The National Challenge

The NHS is facing a significant challenge of patients attending A&E for Mental Health reasons. Across the UK, people are not able to access suitable community-based alternatives, like crisis telephone lines, crisis cafes, or support at home. Sometimes this is because the patients (and healthcare professionals) don’t know about these services, but in most cases, these services are struggling with full capacity and can’t take them on. The result is an increasing number of patients presenting to A&E with Mental Health problems putting pressure on staff and resources. It is estimated that the number of patients attending A&E for Mental Health reasons, and the number of Mental Health patients who are medically fit for discharge, have been on the rise since the COVID-19 pandemic (HSJ 2022). Many patients who are medically fit and do not need to stay in hospital anymore are held back because there is no suitable alternative in the community, or their housing and social care is not sorted. This is a problem for both health systems and all patients, as these cases take up resources and space in A&E and lead to patients feeling stuck and getting worse as they wait.

A&E departments are busy, loud, and uncomfortable, they represent a poor therapeutic environment for someone experiencing a Mental Health crisis and should be considered as a last resort rather than a first point of call. Our senior advisor Kathy McLean (non-executive director at Barking, Havering, and Redbridge University Hospitals Trust, and previously NHS Improvement’s Medical Director) recently expressed her concern upon visiting the King George Hospital’s A&E department in Ilford. With a high number of Section 136 patients detained by police and Mental Health patients taking up beds, the department presents a distressing sight and is symptomatic of a problem which requires an “absolute solution” (HSJ 2023).

The problem is however not located in A&E alone. Care for Mental Health patients involves a range of different professionals and organisations, from early intervention by community teams, to triage and liaison by secondary teams, and onward care by a range of multi-disciplinary teams. Challenges at one end of this pathway have significant effects on all actors and addressing these challenges often takes a lot of time, or requires dedicated clinical improvement teams which can take a while to set up.

However, while large operational improvements have significant long-term impacts, it is also important to build momentum and get teams excited about change. Front-line staff will always be most familiar with the immediate challenges of their department and have ideas with significant potential for impact that they cannot implement because they lack the agency, a forum, or the time to do so. As such, rather than innovating on the ideas alone, providers should look towards how they innovate, to best utilise their human capital.

Brighton & Hove

In Brighton and Hove, Mental Health care involves a range of actors from Sussex Partnership NHS Foundation Trust (SPFT) and University Hospitals Sussex NHS Foundation Trust (UHSx). The A&E at the Royal Sussex County Hospital is in a similar state as that of King George Hospital. At any time, several of its beds and a dedicated Mental Health lounge are taken up by patients who have come in for Mental Health reasons, but who might have been cleared to go home and held back or that are waiting for spaces on wards. Community-based providers are all at capacity, and the A&E and its Mental Health Liaison Team at the hospital are all working under strain to meet these patients’ needs across the hospital.

Innovating on format, not just ideas

In June 2023, leaders from across the system proposed the plan for an Innovation Week: Using 5 days to focus on the Mental Health patients across Brighton and Hove to trial initiatives and bring visibility to the challenges different teams face. The week enabled local teams to suggest and implement their own solutions, and have central leadership support them by providing additional capacity for the week and a licence to try things differently. The approach of concentrating teams and efforts into a single week represented a first for the system and enabled actors with typically low interactions to learn more from each other and collaborate.

By freeing up time from busy teams and clinicians, Innovation Week was able to capitalise on their existing knowledge and expertise. Colleagues developed initiatives to test out during collaborative workshops, many of which came from existing ideas but which had never been tried out in the field. One example provided additional input to the Brighton & Hove Mental Health Liaison Team on housing and social care issues. The team is responsible for assessing referrals for patients with Mental Health needs but is also often relied upon to arrange their discharge from A&E despite not having any expertise on housing and social issues. Help during the week demonstrated the need for this support and made a clear case to provide more expertise on these issues in the future.

Teams were encouraged to try new things and explore the full range of possibilities at their disposal. The week showed the importance of creating space for trial and error, and to vocally support staff to create agency. The close involvement of senior leaders showed the importance of being actively engaged in the process and experiencing the challenges that their front-line colleagues are trying to resolve. This visibility helped foster a collaborative approach and made front-line colleagues able to point to shared experiences in their discussions of ideas.

Finally, the week also showed what power lies in creating excitement and ownership of change. Participants from Trust leadership to front-line staff members came together twice a day to discuss progress and next steps, creating a multi-disciplinary team around the event. This high-paced collaboration helped gather momentum and support around ideas. Now that the week is over, individual participants are further developing the successful initiatives of the Innovation Week into the Brighton Improvement Plan, which is expected to gain increased attention and involvement from the week’s work.

The Chief Medical Officer of SPFT, Dr. Peter Aitken, is a key champion of the Innovation Week, taking the opportunity to visit several teams and place himself in their shoes by working in A&E during the week. He saw first-hand how bringing different teams together in this way helps gather momentum behind ideas that would otherwise lack visibility and support: “What this sort of innovation does, is it shines a light on the art of the possible. It helps staff realise that there are things within their gifts that they can do, that make their own lives easier and make things better for patients.” (BBC Radio Sussex 2023).

To hear the full interview and Dr Aitken’s insights into the week, follow this link to BBC Radio Sussex and skip ahead to the 3:41:00 mark of the broadcast. If you would like to discuss anything in this article or A&E and Mental Health related please get in touch with Harris Lorie at harris.lorie@thepsc.co.uk.

Author: Maurits Bogaards, The PSC Transformation team