Authors

In today’s healthcare landscape, it’s important to look into how we respond to mental health crises. The existing system, while adept at addressing the highest levels of acuity, such as severe psychotic episodes, acute suicidality, and life-threatening psychiatric conditions, is facing difficulties with meeting the needs of those experiencing crises below this threshold. Even though those experiencing below-threshold crises account for a significant number of presentations to Emergency Departments (ED), they are unable to receive the care they need.

Against this backdrop, our project aimed to identify the key features of an alternative mental health support service. With a focus on the diverse populations of Havering, Redbridge, Barking and Dagenham, and Waltham Forest, served by the North East London NHS Foundation Trust (NELFT), our goal was clear: to develop a solution that addresses the unique needs of our community.

What did we do?

To identify the key features of an alternative mental health support service, we conducted a series of focus groups across the boroughs, located in the areas of the boroughs most likely to use the service.[1] Attended by borough residents and those working across the health, local government, and the voluntary sectors, they provided a forum for open, honest, and sometimes lively, discussion around what a new service should look like. We then worked with social inclusion leads to supplement these initial sessions by attending local community groups, from community football to food banks, to listen to as many voices as possible.

The final element of our engagement approach was a survey promoted through the Trust’s Facebook page. By using paid advertisement, we were able to ensure that its reach was limited to the four boroughs in question, reached as many people as possible, and provided a wealth of evidence to confirm what we had heard in person.

What did we hear?  

From this engagement we first sought to understand the nature of the presentations that fall below the acute admission threshold.

What we heard was that there was little commonality between individuals’ experience of crisis. Instead, it was repeatedly outlined that crisis was subjective, and that the threshold between distress and a crisis requiring immediate intervention was blurred. Despite this, many people also noted that the best proxy for understanding the boundary was the risk an individual posed to both themselves and others.

Focus group participant: “Distress is the amber on the pressure gauge, whereas crisis is the red”.

Exploring the drivers behind these episodes of heightened acuity, feedback focused on the slow accumulation of factors such as isolation and financial pressures, rather than discrete tragic events, such as the loss of a loved one. This challenges the narrative of mental health crisis as a surprise occurrence, unable to be predicted or planned for. Instead, it was depicted as the culmination of multiple complex and intersecting factors, and in need of a service that recognises this.

What do people need? 

Across our engagement we identified 23 recommendations of what a new service should look like, with four emerging more frequently than others:

  • The service should be easy to access – As those in a period of crisis or distress have heightened difficulty in navigating what is already a complex healthcare system.
  • The service should be provided in the language of its users – To ensure that London’s healthcare system keeps pace with the city’s linguistic heterogeneity.
  • The service should be staffed by empathetic and compassionate professionals – These individuals can be crucial to help manage a crisis, and should have the correct training to escalate where appropriate.
  • The service should help with the next steps in recovery – It would provide the information, links, and advice to empower a service user through their next steps.

Conclusion

In effectively implementing these recommendations, there are also a range of system integration opportunities. Whether shifting towards preventative care through strengthening the links between individuals and community resources or streamlining access to secondary services through community-based triage, it was abundantly clear from the engagement how the effective integration of existing services could provide value far beyond the sum of their parts.

There remains work to do however, by actively including local voices, health professionals, and voluntary organisations in the design of these services, we have a blueprint for a service supporting those in distress outside of ED. It ensures they can receive the right support, in the right place, at the right time.

[1] Working on the findings of the Marmot Review that a person’s social position is proportionate to their health outcomes and usage of statutory services.