PAUCITY OF ESTEEM

breaking point.

Royal College of Psychiatrists presidentelect Lade Smith likens NHS mental healthcare in 2023 to telling someone with a lump on their breast to ‘come back in three or four years’ time and we will see how you are doing’. When they return, she says, that patient has stage-four cancer.

The Doctor has obtained exclusive data which shows a massive increase in mental health patients presenting at emergency departments in crisis and then trapped there for days or even weeks.

BMA consultants committee mental health lead Andrew Molodynski says the stark statistics show increasing numbers of people are forced into emergency care because of a paucity of specialist services across England. As a result, patients are left in environments which are unfit for purpose and often ‘hugely distressing’.

Our data shows the number of mental health patients waiting in acute hospital emergency departments for at least 12 hours more than quadrupled from 2016-17 to 2021-22. And the figures are still rising. In the space of just seven months from April to October 2022 the numbers had surpassed the annual total from the previous year.

Waiting times soar

In 2016-17, there were at least 1,962 waits of 12 hours or longer at 41 trusts which gave data for that year. In 2021-22 those numbers rocketed to at least 8,971 waits of 12 hours or more at 61 acute hospital trusts. In the first seven months of 2022-23, there were at least 9,504 at 59 trusts.

Many mental health patients spend significantly longer than 12 hours waiting for more appropriate care or assessment. Since April 2016, at least 421 people waited more than 72 hours. One patient was trapped for 744 hours – 31 days – at a London hospital in 2021-22.

The numbers are likely to be much higher as around half of trusts had failed to respond to a freedom of information request at the time of publishing.

Experts are united in their damning assessment of this situation.

Cambridge emergency medicine consultant Adrian Boyle tells The Doctor : ‘If you go to a mental health hospital, it’s calm, it’s ordered, it is a recovery environment [whereas] that’s not the environment I work in.’

Dr Boyle, president of the RCEM (Royal College of Emergency Medicine), says patients ‘turn up because alternative access to help is not good’.

Marcus Bicknell, a Nottingham GP with a specialist role in secure mental health and addiction, described the environment at the Queen’s Medical Centre’s emergency department as at times ‘like a World War One casualty station’.

The BMA has also analysed a vast array of NHS datasets to assess the crisis in mental healthcare. Our analysis paints a stark picture of rising demand, a workforce which simply isn’t big enough and funding and resources nowhere near matching the need in communities.

Before the COVID-19 pandemic, rates of mental illness in England had been slowly and steadily rising. The estimation of the prevalence of common mental disorders, conditions such as anxiety or depression, among adults aged 16 to 64 had risen from 18 per cent in 2000 to 19 per cent in 2014. Updated figures are due in 2023-24.

Evidence suggests rates of mental illness may be growing faster among children and young people than adults. Between 2017 and 2022 rates of probable mental disorder increased from around one in eight young people aged seven to 16, to more than one in six. For those aged 17-19, rates increased from one in 10 to one in four.

The numbers of people seeking treatment have risen even more quickly. There are now more than four times as many children and young people in contact with mental health services as there were seven years ago.

Rejected referrals

Mental health services in England received a record 4.3 million referrals during 2021 alone, up from 3.8 million in 2019. Many of these patients aren’t receiving the care they need. Doctors across the country say the number of those referrals being rejected or signposted elsewhere, rather than accepted into secondary care, are rocketing. Secondary care is overwhelmed by demand and GPs are burdened with managing increased risk and complexity.

Hampshire GP partner Emma Nash says demand is increasing and that around a quarter of the circa 100 same-day requests for appointments her practice receives are mental health-related. Hertfordshire locum GP Neena Jha reports a similar ‘explosion’ in demand.

GPs increasingly find their hands tied. Dr Jha says rejected referrals are often accompanied by a suggestion that ‘if it changes or gets any worse then tell the patient to go to A&E’.

Things are similarly difficult in secondary care. One child psychiatrist in the south-west told The Doctor : ‘I’d hate to work in the referrals team. There is a huge increase in the number of referrals, but there are less staff than there were, which can only go in one direction.’

The Doctor spoke to dozens of health professionals about the drivers of these increases. There is an acceptance that reduction in stigma around accessing mental health services is likely to be one reason, but most felt the state of society – where the welfare safety net has fallen away, and society is becoming increasingly unequal – is a major factor.

Dr Molodynski, a consultant psychiatrist in Oxford, adds: ‘Austerity has stripped away a lot of the softer support in society.’ Dr Jha says the effect of this is her patients now often needing mental health care just to ‘cope with life’.

It is clear COVID-19 itself has caused huge damage too – whether through increasing isolation and loneliness, the anguish of longCOVID or the exacerbation of so many existing inequalities in society. Consultant psychiatrist and Dean of the Royal College of Psychiatrists, Subodh Dave, describes an ‘increased psychiatric morbidity’ as a result.

Analysis of NHS data shows the mental health workforce is simply not big enough and that it is not rising at the rate needed to meet demand or the expected increase in demand on services.

For example, the number of people in contact with CAMHS services has increased by 310 per cent since April 2016 while the number of FTE (full-time equivalent) doctors in child and adolescent psychiatry has only risen by 12 per cent in the same time. On top of this, the average vacancy rate across England for doctors working in NHS mental health services is high, with around one in seven planned FTE roles vacant. Many more are filled with temporary staff.

The average vacancy rate is even higher within nursing roles, at 19 per cent in England, as of last September.

One inpatient child psychiatrist working in a tier 4 unit in England told The Doctor their service had a total of five consultant vacancies but that vacancies were ‘constantly’ advertised with ‘no applications’ forthcoming. Continuity of care is often affected, as a result.

Professor Dave describes a ‘vicious cycle’ of poor pay and working conditions which leaves staff taking on more responsibility on wards

‘There is a huge increase in the number of referrals, but there are less staff than there were’