Dr Emma WhicherA variety of organisations support people in crisis in London and they are working more closely together than ever before to improve crisis care services, as Dr Emma Whicher, medical director at South West London and St George's Mental Health NHS Trust and clinical lead for Healthy London Partnership’s Mental Health Crisis Care Programme, explains in this guest blog.

No one attending London’s first mental health crisis care summit recently was in any doubt that the services and care for Londoners in crisis need to change urgently. 

As the London Health Commission report, Better Health for London, said: “crisis care in London is in crisis itself”.

The summit, organised by the Healthy London Partnership on Thursday, February 25 was the first to bring together mental health and urgent and emergency care in London.

Healthy London Partnership is a partnership between NHS England (London region) and London’s 32 clinical commissioning groups (CCGs) to transform health and care in London and make it the healthiest city in the world.

This includes working with service users, stakeholders and key partners across the health and social care system to improve the consistency and quality of crisis care in the capital.  

There are many crisis care services in London that are doing an excellent job of supporting patients in crisis, and the summit highlighted many examples of best practice.  

However, as all clinicians, staff and managers working in mental health in London know, the quality of crisis care services is often inconsistent. 

Those attending the summit heard first-hand from servicer users who spoke passionately about their experiences of crisis care. As their experiences illustrated, too often people are not receiving the care they need, when they need it and in the right place. 

Healthy London Partnership has worked with Mind, YoungMinds and service users and carers to develop a series of ‘I statements’ showing what Londoners expect from crisis care. 

Service users said they want to be treated with the same respect, confidentiality and care as all other patients. They want to be listened to, they don’t want to be judged and be able to access high quality services when they need them most. 

The work to make the ‘I statements’ a reality brings together services users, those working in mental health and acute settings, social care and other key partners including the Police and London Ambulance Service.

Following engagement last year, Healthy London Partnership is currently focusing on mental health crisis care in emergency departments and London’s Section 136 pathway and Health Based Places of Safety.  

Section 136 of the Mental Health Act gives police officers the authority to take an individual in mental distress from a public place to a ‘place of safety’ so that their immediate needs can be properly assessed.  

There are 23 designated ‘health-based places of safety’ in the capital, but too often these are not available, unsuitable or already in use. 

Yet the use of s136 has increased by 9% across London over the past two years – and is highest among London’s young people. People in mental distress are forced to wait, sometimes for several hours, in unsuitable areas, such as emergency department waiting rooms or police cells. However in London, there has been a 79% reduction in people in mental distress being placed in police cells since 2013).

When people have to wait for a health-based place of safety, this delays access to treatment and can compound a person’s distress, meaning it often takes them longer to recover.  

The quality of care also varies and 25% of London’s health-based places of safety do not have dedicated staffing, with staff being pulled off of mental health inpatient wards to treat people.

In addition, more than 75% of s136 detentions occur outside working hours yet crisis care at these times is not the same as care provided in normal working hours.

Later this year, Healthy London Partnership will publish a consistent s136 care pathway and a Health Based Place of Safety specification, which will set a minimum standard of care to meet the expectations of service users in London.

The specification will cover areas such as staffing, assessments and governance arrangements. The specification will sit alongside a London s136 care pathway to ensure a more consistent pathway of care for Londoners experiencing a mental health crisis. 

To gain a clearer picture of crisis care and the s136 pathway in London, we will carry out a significant data exercise in the next three months. This will help establish the current service provision, demand and the relationships between services. From this data we will then be able to identify any gaps and assess what changes are needed to meet the minimum standards and improve crisis care in the capital. 

In terms of crisis care in emergency departments, again there are examples where emergency departments are working well to support people in crisis. But currently too many are unable to support a patient with a mental health emergency as well as they can support a patient with a physical emergency.  

For example, only 5% of emergency departments meet the London crisis care commissioning standard of four hours to complete a mental health act assessment. This is often because of a shortage of approved mental health professionals who need to be present when a consultant carries out an assessment.  

Healthy London Partnership is looking at how we can ensure London has the mental health workforce it needs, now and in the future.

It is also vital that all clinicians, managers and staff are properly supported. To this end, more detailed guidance for staff and managers in emergency departments is being developed to help clarify their roles and responsibilities with regards to London’s mental health crisis commissioning standards. 

The range of delegates at the summit highlighted the sheer number of agencies and individuals that have a role in supporting Londoners in crisis. 

One of the aims of the conference was to promote collaboration across the system to support the transformation of services for service users. London now has a number of crisis care concordant groups – comprising organisations that include social care and housing organisations – and new urgent and emergency care networks have also been established. 

Events such as the crisis care summit further help to strengthen connections between all the organisations involved in mental health crisis care. Continuing to share best practice and work together across the system is essential if we are to consistently meet the mental health crisis commissioning standards and improve services for Londoners in crisis. 

If you are interested in contributing to Healthy London Partnership’s crisis care programme please contact england.mentalhealthcrisis@nhs.net