A&E crisis expansion ahead of target but more nurses needed

The fourth national Survey of Liaison Services confirmed every consultant-led, 24-hour A&E now has a specialist psychiatric liaison service.

“When someone faces a mental health crisis, they should rightly expect to receive top quality care at A&E”

Matt Hancock 

However, it also shows more specialist nurses and doctors will need to be recruited to provide optimal rapid response care to those who arrive in A&E in crisis.

The survey carried out on behalf of NHS England and the Royal College of Psychiatrists’ liaison faculty found more than two thirds of psychiatric liaison teams are now on duty 24/7 with nearly all reporting extended operating hours.

Meanwhile a third – 33% – of teams are now operating at what is known as Core 24 level with enough nurses and doctors to provide a rapid response at any time of the day or night – which is ahead of government targets.

While the ultimate goal is to ensure people with urgent mental health needs can get the care they need without having to go to A&E, the government has committed to expanding the psychiatric liaison service to cater for the many who do end up in emergency departments in crisis often with psychical injuries linked to their condition.

The 2018 survey, undertaken by Devon Partnership Trust, gathered data from all 175 acute hospitals in England with emergency departments.

It found the number without a liaison service had reduced from three to none since the 2017 survey while an increasing number reported meeting Core 24 criteria.

In all 58 trusts said they were achieving Core 24 by mid-2018. This compared with 22 the previous year and is ahead of a target set out in the Five Year Forward View for Mental Health for 20% to reach the standard in 2018-19. 

Claire Murdoch

Copy of Claire Murdoch

Claire Murdoch

This suggests the government is on track to meet its ambition for half to hit the Core 24 standard by March 2021.

The NHS Long Term Plan for England, published in January, set out the intention for this to rise to 70% by March 2024 with all emergency departments expected to meet the standard in following years.

NHS England said it had already invested £45m in 71 sites since 2017 and a further expansion would be backed by £48m of new funding over the next two years. This was alongside investment in community-based mental health crisis teams.

The survey found more than half of liaison psychiatry services at acute trusts reported an improvement in resourcing since the previous survey with 105 saying resources were better and 45 reporting they had stayed the same.

However, 21 services – about 12% – said resourcing had got worse.

It found 117 services had now moved to operating 24/7 while 51 had significantly extended opening hours. Just three services were only available Monday to Friday from 9am to 5pm.

“The long-term plan will see sustained investment and improvement in services”

Claire Murdoch

Psychiatric liaison teams are usually made up of specialist mental health clinicians such as doctors and nurses and increasingly other professionals such as psychologists, social workers and drug and alcohol workers.

In the latest survey teams needed to include at least 1.5 full-time equivalent consultants and 11 full-time equivalent “mental health professionals” to be said to hit Core 24 standards.

It found there had been “strong and ongoing growth” in the number of mental health professionals – who are mainly nurses – since 2015 with a total of 1742.5 full-time equivalents in place at the time of the 2018 survey.

This meant nearly 500 extra roles had been filled in that period however it showed more than 180 additional mental health nurses and others will be needed to ensure all services in England achieve the Core 24 standard.

Health and social care secretary

Matt Hancock

Source: Department of Health and Social Care

Matt Hancock

Meanwhile, just over 150 more consultants and 532.5 extra nurses and other mental health professionals will be needed for staffing to reach optimal levels – known as “full core 24” – with two full-time equivalent consultants and 13 mental health professionals.

The report went on to acknowledge some of the challenges in getting an accurate picture of services and staffing levels including the fact teams often provide community treatment and crisis services as well as working in hospitals, and the fact some operate over several hospitals.

Meanwhile, the term “liaison psychiatry” was “problematic because so much of the activity of liaison is undertaken by mental health nurses, and many teams have no psychiatrist”, added the report.

Claire Murdoch, national director for mental health at NHS England, said liaison services helped “bridge the gap between physical and mental healthcare” at the same time as lifting pressure on other frontline services.

She said the survey showed the NHS was “already delivering on its pledge to improve care and offer comprehensive mental health support to patients”.

“But this is just the start of the journey and the long-term plan will see sustained investment and improvement in services for years to come,” she added.

Health and social care secretary Matt Hancock also welcomed the findings.

“When someone faces a mental health crisis, they should rightly expect to receive top quality care at A&E just as they would if they had a stroke or heart attack,” he said.

“There is a 24-hour-a-day, seven-day-a-week need across the country”

Dr Katherine Henderson

He continued: “This expansion of specialist teams comes thanks to the extra £2.3bn a year we’re investing in mental health. This extra funding will help ensure not only better mental health support in A&Es across the country, but also better access to community mental health support to help prevent crises in the first place.”

Royal College of Emergency Medicine president elect Dr Katherine Henderson said the extra investment in services “can’t come soon enough for patients”.

“Our members and fellows know there is a 24-hour-a-day, seven-day-a-week need across the country,” she said.

Meanwhile, Dr Annabel Price, vice-chair of the Royal College of Psychiatrists’ liaison faculty, said liaison services benefited a wide range of patients “not just patients in A&E but those of all ages across the acute hospital including children and older people”.

For example, professionals from liaison services have been brought in to assess the mental health needs of patients on general wards including helping diagnose and advise on treatment for dementia, delirium and depression in older patients.

There was also evidence liaison services saved money and research was underway to look at that in more detail, said Dr Price.

The survey findings come just as trials of waiting time targets for mental health are about to get underway.

NHS England said testing of proposed one-hour standards for those who arrive in A&E are due to start in 14 areas later this month.

Meanwhile, trials of a four-hour community response standard will begin later in the summer.