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Re: SB/BK

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06 February 2013

Sir Bruce Keogh

NHS Medical Director

Room 504 Richmond House
79 Whitehall
London SW1A 2NS

Dear Sir Bruce,

RE: Your intention to have a review of the functioning of emergency services in healthcare.

I very much welcome this review and write to seek firm reassurance that the review will include looking at the emergency response to those who present with mental health problems and substance misuse difficulties. As you know mental illness can be associated with high risk to self and on occasions to others.

From diverse sources within the field of mental health, including the Mental Health Collaborative (a body representing the leads for the mental health professions), our own work within the College, feedback from the voluntary sector and feedback from providers there are currently acute pressures within mental health when it comes to the timely delivery of appropriate and emergency response to both individuals who are known to services and those who are presenting de novo.

In some parts of the country inpatient bed occupancy at the weekends is over capacity having to use ‘leave beds’ at the weekends or patients having to be transferred from where they live to up to 100 miles from their own home town.

In working with the president of the Faculty of Accident and Emergency Medicine we are very aware of the current acute pressure on A&E departments. This arises not only because of those with physical health problems but also those with mental health problems, those with complex co-morbidities including substance misuse. Further we know we are not achieving in the field of Section 136 (police conveyance to places of safety). There is still widespread use of police stations for unacceptably long periods of time (there is a report to be published on this shortly). This is a matter of ongoing discussion between the Home Office and the DoH.

As a Royal College we are actively participating in the Royal Academy of Medical Colleges’ drive to offer safe, effective, consistent, 24/7 intervention for all patients. I know there are many ways to improve both effectiveness and efficiency of service delivery. My belief is that, certainly for mental health and probably for physical health, at least a third of referrals attending A&E could probably be dealt with in a better way. In early discussions with President of the Royal College of General Practitioners we have looked at how extended working hours for GP’s might best be used in the specific field of meeting the needs of those with mental health problems who are approaching or are in crisis. As a College we are keen for more Liaison Psychiatrists and General Psychiatrists to work out in Primary Care.

However there are particular challenges in the field of mental health. Through the Future Hospital Forum the rest of medicine are looking to how best they can move their services out into the community. It has to be borne in mind, partly arising out of the state of asylum care, mental health seized the initiative to move into community care long before the rest of medicine.

We know there are some very innovative community mental health teams that offer respite care at the weekends working with the voluntary sector. However I feel I do have to reinforce the point with you that in some parts of the country mental health services, when it comes to out of hours responses, are at breaking point. Even with more effective, efficient and novel ways of working there is a bottom line that without some of the total NHS budget being vired over into more consistent, effective and safe community care for those with mental illness, those with chronic health problems and particularly those with dementia, we will not be able to achieve what we would wish to for those with these long term conditions. Crises will continue to occur with escalating burden of disease and at times very negative outcomes for patients and their families.

I do of course, as president of the college, work closely with the other presidents, with the DoH and in particular have had meetings with Martin McShane and Mike Richardson. My level of concern is such that this is the first time I have formally written to you. I would very much welcome a meeting with you to discuss 24/7 care for those patients with mental illness and possible models of how we can improve ‘out of hours services’ for this important and large group of patients.

With best wishes,

Professor Sue Bailey

Cc: Martin McShane, Mike Richards