Improving the mental health urgent and emergency care pathway: Summary of findings

When first looking at section 136 and HBPoS, transport and travel home was seen by people with lived-experience as a vital way to improve the service.

The system agreed to put that in place straight away, at the moment this is largely by taxis or patient transport – but further discussions and development has led to the piloting of a mental health patient transport.

The police, and ambulance staff, have benefitted from the close working partnership with specialist teams from KMPT and the VCS providing training to increase their understanding and confidence in dealing with mental health services and service users.

Professional advice lines are now in place to support the triage and assessment of people who might be experiencing a mental health crisis by urgent treatment centres, the police and the ambulance trust.

These have been put in place by the VCS to support people to stay well and prevent a crisis escalating when people are feeling vulnerable.

These are mostly open in the evenings or weekends when other mental health services are closed.

Supplementing the existing system of community-based peer support for those with complex emotional disorders.

From 2023, NHS 111 is introducing ‘select option 2’ as a means for people to access information and advice about mental health services and support without first going through the assessment for physical illnesses.

Despite these improvements, the MHUEC transformation programme recognises there is still more to do and has been working with partners, staff, VCS organisations and people and families with lived-experience to continue to improve the pathway. 

Over a five-month period we have been fortunate enough to be able to do a deep dive into how people with lived-experience feel and hear about their experience of services and their views on how to improve the pathway, the health based places of safety and the section 136 service.  

We have also heard from a variety of stakeholders, clinical staff, front line emergency services and those charged with delivering section 136 assessments and keeping people safe from harm. 

Improving health-based places of safety (HBPoS)

• Sensory needs must be considered. Sound should be soothing and not overwhelming, especially for those with autism.
• We need support and an environment with access to fresh air and the outside, a place that is well-staffed and comfortable.
• Activities to occupy you, if there are delays.
• Comforting food and facilities. They should be comforting and friendly and give you hope when you are in an extreme position.
• Things need to work quickly and efficiently when someone is in crisis. 
• Any new facility must be easily accessible, with transport there and back provided safely and in a timely manner, with parking for staff.
• Having different spaces for assessment and sleeping, not built like a ward.
• Places for de-escalation and seclusion or extra care, an area for the volatile and vulnerable to keep everyone safe without closing the facility.
• Carers and families can supply vital information to help with assessment, if they can assist without breaking patient confidentiality.
• Any facilities must be purpose-built and co-designed.
• Difficult having treatment in A&E in a space that is not purpose-built and having to wait for treatment – waiting a week for a bed.
• People get directed to A&E if they feel unsafe, increasing demand on an already overworked hospital and in most cases end up sitting in a separate room for hours.
• Several groups suggested using tools and techniques that we (in peer group) use to help the person in distress, such as breathing techniques.
• In response to discussions as to whether the HBPoS should be centralised, there were mixed views, some positives: “It might cost less to have one place (HBPoS).”
• And some concern about the capacity of a single facility, and the travel to a central location especially from Dartford or east Kent coastal areas. 
• Follow up services should be prompt and it should be checked that people have received these.
• Travel and transport are important – consider both. Transport to be provided, the manner of delivery and the attitude of staff can have a big impact when an individual is extremely anxious. 
• Overall reduction in travel times good for all, improves service.
• The size of Kent can still make travel slow for people being assessed and for staff who need to cover county.
• Generally, people wanted to reduce the involvement of the police, if possible, and welcomed the idea of better education and training for all staff.
• The positives would be a quicker service and it cuts down travel time.
• Single larger site means greater continuity with staff and certainty for AMHPs, doctors doing assessments and patients – some of whom return.
• Easier to plan and coordinate staff.
• HBPoS and difficulties currently of retaining staff, and use of agency staff.
• Central facility means it could be easier to arrange doctors to attend a single facility with the potential for co locating AMHPs/assessment doctors.
• Specialist HBPoS is safest for individuals, it means back up of trained specialist staff.
• Limitations of current facilities mean staff do not always feel safe.

“I was hoping to get sectioned to get fast-tracked to get help. I’ve never been under that service but have thought about suicide to get diagnosis done quicker.”

“I don’t reach out for support when I need it, as I am scared I will be treated as a criminal.”

“Making the phone call is tough enough.”

“Our idea of crisis and the team’s idea of crisis are different. We might be suicidal, and they might call you back after a couple of days.”

“The environment is not therapeutic, and people did not feel validated. Sometimes people’s crisis overspills and it feels like them and me. We should be more humane about it.”

“Person sitting with them literally just sits and watches. There is no interaction at all. Some people need validation at that time. Being sat and observed isn’t validating.”

“One lady waiting with me just cleaned the floor. Their presence was non-existent.”

“Maybe have a sensory room (as a safer option to a warm bath!) and the overall atmosphere should be relaxed, friendly and empathetic. This can only be done with the right sort of people.”

“The environment can be a trigger and a friendly environment is always good”.

“Access to the outdoor space, safe environment, transport home, not too much background noise, somewhere where the situation can be managed better.”

“Having police with you can be overwhelming, instead of therapeutic help.”

“I don’t believe the police should be involved... I know when they were called out to someone as there were no other services available. This made the person panic and think they were in trouble, then they hit out at the policeman and got arrested. It gives mixed messages and as a young girl I wouldn’t feel safe with police officers (sadly).”

“You need the help before you reach a crisis to talk through issues such as not wanting to take mental health medication while pregnant but still needing support.”

“Maybe people might not know about it. I was given a lot of numbers to ring and very limited help and sometimes felt worse. No one said anything about a safe haven and that might have been enough to take the edge of, just to know there is a safe haven.” 
    
“More communication needs to be carried out, so people and services are aware of the existing safe havens. For example, the Single Point of Access helpline did not inform the caller about this Safe Haven option.”

“Attitudes of staff feel very dismissive, like they were thinking we could be treating someone who really needs help.”

“Services can sometimes come across as insensitive and need to be trained in personality disorders and neurodiverse needs.”

“There seems to be community workers that can’t deal with people in a bad place.”

“Being asked by a psychiatrist if you are going to do that again after an overdose – how can you know when or whether you will attempt that again? Your head is probably feeling so messed up you wouldn’t know yourself.”

“I often end up saying what they want to hear as when you tell the truth, nothing is done for you – they give you nothing. So you just say you’re ok as it makes it easier, and is somehow expected.”

“Clinicians do not understand PD and it’s not a pill you can give someone. It’s a really, real crisis and gets labelled or stigmatised as it can happen frequently. As I said you can’t always treat people the same way. So, it does come back to the training and attitude. You want someone who understands, listens to you – I know staff get overwhelmed, desensitised is it possible to set up a service with a volunteer who understands?”

“The layout of a single unit would need to be carefully designed with central office and two distinct areas one for assessment, the other for beds, and a clear means to deescalate volatile situations or people. So, you can manage and not close the whole facility if the behaviour of one person is especially challenging. If it is set out like a ward with a single corridor and five units, it would be more difficult to offer distinct spaces.”

“We need to co-design any facility to include the need for seclusion or de-escalation space within unit, so we could see vulnerable or disruptive people without compromising the whole unit.”

“It would be good to have things for people to do during long waits for assessment or inpatient beds. Currently the waits are lengthy with little to do except sleep.”

“I think a centralised facility is a good plan, especially if it has the capacity to see more people and so process people quicker. It will be easier to coordinate trust doctors if we are using a single unit, especially if they are on a rota system dedicating to covering assessments at that facility.”  

“The layout of a single unit would need to be carefully designed with central office and two distinct areas one for assessment, the other for beds, and a clear means to deescalate volatile situations or people. So, you can manage and not close the whole facility if the behaviour of one person is especially challenging.  If it is set out like a ward with a single corridor and five units, it would be more difficult to offer distinct spaces.”

“We need to co-design any facility to include the need for seclusion or de-escalation space within unit, so we could see vulnerable or disruptive people without compromising the whole unit.”

"It would be good to have things for people to do during long waits for assessment or inpatient beds. Currently the waits are lengthy with little to do, except sleep.”

“It will be easier to coordinate trust doctors if we are using a single unit, especially if they are on a rota system dedicating to covering assessments at that facility.”