In a national report out today (Friday 12 June), the Care Quality Commission (CQC) has raised concerns that public services, such as local authorities, NHS trusts and clinical commissioning groups, are failing to work together to make sure that people in their local areas have access to crisis care around the clock. Also, it found that healthcare professionals, such as those in A&E, can appear to lack compassion and warmth in how to care for and speak to people who are having a crisis, including those who have harmed themselves.
As part of its review, CQC sought views from people who have experienced different types of mental health crisis care. It found that while 86% of those who had received care and support from charities and volunteers felt that their concerns had been taken seriously by them, only 37% said that they felt this from A&E staff. This is worrying as these professionals should be trained in how to care for and respond to them. In particular, people often reported poor attitudes from staff towards their injuries caused by self-harm. Overall, only 14% of people thought the care they received provided the right response and helped them to resolve their crisis.
Although it is difficult to determine the exact number of people who have a mental health crisis, more than 68,800 people were admitted to a mental health ward for urgent care in England as inpatients in 2013/14.
The experience of a mental health crisis can include suicidal behaviour or intention, extreme anxiety and panic attacks, psychotic episodes (when people may experience delusions, hearing voices and a loss of sense of reality), and behaviour that is considered ‘out of control’ or irrational to the extent that the person poses a risk to themselves or others.
When people experience, or are close to experiencing, a mental health crisis, there should be services available to provide urgent help and care at short notice. This includes advice from telephone helplines, assessment by a mental health professional, intensive support at home or urgent admission to hospital.
CQC has reviewed the quality of these services in England to identify what is working well and what must improve. The review team inspected a sample of locations across England; received a survey return from 1,800 people who have experienced a crisis; and examined national data.
As well as staff training, CQC has identified that there is a clear need for better 24-hour support for people having a crisis, particularly during the hours of 11pm and 5am, as CQC found that during these hours availability and accessibility is poor. This means that people often have to go to A&E departments or even to police cells while a ‘place of safety’ is found for them, rather than receive specialist care straightaway.
Dr Paul Lelliott, CQC’s Deputy Chief Inspector of Hospitals (lead for mental health), said: ‘It is not acceptable for people with mental health problems to be treated differently to those with physical health problems.
“We know that people can experience a mental health crisis at any time of day or night, and so the NHS and our other public services must make sure they are equipped to provide the specialist and urgent care that is needed around the clock. Sadly this is not what we have found from our national review.
“What’s more, we found that when people do receive help, hospital and mental healthcare staff are not always compassionate and caring. Worryingly, many people told us that when they were having a crisis, they often felt the police and ambulance crews were more caring and took their concerns more seriously than the medical and mental health professionals they encountered. In particular, people who have inflicted harm on themselves as a result of their mental distress deserve the same respect and compassion as those whose injuries are sustained by accident.
“These findings must act as a wake-up call to our public services. We found some excellent examples of services in areas joining-up and providing effective care, with staff committed to working to make sure people in a crisis received the help they needed. These examples must become universal. This review was undertaken as part of CQC’s contribution to the work of the ‘crisis care concordat’ which is mobilising local services to come together to tackle this problem.”
“NHS trusts and other commissioners of care must make sure that they place a bigger focus on training staff to look after those having a mental health crisis, no matter where they are or when they need help. I feel that no NHS leaders can consider themselves to be a success while these issues go unanswered.”
As part of its national review, CQC has inspected mental health crisis care across twelve areas. Among these, CQC found crisis care and support arrangements within the London borough of Lambeth to be particularly commendable; for example, inspectors noted the way that primary and social care services, voluntary organisations and housing advice services in the area worked together to provide appropriate support, referral and triage for people in need. Also, inspectors praised the joint commissioning of preventative services between Lambeth Clinical Commissioning Group and South London and Maudsley NHS Foundation Trust and its setting up of a ‘crisis house’ in response to the lack of available beds for people experiencing a crisis who needed inpatient care.
The report, ‘Right here, right now’ has been carried out as part of CQC’s commitment to the Crisis Care Concordat.
Other findings include:
• Many people will go to see their local GP first when they are having a mental health crisis. The majority (60%) of people who visited their GP during a crisis were satisfied with the experience. It is vital that GPs access specialist training to help them to identify underlying mental health conditions early, in order to help prevent crises from occurring.
• Most people reported that they came into contact with at least three different services when they had a mental health crisis. 12% said that they had come in to contact with between six and ten services, which indicates a need for them to work more closely together in areas.
• Encouragingly, there has been a significant reduction in the use of police custody as a ‘place of safety’ for people in crisis, as supported by figures released earlier this week by the National Police Chiefs Council. However, CQC has found that there can still be problems with people under 18 being able to access a suitable place of safety. In 2013/14, nearly a third (31%) of people under 18 who were detained, were taken into police custody.
Alistair Burt, Minister of State for Community and Social Care, said: “We asked CQC to do this investigation so we could shine a light and better understand the perspectives of people who have experienced a mental health crisis. It is clear that there is still a long way to go to make sure everyone is treated compassionately in the right place and at the right time.
“We’re tackling historic underfunding and have increased investment in mental health by £300 million last year. We have also introduced the first treatment targets to make sure people get the prompt support they need and mental health is treated on the same terms as physical health. More people than ever before are receiving talking therapies, we are working hard to tackle mental health stigma, and work continues to improve early intervention services to make sure that people get the care they need to prevent crisis situations happening.
“Street triage schemes joining up police nursing are proving to be successful and we have halved the number of people going through a mental health crisis going to police cells.
“Improving mental health care is my priority. I am clear that there is so much more to achieve and we all need to work together to achieve it. The CQC will now inspect crisis care arrangements in every service and I have asked them to continue to help stamp out poor care and help us to make sure that people with physical and mental health conditions are treated with equal importance.”
In response to its findings, CQC has placed a greater focus on how mental health crisis care services are provided, including within A&E departments, during its comprehensive inspections of acute NHS trusts. Also, CQC will continue to ensure that it considers the issues of people who need specialist mental healthcare while in acute hospitals, and it will provide training for its inspection staff on the key issues that have been emerged.
Paul Farmer, Chief Executive of Mind, said: “This is an important review that looks in detail at a vital part of NHS mental health services. We welcome its findings and the thorough, person-centred way in which it has been conducted.
“The report will not come as a surprise to anyone who has found themselves in crisis or who is involved in supporting people when they are at their most unwell. We know that, while excellent services do exist, the emergency response for mental health in many parts of England is just not good enough. We take for granted that when we have a physical health emergency, we will get the help we need urgently. It should be no different for mental health, yet far too many people are just not getting the help they need.
“This report is a clear call to action. Mental health services are the victim of years of neglect and funding cuts over the last few years have taken their toll, at a time of rising demand. National and local commissioners must now make mental health a priority and invest in the future of our mental health services.
“We share the CQC’s optimism that the Crisis Care Concordat is a big opportunity to address the issues raised in this review. Every local area in England now has a detailed action plan for improving the support available for people in crisis, which has been signed by commissioners, NHS trusts, the police, local authorities and other services and agencies. It has been a huge piece of work getting to this point but in a way the work is just beginning. The challenge now is for every local area to deliver on their action plan so that everyone experiencing a mental health problem gets the help they need, when they need it.”
Brian Dow, Director of External Affairs Rethink said:
“This report makes for painful reading, and seems to suggest an upside-down world in which patients feel they get the worst care where they should be getting the best.
“We need a more sympathetic response. Sympathy, understanding and good quality care when a patient walks in the door of A and E, and a sympathetic system where health and social care teams along with charities work in partnership to support the person properly after they are discharged.
“What would be unacceptable for physical illness should not be acceptable for mental illness.”
Read the report by clicking here