Only 24/7 mental health care will halt crisis in emergency departments
This week the Irish Independent revealed a series of incidents where people with serious mental health conditions were left waiting for appropriate care in one of the country's busiest emergency departments (ED) in Beaumont Hospital.
The reasons for this are two-fold. Firstly, by their very nature, crises often occur out of office hours. This is also true of mental health crises. Secondly, the failure of the HSE to deliver 24/7 mental health support services means that people with mental health crises still end up going to the EDs of our public hospital for help. These may be people who are having such a crisis for the first time, or people who are regular users of mental health services.
In the last two weeks, one patient self-harmed in front of other patients waiting for care in Beaumont ED. A psychiatric patient tried to stab a healthcare assistant, while another was left without medication. And gardaí were called to find a patient who had left the ED without treatment.
The 2006 mental health policy, 'A Vision for Change' proposed that each adult Community Mental Health Team have "24/7 multidisciplinary crisis intervention". It specified that "there should be a 'crisis house within each catchment area, offering . . . a safe place to recover their bearings and work . . . to evolve a care plan that will address the key factors that have precipitated their crisis."
This 24/7 crisis service has not happened. The 2015 pre-budget submission of the mental health advocacy group, Mental Health Reform, identified the inconsistencies and lack of 24/7 crisis mental health services around the country. It also highlighted two places where there is good practice.
The West Cork mental health service provides a 24-hour listening service so users always have someone to talk to and, if necessary, refer them to a service. The Celbridge Community Mental Health Team provides services seven days a week. It also gives users a phone number to call out-of-hours. This, combined with every service user having a key worker, provides a safety net and reduces hospital admissions.
Mental Health Reform points out how crisis services are only available in other parts of the country from Monday to Friday during office hours. This is not good enough. The most recent annual report from the Mental Health Commission, which is responsible for inspecting all mental health services, is critical of the absence of the lack of 24-hour provision of child and adolescent emergency services and concludes that this is directly linked to the inappropriate placement of adolescents in adult psychiatric wards.
The HSE's 2015 Operational Plan commits "to build the capacity in emergency departments for 24/7 contact and response" and it details a relatively new "National Clinical Care Programme for the assessment and management of patients presenting to emergency departments following self-harm". These are very welcome commitments but are obviously not in place, given the recent situations of acutely ill mental health patients in Beaumont ED over the last two weeks.
The Beaumont situation can partly be explained by the relocation of acute mental health services for the catchment area of North Dublin, from St Ita's in Portrane, to the new acute mental health service on the grounds of Beaumont - the long-awaited 36-bed Ashlin Centre. Within months of this unit opening in 2014, Beaumont's clinical director resigned, citing the absence of 24/7 assessment in the Ashlin Centre as his reason for going. Because the Ashlin Centre does not provide out-of-hours assessment or access, acute mental health patients end up inappropriately in the ED.
If one is having a mental health crisis, then waiting in a busy ED is not the best place to be. Similarly, if one is waiting for physical care in an ED, then waiting alongside people in acute mental distress can make a difficult situation even harder.
In 2013, over 11,000 people presented to EDs having self-harmed. More than one in five of them are repeat attenders for self-harm. People who self-harm need both physical and mental healthcare. It is known that EDs are an opportune place to intervene with people who self-harm, yet people who end up in EDs having self-harmed report being sent home after waiting hours for care and receiving little or no follow-up.
Speaking on Wednesday morning, at the launch of the new National Suicide Strategy, Social Care and Mental Health Minister Kathleen Lynch said: "We have put . . . 20 specially trained nurses into our emergency departments, there will be 35 . . . to ensure that when someone arrives at an emergency department, they are seen by someone who has a knowledge in the area and they are connected to the appropriate service." While 20 specially trained nurses are welcome, they are just a drop in the ocean for the country's 33 public hospital EDs. Adequately addressing people's mental health requires 24/7 mental health services inside and out of EDs. There needs to be crisis houses across the country and well-trained staff with the time and skills to cope with people who present in EDs, if other services are not available. All of this requires resources - money and staff for community mental health teams - so they can operate seven days a week, not just five, and respond to crises during the hours of the day that crises usually occur, which is out of office hours.
The multiple attendances of patients with acute mental health conditions in Beaumont Hospital coincided with the launch of the new Government suicide prevention strategy. Despite the rhetoric, it is clear that the political will does not exist to deliver 24/7 mental health services for people in crisis in Ireland.