Letter - Minister for Home Affairs to HSS Scrutiny Panel re Ambulance Service - 29 March 2022

Minister for Home Affairs

19-21 Broad Street | St Helier Jersey | JE2 3RR

Deputy Mary Le Hegarat

Chair, Health and Social Security Panel Via Email

29 March 2021

Dear Deputy Le Hegarat

Follow up Review: Assessment of Mental Health Services

Further to your letter of 15 March, please find below responses to your questions in relation to the States of Jersey Ambulance Service. These are provided, as requested, from the perspective of the Ambulance Service.

1. Please can you provide data (for the period from September 2018, if possible) about the number of responses logged by the SoJAS where mental illness and / or mental health issues were the primary reason for the callout?

The table below details the average calls per month in two triage categories against the average monthly total of emergency calls attended. Whilst Psychiatric/Suicide Attempt should accurately reflect calls in that category, Overdose/Poisoning also refers to accidental overdoses and poisoning and alcohol intoxication.

Average calls attended per month (weighted for days in month)

Nb (The above data covers the full year 2018 until the end of February 2022) Whilst the data captures calls logged in these two categories of incident, it must be noted that these figures are taken from the Ambulance Services Computer Aided Dispatch (CAD) system. This data is captured from the caller and triaged according to their answers to triage questions, these figures may differ to actual clinical presentation on arrival of a clinician. In addition, it should be noted that in some cases the call may be categorised according to other presentations, e.g., if the patient has attempted suicide through traumatic means, the call may be registered as a trauma call. In some circumstances it may not be clear at the point of call that it relates to mental health.

a.  Please can you provide data about the number of responses logged by the SoJAS (for the period from September 2018, if possible) that included mental illness and / or a mental health issue as well as a physical health issue?

This data is not routinely captured in this format, a review of data at this level would require a manual trawl through approximately 30,000 paper patient records. We would not have resource to accomplish this.

2. Please can you describe the relationship between the Community Triage Team and the SoJAS?

During the trial period we worked closely to develop processes with clear guidance for when to call out the CTT. There was a limited number of calls where due to the speed of response and the demand levels placed on the ambulance service, the CCT team were able to respond and assist in a timely manner. Therefore, in the majority of cases whereby we currently work together, the Police are often involved and either the CTT are already on scene when ambulance crews arrive, or the police make the arrangements, freeing up ambulance crews until a decision is made to transfer a patient to more definitive care. There is opportunity to review these arrangements, in order to see if improvements in the system and processes could allow for a timelier response, allowing the ambulance service to use the CTT to assist in more cases.

1. Please can you explain the process for a SoJAS emergency response that also requires the Community Triage Team?

If ambulance clinicians determine on assessment that a patient would benefit from an assessment by the CTT, they make contact via control. The on call CTT responder will make contact and run through a series of questions to determine if a face-to-face response would be beneficial, or if they can provide guidance or referral on to Hospital for assessment. If attendance is required, then the ambulance crew will remain on scene until they can provide a hand over. In some cases, they may be required to stay until the decision to refer is either made, or they are no longer required. On occasions they may be required to remain on scene for the safety of the CTT responder.

2. Please can you provide a breakdown of the number of incidents that the SoJAS has been called to that have also involved the Community Triage Team and/or the States of Jersey Police?

CTT - We do not routinely capture this data, however patient records reviewed for the last year, indicate there were at least 5 occasions (it's likely this data is well below the actual number of incidents attended) whereby the CTT attended. As we have not been asked to record this data previously, any data held by the CTT team may differ to ours and is likely to be a more accurate representation.

Police - Sept 2018 – to date, mental health calls with a degree of Police involvement, or the Police notified the ambulance service of the call, a total of 399 calls were found to be recorded.

3. Do you consider that the establishment of the Community Triage Team has reduced the number of incidents involving mental illness / mental health issues that the SoJAS has been required to attend?

We do not hold sufficient data to determine this.

4. Please can you provide an assessment of the success of the introduction of the Community Triage Team? Please refer to data in your response, where possible.

There is insufficient data captured to advise, however the call out of a CTT team member, if on call and not on duty, can lead to ambulance delays on scene, crews are likely to transport to the emergency department if there is likely to be any significant delays. The CTT call out procedures include an initial telephone discussion and a decision by the team on when to attend, this means that they do not always attend in person.

During the initial trial, concerns were raised about single responders from CTT attending, as dependant on the circumstances, the ambulance crew may need to remain on scene for their safety. This presents the ambulance service with potential delays in responding to other calls that may be waiting. No data has been collected by the ambulance service to determine if this has been the case.

We do not believe the success of the team can be determined through ambulance data alone.

3. Please can you describe the relationship, between the SoJAS, Adult Mental Health Services and / or Child and Adolescent Mental Health Services?

Adult Mental Health Services (AMHS) - There was a good working relationship between AMHS and the Ambulance Service in regard to planning services, particularly through the setting up of the CTT trial. Resourcing issues and Covid has impacted on this in recent years, though both services attend a range of multi-disciplinary meetings whereby safeguarding, quality and safety are discussed. There is always opportunity to improve relationships.

Child and Adolescent Mental Health Services -The Ambulance Service does not refer directly into the Child and Adolescent Mental Health Services, all patients within this group would be transported to hospital for assessment. Therefore, there is very little contact with CAMHS.

1. Please advise whether this relationship includes the delivery of any formal training or ongoing support?

Some initial training was provided as part of the CTT trial, there is no evidence of recent training, though support is provided on a case-by-case basis.

2. At a Public Hearing with the Minister for Health and Social Services on 28th February 2022, the Panel learned that "people with complex mental health needs often have multiple interventions from multiple people across the system".  

Please can you provide non-specific examples where the SoJAS would respond to a mental health incident with other key agencies or frontline services?

• Where a patient is in imminent danger

• Where a patient cannot be located after an emergency call

• Trauma calls as a result of attempted suicide

• Where the Community Triage Team is the most appropriate response

• Where other health services are involved in the care of the patient (nursing/care homes, community health lodgings/supported home care)

• Hospital admissions made by a General Practitioner/Health Care Professional

• Section Orders under the Mental Health Law

• Charity involvement e.g., helplines requesting ambulance attendance

• Multi-Disciplinary Meetings

Ambulance crews respond to multiple mental health presentations where the crew feel that they need police involvement to protect themselves or the patient, this is particularly the case if the individual is being aggressive or poses a threat to themselves or the public. Ambulance clinicians/officers will seek advice from the CTT and from the Authorised officers in these circumstances, particularly if the individual lacks capacity, and actions need to be taken under the Capacity & Self-determination law.

Ambulance managers attend the Article 36 forum, whose members include: Ambulance, Police, Mental health team mangers and Authorised officers from the Capacity and self-determination team. The premise of the forum is to drive joint working around those individuals detained in the community under Article 36 of the mental health Law.

Individuals who are detained under section will have SoJAS representation as well as the other services named above.

The Ambulance Service are routinely asked to convey individuals detained under the Mental Health Law from the Emergency Department to Orchid house. This may involve a number of Services.

4. Please can you explain the procedure for a SoJAS response to an adult with known or suspected mental health issues?

The majority of Ambulance Service involvement with those suffering mental health concerns is either when a section order is in place and safe transport to a treating facility is required, or when the individual has reached a crisis point and has called 999.

999 calls are triaged by the combined control centre and an appropriate response is sent. If, during assessment, the attending ambulance crew feel there would be a benefit to involving the Community Triage Team, they will contact them. This service is available to us through an on-call rota, accessed via switch board at the hospital.

Alternatively, if hospitalisation for assessment is deemed appropriate and the patient is compliant and willing to accept help, then the crew may immediately transport to the Emergency Department. The crew may contact the patient's GP for advice and assistance, where this is deemed appropriate.

The role of the CTT is to assess the mental health of a person in the community, where there is a concern. They will ask a series of questions that will ascertain whether a visit is appropriate. On face-to-face assessment, the patient will either be managed within the community, or transported to a place of safety.

There are instances where an individual in the community needs to be placed under an article of the mental health law, and ambulance service involvement is to affect a safe conveyance from the property to a predetermined place of safety. If, because of a 999 call, the ambulance clinician may initiate the process by arranging an assessment by an appropriately qualified person. A plan is put in place either at scene or if circumstances allow for advanced planning, a multi-disciplinary team meeting to ensure everyone is aware of their specific roles and that appropriate risk assessments are carried out to ensure staff and patient welfare. The importance of this pre-planned approach for the Ambulance Service is to ensure that extra resources are put in place with appropriately trained staff.

5. Please can you explain the procedure for a SoJAS response to a child or young person with known or suspected mental health issues?

Similar to adults, ambulance involvement with Children and Young persons in a mental health crisis is usually through an individual calling 999 or an arranged admission. Other Services may be in attendance first and request an ambulance for transportation to the emergency department, or place of safety. Ambulance clinicians may call for police backup if the individual is presenting as a risk to staff, themselves, or the public.

Ambulance managers sit on the safeguarding quality assurance panel as well as the safeguarding review forum that meets every two weeks, States of Jersey Police and Mental Health Services also attend these meetings. Concerns can be raised at these forums and joint working between the various stakeholders is encouraged to ensure Children and young people remain safe.

Ambulance staff will fill out a Children and Young person's safeguarding referral form if deemed appropriate, and subsequent multi-disciplinary meetings may be called that involve both police & ambulance.

a.  Please can you describe how the SoJAS works with the States of Jersey Police to resolve incidents involving children and young people with mental health issues?

This is usually in the same way illustrated above, either through joint working on scene, using persuasion first and only moving on to more restrictive measures when appropriate and with the appropriate authorisations.

Preplanning wherever possible and time allows to carry out written risk assessments and enabling the right resourcing to be present to ensure patient safety, and dignity. MDT meetings ensure relevant information is shared to ensure the best outcomes for all involved.

6. What training is provided to frontline ambulance staff / paramedics to attend incidents that involve patients suffering from mental illness and / or mental health issues?

Ambulance Technician: Training is provided during initial formal training courses, this includes understanding the main reasons for ambulance involvement with patients suffering from mental illness, current legislation, codes of practice and agreed ways of working in Mental Health in the emergency & urgent care setting. Identifying key signs of mental health problems, understanding treatments, and the admission and transport procedure in accordance with the Mental Health law. Understand suicide and suicide risk assessment in the emergency and urgent care setting.  

They will then receive updates as required as part of their annual training programme, or if any changes in policy, procedure, law, or new practices evolve.

HCPC Paramedic: National training, at BSc level, they will gain knowledge of mental health issues that patients may present with, including the recognition, assessment, and referral procedure(s) for appropriate management, with reference to legislation, agreements, and policies. Assessing the physical and mental health needs of the patient and the criticality of their condition.

All staff through their training and development must have a placement with the Adult Mental Health Team and are signed off by a professional in that field, placement periods vary on the qualification requirement.

Locally staff receive training in our local CAPACITY AND SELF-DETERMINATION (JERSEY) LAW 2016, As well as MENTAL HEALTH (JERSEY) LAW 2016

All Staff undertake: Statutory & Mandatory Training: Mental Health, Dementia & Learning Disabilities through our e-learning platform, every 3 years as refresher.

All employees have the opportunity to book on to further H&S Mental Health England Awareness Training.

Yours sincerely

Deputy Gregory Guida Minister for Home Affairs