Never waste a crisis: Dr Jacqueline Huber

There is now broad agreement, at least in New South Wales, Victoria and Aotearoa New Zealand, that police should not be the default response to people experiencing mental health crises. Quite right too. Individuals should not encounter an armed police officer simply because they are unwell. Consumers have repeatedly asked for responses that are calmer, more relational and more clinically informed, and police, for their part, are becoming increasingly vocal about their role as routine responders to situations in which no crime has occurred. The cry has gone out, loud and clear, for a ‘health-led response’. But if ‘health’ is to lead, then ‘health’ must be able to turn up – and ‘health’ must have the support of police wherever and whenever it is needed.

That means mobile clinicians, extended operating hours, senior decision-makers, safe transport, community alternatives rapid, willing access to police when police capabilities are actually required, and, at its best, joint police/health training and experiential placements. Rural and remote services require particular thought; a model that works in the inner city cannot simply be stretched across several hundred kilometres and described as statewide.

Otherwise, an entirely foreseeable problem emerges. Police decline because the incident is characterised as a health matter. Health services decline because their clinicians cannot safely attend without police. Both services enforce their thresholds, and the patient, family member and carer remain uncared for.

In this context, emergency psychiatry discovers one of its recurring truths: organisational boundaries are considerably clearer to organisations than they are to patients.

The same problem follows people into hospital. Emergency Departments (EDs) have become the default destination when community crisis care cannot provide an alternative. Once there, patients with mental health presentations wait longer than other groups, and just as an example, this author group has seen ED lengths of stay beyond 10 days. Usually, this is because the service they actually need lies somewhere beyond the ED: an unavailable inpatient bed, an overstretched community team, a short-stay service packed with long-stay admissions, unavailable accommodation, over-subscribed drug and alcohol treatment programs, or simply nowhere safe to go.

We have developed numerous ways of organising care around the ED, including psychiatric teams embedded in EDs, community and consultation-liaison in-reach, telepsychiatry, mental health beds, short-stay crisis units and specialist psychiatric emergency services. Yet we remain in a situation where there is no convincing evidence that any configuration solves the problem. Some improve flow, satisfaction or admission rates, but much of the evidence remains limited, particularly when we move beyond throughput and ask whether people actually recover, experience less coercion or receive better continuing care.

This raises an inconvenient question. As Australia and Aotearoa New Zealand reduce police involvement in mental health crises, what exactly are we building in its stead?

The answer cannot be more referrals to already crowded EDs. Nor can success be measured by a falling number of police call-outs while ambulance demand, restraint, cancelled community visits or ED stays rise. Useful measures include whether people actually receive assessment, whether planned community responses occur, injuries and near misses, involuntary transport, repeat crises, ED presentations, restraint and sedation, and, rather importantly, what service users and families experienced.

Removing unnecessary police involvement is the right ambition, but removal is not reform in itself. Reform only occurs if something better takes its place. This is a rare opportunity for the RANZCP to rally around what a genuinely health-led crisis response should look like, and to press hard for the workforce, services and infrastructure required to deliver it. We should not waste it.

Dr Jacqueline Huber
Emergency Psychiatrist, St Vincent’s Public Hospital, Sydney
RANZCP Chair of the Emergency Psychiatry Network,