Think! – why A&E?!

You may well be familiar with the NHS ‘Choose Well’ campaign, or versions of it? – the presenting of a series of different characters with various medical conditions and using them to highlight which part of the NHS should have been accessed, like the poster, above?

  • Self-care
  • Pharmacist
  • 111 of NHS Direct type phone line.
  • Walk-in minor injuries units
  • GP or GP out-of-hours services
  • Accident and & Emergency Department

And then we see campaigns that aim to reinforce these principles – most recently, I came across a YouTube video from Blackpool –

It is not my intention here to criticise Blackpool or the principle that we need public eduction about how to make healthcare choices.  Heaven knows the police could also do with some kind of campaign about how to make policing choices given the hilariously inappropriate 999 calls we receive.  But what strikes me about this kind of campaign, which does affect policing and mental health care, is at least two really important things –

  • There is no mention whatsoever about mental health – mental health accounts for 23% of the NHS ‘burden of disease’ and for approximately 15% of all A&E attendances.  Yet is is barely mentioned in the first part of the ongoing NHS England review into Urgent Care and not mentioned at all in this video.
  • The overt reference that someone ‘should not have come here’ – patient blaming, without context.  It assumes that the other options were available, accessible and known to the person in those circumstances. We know this is often not the case.

THE EMERGENCY SYSTEM

One problem that Accident & Emergency has in common with the police and ambulance services, is that it is part of a 24/7 accessible system that is potentially there to ‘do something!’.  Each of those agencies can illustrate demand upon them that should, in an ideal world, have gone somewhere else, but didn’t.  And the police, as a non-NHS agency, have a unique perspective on this where they encounter members of the public who have health issues which may sit outside the expectations of A&E.  Recent discussion about the Crisis Care Concordat highlighted A&E’s perspective that the police were bringing too many people to their services and, presumably should be reminded to ‘choose well’.  I was struck by a couple of things in this observation.

Where a person has been encountered in their home by officers attending a mental health emergency incident and they feel that immediate care is needed, they often have very little option outside referral to A&E. Of course, street triage schemes offer the potential to prevent this need but on my last experience of shadowing a triage scheme, I watched an A&E referral be instigated by a nurse in circumstances where I’m not at all sure I would have done the same. I remember watching the patient walking in to A&E thinking that I hope they got the response they need, because research indicates that many don’t. More importantly, where else could the police, street triage or anyone else refer someone in urgent need? There is no other option, in many instances. Not everywhere has a walk in centre for mental health issues. I must find out what happens if someone in mental distress walks in to a minor injuries walk in centre – does anyone know?

So this comes back to a wider point of discussion:  to where should the police refer someone who believes that they need access to mental health services? There is (usually) nowhere – it is not a standard part of the design of our health services, except for those who are already in receipt of secondary mental health care from community mental health team. Even then, there are capacity problems as CrisisTeams struggle to manage demand, which is estimated to be up 15% over the last five years. In my evenings shadowing street triage, nearly half of the workload I saw was not calls to the police that the attending officers or control room felt could be better managed by the multi-agency car – it was merely overspill from the mental health system who had run out of crisis resource and were now passing non-urgent tasks elsewhere because they could.  And they were not tasks that had any policing component.

EMERGENCY CARE REVIEW

The poster at the top of this BLOG tells us that “A&E is for emergencies and life-threatening illnesses only.”  The problem with this approach, is that no-one appears to have told the rest of the NHS and such simplicity takes no account of that.  My wife broke her finger a couple of years ago: it was not an emergency and it wasn’t life-threatning. Where else would she have been expected to go because I’m sure nowhere else would start taping her fingers up and assuming it was a simple break that would pretty much heal itself until they’d done an x-ray.  Perhaps I’m missing something here?  The number of people who’ve made it clear that they have been signposted to A&E by 111 or by a mental health crisis team are so great that they can’t all be making it up simply to justify their decisions!

I am looking forward to seeing the publication in due course of the Care Quality Commission review into emergency mental health care. It touches on some of these issues but A&E need to understand, as police officers and paramedics do, that much of the demand that occurs for us all comes from the fact that “something’s happening that ought not to be happening about which somebody outght to do something now!” For that reason, I’m also looking forward to the second part of Sir Bruce KEOGH’s review into Urgent Care to see if mental health manages to achieve impact onto our thinking about the contribution. The Urgent Care review is looking across the whole NHS and we already know from Part 1 that it is focussed upon what other, non-hospital services may need to be available, to deliver the prevention and early intervention agenda in health. With 23% of the burden of disease relating to mental health, it will be a big omission if it is disregarded. What about the parity of esteem we hear so much about?  Perhaps the NHS England taskforce on mental health, chaired by Paul FARMER, will address that?

I want to see the above video edited to include a police officer detaining someone under s136 MHA in A&E and taking them to a Place of Safety. That is what we know A&E have called for on a lot of occasions, and not only when the grounds for doing so are legally satisifed. The worst news for everyone is that the new Code of Practice obliges the police to undertake their responsibilities in the least restrictive way. As such, where someone is wanting to access services, it should never be a consideration to legally detain them in order to ensure that those services respond. If the answer to the appropriate NHS location in those circumstances is not A&E, then you just need to let the police know where such patients should be sign-posted or taken. Evidence is  that if police officers know the alternatives, they will use them.

So if I you could just let us know once you’ve decided?!  Thanks. 

I want to conclude by reinforcing that nothing here should be construed as criticism of NHS colleagues in Accident & Emergency Departments I’ve been proud to work alongside for years. These people are not only nailing jellies to the wall each hour, but juggling yet more jellies and nails as they do.  This is a point about systems!


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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3 thoughts on “Think! – why A&E?!

  1. Great post. as ever. In my area, the advice if you need help out of hours is to go to the local ( 6 miles away, 40 minutes by public transport, no public transport at night) Urgent Treatment Centre. Once there you will almost certainly wait for hours to see the liaison worker who will either look to have you admitted after many more hours waiting or send you home. If you call the local helpline, they will call an ambulance which presumably takes you to A&E……. where the same thing happens but takes longer as the liaison person is based 8 miles away at the Urgent Treatment Centre and to add to your problems you are also now in the ‘wrong’ mental health trust area. The Crisis Team/Home Treatment Team is only available if you have been referred to and taken on by them. It is definitely not an out of hours emergency service……. care provided by Custody now starts to look quite good ……..

  2. MIUs seems to vary. There is no provision at some MIU’s for mental health crises at all, even those with a physical component. In my city the MIU advertises that it treats cuts, burns etc, but if your cuts or burn are due to self harm, they won’t treat you, and tell you that you have to go to A&E instead as they have no mental health cover at the MIU. This often involves an ambulance, which seems a waste of resources. Elsewhere in the UK I’ve been to an MIU and it’s been on the same site as an out of hours GP clinic or A&E, so a mental health assessment has been arranged there. It still ends up at A&E though.

    I think you’re right to question the patient blaming that goes on. There is a lot of blaming of frequent attenders (often relating to mental health) at A&E departments for service pressures, yet the data suggest that frequent attenders have a similar, perhaps lower, rate of ‘avoidable’ attendance than the general population, they also tend to be vulnerable and higher risk clinically – they have higher triage category and are more likely to be admitted. It may be easy to blame patients for the burden of work, but I don’t think it achieves much. It ignores the bigger picture of inequalities in health care and barriers to access.

  3. As someone who trains paramedics in mental health awareness (from a service user perspective) I wholeheartedly agree! When I point out to paramedics that mental health can be a matter of life and death and so where should people go if not A&E if they are suicidal I get the response” but A&E can’t do anything”. If there is no other service available to him/her where is someone who is feeling suicidal supposed to go for help? Is it acceptable for an overburdened A&E to turn away someone who is suicidal while accepting someone who might be having a heart attack (but might, in fact, have indigestion) because the latter is a life and death scenario they feel better equipped to deal with than the former? Is it OK for people to die by suicide because our health service is ill-equipped to respond and governments don’t want to resource mental health services adequately? As you say, we ignore the inequalities in health care and the barriers to access.

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