Table 1

Summary of ambulance service (AS) survey responses

AS	Respondent	Trust wide protocol in place	Local pathways in place/being developed	Evaluating self-harm management
1	Area clinical lead	No.	No. Working to develop alternate mental health pathways. Not self-harm specific.	No.
2	Mental health lead nurse	Yes. Mental health protocol including self-harm with options to convey to ED or refer to mental health crisis service as appropriate.	Yes, in certain areas, in partnership with local mental health trust. Variable hours of operation.	No. Planned for 2018
3	Mental health strategy lead	No.	Yes. Triage of 999 calls and response by cars with paramedics and mental health nurses. In partnership with local mental health trust and approved mental health professionals in some areas. Not self-harm specific.	No.
4	Mental health clinical lead	Yes. No further details given.	No.	No.
5	Mental health project lead	No.	Yes. Referral project in which 999 calls are triaged in the dispatch centre and patients are signposted when appropriate to a Mental Health Crisis Team in place of sending an emergency ambulance. Also, a street triage scheme in partnership with local police and mental health service. Not self-harm specific. Highlighted that immediate medical need ‘trumps’ care of mental health problems.	No.
6	Mental health nurse consultant	No. Self-harm would trigger the use of a specific risk assessment tool by the crew on scene. The primary focus is on treatment of physical injury and then onward referral to a crisis team or if necessary, conveyance to ED for psychiatric liaison support.	No.	No.
7	Head of clinical operations	No. Have access to trust-wide mental health crisis teams if injuries are not serious enough to require ED treatment. No specific protocol for self-harm.	No.	Yes.
8	Consultant paramedic, mental health lead	No.	No. Piloting having mental health nurses in ambulance control room. Not self-harm specific.	No.
9	Mental health professional lead	No.	No. Triage in the ambulance call centre with options - conveyance to ED, ‘see and treat’ (ie, attendance but non-conveyance), referral to crisis team, dependent on local service availability. Patients who have overdosed are automatically taken to ED. Paramedics have a crew line to speak to mental health nurses. Introduced in 2016. They are available 24/7 but ‘it is a small team so might not always be able to speak to someone’. Not self-harm specific.	No.
10	Mental health strategic advisor	No.	No. Callers are triaged by the ‘clinical hub’ in the call centre to appropriate response—referred to ED/minor injures unit if required for treatment of injuries, with follow-up by mental health service if patients already known, or to general practitioner if not. Limited access to mental health professionals in the Clinical Hub and to mental health crisis teams has been challenging. Looking to link ambulance service and mental health records.	Auditing self-harm data on monthly basis, this has been updated in February 2018 to include only patients left at home.
11	Interim medical director	No.	No. Currently setting up street triage project with paramedic, police officer and psychiatric nurse to rapidly assess patients in the prehospital setting. Challenging to secure agreement of hospital Trust to provide a qualified psychiatric nurse to undertake clinical triage which is outside the scope of paramedic practice.	No.
12	Clinical governance manager	No. Working on a mental health policy and education package which includes a self-harm section. Physical health is considered first, if injuries are severe or life threatening, the patient is taken to ED.	No. Working on a referral pathway called Distress Brief Intervention being developed with primary care, ED, police and third sector partners (4-year pilot).	No.
13	Head of clinical practice	No. Physical injuries take priority and often indicate need for ED care.	Yes. Have local mental health triage teams consisting of a mental health nurse, a paramedic and a police officer. Hours of operation vary by area. In partnership with police, CCG and mental health trust. Not self-harm specific.	Currently auditing self-harm data.

CCG, Clinical Commissioning Groups.