[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.