Mental health care overlooked by NHS review

Emergency mental health care plays a vital role, especially in inner city areas where demand is greater. Photograph: David Levene

NHS England's large scale review of all emergency services, partly driven by the premature mortality rates across hospitals, seems to have made a significant omission by overlooking mental health emergency care.

While the evidence accompanying the consultation suggests that 4,400 lives a year could be saved if weekend services were as good as those during the weekdays, there is a chance that those experiencing mental ill health could fall through the upgraded safety net.

The emergency review does not mention mental health services, the conditions leading to emergency presentations, or the role of the police, housing and mental health problems. Yet emergency mental health care plays a vital role, especially in inner city areas where demand is greater due to high levels of poverty and other social determinants of ill health and inequalities such as ethnicity, gender and age.

For example, we know there is a higher incidence of schizophrenia in inner city areas, especially among black African and Caribbean people and other ethnic minority groups, particularly in London.

The recent report by Lord Victor Adebowale on policing and mental health concluded that the presence of offending behaviour by someone experiencing mental illness, which can lead them to have contact with the police, is an emergency pathway which needs to be made safer.

Lord Adebowale's findings emphasised the failures of NHS services and police knowledge, as well as emergency communications, in meeting the needs of people with mental illness. These findings have been reinforced in the latest Care Quality Commission (CQC) reports on the emergency removal of people suspected of having a mental illness to a place of safety (under section 136 of the Mental Health Act). These reports found unacceptable emergency practices leading to deaths in police custody, mentally ill people being transported in caged ambulances and suicides on the railways and transport hubs.

The statistics show why urgent attention is required. In January of 2013, the CQC announced there were 48,631 detentions in 2011/2012, an increase of 5% on the previous year. Community treatment orders rose by 10% to 4,220. The commission also reported growing concern about cultures of coercion and containment rather than treatment and support. Around 15% of detained patients said they were not allowed to play a part in the shared decision-making while 4% of decisions were called into question on legal grounds.

The use of section 136 by the police rose to 14,902, 5.6% higher than in 2011/12. The CQC data along with data published by the NHS Information Centre and independent researchers, all point to higher rates of detention for some ethnic groups, yet these differences are still not being tackled.

These unsettling findings suggest emergency services must take account of mental health and ethnicity. If more care is to be provided away from accident and emergency departments, then additional homecare and specialist advice services at the time of critical decisions are necessary.

What is required is not a 9am to 5pm specialist service, but 24/7 home treatment and crisis responses and a better use of social networks, and shared care plans for existing patients to protect their dignity and autonomy. Understanding patients' personal stories and remedying the real fears people have about the quality of NHS care is as important as providing a safe emergency response for the most vulnerable.

For people experiencing mental illness who make contact with hospitals, what is needed is an emergency psychiatric response team staffed by medical and psychiatric specialists, a service model that has been abandoned by commissioners in the recent past. The entire public health system needs an agreed emergency care pathway to be commissioned across the police, mental health providers and local government.

To do this effectively any NHS review has to include the responses of the police and acknowledge the presence of ethnic inequalities in mental health services in its recommendations. If not, the new proposals will fall short of aspirations and will not remedy past failures.

Professor Kamaldeep Bhui is professor of cultural psychiatry and epidemiology at the Wolfson Institute of Preventive Medicine, and is director of the Cultural Consultation Service, Queen Mary, University of London

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