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Transforming London’s mental health crisis care services
In the latest in our series of blogs about #mentalhealth, an NHS England (London) awareness campaign for mental health care across the capital, the Medical Director at South West London and St George’s Mental Health NHS Trust and clinical lead for Healthy London Partnership’s Mental Health Crisis Care Programme discusses crisis care in the capital, why it needs to change and explains how a variety of organisations are working more closely together than ever before to improve services:
No one attending London’s first mental health crisis care summit recently was in any doubt that the services and care for Londoners in crisis need to change urgently.
As the London Health Commission report, Better Health for London, stated: “Crisis care in London is in crisis itself”.
There are many crisis care services in London that are doing an excellent job of supporting patients in crisis, however, the quality of crisis care services is often inconsistent.
Those at the summit heard first-hand from service users who spoke passionately about their experiences of crisis care. As their experiences illustrated, too often people are not receiving the care they need, when they need it and in the right place. It is only by working together to provide a coordinated multi-agency response that we will be able to support service users in crisis and help them feel safe and supported when they need it most.
There is now an opportunity to improve London’s mental health crisis care services through Healthy London Partnership (HLP), with extensive engagement from a system that includes London Ambulance Service, Metropolitan Police, commissioners, staff from Acute and Mental Health Trusts, approved mental health professionals and the charity Mind. HLP is a partnership between NHS England (London) and London’s 32 clinical commissioning groups (CCGs) to transform health and care in London and make it the healthiest city in the world.
HLP is currently focusing on mental health crisis care in emergency departments and London’s section 136 pathway and health-based places of safety. Section 136 of the Mental Health Act gives police officers the authority to take an individual in mental distress from a public place to a place of safety so that their immediate needs can be properly assessed. There are 23 designated places in the capital but too often these are not available, unsuitable or already in use.
Yet the use of s136 has increased by 9% across London over the past two years and is highest among London’s young people. People in mental distress are forced to wait, sometimes for several hours, in unsuitable areas, such as emergency department waiting rooms or police cells. In London, however, there has been a 79% reduction in people in mental distress being placed in police cells since 2013.
When people have to wait for a health-based place of safety, this delays access to treatment and can compound a person’s distress, meaning it often takes them longer to recover. The quality of care also varies and 25% of London’s health-based places of safety do not have dedicated staffing, with staff being pulled off of mental health inpatient wards to treat people. In addition, more than 75% of s136 detentions occur outside working hours yet crisis care at these times is not the same as care provided in normal working hours.
Later this year, HLP will publish a consistent s136 care pathway and a health-based place of safety specification, which will set a minimum standard of care to meet the expectations of service users in London.
The specification will cover areas such as staffing, assessments and governance arrangements and will sit alongside a London s136 care pathway to ensure a more consistent pathway of care for Londoners experiencing a mental health crisis.
HLP has worked with Mind, YoungMinds, service users and carers to develop a series of ‘I statements’ showing what Londoners expect from crisis care. Service users said they want to be treated with the same respect, confidentiality and care as all other patients. They want to be listened to, they don’t want to be judged and want to be able to access high quality services when they need them most.
The ‘I’ statements have informed the initial development of the specification and s136 pathway and HLP will be holding further workshops with service users and carers to develop this work. The workshops are being co-facilitated by service users and will ensure the specification and pathway meets the needs and expectations of Londoner in crisis. The specification will be piloted at a new integrated health-based place of safety unit that will combine previous one-bedded suites situated across a number of boroughs allowing us to evaluate the impact and benefit of it with service users, staff and the wider system.
To gain a clearer picture of crisis care and the s136 pathway in London, we have now initiated a significant data exercise to establish the current service provision, demand and the relationships between services. From this data we will then be able to identify any gaps and assess what changes are needed to meet the minimum standards and improve crisis care in the capital.
In terms of crisis care in emergency departments, again there are examples where these departments are working well to support people in crisis. But currently too many are unable to support a patient with a mental health emergency as well as they can support a patient with a physical emergency. For example, only 5% of emergency departments meet the London crisis care commissioning standard of four hours to complete a Mental Health Act assessment. This is often because of a shortage of approved mental health professionals who need to be present when a consultant carries out an assessment.
HLP is looking at how we can ensure London has the mental health workforce it needs, now and in the future. It is also vital that all clinicians, managers and staff are properly supported. More detailed guidance for staff and managers in emergency departments is being developed to help clarify their roles and responsibilities with regards to London’s mental health crisis commissioning standards.
HLP is also undertaking a large programme of work to support the prevention of mental illness and help Londoners stay emotionally, mentally and physically well at all ages. We are working with stakeholders and key partners to address the gap in life expectancy ‘the stolen years’ between those with severe and enduring mental illness and the rest of the adult population, strengthen mental health in primary care, and improve access to psychosis services, perinatal mental health and psychological services. You’ll read more about these as the month continues.
By supporting service users, stakeholders and key partners to work together, we can help strengthen connections between all the agencies and individuals involved in mental health crisis care. Continuing to share best practice and work together across the system is essential if we are to improve services for Londoners in crisis.
- If you are interested in contributing to Healthy London Partnership’s crisis care programme please contact email@example.com
All these initiatives are concealing the reality that the NHS is now no longer “national” since the removal of the NHS from democratic control as a result of the fundamental changes introduced by the last Conservative led Government in 2013.
Even NHS England cannot guarantee that any identified “improvements” are actually implemented by the now “independent” NHS Foundation trusts and Clinical Commissioning Groups – neither can Jeremy Hunt or the Department of Health.
I am interested to see how ambulance trusts have been involved in the conveyance and pathways around mental health crisis. linking on with police street triage schemes has a significant impact on HVSU activity, greater partnership working and reduced ED conveyance.