Resolution, submitted by the RCN Emergency Care Association and RCN Mental Health Forum
That this meeting of Congress asks RCN Council to lobby to ensure that Emergency Departments are no longer designated places of safety for the purposes of Mental Health legislation.
Section 136 of the Mental Health Act allows for someone believed by the police to have a mental disorder, and who may cause harm to themselves or another, to be detained in a public place and taken to a safe place where a mental health assessment can be carried out. The most appropriate place for this assessment to take place is a specialist mental health facility with appropriately trained staff and an environment conducive to assessment. The majority of assessments occur in such settings.
The Crisis Care Concordat has seen the development of local action plans that have encouraged shared working between police and mental health nurses that have resulted in a large drop in the use of police cells as a place of safety. However, on occasion due to concerns regarding the physical health of the person the police have taken detained patients to emergency departments. Whilst many departments are not now designated places of safety, there are still over 20 emergency departments in England that are.
Within Wales the Code of Practice Mental Health Act 1983 Review was updated to reflect changes to the law and in particular the requirements of the Mental Health (Wales) Measure 2010 identifies how people in mental health crisis in public places are to be supported and kept safe in the most appropriate place of safety for the least amount of time.
The Mental Health (Care and Treatment) (Scotland) Act 2003 came into effect October 2005 and makes provisions for Places of Safety. According to Section 300 of the Act, a place of safety can include a hospital. The code of practice which accompanies the Act, allows local agencies to identify designated places of safety in line with Section 300. However, the code recommends that these are not emergency departments and should, where possible, be a specialised assessment unit closely linked to a psychiatric facility. Designated places of safety must be “suitably equipped and staffed by qualified mental health staff who have experience in management of acute mental disorder.” The code goes on to recommend that any use of an emergency department as a designated place of safety should “be restricted to occasions where the person also has significant physical health problems related to, for example, self-harm of substance misuse”.
Both the existing Mental Health (Northern Ireland) Order 1986 and the new Mental Capacity Act (Northern Ireland) 2016 specifically designate hospitals, rather than emergency departments, as places of safety for people with mental health problems, alongside police stations. However, no hospital in Northern Ireland has the equivalent of the Section 136 suites that exist in England and emergency departments by default are often used for this purpose. Once the Mental Capacity Act (Northern Ireland) 2016 is fully implemented, Northern Ireland will no longer have recourse to mental health legislation for adults, although the power of the police to remove an incapacitous person to a place of safety is specifically defined in the new legislation.
In the past few years emergency departments have become increasingly crowded, often with frail elderly and critically ill patients. It is a noisy environment with constant ringing of phones and bleeping of equipment, and therefore not a suitable place (if without access to an amended or adopted room) to wait for a mental health assessment. A CQC publication in 2015 Right Here, Right Now highlighted the detrimental experiences of those in a mental health crisis being treated in emergency departments versus those accessing other services. We believe the emergency department has neither the appropriate environment, nor the appropriate staff to care for these patients’ needs and call on council to lobby to ensure all emergency departments are designated public places and not places of safety.
In a lively and sometime personal debate that saw many delegates taking to the podium Congress firstly heard a very strong and emotive poem from Janet Youd, an emergency department nurse. She called for places of safety away from emergency departments that are staffed by specially trained nurses, who have the time and facilities to care for patients in time of mental health crisis.
Claire Carson also called for designated places of safety that are fit for purpose, with skilled and expert staff which are quiet and safe. She said that emergency departments are not the therapeutic place that people in mental health crisis need.
Mental health patients deserve to be treated in the appropriate setting, said Tom Murray, just like a cardiac patient. But he felt that changing the status of emergency departments from designated places of safety without first looking at how the issue of mental health is dealt with would not solve the problem.
Claire Beeston, a general nurse with a background in accident and emergency, said that staff in emergency departments is ill-equipped to deal with people with mental health problems due to a lack of training. There isn’t parity of esteem.
Speaking personally and very eloquently, Ellie Mulreany spoke of their personal experiences in A&E after trying to commit suicide, saying that the noisy environment did not provide the level of care an support needed.
But Loretta Johnson said that as a mental health nurse in the community, they have no crisis team where she works, so the only option in their contingency plans is to call 999.
Janet Youd closed the debate saying that she welcomed delegates’ responses, and recognised it was a complex issue. She called for the holistic care of every single patient to be considered and said that the NHS should find appropriate places for mental health patients in crisis before the designated places of safety are removed from emergency departments.