Nestled in between Philip Hammond’s ‘little extras’ for schools in the October budget — and barely anything for local councils and social care — was a figure that finally seemed duly apportioned: the proposed £2bn towards mental health accident-and-emergency (A&E) units. Nevertheless, a recent report by the Health and Safety Investigation Branch (HSIB) proves that the discrepancy in parity of esteem between physical and mental health care in A&E departments will take more than an abstract funding commitment by the Chancellor. It requires sustainable mental health liaison services that ensures sufferers are treated with due care, prioritisation and adequately trained staff.
HSIB’s report, entitled ‘Investigation into the Provision of Mental Health care to patients presenting at the Emergency Department’, was provoked by an incident involving the suicide of Diane, a 57-year-old woman. The day before her death, Diane had visited A&E, where her self-harm was recorded. The report considered ‘what went wrong?’ in her circumstance. Diane, it was discovered, was not referred to mental health liaison services on the last two times she visited A&E before her death — described in the report as ‘missed opportunities’ to work through her suicidal impulses and, ultimately, her avoidable death.
Crucially, HSIB’s research reveals that limited funding is not necessarily the biggest issue facing mental health provision: in fact, throwing money at the project is a hollow gesture unless accompanied by structural reform. The more pressing concern is the lack of guidance and standardisation around referral to specialist psychiatric services. The likelihood of consistent referral is low: only 35 per cent of people get the urgent mental health care they need in the emergency department, and referral rates to liaison services fluctuate between 22 and 88 per cent. Diane’s A&E experience was not anomalous, but scandalously representative of the experiences of mental health sufferers across the UK.
However, the report’s conclusions are still realistic, despite shocking statistics. It did not entertain any notions that A&E departments must become all-encompassing:
‘It would be unrealistic to suggest that emergency departments (EDs) should be equipped to deal with every kind of mental and physical condition someone may experience’, the lead investigator told Shout Out: ‘only that mental health specialists and psychiatric liaison service teams need to be on call and available to help 24/7′.
This nuanced understanding of mental health’s positionality within EDs is something conspicuously absent from Government rhetoric, and therein leads to confusion among service users. In promising arbitrary investments for a vague, catch-all image of A&E without detail, individuals are liable to misread the Government’s agenda — which rightly commits to the creation of appropriate mental health liaison services available within EDs. This does not automatically mean more ‘sectioning’ rooms, the physical expansion of facilities, or simply greater numbers of inadequately trained staff, but improvement of the referral process.
The investigator continued:
‘We found that when these liaison services were permanently integrated into ED networks and local trusts, they had the most benefit. It’s about understanding and recognising when there needs to be referral, and there needs to be prescriptive advice on this. We found that inconsistency emerges where the referral guidance is less clear. This is where the training is essential’.
HSIB explains that one of the major problems is the way investment is currently utilised and recorded among mental health services nationwide. The NHS, like all public services, functions alongside an arbiter of ‘cost-effectiveness’, which can be anathema to something so subjective as mental health. The Government’s obsession with ‘value for money’, for example, is no surprise to civil servants. But whereas physical conditions can be assessed from a cost-efficient standpoint with relative ease, the same models can verge on meaningless when it comes to their mental counterparts.
As the report stipulates, there is a lack of evidence regarding optimal models of care for mental health, while ‘cost-effectiveness’ models do not consider other mitigating factors that might disrupt a trust’s short-term financing arrangement, such as understaffing. For example, the report reveals that while many commissioners had been granted one-year contracts to introduce liaison services into their EDs, two of the trusts involved in the investigation could not actually recruit into the advertised positions. Thus, the services didn’t appear to be running effectively and thoroughly — but not because mental health is ‘untreatable’ in emergency circumstances.
While the money is finally available to improve and develop mental health emergency liaison services — though some argue it does not go far enough — HSIB’s report has made clear that the Government must not withdraw their scarce investment after punitive short-term contracts reveal no objective progress has been made. This is where emotional restructuring comes to the fore: decisions about money must come from human compassion and empathy, not overly rigid models which refuse to consider the complexity of mental health as a medical issue.
While HSIB is itself independent and non-political, a separate petition regarding mental health in EDS has been gaining political ground, which urges Government to guarantee help at A&E to prevent avoidable deaths from suicide. This is as much about putting the human element back into NHS considerations as it is about devising a standardised procedure. Moving towards a parity of esteem, or application of equal value, between physical and mental health conditions is about wholeheartedly reformulating nationwide perceptions of mental health as something curable, and suicide as something preventable.
Recent headlines have revealed just how much mental health sufferers rely on police forces during times of emergency, fearing that hospital services are unable or unwilling to assist. Clearly then, confidence-building as well as investment-pouring is necessary to reverse the UK crisis in mental health. £2bn might sound like a great deal — but the money must be used wisely. It must also be rescued from the depths of ‘cost-effectiveness’ and a stringent desire to prove public value-for-money at any human cost.
As the lead investigator of the report reassured Shout Out:
‘The money is there; the willingness of the staff is there; the window of opportunity is there. We just need them all to cross paths’.