Safe spaces: scoping report

1. Introduction

This paper explores the feasibility of implementing an additional safe space as an alternative to taking people in crisis to an Emergency Department (ED) and for the use of ED as a legal place of safety. It also considers whether safe spaces can act a non-clinical community resource to support people in distress and prevent escalation.

EDs have been, and will continue to be, an important space and service for people experiencing crisis and acute emotional distress. At the same time, the limitations of ED as an environment to support people in crisis suggest that alternative safe spaces within the community are also needed to provide this support and to act as an alternative to ED as a place of safety.

Safe spaces should not replace clinical mental health interventions, but rather help people navigate the mental health system, connect them to local services, and encourage people to develop self-management skills to maintain their mental health and wellbeing. It is also vital that these services ensure equal access to care (e.g. through interpretation services).

The concept of an alternative and/or additional space has consistently been identified as an opportunity to improve the care provided to individuals. The lack of this provision being available across Scotland is creating challenges for delivering a positive experience, access to care, quality of care and equitable service provision. This is particularly evident within mental health and distress unscheduled care provision and the issue is clearest when considered alongside the needs of those in need of a safe space, suggesting that diverse types of spaces are required for different purposes.

A safe space could be defined in many ways depending on the support needed and the specific characteristics of the individual(s) accessing the support. It could, for example, be described as a space that provides:

• a feeling of safety for people who may have experienced barriers or discrimination in accessing and/or using services;
• a calm therapeutic environment for individuals to receive specialist support, assessment, and treatment;
• non-specialist safety monitoring over a limited time period to support the individual over the acute crisis phase of their episode of distress;
• a comfortable space to be monitored and/or remain safe while intoxicated;
• an alternative legal place of safety providing a more comfortable non-clinical environment while a person is assessed/waiting to be assessed; and
• a community safe space which may or may not be staffed by the wider mental wellbeing workforce.

These examples are not exhaustive and not necessarily exclusive of each other; there may be benefits of taking a mixed approach.

1.1. Report Limitations

This report has been compiled predominantly as a desk-based exercise, utilising existing evidence, lived experience, resources, and best practice to better understand the issues associated with making safe spaces consistently available across Scotland from a national perspective. Key stakeholders, including those with lived experience and some providers of additional safe spaces, have been consulted to inform the content of the report.

Evidence contained within this report highlight the importance of involving local communities, service users, and partners in the design of any new safe space, though this involvement should not be limited to the design phase, but should also inform the service’s day-to-day operation and future priorities as well.

1.2. Background

The Scottish Government published the Mental Health and Wellbeing Strategy (the Strategy) in June 2023, jointly with COSLA. This was followed by the Strategy’s first Delivery Plan and Mental Health and Wellbeing Workforce Action Plan, published in November 2023. The new Strategy allows us to look ahead to make sure we are doing the right things to meet changing mental health and wellbeing needs over the coming years. It sets out a clear vision for future population mental health, wellbeing, and care.

The Strategy highlighted the Scottish Government’s work with partners, including Health Boards, Police Scotland, the Scottish Ambulance Service (SAS) and NHS 24, to ensure support is accessible for any individual experiencing distress or mental health crisis. Its ambition is to continue to make unscheduled care improvements with these partners to ensure that those in crisis can access the best care as quickly as possible. The Delivery Plan goes on to outline the action required to achieve this:

Strategic Action 4.5: We will build on work already underway to improve unplanned and urgent mental health care, including for those in mental distress, using a multi-agency response. In doing so, we will take into account the findings from our Equalities Impact Assessment, in order to better understand and support different population and equalities groups and will continue to ensure alignment with the national rollout of the DBI programme.

Sub-Actions:

4.5.1 Continue to invest in NHS 24’s Mental Health Hub, with each Health Board providing access to a mental health clinician 24 hours a day, seven days a week.

4.5.2 Embed the Time, Space, Compassion principles and expand supports that can be accessed to meet a range of needs, increasing access to more existing and developing services and developing a mental health unscheduled care resource pack by autumn 2024.

4.5.3 Increased awareness of available pathways into support and care by developing national awareness raising activity by the end of 2023, followed by the development of tailored messaging for specific population and equalities groups in 2024.

4.5.4 Continue to invest in the Enhanced Mental Health Pathway and promote partnership working to increase Police Scotland and Scottish Ambulance Service access to local clinical support over the duration of the Delivery Plan.

4.5.5 Take action to respond to the recommendations of Her Majesty’s Inspectorate of Constabulary in Scotland’s (HMICS) thematic review of Policing and Mental Health published in autumn 2023, and the subsequent Police Scotland actions on mental health.

4.5.6 Take an evidenced based approach to improvement work to better understand how people are accessing and receiving unplanned mental health care. Lead in work will commence in 2024 to ensure that improvements to unplanned and urgent care are underpinned by robust data, including person demographic data.

1.2.1. Urgent Mental Health Assessment and Triage

Each health board now has a mental health clinician available 24/7 within unscheduled care settings, ensuring that urgent mental health assessments are also available. NHS 24 can make referrals in the Out of Hours period, providing a national pathway to local urgent support. These clinicians are also available to frontline staff, such as Police Scotland and SAS, providing the within clinician support and mental health advice.. However, it should be noted that the SAS pathways are newer or, in some areas, still in development.

Each health board area has a slightly different unscheduled care response in place. To promote a joined up collaborative approach a National Community Triage Guide has been developed for both Police Scotland and SAS to ensure they know who best to contact, when, and outlining alternative arrangements as needed, for example, pathways for children and young people. There is scope to realise further benefits from the availability of this clinical support by increasing awareness of their availability via dissemination of the guide. This could also be further improved through national public messaging on how to access unplanned care. New messaging outlining how people can access urgent mental health support was published on NHS Inform in December 2023, and the Scottish Government and Mental Health Unscheduled Care Network will continue to promote this messaging and are actively considering further improvements to better meet the needs of particular diverse groups.

1.2.2. The Enhanced Mental Health Pathway

The Enhanced Mental Health Pathway provides routes to care for those who contact SAS or Police Scotland in distress or in need mental health support. The Scottish Government has invested nearly £10 million since 2020-21 to support this initiative which ensures that all relevant callers to Police Scotland and the SAS can access the NHS 24 Mental Health Hub to receive timely mental health triage and support from mental health practitioners. It is also contributing to alleviating demand on emergency responders.

Use of the pathway has increased since September 2023 due to further collaborative development work undertaken by Police Scotland and NHS 24. It is anticipated that referrals will continue to increase as the number of staff trained also increases.

There have also been recent positive developments with the SAS pathway to allow for a trauma-informed warm handover of calls from SAS to NHS 24, including allowing calls to be passed back to SAS should further triage suggest that an ambulance response may be required. This improved pathway launched in early December 2023 and it is anticipated that this will also see referrals to the Hub increase.

1.2.3. Distress Brief Intervention (DBI) Programme

This programme provides up to two weeks of personalised, compassionate support to people who present in emotional distress to Police Scotland, SAS and other frontline services but who do not require emergency clinical intervention. People who are considered appropriate for DBI can be referred by staff who have been trained in DBI across these services, where DBI is considered appropriate for the individual. The DBI team has also conducted work with SAS and Police Scotland to introduce national pathways to DBI via their call handling centres. This initiative enables call handling staff to make referrals to DBI instead of sending officers out in response to calls, thus saving key resources. Independent evaluation has shown that DBI is an effective model in supporting people in distress.

1.2.4. Action 15 Funding

Action 15 of the Scottish Government’s Mental Health Strategy 2017-2027 outlined the commitment to fund 800 additional mental health workers to ensure increased capacity to deliver support in key locations where people may need help the most. As of 1 April 2022, there were 958.9 WTE mental health posts recruited because of Action 15 funding. The total figure includes settings where people may require unplanned or urgent care, for example, the recruitment of 179.2 WTE additional mental health workers within ED settings and 35.6 WTE posts in Police Custody suites.

1.2.5. Mental Health Paramedic Response Units

Action 15 funding also supported the expansion of the SAS Mental Health Paramedic Response Unit which allows paramedics to work jointly with mental health professionals to improve decision making regarding onward care and treatment needs. Police Scotland can also refer individuals to this service. Early findings suggests that the service reduces demand on emergency services by reducing the need to convey individuals to ED for treatment. Further evaluation activity is planned to assess care outcomes, obtain user experience insights, and to determine whether it has reduced impacts on wider services.

1.2.6. People Frequently Presenting in Crisis

Like Police Scotland and NHS 24, SAS also receive a significant number of calls from individuals experiencing acute distress and emotional dysregulation, often caused by social determinants. They can present to SAS through the 999 system.

In 2021, a primary scoping exercise was undertaken on a small group of patients which showed a marked reduction in both 999-call volume and incident attendances when patients were supported by a multidisciplinary team. In addition to a reduction in inappropriate demand on the service, this focussed approach resulted in patients participating in their care planning and engaging with the care pathways and services. The results of the scoping were shared with the Scottish Government who, on review of the data, provided £100,000 additional non-recurring funding to expand this project, write and test new operational guidance, and further evaluate the patient outcomes, benefits and risks that undertaking this type of patient intervention presents.

The team identified 137 patients over the age of 18 years old who had generated 12 or more 999 incidents in 3 months, and/or 5 or more 999 incidents in a 1-month period. Four clinicians were recruited to support the process development and function as a single point of contact for patients, staff, and the wider multidisciplinary team. This person-centred approach aided in supporting patients, by enhancing their confidence in accessing care and enabling the service users to hear their own voice in the process of care planning. Patients received the right care for their needs closer to home or within their local community.

Most of the patients in this project showed a definitive decrease in the number of incidents/attendances with the service when care was better provided locally. In total the number of incidents SAS attended nationally in relation to this cohort dropped by 55% from 3216 to 1441. This reduction in attendance and conveyance time meant that crews had increased availability to respond to patients who required conveyance, helping to reduce demand on the service and other healthcare providers. As a result, SAS has embedded this model into their service provision and expanded the service to children and young people.

1.3. Conclusion

Despite these improvements, the current provision within unscheduled mental health care is not meeting the needs of everyone in Scotland and there is room for further improvements, primarily an alternative safe space to allow:

• Dedicated service provision to address the equality and accessibility needs of particular population groups.
• Improved support for individuals who may not need to be seen in a clinical environment but do need urgent short-term care and monitoring to support their safety.
• Improved support for people who do need to be seen within a clinical environment but hospital admission, may not be necessary.
• Improved response for people who may be in mental health crisis but due to intoxication cannot participate in an assessment.
• Improved unscheduled local provision for mental health crisis and distress to reduce unnecessary admission/conveyance.
• Additional services for first responders to convey/refer individuals who don’t meet hospital-based criteria and can be better supported within an alternative space.
• Prioritisation of key communities at greatest risk of crisis / stigmatisation and difficulty in help seeking / excluded from services.