Last weekend, NHS England announced via The Times newspaper an intention to create a network of mental health emergency departments, separate from existing A&E services. On the face of it, it looks like a good idea. Many existing emergency departments are not safe or suitable places for someone facing a mental health crisis. People in a mental health crisis face much longer waits in A&E than others, and many report negative responses from staff in mainstream crisis services.
But is a separate ‘mental health A&E’ really the answer to these problems? One of the big difficulties with this announcement is that we simply don’t know. There is no model to draw on, nor research or evaluation to back it up. Where should these facilities be located? Close to existing A&Es or elsewhere? Who should staff them, and where are those staff going to come from? What is going to be stopped to free up resources to staff them? While NHS mental health services spending has risen in recent years, it remains far below what’s needed and is falling relative to the rest of the NHS.
There are also some inconvenient realities that intrude on the apparent simplicity of this idea. Many people in a mental health emergency also need urgent physical health care, and (to a lesser extent) vice versa. It’s not possible to separate the two in reality, so where do people go if they need help with both?
It has also been pointed out many times that the unacceptably long periods many people wait in A&E in a mental health emergency are very often due to delays in getting access to an inpatient bed. Having a separate A&E won’t remove that problem: if anything, investing in a parallel emergency ward might slow down efforts to improve access to inpatient beds when they’re needed, and to create alternatives to admission when this is possible.
we must acknowledge that A&E is a place where people with a mental illness have a right to go – just as much as anyone else
There’s also potential for duplication of (or diversion of resources from) existing initiatives and service models, including liaison psychiatry services in general hospitals, community-based crisis resolution and home treatment (CRHT) services, and drop-in crisis services and alternatives to hospital admission. Many of these are based on good evidence and, when implemented properly, can produce good results. So why not improve and expand them instead?
We’ve seen in the recent past the consequences of national mandates to roll out models that haven’t been sufficiently tried and tested. The most notorious of those was Serenity Integrated Mentoring – an idea that had a compelling case but wasn’t robustly tested, and whose national rollout had to be reversed when the risks and harms it posed were made apparent.
It’s important in mental health care that we balance and encourage both attention to evidence and innovation. It can be a difficult balance to strike, especially in a resource-starved system where investing in one thing inevitably means cutting back on another. It’s only through innovation that we try new ways to meet people’s needs better. But being informed by evidence is essential to provide safe services and effective interventions. So the two have to work in harmony.
No one should be turned away or treated less well because their emergency is connected to their mental health, or because they happen to have a mental illness.
There may be conditions and situations where a ‘mental health A&E’ would complement existing crisis services, providing a friendlier and more appropriate environment than would otherwise be available. To realise that, we’d need a period of robust testing, developing a model that could be applied and adapted to local needs, that would be culturally appropriate and equitably effective, and whose staffing could be guaranteed to meet needs without diminishing other mental health services.
In the meantime, we must also acknowledge that A&E is a place where people with a mental illness have a right to go – just as much as anyone else. And that means not only accepting and meeting the needs of people in a mental health crisis, but adapting the environment and routines of emergency departments to enable that. No one should be turned away or treated less well because their emergency is connected to their mental health, or because they happen to have a mental illness.
It’s clear that mental health emergency care needs to be better. But it requires a systemic approach to create crisis care that works for everyone who needs it, when and where they need it.
