Reforming emergency care

Harrison & Bruce-Jones (Psychiatric Bulletin, July 2003 correspondence, 27, 276) have misrepresented much of our editorial (Psychiatric Bulletin, March 2003, 27, 81). We fully recognise the limitations of emergency psychiatry, and support the development of more flexible and responsive services for patients in crisis. None-the-less, the accident and emergency (A&E) department is, and will continue to be, a major interface between mental health services and acute trusts – a fact recognised in the National Service Framework for Mental Health (Department of Health, 1999).

As our locality is well served by home treatment teams and a 24-hour psychiatric emergency clinic, significantly less than 50% of A&E attenders are known to psychiatric services, although importantly many are known to A&E. That homeless patients, refugees, patients who have self-harmed and are intoxicated, and those not registered with primary care, will continue to seek help from A&E is just the way of the world – especially in inner cities. Here too, the police will continue to bring individuals they find disturbed in a public place. Increasingly sophisticated and complicated community services may only have a limited impact on many of these presentations.

It is precisely because we believe that psychiatric patients in A&E should expect the same level of service as other patients that we raise our concerns about the 4-hour wait. We did not advocate ‘resistance’ to the 4-hour target, nor did we suggest that there is a correlation between the length of an assessment and its quality. We do, however, advocate a thorough and sensitive assessment of the patients’ difficulties and there are times when this will conflict with the need for the patient to have left the department within 4 hours. Mental Health Act 1983 assessments take time if due process is to be followed. Were Harrison & Bruce-Jones advocating more frequent use of Section 4?

We agree (and stated in our editorial) that adequate resourcing of general hospital liaison psychiatry is important. However, Harrison & Bruce-Jones side step key questions – who should pay for this? and who should be penalised if the targets are not met? Our experience in inner-London leads us to doubt that enhanced community psychiatry will impact greatly on these problems. We suggest that it is vital for psychiatry as a whole to respond to the fundamental issues raised by the imposition of the 4-hour wait in A&E.