London’s mental health joint response car (MHJRC)

Background and aims

The demand of people in mental health crises presenting to emergency departments (EDs) has increased in the UK, especially since the onset of the COVID-19 pandemic.

EDs are busy and often cannot provide the calm environments people in mental health crises need. For example, an ASMAT report (2020) found that staff in 107 EDs across England had concerns about their lack of mental health training and ability to respond to the rising demand of people presenting with self harm.

In London, the London Ambulance Service (LAS) plays a crucial role in the mental health crisis care pathway, as 999 and NHS 111 are often the first point of care for patients experiencing a mental health crisis. Mental health calls are often complex, and take time and specialist expertise to manage effectively, which often leads to patients being conveyed to an emergency department.

If the LAS crew need clinical input into decision-making processes for mental health care for patients that require support but do not need conveying to an ED, 111 has the following process in place:

• The LAS crew calls 111 and presses *5. This puts them through to a call handler in the 111 clinical assessment service (CAS) who takes brief details of the situation.
• A CAS clinician will then call the crew back provide senior clinical advice to enable conveyance to the right place of care or to enable the crew to leave the scene as a follow up appointment is scheduled, such as a directly booked GP appointment or a home visit.

Whilst some may think 111 is masterminding the digital directory of local authority and NHS community services, this is facilitated by the directory of services (DOS) which is the national electronic database of all services that underpins 111.

Solution

An innovation in London was to a pilot new service, the mental health joint response car pilot, which consisted of a paramedic and mental health trust trained crisis nurse. This pilot involved a joint mental health ambulance car service which operated in six ambulance stations across London and was linked to 111 in securing access to user co-designed care plans.

In collaboration with mental health trusts, fourteen mental health professionals were seconded to the LAS to work alongside paramedics. A five-day training week was held for all staff which included sessions on specific mental health conditions, positive risk taking, mental and physical health interface, kit familiarisation, paramedic assist and advanced life support scenarios.

An evaluation was undertaken by NHS England and system partners to measure the impact of this scheme on stakeholder experience and on Ambulance ED conveyance rates; as well as evaluating the connectivity to and effects on the wider mental health system. Following the success of the initial pilot, winter resilience funding was secured, and five additional mental health cars were launched.

Outcomes and benefits

10 in-depth interviews were conducted to collect patient feedback on the mental health joint response cars. The feedback collected was positive and key themes included the specialist skills of the team, the personalized care provided by the team, and the team’s ability to treat people at home.

• Patient feedback was of an overall positive experience, in which patients benefitted from being treated in their community as opposed to being conveyed to the ED. However, due to the pandemic, feedback was collected from a limited sample, therefore more work is needed to assess patient experience.
• When assessing feedback from the MHJRC team, they reported high levels of job satisfaction and care benefits to patients of the multi-disciplinary approach.
• Key themes included the sharing of skills and knowledge, the benefit of a joint mental and physical health assessment, and the positive experience of being able to treat people at home and in the community rather than taking people to ED.

Evaluation

Mental health joint response cars (MHJRC) pilot outcome – January 19^th to April 12^th

Chart 5 shows the volume of combined MHJRC and business as usual (BAU) incident responses during the same period, broken down by London sector.  The South East London sector had the highest amount of responses during the pilot period at 1,118. In comparison, the North East sector had the lowest responses of 487.

Chart 5: Total incident responses during the pilot, split by London sector

Chart 6 shows the comparison of MHJRC and BAU response outcomes by sector. South East London had two cars operating during the pilot which increased the number of incidents they were able to attend in this sector, however, the number of BAU during this period was equally higher than the other sectors.  This infers that the South East sector has a greater number of mental health related calls than the other sectors.

Chart 6: The Comparison of MHJRC and BAE response outcomes, split by London sector

Additional information

Additionally, one of the key findings of the pilot is the reduction in ED conveyance when compared to the BAU response.

• The tracking of the NHS numbers post discharge from the MHJRC shows that only 4% of patients attended ED 7 days after a ‘See and Treat’ intervention.
• Had the BAU incidents been attended by the MHJRC, the projected cost of all ED attendances falls from £921,536 to £510,099. That is a potential cost saving of £411,437 over the year and a 44.6% reduction in ED conveyance. 
• The further evaluation of this service will be on the impact for police services in particular S136 cases. In the case of known patients, staff can access the care plan on via the NHS and support the person to connect with their known and trusted NHS workers in the community.
• Currently 50% of those conveyed to hospitals on a S136 are conveyed by police and an expansion of this service has the potential to reduce this demand on a system partner.