• Every A&E in London should have “dedicated space” for three mental health patients, says report
  • Comes after “huge” increase in reported breaches of 12-hour admissions standard
  • 15 per cent of mental health patients faced 12-hour A&E waits, versus 1 per cent overall
  • One patient had to wait five days for a bed
  • Report suggests creating separate ward for patients not from London

Every emergency department in London has been advised to create “dedicated space” to care for three mental health patients, due to concerns over long waiting times for people in crisis.

A report commissioned by providers in the capital, and supported by NHS England and NHS Improvement, has highlighted major problems within the urgent and emergency pathway for mental health patients. In one case, it said a patient had to wait five days in an emergency department before being admitted to an inpatient service.

The report is based on findings from an audit carried out over three weeks in August 2019, which found 15 per cent of mental health patients were left waiting in emergency departments for more than 12-hours before being admitted or discharged. Less than 1 per cent of physical health admissions breached the 12-hour standard in August.

It also suggested the situation was likely to be significantly worse than the reported figures imply, as waiting times for mental health patients are “underreported on a significant scale”.

The report, obtained by HSJ through a freedom of information request, said: “If a patient is waiting for a speciality bed for physical health care… they can be cared for in a range of acute medicine wards and units while a bed is found, and if needs be some patients can ‘outlie’ in other specialities to avoid long delays.

“Most local systems in London have no comparable option for people waiting for a mental health bed. It is still common for EDs to have a single ‘mental health cubicle’ in the middle of majors.

“Given the audit results it is no surprise that these cubicles are almost always full and that people in crisis are being cared for, often for long periods of time, elsewhere in ED.

“This has a knock-on effect on the flow of the entire ED, including on the ability of ambulances to offload, and of the police to leave patients in the care of NHS staff.

“Our site visits suggest that as a minimum even London’s smallest EDs need dedicated space for three mental health patients at any one time.

“It is not credible to plan on the basis that mental health trusts will always have available beds, or that there will never be surges in mental health attendances.”

It is the first time an audit of this kind has been carried out for London and follows the launch of a citywide agreement between NHS trusts, clinical commissioning groups, local authorities and the police to set new standards of care.

The report added: “This audit has not been carried out before in London so we do not have anything to compare it to, but looking at formal 12-hour breach reporting we can see that there has been a huge reported increase in 12-hour waits for mental health patients in the last year.

“Whether this is a result of better reporting or evidence of real growth (some London systems are reporting double-digit percentage increases in people in crisis attending via ED, despite welcome national investment in community services), we now have evidence about what is going on and need to respond.”

It is also unclear whether the situation in London is worse than other areas of the country, as national data is not routinely published.

Bed capacity

Figures from the audit found almost half of patients waiting for a Mental Health Act assessment waited more than 12 hours, while patients suffering from psychosis were the most likely to experience long waits.

More than one third of patients waiting for an informal admission to an inpatient bed also waited more than 12 hours. 

The biggest driver of delays was insufficient inpatient capacity, with the availability of approved mental health practitioners, who are required to carry out MHA assessments, another driver.

Wider concerns were also raised that independent sector mental health beds in London appeared to be in “shorter supply” due to some providers commissioning “blocks of beds”, meaning fewer available for others to spot purchase, as well as a reduction in the sector’s inpatient capacity following Care Quality Commission concerns.

The report also highlighted that out-of-area mental health patients accounted for around 4 per cent of the city’s inpatient bed usage.

In response to this, the review recommended a specific service and ward for out of area mental health patients is created. NHSE told HSJ a group of mental health trusts are due to pilot a triage ward for out-of-area patients within east London from early 2020.

The report also said that more physical and mental health assessments should be carried out in parallel, as stipulated by national guidance. It said this was happening in just 14 per cent of cases.

The report was written by Judith Fairweather, deputy director of contracting for North and East London Commissioning Support Unit, and led by Matthew Trainer, chief executive of Oxleas Foundation Trust. The audit analysis and preliminary results were provided by NHSI’s emergency care programme improvement lead, Emma Bagshaw, and Geraldine Strathdee, former national director for mental health.