[Content note: A&E for mental health crisis, poor care experiences, suicidal thoughts, self-harm]
The strain felt by A&E departments as we move into winter has been much in the news. Today the Guardian pronounces the whole A&E system to be “emergency care on wobbly legs” and notes that GP practices and ambulance services are also struggling to keep up with demand. Much of this is due to an ageing population – people living longer develop more long-term illness – but there appears to be a growing impatience with people “misusing” or “clogging up” A&E provision. I have no doubt that this is a genuine problem, having once had a conversation with people who thought it quite normal to go to A&E for a weekend ear infection, apparently genuinely unaware of out of hours GP care or the existence of walk-in treatment centres.
With all of this in mind NHS comms teams have been fighting back, producing handy guides to other services people should consider before making the trip to A&E. The most widely shared of these appears to be the “Think! Why A&E?” campaign which encourages trying self-care, making use of community pharmacists, visiting a walk-in/urgent care treatment centre, or calling the 111 helpline before considering attending A&E. The model offers examples of appropriate conditions for different levels of NHS input (for example, self-care for a cough or a hangover, a walk-in centre for cuts or sprains) but not one mental health condition/issue is mentioned despite the fact the Guardian article goes on to note that “people suffering mental health problems are also adding to the pressures on GPs and A&E units because support is not available in the community.”
When I deliver Mental Health First Aid there is a section in the instructor toolkit with which I feel very uncomfortable, and that is where A&E is recommended as a source of help in a mental health emergency. It’s quite clear why the recommendation is there: unless you are already hooked into services with out of hours provision, making your way to A&E or dialing 999 is probably your only way of accessing any support in a crisis – not to mention that many people who are already in services are told, even by so-called “crisis teams”, to use A&E if they cannot keep themselves safe. The message is as clear as it is bleak: we can’t help you, get yourself to A&E if you can, or call 999 if you can’t. Yet I feel deeply awkward making the recommendation because I am fully aware of the reality of the A&E experience for someone in a mental health crisis.
Ask for anecdotal feedback on A&E from those who go there because they are desperate, are suicidal, have harmed themselves (perhaps slightly more than intended and are doing the responsible thing in seeking treatment), or those who have attempted to take their own lives. I am afraid that you will not find a picture of comfort, kindness and safety. As I scroll through my Twitter timeline I see people treated like a nuisance. I see people left completely alone with their psychiatric emergency, in a busy and sometime intimidating environment. I see services who have psychiatric liaison staff but the staff are unavailable, or take hours to arrive. I note that attempters and self-harmers are still being treated with contempt or rudeness, or being made to feel ashamed and a “waste” of professionals’ time. Very sadly, I continue to hear of people who have self-injured being sutured without anesthetic as some kind of passive-aggressive punishment.
By all means let’s not have people calling out of hours GP services for a hangover or attending A&E for a grazed knee. Nobody is helped by that. But we already had a major problem with A&E staff lacking the training or understanding to recognise a genuine psychiatric emergency. That lack of understanding leads directly to a failure to deliver timely, compassionate care and an inability to recognise what a daunting place A&E can be for someone who is very mentally unwell. Campaigns about A&E that completely elide the presence of severe mental health and give out the message that A&E/999 are really only for “chest pain, choking, blood loss or blacking out” add to the idea that A&E is not for the likes of us.
So in the winter of 2014/15, with the NHS under increasing scrutiny as we head toward the General Election, rhetoric about “inappropriate” A&E attenders is being ratcheted up and is likely to decrease A&E professionals’ tolerance for people they feel are wasting a scarce resource. Do A&E and ambulance service workers know that their care is not only some mental health service users’ sole choice out of hours, but is being directly recommended by secondary care staff who don’t have the resources to offer anything else? I doubt it.
We’re supposed to be moving towards parity with physical health care. How this is supposed to be achieved when mental health conditions are entirely ignored in discussions about urgent and emergency care, I really don’t know. A&E staff may well feel that caring for people experiencing a psychiatric emergency is not their job as they are simply not trained for it. Meanwhile mental health services are making it increasingly clear that they don’t have the resources to support people out of hours or who are not already known to services. Desperate, vulnerable people in an hour of great need should not be batted between services. We are not shuttlecocks and the politics of care isn’t our problem. Our problem is survival, and NHS strategic bodies and local commissioners have a duty to sort out the rest.
Unless the parity agenda is pushed, and pushed with some force, this issue will only get worse. People need to “think mental health” not just in service design, but in comms and information campaigns. Statements on appropriate GP use needs to include people worried they may have a mental health problem, not just people who need flu jabs or statins or antibiotics. If we can give people emergency contraception at a walk-in centre, we ought be able to offer short-term pharmacological help for panic attacks. And A&E must be identified as a suitable place to go if you have badly hurt yourself or are close to attempting suicide. Otherwise policies and campaigns (like the chronic underfunding of mental health services) feed into the idea that we are a “nuisance”, that we are “time-wasters” or “attention-seekers”, that a fractured mind is somehow not as real as a fractured neck of femur. It dishonours the NHS to distinguish between “deserving” and “undeserving” emergencies.
purplepersuasion 
We are reaching a point where the ‘undeserving’ may well be obliged to enter a workhouse once more, as they are obliged to stop complaining, get some work and not bother the rest of society. And it is becoming clear that mental health problems have to be very, very severe to be classed as Deserving.
I can assure you that A&Es and ambulance staff are only too well aware that there is often no alternative for people in mental crisis. I also accept that there is often a poor attitude, and I think you are right to highlight lack of training and embarrassment at being unable to offer appropriate care as factors in this (no excuse though). In the short term these issues should be addressed urgently. I can also assure you that those on the ground do bring up MH provision whenever asked about what additional/better services are required.
In the longer term though, why shouldn’t there be MH emergency assessment units, with direct access? These would hopefully provide a calmer atmosphere than the average A&E, with specialist staff. They could even be sited within an A&E – after all, many A&Es have dedicated paediatric areas and staff, so why not for MH too?
You’re slipping into “not all health professionals” there – if you’re not sure what I mean by that I suggest you read my activist colleague Sectioned’s excellent blog on the topic: http://sectioneduk.wordpress.com/2013/08/16/but-were-not-all-like-that/ On the second point, why not just properly roll out psychiatric liaison? Liaison psychs have the knowledge of the MH system, the clout to try an obtain a bed, the assessment skills to know how risky somebody really is. I can’t see how a whole unit would be necessary, since it would only duplicate some of the needs of general A&E (bloods, treatment of injury/OD, ECGs, testing for UTI, etc). What *is* needed is a quiet place for people in acute mental distress to wait without the bright lights and noise and busyness. Of course all patients need privacy and dignity but when someone is feeling like they are losing their mind the last thing they need is for that to observed by a bunch of other patients.
My god, suturing without anaesthesia is assault, abuse and a level of cruelty that should be associated with a bloody prison sentence.
Shame on them.
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My local hospital has a pysch liason team and even though they are based in the pyschiatric unit that is on the hospital grounds to access them you have to go through a and e
It can take hours for them to get to you and even worse if you turn up at handover times.
I have been sutured without local anesthetic, I have also experianced the worse kind of treatment when it comes to doctors and nurses making me feel I shouldn’t be there, I am wasting their time. It does not matter if I’ve gone there before I have hurt myself or after, the treatment is the same and the lack of compassion and empathy is obvious.
Brilliantly written. I could add some more very recent experiences that highlight the dire lack of services as well as
understanding
Because most people can’t ‘see’ mental health crises (it’s all in the head) they don’t understand, don’t want to understand, or just don’t care…seems that the NHS is just like Joe Ignorant down the road.
We suffered a mental health crisis with my sister over the Christmas period and the 111 service let us down badly. The local crisis team said to use 111 as she did not live in my area but was visiting. I was batted about between ambulance (won’t attend unless bleeding, having a heart attack, broken leg or can’t breathe!!) Because of the violence, ambulance would also not attend without police and both reluctant to take ownership so no-one came. After 9 and 1/2 hours of being phoned back, waiting for services which apparently then said they were not down to be coming anyway, I was offered a doctor call back. It was 11.25 at night and the patient had gone to bed. We would have to stay up indefinitely. We were exhausted. We were treated like a nuisance throughout. We took her home by car – 3 hour drive – the next day and A&E told us to go away. Told to go to a police station where they gave me social worker numbers to telephone. At 6pm we arrived at a MH unit (in our own car – police would not own the problem). She is safe now but we should have had access to a psychiatrist at A&E. The whole system treats MH as a nuisance. Some staff may be more sympathetic but we didn’t see them.
In the US, some major university hospitals have CPEPs, or comprehensive psychiatric emergency programs. It is a separate part of the ER, it is certainly small and quiet, but it has the same fears and terrors and humiliations. You see a psychiatrist and social worker, you are gowned and have all your posessions and clothing – including phones, UK is very progressive in not doing that! – you do not have access to the outside world. There are visiting hours, but they are severely limited. You are in a room with a bed and that’s it. There are uniformed guards (not nurses, guards) at the door. And these “wonders” are still heavily traveled, understaffed, too few beds. I have been through the regular ER (segregated in the “psych” area, where you are also relieved of all your clothing and personal possessions, including socks and bra, and where uniformed guards prevent you from leaving) and into the hospital without even making it into the CPEP since it was full. No solutions anywhere, but I will say that even hearing the nightmare stories, I am somewhat jealous of crisis teams and HTT and cpns – we don’t have anything like that here.
Another inspiring post, Charlotte. Thank you.
2014 saw me having to attend A&E on at least 20 occasions due to SH injuries. I would estimate that there were, at most, 3 occasions where I was treated with compassion and dignity – all by the same doctor – who saw fit to treat me in a cubicle away from the busiest area of the department, be as gentle with my wounds as she possibly could, chat to me while she worked, treat me like a human being.
I’ve been the lowest priority in a waiting room full to bursting, doubled over with anxiety due to noise sensitivity. I’ve heard myself discussed from the other side of a curtain, referred to as a ‘deliberate self harmer’ (I hate that expression). So I would certainly like to see A&E better equipped to deal with MH patients…oh, and the last item on my Crisis Plan, written by my care team, is ‘go to A&E’
Thank you so much for writing this, PP. As always, you manage to put into words an experience that is all too familiar. My daughter is in and out of A&E for suturing and overdose treatment, and we have been told repeatedly that she should try to go there “to talk to somebody” *before* it gets to this sort of crisis. But to walk into a&e and just ask to talk to someone – when you’re constantly being told not to use the service – is so daunting that its not surprising she doesn’t do this. Part of her illness is to feel that she doesnt deserve treatment, so she harms herself partly as a way of feeling that she is ill “enough” to be seen. So I feel as if shes trapped in this cycle of self harm by a system that only seems to respond to extreme behaviour. I cant even begin to imagine how much her constant attendance at a&e must cost them.
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If it’s any consolation, in my experience, they don’t do blood loss either. 😉
Just today I was told to attend A&E totally inappropriately by my mental health team.
My mental health team had forgotten to leave me my weekly prescription. Rang up to arrange it. Care co-ordinator off sick . Told to speak to duty worker to arrange it. Duty work tells me they can’t do anything (it’s 11am in Friday) and I should attend A&E to ask them for my regular psychiatric medication prescription.
Fortunately I had the good sense to at least ring up the crisis team before going to A&E to see if they could help. The crisis worker rang duty worker back and then got he duty worker to get up out of their chair and walk to THE NEXT OFFICE to then ask the psychiatrist there to write a prescription for me. Duly done & I collected it an hour later.
An inappropriate A&E visit avoided (just) but still needed the intervention of the crisis team in order to get a prescription for regular, weekly medication written out.
It’s not always by choice that patients go to A&E inappropriately due to their mental health needs.
I am so sorry you had this experience, sounds inexcusable. Exactly, and that is essentially what I was saying in the piece where I ask, “Do A&E and ambulance service workers know that their care is not only some mental health service users’ sole choice out of hours, but is being directly recommended by secondary care staff” – in other words mental health professionals – who don’t have the resources to offer anything else? I doubt it.”
I have “shared” this post on Facebook, I am also going to share it with my MP. Thank You.
I was given the very strong impression, last time i visited A&E with a mental health crisis (August 2014), that because i said i wasn’t self-harming and had no actual plan to kill myself, right then that there was nothing they could do … in fact they more or less said that. I thought it very sad that 2 of the Mental health team eventually came down just to tell me that.
I suppose this goes back to the whole thing of how services have been affected by cutbacks so much… they’d rather wait for you to actually bloody try and kill yourself to offer help, but not to offer anything to try and prevent that!!!!! When i first accessed mental health services (2001/2002) it was a different story and i was helped out in far better, and certainly more sympathetic ways.
Agree totally, I am hearing more and more that MH services aND A&E services are saying that unless you are about to attempt or have made an attempt, there is nothing to help you. You are right, there are no resources for preventative work, the bar is also creeping higher for people to be considering worth a referral to a psychiatrist. The most vulnerable are being hit very hard by “austerity” 😦
“Agree totally, I am hearing more and more that MH services aND A&E services are saying that unless you are about to attempt or have made an attempt, there is nothing to help you.”
If I may say so, round here my personal experience of even when you say that you are about to attempt self-harm (and it is genuine intent rather than a throw-away comment made in frustration and previously you have carried out your stated intent) the response is (1) that’s your choice, I can’t stop you. Closely followed with (2) make sure you get yourself to A&E and they’ll ring the crisis team when you come round. [note: the crisis team is a different team so the self-Harmer will be taking up the time and resources of different sub-team]. There is also no follow up from the team in days following.
If you already have self-harmed or the worker strongly suspects you have. They simply say get yourself up to A&E. They feel no duty of care to call an ambulance, call police for assistance. There is also no follow up.
I really do genuinely wonder what the situation has to be for ANYONE in ANY of the local mental health teams to intervene in any way. I have said many, many times to my care co-ordinator, for my personal case, it’ll only ever really get looked into at a coroner’s court and even then the mental health team will try to cover it up. She agreed with me. Rather than be horrified I appreciated her honesty at seeing her colleagues as they really are.
Sorry, when I said “attempt” I was very specifically talking about attempted suicide with genuine plan to die, not self-harm. Sorry if I was unclear on that. As for SH I don’t here of much decent treatment at the time, let alone follow up x
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Out of date response to blog so prob silly to write a reply now, months later.
I cannot imagine how I would have dealt with that treatment received by those writing above, when I was feeling so so desperate and in need of help – need of anything. Shocking.
Thought maybe worth saying,
I must be very fortunate, that my experience of a&e has actually been, on 5 occasions in the last year, them saying I was not wasting their time, compassion, even empathy by triage, docs, nurses and then the psych consults.
I did have to wait but do not think I had to wait longer than others sitting in chairs because my presentation was not psychical when suicidal or that they put me low on the triage list for for self harm, (twice said moved me up because of concern I appeared highly agitated and distressed. Admittedly on one occasion I was brought in by the police, and another by ambulance so I guess and doesnt count).
My experience of the police has actually also been surprisingly non judgemental and on occasions compassionate (presented as such at least) – the first time I had to deal with them when they ‘returned me to a&e’, the two police women were amazing, reassured that I was not ‘crazy’ attempting suicide and feeling that I had no option, was more common than people think and I should in no way feel I was abnormal or wasting their time or any guilt. I am still touched by their emotion and concern, which appeared totally genuine.
Even the time I was detained under s136, (I could not believe I had caused such fuss and police time), they did not voice any judgement of my actions despite it being ridiculous. In the situation I placed them in, I see they had no choice.
I guess I have big tendency to blame myself and am mortified for wasting docs/ police etc time and the unintentional chaos that I have seemed to create over the last couple of years. Rather than alternative that I struggling and in need of help at that time. But this hasnt been what the medical staff etc have ever said.
The a&e psych consult docs/ social workers or nurses/ amp people (I never really take in who they are or the difference at the time), even though has sometimes been a few hours wait, I have also felt supportive and genuine concern for my welfare.
Generally also have appreciated the Home Treatment Team (although seeing so many different nurses and of varying degrees of help, v not helpful).
Positive view prob also influenced by shock of actually getting anything from the nhs. Has only been crisis services.
Apologies if not helpful to say,
Always helpful to share! My HTT is awesome BTW.