There has been some posting and tweeting recently about mental health in A&E, and very interesting it is too. Against a backdrop of questions about what A&E can do, what they can’t do; what care they give for people who self-present or are brought in by ambulance. Amidst such conversations during the work I did on trying to develop Mental Health Act places of safety for those detained under ss135/6 (or s297 / a130) I wondered about the extent of mental health presentations to A&E.
NB: I wish I could now re-find the on-line research article which gave these stats(!) but I remember the proportions anyway – if I land upon it, I’ll put the hyperlink in here! You can tell I’m not an academic!
The article studied presentations to major A&Es over a certain period. There were two statistics from the sample which settled the question of mental health.
- 1 in 6 of all patients presenting to A&E had some form of mental health presentation;
- 1 in 3 of those were present in A&E just because of their mental health problems.
- 5%+ of A&E volumes in the sample were mental health only;
- 15%+ had mental health problems as a part of the overall picture.
This is why I find it unusual to read reports like that from the Academy of Medical Royal Colleges which talks about how usual it is for there to be little training for nursing / medical staff in A&E. For 15% of the demand?
A person has presented to A&E or been taken there by someone other than the police because of mental health problems which may or may not have included medical issues wuch as injury, overdose, self-harm: remember, the ambulance service’s only option for a mental health call is “A&E” because they have no pathway to other parts of the NHS.
Once there, A&E commence triage and if need be arrange a mental health act assessment. Prior to the assessment taking place, or having taken place and admission being necessary a bed having not been found, the person becomes unwilling to stay – I’ll be frank: this usually occurs at a point where they have waited a period of time that would start to test most people’s patience. Eight or nine hours is not uncommon; more has been known.
The person having then decided to leave the department, a phone call is put in to the police reporting a high risk missing person. Immediate thought by me: what does ‘high risk’ mean with regard to the legal ability (or duty?) of A&E to consider trying to prevent the person leaving … especially for example if a patient has already been deemed in need of admission under the MHA? If the risks associated with the person leaving were so high, why aren’t security usually found in attendance and / or why haven’t the police already been called?
(I need to acknowledge here, that police responses to such requests can be unhelpful – nonsense such as “not a public place” and “already in a place of safety” get trotted out.)
Cue police activity and within half an hour or so the patient has been found. Let’s imagine they are found in a public place, they can either persuade the patient to return, or detain them under s136 / s297 / s130. Let’s imagine they find them in a private dwelling because they went straight home – they can do nothing other than inform NHS services of the patients whereabouts. Of course in the latter situation, A&E will no longer be interested in the practical problems of the police having no legal powers at all, because they are now a police responsibility; MH services will provide their usual response when police call for assistance to a private premises.
If one does persuade the person to return or uses s136 / s297 / s130 to enable it to occur, the response at A&E will be telling. Once you arrive back, they will almost certainly (in my operational experience) refuse to have the person returned to them. “What do you want to do with the person?” “Arrest them under s136 but they can’t come back in here.” “Seriously?! They were here for nine hours and now they’re banned? For being mentally ill and frustrated at waiting times / bed unavailability.” I used to worry about this course more when in practice it meant banishment to the cells because of there being no NHS place of safety in existence.
It has made me wonder in my more frustrated moments why A&E don’t have a routine policy of ringing the police every time they have a mental health presentation asking for the person to be arrested. This sounds extremely facetious, doesn’t it? But think the law through: s136 and similar powers can be used if the person ‘is in a place to which the public have access, appears to be suffering from mental disorder and is in immediate need of care (or control) in their own interests (or for the protection of others).’ Taking that paraphrase as it stands, one could argue this applies to anyone banging on the door of A&E for help.
All of this is a red-herring though: whether or not NHS Places of Safety exists and operate effectively in any area, there are going to be problems. The variety of demands – the types of incident – which lead to the need for access to community mental health crisis services, A&E services or emergency services like police or ambulance are not integrated. These organisations are not one coordinated system and they have conflicting operating models which leave gaps and create tension.
Perceptions in the quality in the service received by those in need will be determined by the efficacy of the system to flow seamlessly from one part to another. Currently, there are obstacles of various types scattered left right and centre because the service provision for such cases is functionalised into as many as eight different organisations who do not necessarily know or talk to each other.