Responding to Mental Health Crises in the Community 
Audit summary
Background
Mental illness touches many lives. Nearly one in five Victorians experience mental illness each year. While many people successfully manage, or recover from, mental illness, there can be times when a person is so acutely unwell they may become a risk to themselves or others. This is a mental health crisis.
A person in mental health crisis needs urgent assistance to maintain their safety and that of others, and to receive assessment and treatment. This often requires responses from Area Mental Health Services (AMHS), which the Department of Health (DOH) fund, and Victoria Police and Ambulance Victoria.
To respond effectively, these agencies need to coordinate and focus on the person’s needs, while also addressing any safety risks. The Mental Health Act 1986 and the Victorian Charter of Human Rights and Responsibilities Act 2006 describe how agency responses need to minimise restrictions on individual freedoms and interference with people’s rights and dignity. Consequently, all relevant agency staff need appropriate training, guidance and feedback.
This audit assessed the coordination, preparation, and effectiveness of police, ambulance and mental health triage and Crisis Assessment and Treatment (CAT) service responses to mental health crises. As such, the audit did not examine the broader mental health service system. It examined DOH, four AMHS, Victoria Police and Ambulance Victoria to assess whether:
·	agency responses to mental health crises are coordinated
·	agencies are adequately prepared to respond to mental health crises, and respond appropriately
·	agencies can show the effectiveness of their responses to mental health crises.
Conclusions
The Victorian Mental Health Reform Strategy 2009–2019, that DOH developed, articulates agency commitment to improving services in mental health. Government investment through the reform strategy should strengthen the broader mental health system, providing better support to prevent and respond to crises. Victoria Police has also started organisational change in responding to mental health issues through the development and implementation of their Peace of Mind strategy.
Presently however, responses to mental health crises are not consistently meeting the standards set out in the Mental Health Act 1986 or in agreed interagency protocols. The needs of the person in crisis at times comes second to other considerations, such as competing demands on time and resources, and historical and cultural practices.
There is demonstratable agency effort to improve responses to mental health crises through reform initiatives, such as DOH’s project to expand mental health triage services, Victoria Police’s investment in mental health research, and the trial of a new collaborative service model called Police, Ambulance and CAT team Emergency Response, or PACER. However, coordination between agencies can improve, and greater effort is required to make sure agency staff comply with protocols and receive appropriate training.
There is a lack of information showing the effectiveness of triage and CAT services, and police and ambulance responses to mental health crises. This prevents quantitative analysis and robust performance monitoring, allowing service gaps to go unaddressed.
Main findings
Measuring effectiveness
DOH lacks useful data about triage and CAT service responses to mental health crises. CAT services have run for 15 years, but DOH does not know the number of urgent referrals received, how services respond, their timeliness or the outcomes. DOH intends to collect this information and set performance indicators as part of its expansion of mental health triage services. DOH needs to make sure indicators targets and benchmarks are relevant and appropriate by basing them on comprehensive and accurate baseline data.
Through their mental health strategy, Victoria Police has identified the need to collect information about its responses to mental health crises. It is working with the Centre for Forensic Behavioural Science at Monash University to research police responses to mental illness, and has started collecting data about apprehensions made under the Mental Health Act 1986 of people experiencing mental health crises.
Until agencies have access to robust information about response effectiveness, they cannot identify successes or areas to improve in their own crisis response operations, nor can they review their joint performance to identify system-wide issues.
Preparation
While a mental health crisis is often unpredictable, the response to the crisis should not be.
Victoria Police provides its staff with some training and resources on responding to mental health crises, but people with a mental illness are still over-represented in fatal shootings. While police report that voluntary mental health first aid training is improving their ability to respond to crises, the standard training that they all receive is not meeting the needs of police in the field and does not promote expectations set out in the protocol between Victoria Police and DOH. Victoria Police has begun to improve its standard training.
There are also significant gaps in training for CAT clinicians and ambulance paramedics in responding to mental health crises, such as de-escalation strategies and how to interact with other agencies. Agencies also lack opportunities for interagency learning and exposure to consumer experience.
Appropriateness of response
The responsiveness of CAT services to mental health crises was an issue frequently raised by police, paramedics and consumers. Police often do not request assistance from CAT services because of long waits for a response, and report hours spent waiting in emergency departments for a mental health assessment to commence. Engagement with mental health services was the number one challenge that police identified in 2009 research into their ability to respond to mental health issues. 
Without performance data and clear expectations for CAT service responsiveness, it is impossible to assess CAT service crisis responses. However, some of the dissatisfaction with the service probably reflects unrealistic expectations for immediate, emergency responses that CAT services do not have the capacity to provide. The lack of clear communication about expectations and limitations of CAT services is contributing to negative stakeholder impressions of the service. 
The sites used to conduct mental health assessments, and modes of transport used do not always reflect the guidance in agreed agency protocols, and the principles in the Mental Health Act 1986 and the Victorian Charter of Human Rights and Responsibilities Act 2006. Agencies and their staff do not always prioritise the needs of the person when determining their responses. This is often due to the preferences and attitudes of staff, lack of training and awareness of protocols, and pressures on staff resources. As a result, people in mental health crisis may be transported in police divisional vans, and held in police cells, when there is no policing or safety need, and when better options are available. 
Response coordination
There are committees and protocols to support interagency coordination, but agencies can make better use of these to improve outcomes for consumers.
The state-level Interdepartmental Liaison Committee (IDLC) and local area Emergency Service Liaison Committees (ESLC) are bringing police, mental health and ambulance services together to communicate, build relationships and understand each other’s roles and ways of working. Similarly, interaction between DOH and Victoria Police to review and revise their interagency protocol has helped them identify and discuss issues that affect people in crisis.
However, DOH and Victoria Police have not shown how they will encourage and monitor compliance with their revised protocol. Given that awareness of, and compliance with, the current protocol is inconsistent; there is a risk staff will not follow the revised protocol. Agencies can strengthen protocols by making sure staff understand their importance, link them to training, and monitor staff compliance. This would help translate these protocols into appropriate staff behaviours and partnerships.
The protocol between Ambulance Victoria and DOH is almost 10-years old and there is confusion among paramedics about roles and responsibilities in mental health crises, demonstrating it is time to review this protocol.
The IDLC is also not effectively monitoring and providing support to ESLCs. There is little communication between the IDLC and ESLCs. This limits identification of system‑wide issues and protocol non-compliance, and sharing of good practice. Committees also lack consumer representation, despite it being a requirement under the interagency protocol.
Recommendations
Number	Recommendation	Page	
1.	DOH and AMHS demonstrate the effectiveness of their responses by:
·	working together to develop and implement ways to measure demand for, and effectiveness of responses to, mental health crises
·	using this information to identify and address service gaps and areas for improvement.	20	
2.	Victoria Police, as indicated in the Peace of Mind Strategy, develops and uses measures to evaluate their responses to mental health issues.	20	
3.	IDLC and ESLCs jointly review performance in responding to mental health issues.	20	
4.	All agencies continue collaborative innovation by:
·	continuing the PACER trial and acting on its evaluation
·	focusing on opportunities to address issues particular to regional/rural settings.	20	
5.	Victoria Police complete enhancements to mental health training to:
·	support interagency coordination and protocol compliance
·	improve consistency and quality of responses for consumers.	34	
6.	AMHS and Ambulance Victoria address training gaps for paramedic and CAT/triage staff.	34	
7.	Each agency incorporates consumer experience and perspective in staff training.	34	
8.	DOH, AMHS, Victoria Police and Ambulance Victoria explore and trial opportunities for interagency training/learning opportunities.	34	
9.	Ambulance Victoria, DOH and Victoria Police, work together to investigate and trial alternative transport solutions.	34	

Recommendations – continued
Number	Recommendation	Page	
10.	DOH, with AMHS, clearly articulates and communicates expectations for CAT service responsiveness to crises.	34	
11.	ESLCs, supported and monitored by the IDLC, introduce protocols to minimise police delays at emergency departments.	34	
12.	Police should not use divisional vans as mental health transportation unless there is a clear policing or safety need.	34	
13.	Police should not use cells to detain persons under section 10 of the Mental Health Act 1986 unless there is a clear policing or safety need.	34	
14.	IDLC formalise and maintain communication, monitoring and reporting processes with ESLCs.	40	
15.	All ESLCs and the IDLC incorporate consumer representation.	40	
16.	DOH and Victoria Police support their review of the interagency protocol by:
·	developing a communication strategy to educate stakeholders about the protocol
·	identifying regions/services where the protocol is not being followed and work with them to address the barriers.	40	
17.	DOH and Ambulance Victoria review their joint protocol.	40