Mental health and A&E: Finding a path forward
Dr Mark Buchanan is an adult and paediatric emergency medicine consultant working in Arrowe Park Hospital, part of Wirral University Teaching Hospital NHS Foundation Trust.
He has developed an interest in improving care given to adults and children attending the emergency department in a mental health crisis and is the Royal College of Emergency Medicine Mental Health Sub-Committee chair, having worked on projects with NHS England, Health Education England and the Department of Health and Social Care.
I recently supported an acute and mental health interface roundtable event hosted by the NHS Confederation. The attendees represented a wide range of professions and importantly included persons with lived experience.
The proportion of people accessing A&E for a named mental health disorder or mental health crisis is relatively small. While issues with data do hide the true number, it is thought to be 3-5% of the total attendances.
So why does it matter, particularly given the many other challenges facing urgent and emergency care? Well, out of the 206,025 attendances in 2023/2024 where the chief complaint could be identified as a definite or possible mental health issue, more than 80,000 waited in an emergency department for more than 12 hours, with 26,000 spending more than 24 hours.
In fact, it is not uncommon for waits to be considerably longer than this. The Royal College of Emergency Medicine in November 2023 surveyed emergency departments and at the time of responding, 45% of departments had at least one adult awaiting over 5 days for a mental health bed.
In his report, Lord Darzi highlighted a patient with complex mental health needs spending more than 18 days in an A&E department in August 2024.
These are people in crisis, with the two main reasons for attendance being due to suicidal thoughts or self-injurious behaviours. Imagine how it must feel for a patient in crisis, at the most difficult point in their life, waiting in a busy department that is not able to offer a proper bed, shower facilities, fresh air or exercise. The lights are always on, and there's little to no respite from the hustle and bustle.
Stigma is also a problem, and this came out very strongly in our discussion. Speakers highlighted the way that patients attending in crisis can be judged and made to feel unwelcome and unwanted. Beyond the length of waits, there was a clear need for empathy, compassion and validation for patients in distress. In many ways this was paramount – a patient can accept having to wait, but being treated in this way is unacceptable.
We also continue to see a lack of understanding about whether A&E is the right place for mental health patients. Separate to the need for alternative community provision, we have to remember that a mental health crisis is a serious medical emergency and attending A&E is entirely appropriate as a means of keeping that person safe and ensuring their immediate needs can be met. The key question is whether or not care is actually being tailored in a sensitive and considerate way to meet those needs.
The long waits and difficult trade-offs relating to caring for mental health patients within emergency departments are well known and have been widely publicized. They also featured in Lord Darzi's independent investigation into the NHS. Our aims in this conversation were to go beyond the diagnosis to begin identifying the factors within our control, and to bring together people from disparate sides of the system to develop a common understanding of where the solutions lie.
Of course, this cannot be done from only one side, and needs to be multiagency, including general practitioners, emergency department staff, qualified psychiatrists and mental health nurses, paramedics, police, and social services to name a few, as well as patient representatives and those with lived experience.
Some of the opportunities for improvement that were identified included:
- The absence of communication – what to expect, how triaging and assessments work, when a bed will become available, when associated professionals will arrive, and an overall failure to manage expectations about the likely length of these waits.
The need for appropriate training on how to respond to and interact with people in crisis, particularly for staff who may be focused on delivering physical health care.
Risk management was also highlighted with lack of useful powers to help keep patients safe in their hours of need – mitigating risks of absconding without the kind of safety mechanisms that a mental health hospital has, and the need to balance the privacy and dignity of patients while ensuring that they do not have an opportunity to harm themselves.
The need to develop a system of joint ownership with ongoing management by both emergency and mental health staff, as well as ensuring early involvement of the mental health liaison teams in the process right from the moment of admission.
- The fear of diagnostic overshadowing, attributing the problem to mental health rather than a medical or surgical problem. Many mental health and emotional disorders manifest in physical symptoms which can be mistaken for physical health emergencies, and patients with severe mental health illness (SMI) have higher rates of chronic medical conditions compared with the general population.
While not a factor directly within the control of teams, shortage of staff was discussed at all points of the care pathway: specialist mental health social workers (AMHP’s), mental health liaison staff, psychiatrists, trained clinicians in mental health act assessments. There are opportunities to share capacity through partnership working, including with the VCSE sector.
We also noted that similar challenges are seen in the care of children and young people, which is something that I see in my own work.
Despite some tension and strong feelings on both sides, I was pleased to see that there was also a lot of common ground.
While many issues were raised, and the impact on patients when the right care is not delivered cannot be understated, there was a willingness to take time to understand each other’s perspectives, and a real appetite to get this right.
This workshop identified the need to work collaboratively to identify and implement longer-term solutions, and I am pleased to have been invited to be an ambassador to lead on the NHS Confederation’s new Interface Improvement Programme for Mental Health and Acute Care, which will open for applications shortly.
Mirroring the Interface Improvement Programme that supported teams in Primary and Secondary Care earlier this year, the programme will be open to groups of professionals working at the boundaries of Mental Health and Acute and Emergency Care.
Intensive support will be provided to help bring your team together, to explore the problem that you are interested in overcoming, understand the data, test out ideas, and go through a process of learning and monitoring, before implementing your improvements and spreading and sustaining the outputs.
Applications will open in January 2025, and the programme will launch in May 2025. We will be looking for six teams in total, with the virtual programme consisting of six workshops and three webinars spread across a 12-month period. Each team will be assigned a dedicated facilitator who will be available to provide support throughout.
We are welcoming initial expressions of interest for the programme ahead of applications officially opening in the coming weeks.
To express an interest or to find out more about the new programme, please reach out to either:
- Emma Fulton, Senior Policy and Delivery Manager, Acute Network – emma.fulton@nhsconfed.org
- Alex Stewart, Interim Assistant Director, Mental Health Network – alex.stewart@nhsconfed.org
