In England, it is estimated that 5% of all hospital emergency department attendances are primarily due to mental ill-health. The Five Year Forward View for Mental Health is attempting to address this situation by increasing the presence of liaison mental health services in acute hospitals. This investigation reinforces the need for emergency mental health care 24 hours a day, seven days a week.
The reference case in this investigation is Diane, a 57-year-old woman who died by suicide. The early investigation focused on her last four presentations at her local emergency department, the last one being the day before she died. The investigation also examined her interactions with local healthcare services spanning two years.
Identifying the opportunities missed in Diane’s care fed into a broader investigation, examining the integration of mental health liaison services into the emergency department. It also looked at how staff assess, understand and manage risk when patients present in mental health crisis.
We've made safety recommendations to NHS England, the National Institute for Health and Care Excellence, the Royal College of Emergency Medicine in conjunction with the Royal College of Psychiatrists and the Care Quality Commission as a result of this investigation.
NHS England ensures there is a sustainable funding model to support 24/7 urgent and emergency mental health liaison services in acute general hospitals with emergency departments.
Response received 23 November 2018:
Thank you for sharing the report with NHS England, and to the investigation team for their engagement throughout the investigation.
We were sorry to read the reference case about Diane who tragically took her own life. Please do pass on our condolences and gratitude to Diane’s family, with whom we know you have been working closely with during this investigation.
NHS England is happy to accept the recommendation made in the report. We are pleased that the recommendation supports our policy to expand provision of liaison mental health services across England. In particular, we welcome the emphasis your report places on patient safety and quality as the primary benefit of liaison mental health services in emergency departments.
As you will be aware, a national policy position on liaison mental health was set for the first time in 2016. Implementing the Five Year Forward View for Mental Health set an initial target that by 2021, all hospitals with type 1 A&E departments should have a liaison mental health service that can meet the needs of all ages, and that for adults and older adults 50% of these will achieve the ‘core 24’* service level by 2021. We intend to set out ambitions beyond 2021 as part of the NHS long term plan, due to be published shortly.
Since 2016, NHS England has invested £30m in over 70 hospital sites to achieve the core 24 service level. The 2018 survey of liaison psychiatry should be complete by the end of the year, and we expect it to show positive progress. While the data hasn’t yet been fully processed, preliminary findings suggest that there is now no A&E in England without a liaison mental health service, the number of services operating 24/7 has increased from 39% to 66% over the past 2 years (with many of the others having extended their opening hours), and staffing in the teams has increased significantly. We hope that your report will help local commissioners to make the case as expansion continues across the country.
With regard to the recommendations made to NICE, RCPsych, RCEM and CQC, NHS England also supports these, and we look forward to working with those organisations as they develop and implement the recommendations.
*Core 24 refers to: (i) 24/7 hours of operation; (ii) providing 1 hour response to referrals from emergency departments, 24 hour response to referrals to inpatient wards (iii) staffed in line with recommended levels.
Update received 16 July 2019:
The NHS Long Term Plan, published in January, set out the intention for this [the number of liaison mental health services operating 24/7] to rise to 70% by March 2024, working towards 100% coverage in the following years.
NHS England has already invested £45m in 71 sites since 2017, and the further rollout is backed by £48m of new funding over the next 2 years.
National Institute for Health and Care Excellence (NICE)
The National Institute for Health and Care Excellence review and amend guidance for the management of self- harm in the emergency department.
Response received 31 January 2019:
In response to your recommendation we have reviewed the two relevant guidelines referenced within the report: NICE Clinical Guideline (CG) 16 Self-harm in the over 8s: short-term management and prevention of recurrence and NICE Clinical Guideline (CG) 133 Self-harm in over 8s: long-term management.
On the basis of your report we will update and merge the two guidelines which will hopefully provide clearer and more concise guidance on the transition between short and long-term care, particularly emergency department attendance and immediate follow up.
Notwithstanding there is a regular prioritisation of topics across the work programme, we plan to start this work in spring 2019 with publication likely in 2021.
Royal College of Emergency Medicine (RCEM) and Royal College of Psychiatrists (RCPsych)
The Royal College of Emergency Medicine, in conjunction with the Royal College of Psychiatrists, develops and disseminates national guidance for emergency department practitioners to standardise the initial assessment of a person presenting following a mental health emergency.
Response from RCPsych received 6 February 2019:
We very much welcomed the Report on such an important issue and the focus that you gave to the contribution that effective assessment of a patient following a mental health emergency can have on securing better outcomes. In relation to the area that you were looking for the College to undertake work on in conjunction with the Royal College of Emergency Medicine (RCEM), there are a number of pieces of activity in train and these are set out below:
- The RCPsych and RCEM are working on a joint position statement on parallel working between Emergency Department and Liaison Psychiatry staff to ensure that patients with mental health presentations are triaged and assessed in a timely manner.
- The RCPsych and RCEM are working with NHS Improvement to collate, disseminate and, if necessary, develop, care pathways for patients presenting to Emergency Departments with acute mental health problems.
- The RCEM annual Emergency Department audit for 2019 will include specific standards for mental health triage, including risk assessment and observation.
- In addition, the RCPsych and RCEM will offer to collaborate with NICE on safety recommendation 2, in amending guidance for the management of self-harm in the Emergency Department.
Care Quality Commission (CQC)
The Care Quality Commission reviews and updates its inspections criteria for emergency departments to ensure equal weight is given to the quality of care provided to people with urgent mental health problems as they do to people with urgent physical health. This would be consistent with its commitment to parity of esteem for mental health.
Response received 11 February 2019:
This report reinforces how important it is for emergency mental health care to be available to anyone that needs it 24 hours a day, seven days a week.
A significant proportion of those who attend hospital emergency departments do so because of a mental health problem. This is because people experiencing a mental health crisis may also require urgent medical treatment, as a result of self-harm, or because they experience difficulty in accessing urgent support from mental health services out of hours. They may see a hospital emergency department as their only option.
Last year we introduced changes to strengthen our assessment of the quality and safety of care provided to people with mental health needs during our inspections of acute hospitals. Mental health inspectors now routinely participate as members of teams that inspect acute trusts; including those that have emergency departments. New key lines of enquiry focusing on mental health have also been added to our inspection frameworks and updated guidance, tools and training have been developed for inspectors.
We are committed to playing our part in ensuring a parity of esteem between mental and physical healthcare and continually seek to evaluate our approach to identify where we might be able to further strengthen this important part of our acute hospital assessments.
This investigation makes the following safety observations:
- The data regarding mental health presentations is not sufficiently robust to allow for demand for mental health services to be adequately assessed and the impact of service provision to be measured.
- Initial assessment of patients on arrival at an emergency department may benefit from inclusion of key factors from the Royal College of Emergency Medicine’s Best Practice Guideline The Patient Who Absconds dated 2018.
Safety observations are made when there is insufficient or incomplete information on which to make a definitive recommendation for action, although findings are deemed to warrant attention.
The National Institute for Health and Care Excellence has changed the wording of clinical guideline CG16 as follows, to reflect the findings of this investigation:
220.127.116.11 Consideration should be given to introducing the Australian Mental Health Triage Scale, as it is a comprehensive assessment scale that provides an effective process for rating clinical urgency so that patients are seen in a timely manner.
Do not use the Australian Mental Health Triage Scale to predict future suicide or repetition of self-harm.
Safety actions are actions taken during the course of the investigation as a response to the issue under investigation.