability and longevity. 9 The existing PRMHT arrangements were sometimes referred to as a ‘short-term fix’ or ‘sticking plaster’. 9 Some police officers believed that they personally should be bypassed whenever possible when incidents are clearly health related. 9 One police manager described a long-term aim of moving to a situation when a police response is only required in the presence of immediate safety concerns for a client or the public:53

So one of the objectives of [project name], is the long term, almost a generational piece of work, to actually place mental health risk, mental health responsibility, back into the NHS, because it has never been in the NHS, because culturally the wider thing is the police in the UK scoop up everything.

05, police, manager, location 1.

Reproduced from Horspool et al. 53 © The Authors, 2016. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

One strategic mental health police lead described their aim of moulding ‘a single acute care pathway’ that takes account of L&D, triage, rapid assessment, intervention and discharge within a primary care health setting, while also looking at the S136 and S135 processes. 9

Pathways for intoxicated individuals present a recurring issue in one study, with there being some deliberation as to the best place to support such individuals. 46

Benefits of interagency co-ordination

The most commonly reported themes related to perceived improvements in care planning, co-ordination and effective interagency relationships. 9 Stakeholders in one scheme perceived that collaborative working at operational and managerial levels led to an improved understanding between the different organisations by dispelling misconceptions and building rapport between operational staff. 53 Police officers in another scheme reflected that access to telephone support had improved mutual respect between police and psychiatric health staff, and increased reciprocal awareness of each other’s professional knowledge, skills and work pressures. 42

The combination of police and MHPs within other schemes was viewed as being complementary, and enabled police to utilise different options to achieve positive incident outcomes when they may previously have exercised S136 powers. 50,53 In one study, police officers were perceived to be less risk-averse when decision-making was shared,53 although, in another, officers felt that the responsibility for S136 cases was not fully shared, and despite taking the advice of the nurse, officers still felt that their ‘neck is on the line’, which can make them reluctant to not use S136. 46 Nurses, nevertheless, reported improved partnership working with police and more appropriate use of S136. 46

In one telephone support scheme, when S136 was initiated, handovers from police to health professionals were seen to be improved in terms of risk and potential harm, being better managed with assessments completed more speedily. 42

Other perceived benefits of improved interagency working included improved responsiveness from hospitals when MHPs were involved,9 and triage nurses gaining a better understanding of the limits to police powers. 9 The presence of MHPs was also thought to help calm situations when problems arose around police uniforms. 9 It was recognised that mental health staff were perceived less confrontationally than police officers by people in need; the fluorescent jackets and stab vests worn by officers were viewed as both presenting a physical barrier and heightening anxiety within certain situations. 50

Staffing and co-ordinated working

Staffing of the schemes was mentioned in terms of both facilitators of and barriers to successful implementation. In one case, it was strongly indicated that more consistent staffing arrangements would be welcomed, as it was recognised that staffing of the operation was irregular from both police and mental health perspectives. 50 Consistent staffing on this scheme was considered to enable the formation of stronger relationships and result in better outcomes for individuals in need. 50 Conversely, inconsistent staffing arrangements resulted in less effective utilisation of time, as expressed by police officers not knowing what to do or how to add value within the control room during quiet periods. This was equally the case during incidents when an assessment was being completed. 50 The benefits of consistent staffing may be linked to the extent of police staff enthusiasm for mental health-related work, with clinicians in one scheme reporting a qualitative difference between officers who were motivated to learn about mental health and those who were attracted to the scheme as a result of overtime payments (which led to the police officer sometimes acting simply as a ‘chauffeur’). 46 One study noted that a minority of police colleagues felt that mental health should be the responsibility of the health service. Thus, a less enthusiastic response from some officers may pose challenges to the implementation of PRMHT services. 53

Information shared by police and health colleagues

Again, police officers noted the sharing of information as a key component of effective interagency working, increasing their confidence and knowledge around mental health-related incidents and awareness of appropriate outcomes for users. 9 Officers in one study said that although the provision of advice and information from MHPs might simply be seen as a ‘nice-to-have’ resource, it was actually recognised to potentially make ‘the difference between life and death’ within certain incidents. 50 Elsewhere, the ability of police and nurses to work together when presented with someone in distress was said to facilitate the ‘bigger picture’, ensuring that more accurate decisions were made around risk. Police could provide information on an individual’s offending history, risk of assault and use of weapons, while the nurse could provide information around medication, diagnosis and care plans. 46 Police officers have expressed confidence and gratitude in receiving support from triage nurses. 9

In one case, managerial staff highlighted how the establishment of a co-response scheme had initiated a review of local agreements related to collaborative working with MHPs, police and emergency care. This led to improvements, such as a new information-sharing agreement that clarified the types of information that could be shared, and enhanced access to information that was felt to improve police decision-making, both during and outside street triage hours. 53

Barriers to effective interagency working

A number of challenges around joint working were also raised. Although police officers expressed a respect for the judgements of mental health staff, there was confusion (and sometimes tension) in relation to the decision-making processes around deployment. This was heightened when resources were scarce on the ground and control room staff saw the car/team as a deployable resource. 50 One study noted occasional disagreements about the most appropriate place of safety, which significantly impeded and delayed the progress of assessments and ultimately the resolution of incidents. This seemed particularly the case when alcohol, drugs and/or risk of violent behaviour were significant, and there was disagreement about the level of risk presented and the appropriate setting for a person to be located at. 42

One study raised the importance of establishing lines of accountability and responsibility for such decision-making. For instance, it is critical to consider who holds responsibility for the shared decision to withdraw officers from the scene of an incident (i.e. taking no further action) in which a person expressing suicidal thoughts then goes on to commit suicide. This type of dilemma directly relates to the gap in police powers between S135 and S136, an unplanned detention of an individual to a place of safety. 50 Officers in one study felt more comfortable leaving an individual threatening self-harm or suicide if the nurse had conducted their assessment and felt that it was safe to do so. 46

Poor co-ordination between external organisations was a noted challenge. For example, a ‘lack of join up’ between different NHS trusts led to delays in both patient care and the release of officers from incidents. 9 In one scheme, police service boundaries encompassed many NHS trusts and police officers would need to identify which NHS trust was responsible for care when responding to a mental health incident. 53 Staff on one scheme noted the difficulty of maintaining a complex set of inter- and intra-agency relationships, including those with police officers and mental health service providers in the voluntary and statutory sectors, as well as managing their own internal networks. 50

Positive effects on quality of care

Police, health staff and service users all noted an improvement in the quality of care with PHMRT schemes. 9 Participants in one study frequently emphasised the importance of the scheme in delivering a better-quality service to people in need, rather than simply freeing up resources. 50 It was felt that individuals in need responded more positively to MHPs on the ground, with the MHPs’ communication skills being critical to the positive resolution of specific incidents. 50

Elsewhere, the positive impact on service users was acknowledged by police officers:

. . . when the street triage team go, they get a better service. Certainly get better handling . . . wherever the person is at a time of crisis, and threatening to harm themselves, saying, I want to hang myself . . . I just want to kill myself, leave me alone . . . then giving them a bit of a brief intervention, talking to them, and making arrangements for them, their care, moving forward, to speak to their family has to be a good thing. For a mental health professional to be able to do that is fantastic because that person then does not go into detention, they do not end up in police cell or a hospital where they don’t want to be . . . whereas the police couldn’t make those sorts of judgement calls, so the service user often ends up in custody at the police station.

Police officer,

Reproduced from Dyer et al. 41 Mental Health Street Triage. Policing: A Journal of Policy and Practice, vol. 9, iss. 4, pp. 377–87, by permission of Oxford University Press

Officers noted that an asset of one telephone-based service was the ability, when appropriate, to pass their mobile phone to the person who was the subject of the call so that they could talk to the MHP. 42 This was considered to have the following advantages:

• The distressed person could immediately speak with a trained MHP, which tended to calm situations.

• It demonstrated that the police officers were taking seriously both the person’s views and the difficulty of their circumstances.

• Police officers were seen as more welfare focused.

• Officers felt that they were more frequently trusted and that any proposed plans to take people to hospital were seen to be more believable. 42

Police-related mental health triage schemes were seen as generating a positive cultural change that has benefited users. 9 One officer said that they would never previously have taken people home as they would have lost S136 powers on entering the premises, thereby potentially losing what had been seen as ‘the safest option’. 9

An additional consequence of more contacts in private dwellings was that individuals’ families were more frequently included in the care pathway, instead of people being isolated. 9 In particular, this was observed in the de-escalation of domestic situations, leading to fewer young people being seen in custody. 9 The involvement of PRMHT was reported as reassuring for family or friends who were often at the scene, which was predominantly the service user’s home. 46

Reports on the DHSC-funded schemes noted fewer S136 assessments presenting in hospitals. 9 PRMHT nurses reported that this helps prevent service users from feeling criminalised for their mental health problem. Service users in one study felt reassured and calmed by the nurse’s presence and appreciated the fact that the incident was often resolved in their own home, without having to go to hospital or be held in custody. 46 When issues could not be resolved in the home, other service users expressed relief at being taken to hospital instead of police custody, as this was less shameful. 9

Service users generally (although not universally) commented that follow-up calls were valued. 9

Resource savings

One study42 noted resource savings from a telephone support-based PRMHT intervention, with officers reporting that it had saved police time when responding to and dealing with calls when mental health challenges were present. This was particularly the case when an individual required hospital assistance. Prior to the PRMHT scheme, when S136 was used to remove someone to a designated place of safety (typically an A&E department), officers would have to wait a considerable amount of time until a medical doctor and a social worker were available to make an assessment and a decision. 42

Unused resource

Another study, in which a qualitative researcher shadowed a co-response team, reported some apparent ‘down-time’ between jobs, alongside occasional long journeys to attend incidents. 46 The presence or absence of such factors would need to be considered when planning for efficient PRMHT resource use. However, it was noted in the same study that individuals did not seem to mind waiting some time to be seen by the team. However, there were resource implications for the other officers on-scene who could not leave until the PRMHT team attended. 46

Availability of mental health professionals

Police officers in two studies41,42 noted the importance of MHPs being immediately available through the PRMHT scheme. In one, the services offered by a PRMHT co-response team were considered to be different from those offered by existing services, such as the crisis team, because nurses based with police officers were available to immediately respond (providing that they were on duty) to police requests for assistance. 41 The second study noted the particular importance of being able to call PRMHT telephone support in ‘real time’ at the scene of an incident (24 hours a day, 7 days a week). 42 Although there were occasions when officers did not access support because the line was engaged or not answered, this was generally the exception and became less frequent over the final period of the pilot. 42 A direct, dedicated PRMHT line was seen as a preferred route to bypass switchboards and non-emergency services and talk to a trained individual who had access to health records and quite often knew, or knew of, the person who was the subject of the call and could respond and advise quickly. 42

Police officers considered the unavailability of PRMHT staff to be a significant barrier to access and felt that additional resources were needed to ensure that staff are available to respond when needed. 9 There was some suggestion that the control room might be reluctant to deploy mental health staff to incidents because of the risk of them becoming unable to respond to other requests while deployed at the scene. 9

One study reported related concerns about staff availability and a perceived rise in the number of people driven to the hospital by police officers and left at the front desk. 41 Some police officers were suggested to have bypassed the PRMHT service when it was unavailable. Some police officers argued that it was easier and quicker to take a person directly to hospital if they agreed to attend on a voluntary basis, rather than wait for PRMHT staff to attend the scene; in other cases, the police officers disagreed with the advice given by the nurse. 41

Both police and health staff expressed disappointment at PRMHT services not being available around the clock. 9,41 A nurse noted the potential waste of resources in promoting a service that officers found not to be consistently available, leading to the risk that officers learn to ‘do without’ it. 9

Allocation of staff resources to police-related mental health triage teams

Some respondents raised concerns about the reallocation of staff resources to PRMHT from elsewhere. In one study,50 some police response officers felt that they were letting down their Incident Resolution Team (e.g. exposing their colleagues to a greater degree of risk) when deployed to PRMHT duties, rather than adding wider, systemic value. From the mental health perspective, it was indicated that, more recently, ‘bank staff’ were increasingly assigned to the operation. 50

When one co-response PRMHT service was adopted as ‘routine’, it was staffed by an officer from the regular shift. 53 Some interviewees felt that, at busy times, losing one officer from the shift compromised their ability to respond to incoming police incidents. 53 Managers were aware of this criticism but justified the decision with evidence suggesting that having one officer dedicated to mental health incidents would reduce the workload associated with mental health for other colleagues on the shift. 53 Health staff also raised concerns about competing demands when people were reallocated from existing mental health teams to PRMHT. 53 This was compounded by perceived additional demand created by PRMHT referrals. 53

Technological resource considerations

One of the DHSC-funded teams highlighted that it was crucial to develop a means of sharing electronic information on different information technology (IT) platforms or within a single shared IT platform. 9 One scheme developed models for effective record keeping and information exchange. 42 Another developed new information-sharing agreements,53 but there remained examples of incompatible technology hampering the expansion of the service. Police interviewees who proposed minimising police involvement in mental health response acknowledged that transferring this workload to health-based services would be challenging for technological reasons, such as incompatible computer systems and limitations in the call transfer systems (but the key challenge would be the absence of additional funding for mental health services to do this work). 53

Other technological considerations included the means of communication with remote mental health support. Police officers in one study expressed a preference for a dedicated mobile phone rather than contact via their radio sets. 42 This was because (1) the mobile phone could be passed to a service user if they needed to speak directly with the mental health practitioner, without having to share the officer’s personal radio earpiece, and (2) allowed officers to safely retain their radio set in case they urgently needed to call for assistance from colleagues. 42 However, some officers were unsure whether or not their use of personally owned mobile phones would be considered inappropriate and, in another scheme, limited local mobile signal coverage was reported as an occasional barrier to contact. 53 One study of a co-response model suggested that portable electronic devices might allow nurses to record notes between jobs, rather than doing this without pay after the end of a shift. 46

Recruitment

Several respondents across the studies discussed recruitment considerations. One particular difficulty in this respect was recruitment delays caused by the strict police vetting process. 9 The procedures for recruitment to PRMHT teams were rarely reported, except for one pilot, in which a senior nurse, police officer and paramedic were all involved in appointing people to the relevant roles. 9

Both police and mental health respondents from one primarily telephone-based scheme said that they would welcome more consistent staffing arrangements, because irregular staffing adversely affected continuity. 50 However, it was acknowledged that a downside of this might be that the benefits for staff, in terms of increased knowledge between the organisations, might be more isolated to a core set of individuals. 50 Respondents in another study discussed the implications of making PRMHT involvement obligatory for all staff, expressing concern about a negative impact on motivation levels, while recognising the benefit of spreading knowledge about mental ill health more widely across the force. 46

In terms of personal characteristics, stakeholders in one PRMHT scheme described the police and mental health staff as compassionate and motivated individuals who work on the service and described these attributes as being important to the success of the service. 53

Learning and sharing of knowledge within police-related mental health triage teams

A number of comments around knowledge and learning were presented across the studies. In the case of co-response models, ongoing learning was developed through continual discussion and debriefing between the police officer and nurse sharing a response car for several hours. 9

Another study53 noted the importance of PRMHT mental health staff having appropriate knowledge of, and access to, existing mental health services (e.g. community-based mental health teams). This was more easily facilitated if the MHPs were familiar with services because they had worked with them previously.

One scheme9 began work on a joint training initiative to address confusion around the powers and procedures of both police and health organisations (e.g. the limits to police powers to detain to a place of safety when most face-to-face assessments are made within private dwellings).

Other training and support issues

One study50 suggested that better communication about the PRMHT scheme to front-line officers would support how the scheme is perceived and valued within incident resolution teams.

Service users in one police force evaluation believed that police officers needed more face-to-face contact with service users and suggested on-the-job training. 9

The idea of providing nurses with protective clothing received mixed views, with some concerned that it would affect the rapport that a lack of uniform provides. 46 Others pointed out that although MHPs did not wear protective clothing in the course of their PRMHT duties, police officers sometimes felt concerned about operating as a single-crewed unit with a civilian on board. 46

Acceptability

In general, police staff appeared to value PRMHTs, both officers with an interest in mental health and those who felt that mental health should not be a police responsibility. Both police and health staff noted an improvement in quality of care.

Although some service users reported improved experiences with PRMHT teams compared with previous arrangements, service user feedback was rare. Some qualitative evidence suggested that service users preferred to interact with MHPs rather than police officers. This was attributed to MHP communication skills and the association of police uniforms with authority and criminalisation. Any future provision of protective clothing (e.g. stab vests) for MHPs responding to incidents may need to consider the impact on user perceptions of MHPs as well as MHPs’ safety.

Feasibility

Most evaluated PRMHT models only addressed immediate concerns around the use of S136 by police called to mental health-related incidents. However, there are wider consequences of introducing these schemes for both police and health services, particularly risks of displacement or duplication of existing services. Strategic response to mental health-related incidents may need to consider, at the highest level, which pathways prove to be most effective for service users and make the most appropriate and efficient use of both police and NHS resources. Some barriers to successful outcomes lay outside the control of police or even PRMHT staff (e.g. lack of co-ordination between neighbouring NHS trusts). Similarly, the availability and resources of local services need to be taken into account. For example, PRMHT’s attempts to reduce the number of repeated crisis calls from an individual may prove unsuccessful if they are referred to local mental health services with long waiting times.

The reported advantages and disadvantages of retaining consistent staff on PRMHT duties may be of interest to service managers. Advantages may include enhanced relationships and understanding, greater efficiency and less frequent issues around police vetting procedures. However, disadvantages could include mental health knowledge being restricted to fewer police staff and poorer integration with the wider force. The service impact of reallocating police and MHP staff to PRMHT from other active roles should also be carefully considered.

Barriers

Some comments indicated uncertainty about how and when it is best to deploy MHPs to the scene of an incident. There may be a trade-off between MHPs having better access to records in a hospital/control room and using their hands-on skills to aid in incident resolution. In conjunction with other information-sharing measures, this kind of barrier might potentially be overcome by providing MHPs with improved mobile information technology. PRMHT staff from our advisory group have noted the value of being able to obtain information while en route to a service user.

Reveruzzi and Pilling’s9 evaluation appropriately recommended that the role of street triage schemes should be reviewed in relation to referrals from, and contacts in, private settings. However, since the recommendation was originally made, the Policing and Crime Act 20174 has resulted in changes to S135 and S136. 2 In theory, these changes should mitigate some of the previously identified problems around police officers being unable to enter private premises to make an assessment. However, the effect of these changes has yet to be properly established. In addition, it was clear from the evidence that not all staff were aware of the nature of police powers in public places and private premises. All MHPs and control room staff involved in PRMHT interventions being knowledgeable about the constraints on police powers may prevent misunderstandings or inappropriate recommendations for action.

Data collection is often incomplete and restricted in scope, which limits the opportunity to continuously evaluate and improve services. Methods for comprehensive, accurate and efficient data collection (that do not place undue additional demands on front-line police or health staff) may need to be developed. As PRMHT interventions are multiagency, data collection and evaluation may benefit from being correspondingly integrated and strategic. Data collection (like information-sharing) may also benefit from being governed by relevant protocols and facilitated by appropriate technology. As well as routine data collection of outcomes, such as S136 rates, future evaluations would benefit from data on quality and timeliness of assessment, referral and treatment, mental health outcomes, demand on police resources and police officer time, demand for community mental health services, rates of hospitalisation via A&E or acute mental health services, level of service engagement, experience of services for service users, and costs and savings to health and police services, including estimates of skill mix and other workforce resources. One barrier to effective interagency data collection may be obtaining the necessary staffing and resources across all of the relevant services. Other barriers include a lack of clarity from commissioners about why certain data should be recorded, obtaining consent to share individuals’ data between services and difficulties where boundaries are not coterminous (e.g. different NHS trusts overlapping one police force area or people being referred to out-of-area hospital beds).

Some qualitative studies noted the challenge of disproportionately high demand created by repeat service users. Some comments suggested that efforts could be made to work towards a distinctive and separate partnership between police and health-care services for repeat callers,50 or towards reduced police input for callers for whom there are no immediate safety concerns. 53

Such efforts may be worth further consideration and evaluation in any future implementation of PRMHT interventions.

Facilitators

The qualitative evidence as a whole emphasised Reveruzzi and Pilling’s9 conclusions around the importance of strong partnerships between police and health services, co-location of services and the value of shared information. The latter point in particular crossed several themes; shared information underpins the achievement of organisational objectives, such as reducing S136 arrests, speeding up user needs assessment and enhancing collaborative working. Future PRMHT interventions would probably benefit from immediate access to shared information across the police/health interface, facilitated by agreed protocols and underpinned by appropriate technology that permits compatibility of data across police and health systems.

In all cases, lines of accountability and responsibility need to be clear among all PRMHT staff. This is because differences in attitudes to risk between police officers and MHPs have been observed (e.g. around threats of self-harm and suicide), and because the presence of factors such as alcohol, drugs and/or the risk of violent behaviour can increase the complexity and difficulty of making judgments about the best course of action. Similarly, roles, responsibilities and reciprocal arrangements need to be clearly defined between PRMHT services, crisis teams and other related health services.

Immediate and consistent availability of MHP support was very important to police officers who were responding to mental health-related incidents, with immediacy sometimes seen as a key difference between PRMHT and crisis teams. As stated by Reveruzzi and Pilling,9 24-hour availability appears to be crucial to providing officers with a resource that is considered reliable. Appropriate communication technology may improve accessibility, such as mobile phones dedicated to the task of consulting MHPs that can have some advantages over police radio sets, although difficulties may be encountered in rural locations with poor signal coverage.

Many resource savings attributed to PRMHT interventions stem from their value in accelerating the assessment of user needs. Whereas most UK interventions have focused on retaining MHP partnerships to facilitate assessments, the US literature is more focused on interventions where police officers receive mental health training without the same level of ongoing specialist support from MHPs. No evidence was found comparing these two models, despite their potential to have quite different costs and benefits.

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((((TITLE-ABS-KEY (‘mental health crisis’) OR TITLE-ABS-KEY (‘mental health crises’))) OR (TITLE-ABS-KEY (‘mental health emergenc*’)) OR ((TITLE-ABS-KEY (‘psychiatric crisis’) OR TITLE-ABS-KEY (‘psychiatric crises’))) OR (TITLE-ABS-KEY (‘psychiatric emergenc*’))) AND (((TITLE-ABS-KEY (police) OR TITLE-ABS-KEY (policing))) OR ((TITLE-ABS-KEY (law AND enforcement AND staff) OR TITLE-ABS-KEY (law AND enforcement AND personnel) OR TITLE-ABS-KEY (law AND enforcement AND officer*) OR TITLE-ABS-KEY (law AND enforcement AND official*) OR TITLE-ABS-KEY (law AND enforcement AND worker*))))) OR (((TITLE-ABS-KEY (‘psychiatric disorder*’)) OR (TITLE-ABS-KEY (‘mental health’)) OR (TITLE-ABS-KEY (‘mental disease*’)) OR (TITLE-ABS-KEY (‘mental* ill*’)) OR (TITLE-ABS-KEY (schizophren*)) OR (TITLE-ABS-KEY (‘personality disorder*’))) AND (((TITLE-ABS-KEY (police) OR TITLE-ABS-KEY (policing))) OR ((TITLE-ABS-KEY (law AND enforcement AND staff) OR TITLE-ABS-KEY (law AND enforcement AND personnel) OR TITLE-ABS-KEY (law AND enforcement AND officer*) OR TITLE-ABS-KEY (law AND enforcement AND official*) OR TITLE-ABS-KEY (law AND enforcement AND worker*))))) OR (((TITLE-ABS-KEY (triage) OR TITLE-ABS-KEY (‘street triage’) OR TITLE-ABS-KEY (‘mental health triage’))) AND (((TITLE-ABS-KEY (police) OR TITLE-ABS-KEY (policing))) OR ((TITLE-ABS-KEY (law AND enforcement AND staff) OR TITLE-ABS-KEY (law AND enforcement AND personnel) OR TITLE-ABS-KEY (law AND enforcement AND officer*) OR TITLE-ABS-KEY (law AND enforcement AND official*) OR TITLE-ABS-KEY (law AND enforcement AND worker*))))) OR (((TITLE-ABS-KEY (‘crisis intervention*’)) OR (TITLE-ABS-KEY (‘crisis response*’)) OR (TITLE-ABS-KEY (‘crisis coresponse*’)) OR (TITLE-ABS-KEY (‘crisis program*’))) AND (((TITLE-ABS-KEY (police) OR TITLE-ABS-KEY (policing))) OR ((TITLE-ABS-KEY (law AND enforcement AND staff) OR TITLE-ABS-KEY (law AND enforcement AND personnel) OR TITLE-ABS-KEY (law AND enforcement AND officer*) OR TITLE-ABS-KEY (law AND enforcement AND official*) OR TITLE-ABS-KEY (law AND enforcement AND worker*))))) OR ((TITLE-ABS-KEY (collaborat* W/2 police*)) OR (TITLE-ABS-KEY (partner* W/2 police*)) OR (TITLE-ABS-KEY (interagency W/2 police*)) OR (TITLE-ABS-KEY (multidisciplinary W/2 police*)) OR (TITLE-ABS-KEY (corespons* W/2 police*))) OR (((TITLE-ABS-KEY (divert*) OR TITLE-ABS-KEY (diversion*))) AND ((TITLE-ABS-KEY (‘psychiatric disorder*’)) OR (TITLE-ABS-KEY (‘mental health’)) OR (TITLE-ABS-KEY (‘mental disease*’)) OR (TITLE-ABS-KEY (‘mental* ill*’)) OR (TITLE-ABS-KEY (schizophren*)) OR (TITLE-ABS-KEY (‘personality disorder*’)))) AND (LIMIT-TO (PUBYEAR, 2017) OR LIMIT-TO (PUBYEAR, 2016)) AND (LIMIT-TO (LANGUAGE, ‘English’))

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- SubjectTerms:’police’ including this term only - AND AllFields:’mental or psychiatr* or schizophreni*’ - AND PublicationYear:’2016 2017’

Fifteen records.

- AllFields:’crisis intervention*’ or triage’ - AND AllFields:’police* or policing’ - AND PublicationYear:’2016 2017’

Six records.

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College of Policing

See URL: www.college.police.uk/.

Browsed the Research/What Works Centre sections and any subsections of the following: systematic review series, college published research, What Works briefings, what works in policing to reduce crime.

Used the Research/National Police Library section/Police Library Search function using the terms ‘street triage’ OR ‘mental health’. Browsed all documents found while searching.

Mental Health Foundation

See URL: www.mentalhealth.org.uk/.

Browsed the full list in the publications section.

Crisis Care Concordat

See URL: www.crisiscareconcordat.org.uk/.

Selected ‘Explore the map’ and browsed all counties for relevant documents and the research section.

Centre for Mental Health

See URL: www.centreformentalhealth.org.uk/.

Used the search box on the main page and first searched for ‘mental health’ then browsed the results. Next searched for ‘street triage’ and browsed the results. Then also browsed the following sections in ‘Publications’: criminal justice, physical and mental health, mental health policy and archive.

Connect Evidence Based Policing

See URL: http://connectebp.org.

Used the search box on the main page and first searched for ‘mental health’ and browsed the search results, next searched for ‘street triage’ and browsed the search results, then also browsed the ‘Research Streams’ section.

The East Midlands Police Academic Collaboration

See URL: www.empac.org.uk/.

Used the search box on the main page and first searched for ‘mental health’ and browsed the results; next searched for ‘street triage’ and browsed the results, then also browsed the ‘Research Networks’ section.

Google search

See URL: www.google.com/advanced_search.

1. ‘street triage’ OR ‘mental health triage’, limited to English, region set to UK, portable document files (PDF), first 100 results downloaded

2. ‘crisis intervention’ AND ‘police’, in English, region set to UK, PDF, 43 results returned, all downloaded.