Mental health care overlooked by NHS review of emergency services

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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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

This article is published by Guardian Professional. Join the Healthcare Professionals Network to receive regular emails and exclusive offers.

View the original article here

Researchers urge review of health system-wide pediatric injury training, triaging and prevention efforts

Main Category: Pediatrics / Children's Health
Also Included In: Health Insurance / Medical Insurance;  Public Health
Article Date: 31 Jul 2013 - 0:00 PDT Current ratings for:
Researchers urge review of health system-wide pediatric injury training, triaging and prevention efforts

New research from The Center for Injury Research and Prevention at The Children's Hospital of Philadelphia (CHOP), signals that emergency and outpatient healthcare providers may need to prepare for higher demand for treatment among younger patients with mild and moderate injuries. As federal and state policies encouraging people to be covered by health insurance go into effect, researchers estimate the potential for more than 730,000 additional medically attended injuries annually, or a 6.1 percent increase if all currently uninsured children and young adults (ages 0-26) become insured. The estimates are based on 2008 injury data from the National Health Interview Survey. The study was published in this month's Clinical Pediatrics.

"In order to assist planning efforts by healthcare systems and policymakers, we aimed to examine the impact on trauma systems of increases in young people with health insurance" says Flaura Koplin Winston, MD, PhD, lead author and Scientific Director of the Center for Injury Research and Prevention at CHOP. "This study signals a need to prepare for potential large increases in demand for care of minor and moderate pediatric and young adult injuries in both emergency department and outpatient settings."

According to the study, a significant portion of the increase will come from currently uninsured young adults (18-26 year olds), who will now be able to remain on their parents insurance until age 26 or find affordable care through exchanges. Researchers found that the causes and nature of medically attended injuries differed between insured and uninsured young adults. The uninsured sought medical care for more serious injuries like fractures when compared to other types of injury. The insured sought medical care for a wider distribution of injuries-- with the most common being sprains and strains, as well as open wounds. Of interest, among children under age 18, 11 percent of medically attended injuries among insured kids were related to overexertion, but this injury mechanism did not cause uninsured children to seek care.

Winston and her colleagues based their estimates on recent injury care data and the assumption that those new to insurance would have a probability of medically attended injury that equals that of those who already have insurance. With these assumptions, they predict that each year as many as 510,553 additional children and young adults could be seen for injury treatment in outpatient settings, nearly 195,838 in Emergency Departments or admitted to hospital, with another 30,689 being attended to through phone- only encounters. Winston cautions that the actual health system utilization rates and sites of care may vary as newly insured people may access care differently from those who are already insured.

"Health care delivery systems across the US need to have sufficient numbers of general and pediatric healthcare providers who are trained in treating moderate trauma and injury and can staff urgent carecenters, health centers, primary care practices, call centers, and emergency departments," says Dr. Winston. "In keeping with the aims of the Affordable Care Act, the goal should be that all young patients who seek care for their injuries get the appropriate care at the right time and right place."

The study authors recommend several steps health care systems can take to manage the potential increase in patients and avoid both the expensive overuse of emergency services and the long-term effects on communities of inadequately treated injury:

Train medical students and residents with relevant course content on diagnosis and treatment of concussions, musculoskeletal injury, sports medicine and open wound care. Expand programs such as Poison Control Centers and call centers, and remote medical command for triage and treatment of non-life-threatening injuries. Prevent injuries to children by allocating federal and state resources to proven injury prevention strategies. They cost less than medical care needed to treat injuries. Implement the Centers for Disease Control and Prevention's National Action Plan for Childhood Injury Prevention. Develop or expand proven off-the-job injury prevention strategies. The cost of insuring this new population of youth, the majority of whom currently live with an employed head of household, may fall to employers.

"Injury is the leading health risk for children and young adults. Proven prevention strategies and appropriate acute care will reduce fatalities and the long-term consequences that injury can have on quality of life," says Dr. Winston.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our pediatrics / children's health section for the latest news on this subject.

Dr. Winston's co-authors include Mark R. Zonfrillo, MD, MSCE of CHOP, J Felipe Garcia-Espana, PhD of Coriell Institute for Medical Research, and Ted R. Miller, PhD of the Pacific Institute for Research and Evaluation. The study was supported by National Science Foundation Center for Child Injury Prevention Studies, Pennsylvania Department of Health, and the Health Resources and Administration's Children's Safety Network.

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Liverpool care pathway review shows challenges in palliative care

The Liverpool care pathway has been encouraged to avoid unnecessary interventions in the care of people who are dying. Photograph: Voisin/Phanie/Rex Features

The law of unintended consequences can be insidious. The Liverpool care pathway (LCP) has been encouraged over the last decade with the express objective of avoiding unnecessary interventions in the care of people who are clearly dying, and ensuring they achieve a good death. However, it should now be phased out and replaced by an individual end-of-life care plan, according to the findings of the independent review led by Lady Julia Neuberger.

Almost a decade ago, the House of Commons health select committee conducted an inquiry into palliative care and while it supported the take up of tools such as the Gold Standards Framework and the LCP, the committee cautioned "that there are significant challenges in raising the skills and awareness of all healthcare staff in palliative care." The findings of the independent review provide testimony to the continued failures of training around the LCP, with the result that far from providing a model of good practice in palliative care, the LCP too often leads to poor practice – "uncaring, rushed and ignorant".

This is a shocking indictment of the care of people in their final days of life, often very elderly people whose relatives were left with the impression that their life was no longer valued. Withholding food and drink has caused the greatest concern and distress with staff apparently on occasion refusing to allow liquids for people who were thirsty and dehydrated. The review is in no doubt that the failure to provide oral hydration and nutrition "when still possible and desired should be regarded as professional misconduct."

Poor communication with patients and relatives is at the root of many of the failures and criticisms of the LCP, and evidence to the review found significant numbers did not feel involved in discussions about the care plan, or were not given the chance to be involved. People are sometimes not told that a loved one is dying or what they can expect to happen.

Inappropriate use of opiate pain killers and tranquillisers was also the focus of criticism, particularly when this led to a patient becoming drowsy, and relatives left wondering if the use of drugs had hastened death.

The review has recommended that the LCP should be phased out, and this has been accepted by health minister Norman Lamb. However, it is vital not to abandon the core principles which underpin the model. The failure of the LCP has been in its application and poor support; the review found that when used appropriately "patients die a peaceful and dignified death", but that implementation is sometimes associated with poor care.

The clear thinking and pithy recommendations of this review will be welcomed, so too will the speed of response from government. It is clear that when the LCP is operated "by well trained, well-resourced and sensitive clinical teams, it works well." The reverse is also true and the need for new guidance and training for all staff is evident. Nonetheless, existing guidance is not being adequately followed or understood and major cultural change is needed at all levels of health and care to prioritise good quality end-of-life care. The review identifies the need for a strategic approach from NHS England down to clinical commissioning groups, and with the Care Quality Commission taking a lead in reviewing how well dying patients are treated.

It is distressing that what began as a model to raise the quality of care for the dying has too often been reduced to a tick box procedure which takes insufficient account of individual needs or wishes, and where vital care and compassion are absent. It is a tragedy however for families and carers who have lost relatives who have been cared for under the LCP, and for whom there will remain considerable distress and unanswered questions. Did their relative die a hastened death? Did they suffer unnecessarily because of the interpretation of the LCP? And would they actually have been able to live longer and die better without the involvement of the LCP?

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