From despair to hope: improving the A&E experience in a mental health crisis

“What on earth is happening to me?”

These were the words I just couldn’t get out of my head beneath the piercingly bright lights and above the incredibly loud noise of my surroundings. People shouting, pacing up and down, being rushed past on trolleys, attached to tubes and masks. What a nightmare. Why on earth had I come here? I was desperate to leave, though I knew I had to stay. 

While A&E is often not the best place for someone experiencing a mental health crisis, and there are widescale movements to ensure that alternative options are available, it is still a legitimate medical emergency and appropriate as a means of keeping that person safe and ensuring their immediate needs can be met. It is therefore important that these experiences are therapeutic and do not add to the distress that people are feeling. This is particularly true because there is often an overlap between physical and mental health needs. Listening to and learning from patients and members of the public - our experts by experience - is essential. 

Unfortunately, since that first experience in A&E my mental health fluctuated over the following few years and I found myself in other emergency departments. Though despite having other difficult experiences, I also discovered that not all departments were the same. In one, that I attended rather too frequently, I met Helen, a mental health triage nurse. Helen quickly developed the ability to be able to tell if I needed just a cup of tea or a Mental Health Act assessment. Fortunately, over time it became more of the former than the latter. That particular department also had a quiet space with comfortable seating and low lighting, which made such a difference. 

Spreading good practice

Fast forward a few years and my visits to emergency departments became less frequent, with my attention shifting towards how to ensure that good practice is more widespread.

And that is the role I have been involved in. 

For just over a year now I have been the lived experience ambassador for the NHS Confederation’s Interface Improvement Programme for Mental Health and Acute Care, in collaboration with NHS England’s GIRFT team. I have worked with 12 project teams across the country, all with the determined commitment to improve the experience and outcomes of people attending emergency departments during times of mental health crisis.

I have helped others through sharing my insights gained through years of using emergency departments, and I have learned much from others sharing theirs.

Key learnings from experience

So, from that informed experience, I can share key learnings that anyone working in emergency departments (or indeed any healthcare service) can take to improve the experience of someone in a mental health crisis who may be experiencing one of the worst days of their life:

• Use calm, kind words from the outset – you may need to repeat things or explain in different ways.
• Ask ‘what’s happened to you?’ not ‘what’s wrong with you?’ and possibly not straight away.
• Offer eye contact – bearing in mind not everyone would want that or be able to hold another person’s gaze.
• Always be empathetic and understanding – body language and unspoken communication really matters.
• A cup of tea or water can go a long way to helping someone feel safer.
• A quiet space if possible – think and ask about the lights and noise.
• Regular check ins – have a brief chat, don’t just do observations.
• Have a plan asap and involve the person where appropriate – try to explain what is going on at every step of the way.
• Remember to enquire about families, friends and carers, as well as the person’s social situation and safety/safeguarding.

Expanding community provision and providing a range of appropriate crisis services is absolutely the right ambition, though the reality is that some people need help right now. Ensuring A&E can consistently deliver safe but compassionate care for everyone is essential and it has been heartening to me to see the commitment of teams to this effort.

To offer one final piece of advice for helping someone in a mental health crisis: remember that this person’s crisis is - both to them and clinically speaking - a medical emergency and should be treated as such. Try to hold hope for people when they may be feeling at their most hopeless and be the person who helps them on their way to becoming the person that they would much rather be.

Ian Callaghan is the lived experience ambassador for the NHS Confederation Interface Improvement Programme for Mental Health and Acute Care. You can connect with Ian on LinkedIn.