Creating a place of calm in Bedlam?

When Jane had, at the time an undiagnosed, brain bleed, our first port of call was our local Urgent and Emergency Care (UEC) services - (in old money, the A&E department). We were seen and triaged within 10 minutes of arriving. The waiting area was quiet, warm and welcoming. All very encouraging, I thought. However, as I sat and watched ambulance after ambulance roll up, I thought we were going to be in for a long wait. I wasn’t wrong. The passage through the unit took many hours. At times, Jane was cared for on a trolley in the unit’s corridor. Eventually, and thankfully, she was blue lighted to a specialist neurological unit at a different hospital.

It was clear that the demands on the emergency service were unrelenting. There was a degree of chaos about the place, but everyone we encountered was calm, civil and sympathetic. That didn’t stop me feeling almost overwhelmed by a sense of being totally unable to help or protect Jane in her moment of need.

Crowded emergency departments result from a range of reasons. It’s estimated that over a third of people presenting at an emergency department, don’t need to be there. Their issues are either self-limiting or can be treated by primary or community care services. However, these people still need to be seen. Some folk who present with non-life-threatening problems, may be diverted to a Same Day Emergency Care (SDEC) centre, or an Urgent Treatment Centre (UTC) either at the hospital or in the community. Both these service provisions have been around for some time but the demand for emergency care services keeps growing.

One other issue is the availability of a bed, if someone needs to be admitted. Again, SDEC and UTC services can help here. There can be large numbers of patients already in a hospital bed who are medically fit for discharge, but for various reasons cannot be discharged. Often, it’s because their continuing health needs can’t be appropriately or effectively met by community services. These difficulties stop the ‘flow’ of patients through the hospital. It is a national problem, and not just for those with a physical illness. The problem applies equally to those with mental health issues, whose needs could be better met in the community rather than a hospital. Often such services are simply not available.

In many parts of England, the available health resource is disproportionately focused on the provision of hospital-based care. As I noted in a recent blog, hospitals are still viewed by most people to be the ultimate safe provider of health care. There are not enough health and social care staff or adequate community facilities available to shift this dial. Perhaps reflecting how difficult it is to free up transpositional funding (from hospital to community), back in 2023, the then UK government announced a £150 million allocation to improve UEC services for those people presenting with a mental health crisis.

Last week, NHS England announced it would be using this investment to develop a national network of dedicated mental health emergency units. We already have some of these types of units operating. They do indeed promise to see everyone within 10 minutes, assess their needs and start whatever intervention is deemed appropriate to meet those needs. The announcement was largely welcomed by many involved in providing mental health care, and I too welcome any additional investment in future mental health services. That said, I do wonder about this approach.

UEC departments can be a frightening place. Having somewhere that is calm and welcoming would clearly be helpful for someone experiencing a mental health crisis. There are examples in the UK and the US, where such services have been set up and which do appear to provide a more appropriate alternative to the more general UEC service. However, the same issues described above that slow down the ‘flow through’ current UEC services would also apply to a dedicated mental health UEC. The availability of beds to admit people into, already means that people can be placed a long way away from their home if an admission is required.

As yet, we don’t have a range of comprehensive community services that might steer people away from a hospital admission, and the national difficulty in recruiting to the mental health workforce adds to these problems. If I were talking to Jim Mackey (Chief Executive NHS England) I would be urging him to focus more of the available funding on early intervention services and community services that are intentionally integrated, and which reflect local neighbourhood needs. It might be literally a case of watch this space.