ITEM 4b
Herts County Council
Mental Health Presentations at A&E
Scrutiny Topic Group
19 January 2012
Report Author:
Graham Munn,
Commissioning Manager, Hertfordshire Joint Commissioning Team
Introduction
The report highlights some of the concerns and issues relating to how people
with mental health issues are dealt with at A&E departments. Member interest in
this area is welcome as there is a sense, from individual accounts and
anecdotally, that services may need to be improved, and that there is a need to
at least look at practices and systems and consider what can be done to improve
service users’ experiences.
A&E Provision
There are 3 A&E units in Hertfordshire located at the Lister, QEII and Watford
Hospitals. Hertfordshire residents also use the A&E facilities at the Princess
Alexander (Harlow), Chase Farm (Enfield) and Barnet Hospitals where, if they
present with a mental health issue, they will have to wait until the HPFT Crisis
and Treatment Team (CAT) attend to see them.
At each of the hospitals in Hertfordshire there is a Mental Health liaison service
(Community Psychiatric Nurses) and the CAT team are also accessible if
needed.
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Mental Health Presentations at A&E
People go to A&E seeking help for a varied assortment of mental health
conditions. In the main these tend to be for serious issues such as having taken
overdoses of drugs (medication) and suicide attempts. In effect people are facing
some form of crisis and attend A&E seeking help with this.
For people who have a mental illness a crisis can be particularly difficult. Crisis
may result from a variety of factors, such as deterioration in their mental and or
physical health, or because of relationship problems or as a result of problems
with practical day to day living issues such as financial or housing problems.
Appropriate crisis services are needed especially where someone’s mental
health has deteriorated to the extent that they may harm themselves or others
and when they need intensive specialist support and treatment.
In one study (Economic evaluation of a liaison psychiatry service by Sainsbury
Centre for Mental Health *) in Birmingham of a hospital service for people
presenting in a mental health crisis the reasons for presenting for help included: -
Deliberate self-harm
Depression
Cognitive impairment, confusion, dementia
Alcohol misuse
Suicidal ideation
Psychosis
27%
16%
13%
12%
10%
8%
Why people present at A&E Units therefore may be the result of many factors
and the above study provides at least some indications and understanding of the
possible reasons.
In addition, the Community MH services and GP’s may also be recommending to
their service users and patients to go to the A&E especially at out-of-hours times
(evenings and weekends) when its known that they will at least be seen by
someone.
Suitability of A&E units
There are a number of possible reasons why A&E units aren’t right for people
presenting with mental ill-health. These include: o Poor environment for an initial response to a crisis
o Potentially unsafe, unfriendly, and stressful environments
o The availability of specialist workers to carry out assessments may be limited.
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o lengthy waiting times may be experienced
o Poor environments for waiting to see specialist
o Levels of anxiety, stress and difficult behaviour may be left unattended to
while waiting to see a specialist.
o The quality of the service provided by staff at A&E units – staff attitudes and
practices - can vary
o How well trained A&E staff are in mental health issues is a factor as is how
well they are trained to deal with patients face to face.
In the A&E units in PAH and Chase Farm people presenting there have to wait
for a CAT team worker(s) to come to the hospital which may mean lengthy waits,
and with no interim intervention from the hospital staff being provided because
any treatment delivered is the responsibility of the Hertfordshire MH service.
The CAT team that services these two A&E Departments report several
deficiencies with current arrangements and some of these are explained in the
following statement: “With regard to facilities I do not feel they are appropriate or safe as
service users are screened by A&E then referred to us we have to
respond with in 4 hours
The information collected is minimal and on occasion the service user
waits to see us only to report that they have run out of medication and
need advice or they want to know what service to be signposted to.
Other times they are left in an extremely distressed state even at our
request to prescribe something to ease anxiety or distress we are told no
as they are Hertfordshire patients the psychiatrist from both hospitals will
refuse to see the service user if there are complications we have to
arrange for the CAT doctor to review which in turn adds to the length of
time the service user has to wait.”
What Service Users Want from a Crisis Service
Service users tend to be critical of the service they receive in A&E departments.
In one study (Open All Hours, which evaluated a Psychiatric Emergency Team
**) service users said they would like: o
o
o
o
o
More sensitive services
A speedy response
available 24 hours a day, 7 days a week
Where they can have face to face and telephone counselling
Services at home
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o Self-referral possible
In the same study GPs, like service users, wished for “rapid access to an
experienced professional’. They also advocated a single point of access to
specialist mental health services.
Leading by Design and Transforming HPFT Mental Health Services
HPFT are in the process of re-designing their services to take account of many
changes in Mental Health policy and practice. It is expected that these changes,
which include a single point of access will lead to improvements in how crises are
responded to. HPFT will have to work very closely with their various partners and
colleagues in many different organisations, such as the A&E departments, in
introducing these changes and are currently looking comprehensively at how to
improve the ‘care pathways’ they provide for people experiencing mental ill
health, from the times of crises through to recovering and discharge.
Conclusion
The interest of the Scrutiny Panel in this topic is most welcome. It is anticipated
that its findings will contribute significantly to our understanding of the issues and
what might be done to effect improvements in services and practices.
References
* Economic evaluation of a liaison psychiatry service by Sainsbury Centre for
Mental Health
** Open All Hours, which evaluated a Psychiatric Emergency Team
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