Emergency care for people with mental health problems: NHS England Consultation is open until 11th August
NHS England are undertaking a review of all emergency services, in part driven by an awareness of variable quality and premature mortality rates across hospitals and by geography. Of course there are background variations in the socio-economic determinants of illness and demands for emergency services related to alcohol use, dementia, substance misuse, acute crises for those with existing mental illnesses, and new mental illness episodes. The role of offending behaviour in presenting mental illnesses and contact with the police is also important to emphasise given the Adebowale report and the recent CQC/police reports on section 136 of the mental health act which permits the police to take a person they suspect of having mental illness to a place of safety. These reports found unacceptable practices in response to crises, leading to deaths in police custody, people bring transported in caged ambulance vehicles, transport related suicides, and widespread agreement on the need for care response models for substance misuse intoxications (http://www.hmic.gov.uk/media/a-criminal-use-of-police-cells-20130620.pdf). The role of the NHS in failing to provide a consistent and reliable emergency response is highlighted. So what should the NHS do? MIND completed an excellent review of what commissioners might look for when procuring new services ( http://www.mind.org.uk/assets/0002/2011/CommissioningExcellence_WEB_VERSION_2.pdf).
The links of emergency mental health presentations with emergency medical services might be overlooked unless explicitly specified and understood. Thus alcohol misuse can cause liver failure, fractures, trauma, gastritis, domestic and street violence and loss of control with impulsivity leading to self-harm, suicide, and risky or dangerous behaviours. Dementia related presentations are also relevant and include falls, fractures, unidentified and untreated infections, pain, co-morbid physical conditions, and confusion and delirium which is a medical emergency. Mental health related presentations include self-harm and suicide, accidents and injuries , relapse of psychoses and new illness episodes, and mental illnesses due to substance misuse or medical complications. These require home treatment and crisis responses and better use of social networks and shared care plans that deliver adherence and protect dignity and autonomy, alongside much closer working between different specialities and sectors, for example, NHS and the police.
Overall what we need is an emergency response team within hospital settings, such as liaison services in which highly skilled psychiatric specialists can assess and treat medical and mental illnesses quickly, or identify where there are physical and psychiatric elements that require distinct care plans and teams. Secondly, a broader community response is required, including the police and NHS crisis services, with better first aid for mental illness crises, for a variety of common states of psychological distress, protections for the vulnerable, alternatives to admission or detention in hospital and better accommodation options (for example crisis houses). This community response should include provision of better information for the public and earlier and quicker access points to high quality specialist advice, not requiring numerous filters that will ultimately delay timely intervention. The role of social media and support, families and schools, work settings – the entire public health system- requires careful deliberation in close collaboration with local government.
Have your say, and respond the consultation now at http://www.england.nhs.uk/uec-england/
Prof. Kamaldeep Bhui MD FRCPsych
Public Health Lead
Royal College of Psychiatrists