Is the ED the right place for someone experiencing a mental health crisis?
The governments announcement of a major investment in mental health provision in emergency care has been welcomed, but the RCN highlights the paucity of services available
In his autumn budget, the chancellor of the exchequer Philip Hammond said mental health funding would rise by at least 2 billion a year in real terms by 2023-24.
extra a year spent on mental health by 2023-24
That represents a significant chunk of the extra 20 billion available and will be invested in new crisis services, including extra mental health support in the 111 service, more crisis support in the community and mental health liaison teams in all emergency departments (EDs).
Mr Hammond said there were few more pressing demands than mental health so it was only right the government in England had made...
The government’s announcement of a major investment in mental health provision in emergency care has been welcomed, but the RCN highlights the ‘paucity of services available’
In his autumn budget, the chancellor of the exchequer Philip Hammond said mental health funding would rise by at least £2 billion a year in real terms by 2023-24.
extra a year spent on mental health by 2023-24
That represents a significant chunk of the extra £20 billion available and will be invested in new crisis services, including extra mental health support in the 111 service, more crisis support in the community and mental health liaison teams in all emergency departments (EDs).
Mr Hammond said there were ‘few more pressing demands’ than mental health so it was only right the government in England had made this ‘extraordinary commitment’.
These measures were already in the process of being rolled out, but confirmation of the extra funding ensures they will continue, mental health charities say.
In terms of support in EDs, the announcement will see psychiatric liaison teams in all units by 2023 with the biggest departments expected to have 24-hour cover.
RCN professional lead for mental health Catherine Gamble says the announcement on funding is ‘welcome’, but the fact extra support is needed in EDs in the first place is telling.
‘Not good enough’
‘It highlights the paucity of services available. It’s not good enough that the main point of access for treatment remains a GP or ED.’
Ms Gamble also says that liaison services can find themselves with limited options when it comes to referring patients on somewhere.
‘We simply don’t have the community services available and if someone is admitted into a psychiatric unit there are insufficient local beds, so they can end up many miles away.
‘When you compare that to the pathway options for someone who has had a heart attack, for example, it is completely different. Mental health patients are treated as third-rate.’
Nearly 50% rise in patient numbers
The emphasis on supporting the emergency system is clearly much needed. Data released by NHS Digital in 2017 showed the number of patients attending ED units with psychiatric problems had risen by nearly 50% to 165,000 in the past four years.
While this represents only a small minority of overall attendances – just over 1% in total – it is thought that the true figure is much higher as the data only included cases where a psychiatric condition was recorded as a primary condition.
The benefits of psychiatric liaison
One of the longest running and most successful psychiatric liaison services is run by Birmingham and Solihull Mental Health NHS Trust.
It provides 24-hour support to five hospitals, employing around 90 staff, more than half of whom are nurses.
The service was launched in 2009 and now sees around 1,500 patients a month in EDs, clinical decision units and on wards.
Lead nurse Angela Preston says: ‘We are busy. A lot of the time we are a constant presence at hospitals. The great thing is that we can tend to the patient at the same time as they are getting treatment for any physical condition.
‘For example, if someone comes in with an overdose and they are on a drip, we can be called straight away. If we weren’t here, the hospital would have to wait until they were well enough before getting mental health involved.’
To help improve care, the service has set up a psychiatric decision unit. It is sited away from the ED at one of the trust’s mental health centres to help reduce admissions.
‘We don’t keep them there longer than 12 hours. It just gives us the opportunity to have a chat, a cup of tea and assess what they need,’ says Ms Preston.
Number of times people who have a mental health condition are more likely to visit the emergency department
Source: The Health Foundation (2015)
Research by The Health Foundation in 2015 has suggested people who have a mental health condition are 3.2 times more likely to visit an ED.
But what difference will it make to nurses working in EDs?
Currently under half of EDs are thought to have community services. Their roll out has been rapidly expanding following the government’s decision in 2015 to stop police cells being used as a place of safety for people needing to be detained under section 136 of the 1983 Mental Health Act – generally known as being sectioned.
Where they are in place, staff find them invaluable, says RCN Emergency Care Association chair Janet Youd.
Citing her experience of the team at Calderdale and Huddersfield NHS Foundation Trust, she says: ‘It makes a huge difference having a service you can call on to provide that expert care.
‘It means we no longer have to wait for a patient to be medically fit before getting psychiatric help. It’s comprehensive care.
‘But you need the right area. You cannot see people who have a mental health condition in the middle of a busy ED. It has to be separate.
‘There’s guidance – you can’t just see these patients in a family room. Some places could struggle.’
She is also concerned about whether these teams will be able to provide a service for children given ‘how stretched’ child and adolescent mental health services are.
- RELATED: Evaluation of a mental health liaison team. Part 2: the themes and their effect on practice
Create a bottleneck
Another challenge, according to Justin Walford, an ED nurse at Brighton and Sussex University Hospitals NHS Trust, is that the wider demands on mental health services can create a bottleneck.
‘These psychiatric liaison services are just one cog in the wheel. At Brighton we have a good team.
‘However, the section 136 suites are often full. At times they are used for patients who have been admitted on to wards because there is no free bed. This means that patients have to come into the ED and stay there rather than go to the suite.
mental health nurse posts are still unfilled
Source: House of Commons Health Committee (2018)
‘The ED is not the right environment for a person in crisis.’
He also cites the shortage of mental health nurses as a significant barrier in rolling out these teams – 14.3% of posts are vacant.
‘I wonder where the nurses are going to come from. The shortages are just going to get worse with the removal of the bursary.’
A ‘safe, calm and welcoming’ environment
Southern Health NHS Foundation Trust has set up a crisis lounge in Southampton for people who have mental health problems to reduce demand on the local ED.
It opened in autumn 2017, initially from Monday to Thursday from 4pm to midnight.
It proved so successful, the hours were extended to 24/7 in the summer.
The lounge is staffed by mental health nurses and peer supporters to offer help to those who need it, although it does not take people under the influence of substances or those who lack capacity or display aggressive behaviour.
There are bean bags, a rocking chair, soft lighting, and music can be played.
Acute care matron Natascha Eden says the aim is to offer ‘rapid triage, assessments, interventions, advice and support’ in a ‘safe, calm and welcoming’ environment.
- The Health Foundation (2015) People with mental ill health and hospital use
- House of Commons Health Committee (2018) The nursing workforce
- NHS Digital (2017) Freedom of Information Request
- Rethink Mental Illness (2018) Section 136
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