Sparks fly over long waits in A&E

Late on Thursday before the sunny bank holiday (NB: all the best news stories happen in the most sleepy slots), I revealed moves by the regulators to end long waits in emergency departments for mental health patients.

There have been advanced and high-level discussions in NHS England and Improvement about telling acute providers they cannot keep patients in accident and emergency while they are waiting for admission to a mental health bed, or for a Mental Health Act assessment.

This appears to have been triggered by the astonishing amount of recorded “12-hour breaches” – where patients wait more than 12 hours from a decision to admit to an admission – which are mental health patients.

HSJ has heard very reliably that a letter to the system along these lines has been in drafting, but we were assured on Thursday that one is not actually going to be sent.

The idea is already resulting in some backlash from acute providers and clinicians, which is perhaps why the centre has been apprehensive to make the leap.

For many close to the frontline, this move would seem to be a poor fix to the long-standing problem of a severe lack of mental health beds and preventative services.

However, from the perspective of a mental health patient, who is being forced to wait for hours and sometimes days for an appropriate response, in my view a ward is preferable to a noisy and distressing emergency department.

That being said, if mental health patients, once assessed, are to be admitted onto acute wards, some clear caveats will need to be in place while they wait for an appropriate bed.

Any acute ward will need significant additional resource to support the mental health patient or patients – ideally a clinician with mental health training, which will not come easily or cheaply.

Both mental health and acute providers will need to be extremely careful that patients do not end up forgotten and left languishing on an acute ward – after all, as some on Twitter have highlighted, the benefit of trolleys in A&E is they are hard to ignore.

There’s also the knock-on effect this may have on those needing to be admitted into an acute bed with physical health problems. Regulators will want to avoid anything which inadvertently creates longer waits overall.

Whatever your stance on the debate, the centre’s focus on long waits for mental health patients is welcome and long overdue.

The spotlight could finally lead to positive changes if it mobilises the systems to try to address the problem. In Lancashire – where instructions along these lines have already been issued because of very severe problems – this is what appears to now be happening.

The hidden waits

If the centre is worried about mental health patients officially breaching 12 hours, it should be equally worried about those who are not being recorded at all.

Under the current national rules, 12-hour trolley breaches are only recorded once a decision to admit has been made, leaving a door wide open for gaming.

This is partly why NHS England in its targets review is testing a new measure of average total time in A&E as part of its clinical review of standards.

While the current fault means waits for all types of patients are underestimated, emergency care clinicians speaking with HSJ were particularly concerned about mental health patients.

Those working in emergency departments at five different trusts told HSJ that long waits, lasting more than 12 hours and sometimes days, regularly go unrecorded.

Catherine Hayhurst, mental health lead for the Royal College of Emergency Medicine, explained: “In some cases, it will have already taken six to eight hours for a patient to see a liaison psychiatry staff member who then requests a Mental Health Act assessment.

“Only after the assessment is the decision to admit made, or if liaison [psychiatry team] are worried, they ask a crisis team to see the patient and it is the crisis team who come in from the community, leading to (another delay) to make the decision to admit.”

Moving to a measure of total time in A&E would mean situations like the above should be accounted for.

A mere change to the target won’t in itself reduce the waits but it could provide more evidence for lobbying government to turn around the lack of mental health beds.