History and Overview of the Paramedic Role

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Introduction

Before considering paramedics’ perceptions of caring for people who SH, it is important to recognise the context for the care that is provided by paramedics. Whilst it is beyond the reaches of this thesis to provide detailed anthropological insights into the development of paramedics as a cultural group, considering the contextual issues that affect the way care is provided, and how they are perceived by those they care for, their development as a group, and response to changing societal needs, will provide the reader with an appreciation of some of the complexities they face when caring for people who SH.

In this chapter a discussion is presented acknowledging the move towards clinical effectiveness, governance, and evidence-based care in ambulance services, and its role in the development of United Kingdom (UK) ambulance services and the paramedic profession. The historical context of the development of paramedics is considered, reflecting their origins, which stem from dealing in military conflict, and how this influenced the trajectory of paramedic and ambulance service care, to initially focus on trauma and life threatening emergencies. With the advent of technology, drugs and equipment, paramedic care increasingly focussed on the development of advanced life support for life threatening problems such as out-of-hospital cardiac arrest. These origins of paramedic care, focussing on trauma and life-threatening emergencies, began to lack relevance for paramedics, as case mixes changed, and members of the profession increasingly had to manage minor illness or injury and psychosocial presentations such as people who SH, those with chronic diseases, and mental health problems.

The chapter explores how current policies, legislation and guidelines are increasingly reflecting this modern context of paramedic care, and the reader is presented with details of these policies, legislation and guidelines, along with a discussion of their implications for ambulance services and paramedics.

Current prehospital care provision: Within the United Kingdom and internationally

There are two broad ‘models’ for Emergency Medical System (EMS) staffing in different parts of the world: the Anglo-American model and the Franco-German model. The Anglo-American model uses non-physician EMS units. This model is largely driven by the higher staffing costs of physicians compared to Emergency Medical Technicians (EMTs), and paramedics. In contrast, the Franco-German model relies on physicians, and emphasizes a high degree of on-scene stabilisation prior to transportation to hospital. The Franco-German model is also utilised in many areas of South America, particularly in Argentina, Chile, Uruguay, and Brazil (Al-Shaqsi 2010). The UK has traditionally followed the Anglo-American model, relying on non-physicians such as Emergency Medical Technicians and Paramedics to staff ambulances. Models ambulance staffing will undoubtedly impact on care for people who SH, and the transferability of any research in this area should recognise such differing contexts of EMS provision. Education, skills, competence and even the availability of pharmacological agents which may be used to restrain individuals following SH are some examples of potential differences in physician versus non-physician models of EMS provision. Mental health legislation also differs across the world, which may also influence care in areas such as powers of detention of people who SH.

UK Ambulance Services are increasingly resisting characterisation as either Franco-German or Anglo-American, as a range of medical and allied health professionals now deliver services, and models of care are emerging which include mental health nurses and GPs working together in ambulance control rooms, or joining police, ambulance and mental health triage teams, which are then deployed by ambulance services.

The development of the paramedic role

The roots of modern paramedics and ambulance services lie in the battlefields of the Crimean war, which saw the formation and organisation of ambulances and medical attendants, dedicated solely to the care of the wounded. Since this time UK ambulance staff and paramedics have evolved their role, where early ambulance attendants in the UK were once only required to  hold a drivers licence vehicle and offer vocational first aid (Kilner 2004), to today’s greatly expanded range medical care provision by paramedics, supported by national standards in education and training, laid down by a range of organisations, such as the Health & Care Professions Council (HCPC) and professional college, the College of Paramedics (CoP) which are respectively their registered professional body and professional college.

A series of significant events occurred in UK ambulance service provision which supported the development of UK paramedics. This included the Ministry of Health Committee (1966a; 1966b) report on the equipment and training of staff in the UK NHS ambulance service, which recommended a basic training programme lasting eight weeks for all emergency ambulance staff. The course included first aid training along with other general and technical subjects, and included learning to care for mentally ill patients and some of the legal aspects associated with this care. After 12 months of experience and satisfactory reviews, the Ambulance Services Proficiency Certificate, also known as the Millar program and certificate (Ministry of Health 1966a, 1966b), was awarded as the basic qualification to ambulance staff. The Millar (Ministry of Health 1966a, 1966b) programme evolved into the Institute of Health and Care Development (IHCD) ambulance technician programme (IHCD 2000), which was equivalent to its international counterpart, the Emergency Medical Technician (EMT) programme (Pozner et al 2004). During the 1980’s and into the 2000’s, UK ambulances were staffed by ambulance technicians. However, many locally-based paramedic and extended training schemes began to evolve during the 1980s, that were led by enthusiastic medical staff who formed steering groups in individual health board areas (Carne 1999). In the 1990s these schemes were combined into the National Health Service Training & Directorate ambulance extended training scheme (NHSTD 1991), and later the Institute of Health and Care Development (IHCD) paramedic programme which then followed (IHCD 2003). The IHCD Paramedic programme had a major focus on the management of trauma, resuscitation and life threatening emergencies, with limited provision for psychosocial, mental health or behavioural presentations (IHCD 2003).

Higher education of UK Paramedics

Since the development of the initial UK IHCD Paramedic programme, it has been increasingly recognised that the focus of paramedic training and education on major trauma, resuscitation and acute conditions such as cardiac and respiratory emergencies, no longer reflects the case mix that paramedics encounter in their day-to-day practice (Lendrum et al, Kilner et al 2004). It has been estimated that only 10% of patients in the 999 case mix, for example, have a life-threatening condition (DOH 2005). Pressures on the urgent and emergency care system have increased relentlessly over the past decade, and are no longer confined to the winter months (NHS Confederation 2015). This increased demand has created conditions of increasing and unremitting pressure in ED, with ambulance services suffering greater and greater delays at turnaround (the time from arrival at ED to becoming available for another call) (Robertson-Steel 2004). But despite this increase, 43% of ED attendances conveyed by ambulance are discharged, with over two-thirds of those discharged not needing follow-up treatment (DOH 2009).

In order to meet the needs of patients presenting with urgent or non-life threatening conditions, the Department of Health report: Taking Healthcare to the Patient: Transforming NHS Ambulance Services (DoH 2005) recommended that:

“Ambulance clinicians should be equipped with a greater range of competencies that enable them to assess, treat, refer, or discharge an increasing number of patients and meet quality requirements for urgent care” (DoH, 2005, pg. 44)

This statement supported the shift of paramedic education towards higher education. In 2001, the introduction of the Health Professions Order (Health Professions Order 2001) required UK paramedics to register with the regulatory body the Health Professions Council from July 2003. The Health Professions Council Standards of Education and Training (2009) set the entry level to the register as a paramedic at equivalent to Certificate of Higher Education for Paramedics. Higher Education Institutions (HEI’s) developed Paramedic Science Programmes, through partnership with ambulance services that exceeded the HCPC academic entry level. These programs initially included a Foundation Degree (FD or FdSc) in Paramedic Science or Diploma of Higher Education (DipHE) in Paramedic Science. Higher education for Paramedics has evolved further since conducting this study towards a minimum requirement of a BSc as the threshold entry onto the HCPC register; this is discussed later in this thesis.

Move towards clinical effectiveness, governance, and evidence-based care in ambulance services:

Along with changes to education for ambulance staff, throughout the 1990s and 2000s a move towards clinical effectiveness, governance, and evidence-based care in ambulance services resulted in an evolution of the direction of UK Ambulance Trusts and the paramedic role. The consultation document A First-Class Service: Quality in the new NHS (DOH 1998) set out the framework for quality improvement and fair access in the NHS, the main components of which were communicated by the National Health Service Executive (1999 p.3) Clinical Governance: in the new NHS, which included:

• Clear national standards for services and treatments. through National Service Frameworks and a new National Institute for Clinical Excellence (NICE)

• Local delivery of high quality health care, through clinical governance underpinned by modernised professional self-regulation and extended lifelong learning

• Effective monitoring of progress through a new Commission for Health Improvement. A Framework for Assessing Performance in the NHS and a new national survey of patient and user experience.

The National Service Framework for Coronary Heart Disease (NSF CHD), published by the Department of Health (NHS Executive 2000) recognised the role of Ambulance Trusts in caring for patients with suspected acute myocardial infarction (AMI). It set out organisational goals and milestones, for the care of AMI, and many ambulance Trusts responded with strategies which included further development of their extended training into paramedic schemes. The NHS research and development programme helped with the production of evidence needed to inform clinical decision-making and service planning.

The role of ambulance Trusts was recognised in many other National Service Frameworks (NSFs), influencing the direction of ambulance Trusts and their delivery of care, evaluated through research. Examples of other NSFs which referred to the role of ambulance staff included the: NSF for Older People (DOH 2001), which advocated that ambulance crews refer older people who fall to community-based care, which resulted in a range of referral pathways for elderly fallers being initiated by ambulance Trusts. Such referral pathways for older people who fall have been evaluated through large scale research studies, such as the SAFER studies by Snooks et al (2004, 2012, 2017a, b). The NSF for (neurological) Long Term Conditions (DOH 2005) influenced the education of paramedics in early recognition of stroke, and referral to specialist assessment treatment, which were again informed by research, and followed by large scale studies such as PASTA (Shaw et al 2016) and RIGHT-2 (Bath et al 2009, Ankolekar et al 2012, 2013). Despite these developments, the NSF Mental Health (DOH 1999) failed to mention the evolving paramedics role, and ambulance services were only mentioned once, where it was acknowledged that people with mental health problems during out of hours may: ‘phone for an ambulance’ (DOH 1999 p. 28). This lack of acknowledgment of the role of ambulance services and their staff has since changed, and is discussed later in this thesis. However, when considering the significant influence of policies such as NSF CHD (2000) over the evolution in the role and education of paramedics, greater recognition in mental health policy of the impact on ambulance services, and the potential contribution their staff could make to the provision of mental health care, may have resulted in better opportunities to influence education and the development of the paramedic role at a time of significant transition and development?

Ambulance services as clinical providers of care:

Health services across the west continue to face challenges with an ageing population, with increases in long-term conditions, and changing expectations and demands from patients and the public alike. In 1997 Ambulance Services were placed at the forefront of the new NHS modernisation programme (UK Parliament 1997), aiming to ensure that they play a key role in the development of quality systems of healthcare delivery. The new NHS modernisation programme emphasised the importance of national standards to ensure consistent, high-quality care as specified in a first-class service (NHS Executive 1998), and the health service circular: Modernisation of Ambulance Services (NHS Executive 1999) set out the government’s view that quality care should be at the heart of the National Health Service. Ambulance services have continued to evolve the vital role they should play in addressing these challenges, and ensuring all patients get the right care, in the right place, at the right time, by fitting their work around the emergence of new ambulance services, and becoming a main provider of care to the population. The NHS is an expanding organization, and since the year 2000 there has been a 17% increase in ambulance staff (NHS Confederation 2007b).  This expansion has been influence by many factors, such as changes increased demand for services and changes in provision for urgent and unscheduled care, yet it must be recognised that a major influence on the recent improvements in clinical standards and the design of services has been the introduction of UK National Service Frameworks.

Future direction of ambulance Trusts and paramedics

A vision for the future of urgent and emergency care in the UK was presented in the Urgent and Emergency Care Review (Keogh 2013). This positions the ambulance service, and paramedics at the centre of care for people not only with life threatening problems, but also those with urgent (non-life threatening) conditions, providing highly responsive, effective, and personalised services outside of the hospital. The Urgent and Emergency Care Review (Keogh 2013) sets out a vision where sustainable, high-quality care in hospitals will be achieved in future by relieving pressure on hospital-based emergency services, thus maximising the chances of survival and recovery for people with more serious or life-threatening emergency needs. Ambulance services were called upon to develop alternative approaches to care, such as condition specific pathways of care in order appropriately reduce ED attendances. This would also require Paramedic education, policies and legislation to evolve to achieve this vision.

Guidelines and policy on care for those who Self Harm (SH)

Acknowledging the link between SH and suicide, the UK Government has sought to reduce suicide through strategies involving collaboration between professional groups, and guidance and training for health staff (NICE 2004, NSF Mental Health 1999. The NSF (1999) identified care for those who SH as a key area to meeting a 20% reduction in suicides by 2010, and the National Service Framework on Mental Health (NSF MH 1999) was published to help meet these targets. However, when considering the impact of such strategies and comparing trends over time it is important to look over a relatively long period, as there may be natural fluctuations year-on-year which may present false increases or decreases that are attributable to any psycho-social predictors (Samaritans 2012). Suicides statistics can give a misleading picture of the prevalence of suicide when considered alone, as rates per 100,000 people are often reported which take into account the effect of population size on the number of suicides (Samaritans 2012). However, a reduction have been seen in the baseline rate of 9.2 deaths per 100,000 population, in 1997, to 7.3 deaths per 100,000 population in 2011 (ONS 2014 b.). This general decline in suicide deaths across all ages is shown in Fig 2.

Figure 2: Age-standardised suicide rates by sex, deaths registered between 1981 and 2015 (ONS 2015).

In 2004, the National Institute of Clinical Excellence (NICE) published guidance on SH to advise on the short-term physical and psychological management and secondary prevention of SH in primary and secondary care (NICE 2004). These guidelines were developed by a multidisciplinary group of healthcare professionals, patients, and researchers, and were influenced by the best available evidence. The guidelines were intended for use by clinicians, and commissioners of services intent on providing and planning care for those people who SH, while also emphasising the importance of the experience of care for service users and carers.

The NICE (2004) Guidelines on SH recognise that people who have self-harmed, their friends and their relatives frequently turn to the ambulance service for help. They recognise that ambulance staff are increasingly better trained in providing care and treatment at the scene and during transportation to hospital for patients with diverse medical conditions, and are in a privileged position to give early treatment and psychological support for patients following SH. NICE (2004) also acknowledges that ambulance staff often have access to the person’s home environment, and can and gain insights from family and friends, not present during hospital treatment, on events leading up to the incident of SH.

NICE (2004 p.29) recommend a range of key aims and objectives in the treatment of SH. These are presented in more detail in Appendix A. They include the need for rapid assessment of physical and psychological need (triage), effective engagement of service users, effective measures to minimise pain and discomfort, timely initiation of treatment, rapid and supportive psychosocial assessment (including risk assessment and comorbidity), and prompt referral for further psychological, social and psychiatric assessment and treatment when necessary, and an integrated and planned approach to the problems of people who self-harm. Nice (2004 p.48) also forwards key priorities for implementation, which are provided on more detail in Appendix B, and include the need for respect, understanding and choice, staff training, effective triage, and an assessment of risk.

NICE (2004) recognises that:

“Ambulance staff have an increasingly important role in the assessment and early treatment of self harm, a role that needs to be well supported through effective collaboration with other professional groups” (NICE 2004, p15).

The recommendations from NICE (2004 p.55) dedicated to ambulance staff are presented in appendix C. They apply many of the general principles in caring for SH set out above. They call for ambulance staff to urgently establish the likely physical risk, and the person’s emotional and mental state, in an atmosphere of respect and understanding. These recommendations call for Ambulance staff to be trained in the assessment and early management of SH, and how, if following SH, the service user does not require emergency treatment in the ED, ambulance staff should consider, taking the service user to an alternative appropriate service, such as a specialist mental health service, and that the decision to do so should be taken jointly between ambulance staff, the service user and the receiving service. NICE (2004) also provide clear guidance to Ambulance Trusts, the ED and Mental Health Trusts on the need to work in partnership to develop locally agreed protocols for ambulance staff to consider alternative care pathways to emergency departments for people who have SH

Since the publication of the NICE (2004) SH guidelines, the role of ambulance staff in the care of people who SH appears frequently in guidelines. RCPsych (2006) echoes many of the points raised in relation to ambulance staff in NICE (2004) guideline. These recommendations are summarised in Appendix D, and again call for Ambulance services to work with other organisations to develop care pathways including service users being taken directly to mental health units, primary care, crisis intervention teams or to social services. RCPsych (2006) suggest that Ambulance trusts, the ED and mental health trusts should develop locally agreed protocols for alternative care pathways for people who have self-harmed. They also call for Ambulance staff to have access to telephone advice from crisis resolution teams, from approved doctors and social workers, regarding the assessment of mental capacity and the possible use of the Mental Health Act (1983).

The Joint Royal Colleges Ambulance Liaison Committee (JRCALC) provides clinical advice, and produces a set of nationally applicable evidence-based clinical practice guidelines, which are regularly reviewed and updated. JRCALC gather the available evidence in areas of ambulance service and paramedic care, which is discussed by a team of academics, clinicians and ambulance service representatives. The guidelines provided by JRCALC offer support and advice to paramedics and ambulance services, informed by the best available evidence.  Despite this, organisations such as the College of Paramedics have previously criticised JRCALC for their poor referencing of such evidence (CoP 2008). However, it has long been recognised that much of what is currently believed about pre hospital and paramedic care is based on custom and tradition rather than sound scientific evidence (Lemonick 2009), and Callaham (1997 p231) described the situation as: “The scanty science of pre hospital care” (p.231). It is therefore important that care for people who SH is based on good evidence in order to provide clinically and cost effective care.

Since staring this study, JRCALC has published three updated sets of guidelines (JRCALC 2004; 2013; 2016). As these guidelines have evolved, they increasingly reflect the recognition of the role of paramedics in the care for people who SH. JRCALC (2000) provided limited guidance in relation to SH. Advice was provided on medically managing the physical consequences of SH, such as dealing with the effects of poisoning, overdoses and care of wounds following SH. There was limited information on the psychosocial aspects of SH discussed earlier in this thesis, such as why people SH, what people think of care after SH, and the link between SH and completed suicides. JRCALC (2000) did however, provide a discussion on SH in relation to consent. They recognised that cases of SH presented challenges for health professionals such as paramedics. JRCALC (2000) advised that where a patient can communicate, an assessment of mental capacity should be made as a matter of urgency. If the person lacked mental capacity JRCALC (2006) advised that they must be treated in their best interest unless there is an existing living will. However, JRCALC (2000, 2006) advised that if the patient has capacity and refuses treatment, the patient’s GP should be contacted urgently to fully assess their level of capacity. They added that if the incident was more critical, and there was insufficient time, crews should act more formally, and in the patients best interest as they currently act rather intuitively, using documentation to assess whether they perceive the patient to be at risk of suicide.  They advocated the use of a suicide assessment form (fig 3) for this, which they advised may be of value in assessing some mental health patients who either lack mental capacity or rationally. This suicide checklist was included in the 2013 JRCALC guidelines (JRCALC 2013), which were current when the research reported in this thesis first started

Paramedics are not taught how to conduct a psychosocial assessment within their training and education, but nevertheless may increasingly using such risk assessment tools advocated by JRCALC which are commonly used in ED. Risk assessment tools are checklists of risk factors, symptoms or antecedents, but evidence for their effectiveness is limited (Hawley et al 2006 NICE 2006). Quinlivan et al (2014) found that a wide range of invalidated tools were in use among ED’s and mental health services, which, they suggested demonstrates little consensus over the best instruments for risk assessment, and reflects the style of service provision in that setting and a ‘high risk’ approach to management. Quinlivan et al (2014) also found that mental health staff were less likely to use published risk scales, reflecting a greater reliance on comprehensive psychosocial assessment. Whilst such assessment forms may be of assistance to paramedics in the care of people who SH, RCPsych (2010) suggests that the prediction of suicide, and the assessment of suicide risk in respect of any individual patient is virtually impossible, and such tick box assessment mentally “removes staff from people, devalues engagement and impairs empathy…empathic listening and talking have key therapeutic benefits” (RCPsych 2010 p79). Overreliance on assessment tools leads to complacency, they suggest, and can misdirect people away from a detailed history-taking and mental state assessment (RCPsych2010). Assessment, in which the patients’ views are taken seriously, and where they are encouraged to participate in decisions about their care and treatment, and have clear explanations for decisions taken, are highly rated (Taylor et al, 2009). Paramedics for a long time may therefore have been using invalidated risk assessment tools in the care for people who SH, with limited capacity to provide the psychosocial assessment called for by NICE (2004) for all people who present following SH. This reflects some of the limits of Paramedic care for people who SH, such as the need for collaboration with other professional groups who can provide an effective psychosocial assessment called for by NICE (2004).

Throughout this thesis, it is consistently recognised that paramedics are often the first professionals to encounter people who SH. Paramedics encounter people who threaten to harm themselves, engage in SH or die by suicide, yet few have sought to investigate their care for this patient cohort. In order to improve care in this encounter, it is important to understand SH, what SH is and what it is not, so that subsequent care and treatment is appropriate to the needs of the person. The many definitions of self-harming behaviour were explored, and whilst the RCPsych (2010) definition is presented in this thesis, the challenges and limitations of such definitions are recognised. The Royal College of Psychiatrists (2010) hold that SH is a behaviour trait, a manifestation of emotional distress, and an indication that something is wrong, rather than a primary disorder. Such factors therefore have implications around the assessment of SH as a mental health problem, and application of legislation such as the Mental Capacities Act (2005) and Mental Health Act (1983).

The factors associated with SH, what motivates a person to SH? and wider issues which influence SH, are also important considerations to improving how paramedics respond to people who SH. Guidelines recognise many of these factors, but in order to make meaningful improvements in the care for people who SH, recognising this is not enough. There needs to be an understanding from the paramedic perspective why people SH? and how the multiple and complex issues, influence their delivery of care. Social and demographic factors in SH, historical factors influencing SH, psychological, psychosocial, motivation and intent of SH, the nature of the act of SH, the link between SH and suicide, are all aspects with potential to influence attitudes of paramedics, their view of SH, and their response.

Mental Health Legislation relevant to paramedic care for people who Self Harm (SH)

In the UK two pieces of legislation are of fundamental importance in SH. These are the Mental Health Act (MHA 1983) and the Mental Capacity Act (MCA 2005). NICE (2004) recognises that in the pre hospital setting, those who SH may refuse treatment. In the UK, the Joint Royal Colleges Ambulance Liaison Committee Paramedic Guidelines (JRCALC 2006) suggest that when a patient can communicate; an assessment of their mental capacity should be made urgently, and that if they lack capacity they must be treated in their best interest unless there is an existing living will. However, if the patient has capacity and refuses treatment, the patient’s GP should be contacted urgently to fully assess their level of capacity.

Following SH, all patients should have a full bio psychosocial assessment carried out by a skilled and experienced clinician (RCPsych 2010, NICE 2004) which assesses a range of factors such as personal circumstances, social context, mental state, risk and needs, and is central to the clinical management of SH. Kapur (2003) found that receiving psycho social assessments can halve the risk of repetition of SH, yet fewer than half of SH patients attending A&E have been reported to received assessment (Kapur 2003, NICE 2004). Many who present to Paramedics and Police following SH and are at risk of further SH, suicide, or injury to themselves and others refuse to attend ED for such assessment and treatment (Rees et al 2016, IPCC 2015). In such circumstances the UK Mental Health Act and Mental Capacities Act (MHA 1983, MCA 2005) are of relevance. The MCA (2005) upholds the right of an individual to make one’s own decisions, and advocates a functional approach to decision-making around capacity that involves establishing the extent to which an individual’s abilities meet the demands of a particular decision. Measuring such capacity requires the patient’s ability to make decisions as well as:

• Understanding information relating to the specific decision

• Using the information to make a choice

• Communicating that choice.

The MCA (2015) reflects the Shared Decision Making (SDM) approach which has been advocated in UK NHS policy for several years (Coulter et al 2017a, National Voices 2013). Following a recent landmark ruling, SDM became a legal imperative throughout the UK, requiring that people with full mental capacity must be properly advised about their treatment options and the risks associated with each option so that they can make informed decisions when giving or withholding consent to treatment (Coulter et al 2017 a.). Paramedics therefore have an ethical, legal and professional responsibility (HCPC 2017) to apply the principles of SDM and MCA (2005), this is unless the UK Mental Health Act (MHA 1983) applies (NICE 2004). The MHA (1983) sets out when a person can be admitted, detained and treated in hospital against their wishes. The sections used in emergency detention of SH are summarised below:

• Section 4: Is applied in emergency situations to detain a person for up to 72 hours in the interests of their own health and safety or to protect other people. An application for admission must be made by an Approved Mental Health Professional (AMHP) or a nearest relative with recommendation of one doctor.

• Section 135 (a): an AMHP can seek a warrant from a magistrate, to allow a police officer, the AMHP and a doctor to enter premises and remove a patient to ‘a place of safety’ for assessment.

• Section 135 (b): a justice of the peace may grant a warrant allowing a police officer to force entry to a premises in order to search for a person who is ‘absent without leave’ or ‘liable to be detained’. Officers may then use other powers under the MHA (1983).

• Section is applicable if:

• “A constable finds in a place to which the public have access a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons, remove that person to a place of safety.” (Sec. 136 1983 MHA)

Since publication of the Mental Health Act 1983, there have been many policy documents which have supported and developed its application. The legislation itself has also evolved throughout the duration of this Phd, which culminated in changes to the sections above of the MHA (1983) through the Police and Crime Act (2017).

In 2008 the Mental Health Act 1983: Code of Practice was introduced (Mental Health Code of Practice 2015). It is statutory guidance for registered medical practitioners and other professionals in relation to the medical treatment of patients suffering from mental disorder. As there have been substantial changes and updates in legislation, policy, case law, and professional practice, this code was revised in 2015 to reflect and embed developments in areas including the use of restrictive interventions, seclusion, use of police powers to detain people in places of safety, and the use of community treatment orders. The Mental Health Code of Practice (2015) provides statutory guidance to registered medical practitioners, approved clinicians, managers, providers of care, other staff and approved mental health professionals on how they should carry out functions under this Act in practice.

The Mental Health Code of Practice (2015) calls for ambulance services to ensure they have in place a clear joint policy for the safe and appropriate admission of people in their local area, agreed at board or board-equivalent level by each party, and that each party should appoint a named senior lead. The Code advises that those privy to the local policy should meet regularly to discuss its effectiveness in the light of experience, and review the policy where necessary, to decide when information about specific cases can be shared for the purpose of protecting the person or others, in line with the law. Those carrying out functions for these parties should understand the policies and their purpose, the roles and responsibilities of other agencies involved, and follow the local policy and receive the necessary training to be able to carry out fully their functions. In terms of SH, the intention of the Mental Health Code of Practice (2015) is to protect patients, and particularly those at risk of suicide and SH. However, it is recognised that any arrangements should also aim not to impose any unnecessary or disproportionate restrictions on patients or to make them feel as though they are subject to such restrictions.

In December 2017, amendments to sections 135 and 136 of the Mental Health Act came into force following changes to the Police and Crime Act (2017). These changes were designed to ensure police officers can act quicker and more flexibly, whilst ensuring that people receive the assessment and treatment they need in a timely manner. The changes also now allow for a person to be kept at a place of safety (and not solely removed for a mental health assessment if it is appropriate and they consent.

The Police and Crime Act (2017) changes included the definition of public place; by identifying the following places where police cannot exercise their powers under section 136:

a) any house, flat or room where that person, or any other person, is living, or;

b) any yard, garden, garage or outhouse that is used in connection with the house, flat or room, other than one that is also used in connection with one or more other houses, flats or rooms.’

Other than these excluded areas, the police will be able to exercise their powers under section 136 anywhere which will facilitate the Police to act quickly to protect people found in places such as railway lines, offices and rooftops which have previously not necessarily been considered as places to which the public have access.

Another important change introduced by The Police and Crime Act (2017) is that where practical to do so, the police have an added duty to consult a registered medical practitioner, a registered nurse or an approved mental health professional, before deciding to remove a person to or to keep them at a place of safety. The amendments also make clear that a suitable private property (with consent of the occupier) is an appropriate place of safety. A place of safety may therefore be a person’s own home or other places such as community centres or other multiple use buildings. The new addition of Section 136A prevents the use of police stations as a place of safety for under 18s and seeks to limit the use of police cells as places of safety for adults increase the safeguards in place where a police station is used as a place of safety for an adult. Section 136A also permits the secretary of state to make regulations regarding the use of police stations as places of safety, and may in future include provision for regular review and availability of appropriate medical treatment.

Important changes around timings of detentions were also introduced through the Police and Crime Act (2017). The maximum period for detention to allow for a mental health assessment under section 135 and section 136 changes from 72 hours to an initial maximum period of 24 hours, which commences from the time when the person arrives at the place of safety or the time a police officer enters the property if he/she subsequently decides to keep the person at that place. at the end of the 24-hour period an extension of up to 12 hours may be granted by the registered medical practitioner responsible for the examination of the patient. A more detailed presentation of these changes provided by Brown (2018) can be found in Appendix (  ).

Along with legislation and guidance documents on the application of such legislation, there is overarching strategy and policy which has implications for caring for people who SH. In 2014 the UK Department of Health published the Mental Health Crisis Care Concordat: Improving outcomes for people experiencing mental health crisis (Mental Health Crisis Care Concordat 2014). The aim of the Concordat was for collaboration and improved care in a crisis for people with mental health problems, however the concordat resulted in joint statements, written and agreed by signatories, describing what people experiencing a mental health crisis should be able to expect of the public services that respond to their needs. The concordat serves as a joint statement of intent and common purpose, and of agreement and understanding about the roles and responsibilities of each service. This is intended to ensure people who need immediate mental health support at a time of crisis get the right services when they need them, and get the help they need to move on and stay well. Ambulance services and paramedics feature frequently in the Mental Health Crisis Care Concordat (2014), which also involves a wide range of partners including health and social care, commissioners, the police, and local communities. The vision of the Concordat recognises the role of paramedics in providing initial assessment to people in mental health crisis, whilst acknowledging concerns, and that services do not always respond well, stating:

“Every day, people in mental health crisis situations find that our public services are there when they need them – the police officers who respond quickly to protect people and keep them safe; the paramedics who provide initial assessment and care; the mental health nurses and doctors who assess them and arrange for appropriate care; and the Approved Mental Health Professionals, such as social workers, who coordinate assessments and make contact with families.” (p.6)

And:

“These services save lives. There is much to be proud of. But we must also recognise that in too many cases people find that the same services do not respond so well. There have long been concerns about the way in which health services, social care services and police forces work together in response to mental health crises.” (p.6)

The concordat reinforces how emergency staff should treat people who have self-harmed which is in line with the NICE (2004) guidance. As with the NICE (2004) guidelines, the Mental Health Crisis Care Concordat (2014) again emphasises how screening, following SH, should determine a person’s mental capacity, their willingness to remain for further psychosocial assessment, their level of distress, the possible presence of mental illness and their need for referral for appropriate psychological therapies and follow-up. There also is further detail given in the concordat on what to expect when a decision is made by a police officer to use their power under section 136 of the MHA (1983), and how it is essential that the person in crisis is screened by a healthcare professional as soon as possible. Recognising that ambulance staff are often the first health professionals in contact with somebody following SH, the concordat recognises that in most cases it will be the ambulance service that will screen the person to exclude medical causes or complicating factors and advise on the local healthcare setting to which the person should be taken.

The Mental Health Crisis Care Concordat (2014) provides specific guidance for ambulance services. This includes making sure there is provision for round-the-clock advice from mental health professionals, within the clinical support infrastructure in each 999 ambulance control room. Enhanced levels of training for ambulance staff are called for, on the management of mental health patients. This could be multi-agency training to ensure a truly joined up approach. The Concordat also provides examples of good practice such as the section 136 working group for Lincolnshire. This group is made up of the police, the Lincolnshire Partnership Foundation Trust (LPFT), the ambulance service, Approved Mental Health Professionals (AMHPs) and the Local Authority. They have created a joint mental health process which fully outlines operational protocols and responsibilities. Their protocol includes a central 136 number for the police to use to enable them to access information and support from mental health professionals.

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