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The report, ‘Right here right now’, was the culmination of feedback gathered by 1,800 people with experience of a mental health crisis, alongside local area inspections that analysed how services work together.
The report found that the quality of care experienced by a person in crisis can vary greatly depending on where they are and what help they require. Many people also experienced problems getting help when they needed it, and found that healthcare professionals sometimes lack compassion and warmth when caring for people who are having a crisis. The report, although by no means attempting to cover up the cracks, hints at an inconsistency and variation in service that cannot be ignored.
Gauging public opinion
Public opinion on mental health is undeniably changing. It seems there is a growing understanding that, while it maybe at a glance less noticeable, mental health requires the same right to high quality care as physical ill health, and that more measures need to be put in place to accommodate the growing concerns for those suffering from mental health.
The Mental Health Policy Group reflects this shift in opinion, and published its ‘Improving England’s Mental Health’ plan at the end of May. This outlined what the government should do to improve the lives of people with mental health problems during the first 100 days of the new Parliament. The Group reported that poor mental health In England carries an economic and social cost of £105 billion annually and that business lose £26 billion due to mental ill health every year. It also raised concerns that just 25 per cent of people with depression an anxiety access treatment and only 65 per cent of people with psychosis receive support.
The shift in public attitude is being reflected in government policy. Just prior to the March Budget, then Deputy Prime Minister Nick Clegg revealed that mental health services were to receive £1.25bn of funding, and in the same week Education Secretary Nicky Morgan outlined new measures to support mental health in schools and Clegg launched a mental health in sport initiative via the Mental Health Charter for Sport and Recreation.
The initiatives prompted a desire for more changes, with the Children and Young People’s Mental Health Taskforce highlighting a number of changes that it wished to see implemented by 2020 in its report ‘Future in mind’. This included tackling stigmas and improving attitudes to mental health, as well as providing easier access to young people experiencing mental health problems. Recommendations included a ‘one-stop-shop’ community service and rigid waiting-time targets.
However, the Care Quality Commission (CQC) report found that the quality of care experienced by a person in crisis varied greatly depending on location and what help is required. It also reported that healthcare professionals were sometimes found wanting in the desired compassion and warmth expected of them when caring for a person in a crisis.
Alastair Burt, Minister of State for Community and Social Care, stressed that the report must act as ‘a wake up call to our public services’. Burt 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.”
Long term research
In his foreword to the report, Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (Mental Health), explained how the report is the work of a six-decade spanning movement. In the 1950s, pioneers campaigned for mental health legislation that was based on human rights. Between the 1960s and the 1990s, the asylums that segregated people with mental health problems from society, were closed to be replaced by an integrated system to care for people living in the wider community. More recently, the ‘Time to Change’ campaign has worked tirelessly to reduce the stigma, discrimination and disadvantage experienced by people with mental health problems.
In 2004, the National Institute for Health and Care Excellence (NICE) introduced its own clinical guidelines for the care of people who self harm. Over ten years later, many services are still failing to provide an empathetic response when presented with a person who may have harmed themselves. Carers still feel they are not being listened to and are struggling to get useful advice and support they need. Getting the right help at the right time must become a priority.
While Lelliott is keen to emphasise the lack of haste in the making of the report, he is also clear of similar initiatives – notably the Crisis care Concordat. Launched in 2014, the Crisis Care Concordat is national agreement between 27 services and agencies involved in the care and support of people in crisis, including the CQC, on how to improve the way that services work together, mainly via access, urgent access, quality of treatment and recovery. The Concordat is being seen at the mechanism that can really instigate change.
Paul Farmer, chief executive of Mind, said: “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.”
The report showcased a gap between patient’s perceptions of how they are treated by staff working in accident and emergency (A&E) departments and specialist mental health services compared to other services. Fewer than four in 10 respondents gave a positive response about their experience in A&E when asked whether the felt they had been listened to, taken seriously or treated with compassion. Those coming into contact with specialist mental health services were only slightly more positive.
Comparatively, GPs, ambulances and the police were all perceived as being more successful in providing caring and empathetic responses to people in crisis. Volunteers and charities received the most positive responses from those who come into contact with them but the gap between satisfaction with the experience of the voluntary and statutory sectors was substantially higher (20 per cent in most cases). Overall, only 14 per cent felt that the care they received provided the right response and helped resolve the mental health crisis. Additionally, 42 per cent said it helped, but not completely, while a further 42 per cent said it did not help them. The report commented that ‘a health and care system where over four in 10 respondents feel their crisis was not resolved raises serious questions about the fairness and safety of service responses’.
On average, one in four patients registered with a full time GP requires treatment for a mental health condition. In a different context, there were nearly three million adults on local GP registers for depression in 2013/14, and nearly 500,000 people on GP registers for a serious mental illness. Additionally, in 2013/14, over one and a half million people were in contact with NHS trusts providing specialist mental health services, the vast majority of who were supported by community-based mental health teams.
Moreover, around five per cent of all A&E attendances are recorded as relating to mental health problems. People may go to A&E at a time of crisis because of self harm, or fear thereof, or a referral from a GP. The report found that the rate of people admitted to acute hospital via A&E for a mental health condition varied across the country.
Access to appropriate services
People experiencing a mental health crisis should have access to the help and support they need 24 hours a day, seven days a week. This is crucial to achieving parity with physical health care. Stats show that most people with a mental health condition, excluding dementia, are admitted to hospital via A&E in the evenings (outside of 9am and 5pm). In particular, the peak hours for self-harm admissions are between 11pm and 5am when it accounts for six per cent of all people admitted via A&E. This may indicate that there are problems with other services providing support out of hours, so that people turn to A&E for help because other support is not available.
Ultimately, the report found that access to, and the quality of, services after 5pm was not good enough. Commissioners and providers should make sure that they have the most appropriate services with the staff that have the right skills working at the times when people with mental health needs are more likely to access them.
One way to combat this and bridge the gap between mental and physical healthcare, is to introduce liaison psychiatry teams. These teams provide patients who are in distress in hospital with assessment and short-term care, and link with the follow-up support they need. It is therefore vital that commissioners take an active role in commissioning adequate and effective liaison psychiatry services across acute settings that deliver value for money, alongside improving outcomes for people who come into contact with them.
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