Trust in collaboration introduces a project aiming to help people with high intensive patterns of behaviour, eliminating the need for crisis calls and reducing hospital admissions

Across the UK, police forces are struggling to manage a small number of repeat callers with complex mental health needs. In a typical policing district, a very small number of known people will regularly cause up to a third of all crises, mental health demand, not only to police but also to other emergency and heath care services.

These individuals are often chaotic in nature, anti-social in behaviour and occasionally criminal in their conduct towards relatives, friends, members of the public and public service personnel. In the most extreme of cases, mental health professionals describe them as ‘unmanageable’. In June 2013, 6 such service users and their mental health nurses were joined on their clinical journeys by a police officer. The officer showed the compassion of a nurse but also brought with him, boundaries and consequences not offered by the NHS.

The rules started to change and the service users soon realised that behaviours that had once worked were no longer acceptable, excusable or usable without consequence. The recovery pathway had become integrated and the language consistent. Our most significant achievement is knowing that every service user is in a better and more hopeful situation in their life. An integrated approach had made a significant contribution to patient recovery. In July 2013, IOW used police custody for a mental health crisis for the last time. We have not used a police cell since and manage service users through a multi-disciplinary partnership approach.

Challenges

Across the UK, police forces are struggling to manage a small number of repeat callers with complex mental health needs.- In a typical policing district, a very small number of known people will regularly cause up to a third of all crises, mental health demand, not only to police but also to other emergency and heath - care services. - These individuals are often chaotic in nature, anti-social in behaviour and occasionally criminal in their conduct towards relatives, friends, members of the public and public service personnel. - In the most extreme of cases, mental health professionals describe them as ‘unmanageable’.

Actions

Evidenced based: SIM is supported by strong data that has been gathered using both qualitative and quantitative methods. Involving critical partners: We always seek the feedback from service users who have been supported by SIM at every opportunity and we are currently in negotiations with a leading mental health charity to see if we can further professionalise towards ‘co-production’.

Understanding of commissioning: Innovation must be constantly ‘commissioning compliant’. We are moving towards commissioning structures that will select projects for ‘speed of access’ – ‘local needs’ – high priority groups’ – ‘pathways and partnerships’ – ‘outcomes’ – ‘costs reduction’ and ‘data strength’. SIM can be measured using all of these parametres. Open minded about adaptation: We remain constantly open to adapting this model of care to fit different clinical environments. SIM can also potentially be applied to both ED and GP practices.

Results

In the 3 years so far, we have proven that this model: - Reduces the intensity and frequency of this types of crisis. - Reduces operational response costs to all 4 teams by up to 92%. - Leads to improved personal outcomes for service users. - Reduces pressures on hospital wards.

Value

The benefits to the mental health community, clinical settings, wards and patient health include: - More accurate and collaborative management of risk. - Increased transparency and consistency in managing behaviour - A reduction in hospital admissions - Less staff sickness and improved professional outlook towards their clients. - Calmer wards and clinical environments due to less chaotic and disruptive behaviours triggered ill-health in other service users. Our Health Economic Analysis demonstrates how basic operational costs to police, ambulance, ED and mental health settings were around £19800 a year per patient but when managed by a SIM team, these costs reduced by 92% within 2 years.

It shows how demand for each team reduced following SIM intervention, how the use of s136 powers by police officers reduced overall by 70.2% by using a combination of: A)Street Triage as a crisis response team B)SIM working behind the scenes with each patient as they are identified. Finally we demonstrate the reduction in Mental Health Act assessment costs due to decreasing number of people in crisis arriving at places of safety. Since SIM, we have reduced these costs locally by over £40000. That itself pays for employing the SIM police officer.

In detail

AMBITION

Hampshire Constabulary was the first police service in the UK to launch a Street Triage (joint police & mental health response car) in Nov 2012. The serenity partnership started on the Isle of Wight and developed from a simple focus on crisis response teamwork, to many wider conversations including one that specifically focused on patient behaviour and types of treatment pathways. By the end of the first year, performance data indicated that a number of service users were repeatedly requesting police attendance whilst simultaneously using A&E, ambulance, GP and other core services. In particular: 69 service users were found to have caused 165 incidents requiring the use of police arrest powers under s136 of the Mental Health Act 1983 but within this cohort of 69 people, just 8 individuals stood out from the crowd.

These 8 individuals had caused 54 incidents - 32% of all crisis incidents.

INVOLVEMENT

The names of these service users were fairly familiar to the police officers on the frontline but no one from the police service had ever made significant enquiries to understand why these 8 individuals were frequently being found in crisis incidents. The serenity partners started to discuss these 8 service users. It soon became apparent that their behaviour was having significant impact on all emergency and healthcare services, not just the police. All 8 individuals were female within an age range of 20-63 with a clinical diagnosis of Borderline Personality Disorder. Many of them had a secondary diagnosis of anxiety or depression.

In June 2013, 6 such service users and their mental health nurses were joined on their clinical journeys by a police officer. The officer showed the compassion of a nurse but also brought with him, boundaries and consequences not offered by the NHS. The rules started to change and the service users soon realised that behaviours that had once worked were no longer acceptable, excusable or usable without consequence. The recovery pathway had become integrated and the language consistent. 18 months later and the 6 service users were assessed by a multi-disciplinary team (MDT) to see if any medical progress had been made. The MDT consisted of; -1 NHS Mental Health Consultant -1 Psychiatrist -1 NHS Clinical Psychologist -7 NHS community care co-ordinators -1 NHS ward nurse -1 university research assistant -1 specialist MH police sergeant -1 police constable working in a MH support role.

OUTCOME

Results showed that an integrated approach had produced some significant and sometimes startling clinical improvements. -A service user who had once controlled her NHS clinician was now ready for full medical discharge. -In ALL cases, crisis calls to police, ambulance had reduced and in most cases had been eliminated altogether. -Admissions to A&E for false, malicious or disproportionate reasons had reduced greatly and in most cases completely stopped. -Exhausted families felt reassured that ‘all was being done’. -Mental health nurses reported improved relationships with their clients and were subject to less abusive behaviour. -Thousands of pounds of treatment costs had been saved and spent elsewhere within the NHS. -Community risk and suicide risk had reduced. -Service users had refocused on the need to participate in recommended pathways. No one service user had made every improvement listed above but every service user was in a better and more hopeful situation in their life. An integrated approach had made a significant contribution to patient recovery.

VALUE

Utilisation of public services more than doubled within the two years before the intervention The two year period after the start of the intervention demonstrated significant reduction in utilisation of public services: -Police incidents: -97% -NHS assessments: -94% -Ambulance deployments: -81% -A&E attendances: -69% -Mental health bed days: -100% -Other NHS bed days: -57% Total costs for 4 High Intensity Users for the utilisation of the public services was reduced substantially from £78,000 in the year of the intervention (Y0) to £35,000 in year 1 and £6,200 in year 2

SPREAD

February 2016: outcomes shared with Wessex AHSN who have supported the spread and scalability of SIM into Hampshire and NIA Fellowship process

August 2016: Health Education Wessex fund a MH Nurse specialist to support workforce development of SIM in Hampshire.

September 2016: Surrey Police, through its Police Crime Commissioner has now adopted SIM and funded a SIM Officer

October 2016: Winner of HRH Prince of Wales Award for Integrated Approaches to Care – Nursing Times Awards

October 2016: Sgt Paul Jennings - SIM Innovator - awarded NIA Fellowship from Sir Bruce Keogh to accelerate spread and support adoption of innovation at pace across England.