HSJ’s fortnightly briefing covering safety, quality, performance and finances in the mental health sector.

Acute and mental health trusts in London have signed a new agreement setting standards for access to inpatient and emergency mental health care. 

In June this year, a 61-page agreement was signed between NHS England and NHS Improvement and all of London’s trusts, clinical commissioning groups, local authorities, police services, and associations of children services and adult social care.

The document, entitled Access to mental health inpatient services in London and seen by HSJ, sets multiple standards on waiting times, data recording and emergency pathways for mental health patients.

While some aspects of the agreement are highly ambitious, surpassing current national requirements, others appear to address existing practices which perhaps are not being carried out as they should be.

An agreement about the time the clock starts for patients waiting for admission via an emergency department falls into this latter category.

The new London guidance states the decision to admit should be recorded at the point when it is decided that a patient requires a bed, not when a vacant bed has been found.

Shouldn’t that already be the current practice, I hear you ask?

Yes, it should, but conversations with a few ED experts will tell you this is often not how it works in practice across England. Mental Health Matters has previously examined the hidden mental health waits linked to when a decision to admit is recorded, with the effect that 12-hour breaches have been under-reported.

London’s agreement will partly address this, but not where a mental health patient is waiting for an initial assessment. This will only be addressed by starting the clock from arrival, as the new acute clinical standard pilots are currently trialling. 

That aside, conversations with leaders in London have suggested the recent city-wide agreement could result in recorded 12-hour breaches increasing significantly in the capital’s acute trusts. A quick dig through trust board reports and national data reveals some early signs this is already happening.

Camden and Islington FT said in its September board papers that 12-hour breaches for mental health patients have risen in London acute trusts directly due to the guidance. Looking at data for one of Camden and Islington’s acute partners, University College Hospital London FT, 12-hour breaches went from seven across the whole of 2018-19 to six in the month of July 2019.

For Croydon Health Services Trust the jump appears to have been more dramatic. It had just five breaches last year, and 38 were recorded in July. There may be another explanation for this, but it looks curious.

If there is a substantial increase in breaches this year, directly related to improved reporting of mental health waits, will there by any leniency for London from regulators? If not, should there be?

Ambitious or just aspirational?

There were many other agreements in the document which go beyond the new nationally-proposed standards for emergency mental health care.

The most noteworthy are:

  • Individuals arriving in a health-based place of safety or ED should have both a physical and mental health assessment and a care plan in place within four hours of arrival or from point of referral;
  • For patients detained under section 136 of the Mental Health Act, the London Ambulance Service should attend within 30 minutes, or eight minutes if an individual is being physically restrained;
  • Once a place of safety has been identified and agreed to have capacity, police and ambulance staff should not have to wait more than 15 minutes;
  • If an individual has been waiting more than six hours to be admitted to inpatient care, this should be escalated;
  • Once the individual is at a place of safety, an initial assessment should be completed by the health-based place of safety team within one hour of the individual’s arrival; and
  • Unless there are clinical grounds to delay the assessment, the approved mental health professional and section 12 doctors should attend within three hours of being contacted to conduct mental health act assessments. These assessments must not be delayed over uncertainty regarding the availability of a bed.

To some readers, the above agreements may seem ambitious to the point of merely aspirational.

However, the agreement does go further to advise organisations how they should address or mitigate situations where targets aren’t met.

Whether or not organisations are likely to meet the agreed standards, I would argue the aspiration is not a bad thing.

The simple fact so many organisations have all signed up to this agreement is a victory as it puts emergency mental health care firmly on the agenda.

Mental Health Matters is written by HSJ’s mental health correspondent Rebecca Thomas. Tell her what you think, or suggest issues she could cover, by emailing her in confidence at rebecca.thomas@wilmingtonhealthcare.com or by sending a direct message on Twitter.

Join us at the HSJ Transforming Mental Health Summit (28-29 November 2019, Hilton Leeds) as senior peers from across the NHS, local authority and wider mental health service delivery landscape discuss the remaining challenges as we reach the end of the Five Year Forward View. Register your interest here: http://bit.ly/2KbYAzJ