Emergency Care: finding calm in a crisis

Last week, I shared an amazing experience with Jane. I accompanied her to an appointment with her neurology rehabilitation consultant. It was at the Lancashire Teaching Hospital near Preston. It has the worse visitor car-parking of any hospital in the North West. Like many visits I made last year, I eventually abandoned the search for a parking space, and we parked in the nearby local supermarket, and walked across.

The consultation was reassuring and helpful. What made it amazing was the consultant taking us through Jane’s various scans. I still find it fascinating that he was able to show us inside Jane’s head, where her VP shunt was located and where the aneurysm bleed had occurred. It was hard to grasp how the surgeons had both stopped the bleeding artery, and then subsequently fitted the shunt. What the consultant couldn’t show us was the original CT scan taken when we first attended the Emergency Department (ED) at Blackpool Victoria Hospital.

Apparently, the scans ‘belonged’ to Blackpool, and not Preston. One NHS? Shared patient records? Left shift, from analogue to digital? It was disappointing for sure. I was also reminded, in a PTSD type of way, of that dreadful experience, of sitting in a cold, noisy, uncomfortable and overcrowded ED waiting room for hours, waiting for someone to see Jane and tell us what was going on. That said, Blackpool ED is no different from many (most) accident and emergency departments in England.

Many EDs are not fit for contemporary emergency care. They are overcrowded, both because of the unremitting and increasing demand for help and care and because it can be so difficult to find a bed for those who need inpatient care. Increasingly, EDs are being negatively characterised by ‘corridor care’ as being the norm. These are not places you really want to be in, if you can help it. Despite this over 35% of those folk attending an ED for health care don’t actually need emergency care. Why do they go there?

If these difficulties are true for those presenting with some physical problem, it’s arguably more so for those experiencing a mental health crisis. Although people with mental health problems account for about 2% of all those who attend an ED*, one in four people presenting with a mental health problem will wait longer than 12 hours there. This compares to one in 10 of all other patients. Waiting in an overcrowded, noisy, busy and often chaotic environment is unlikely to be conducive to reducing distress or agitation.

The NHS 10 Year Health Plan recognised the problems experienced by healthcare professionals in responding appropriately, and in a timely way, to the needs of those attending ED in a mental health crisis. The plan sets out a transformational investment of £120 million over the next decade to develop a range of specialist mental health crisis assessment centres. These are to be located in, or co-located with existing EDs.

There are currently 10 pilot sites across the NHS. One of which is at the Blackpool Victoria Hospital ED. It is co-located next to the main ED. Anyone who is triaged as needing a mental health assessment, can get this by literally stepping across the road.

Whilst some have described this policy approach as being almost Cartesian in approach (splitting the mind from the body), services such as the Blackpool one can provide access to both mental and physical health care expertise. The Centre for Mental Health note that some 42% of people presenting at their ED with a mental health problem will also be flagged with a non-mental health diagnosis. Whilst liaison psychiatry services can help here, often these folk are few and far between in EDs.

I welcome these developments in mental health crisis care, well at least the Blackpool type model. But I also know that such services won’t, in themselves, deal with the problem of finding a bed where inpatient care is the appropriate way forward. Likewise, I also know that some 70% of people who chose suicide as a way of resolving their mental health problems, haven’t been anywhere near an ED. There really is no health without mental health, and finding ways of recognising this in practical ways has always been a challenge. However, improving ED mental health crisis services does feel like a positive step in transforming how good mental health care might be provided.

 

* Despite recent announcements to invest in mental health care, mental illness represents 20% of the UK’s disease burden but receives only 10% of health funding.