The UK is trapped in a “mental health crisis,” according to the Royal College of Psychiatrists, with demand for services soaring. But any NHS medics say the system is struggling to cope.
This week a doctor in training to be a psychiatrist, who treats mental health patients in England at both A&E and inpatient wards, has described the “chaos” he recently faced on four night shifts in a series of interviews with The i Paper.
Here, the doctor – using the false name of Adam to protect his identity and those of his patients – explains why the problems have become so acute.
In emergency departments, we see people who have reached moments of such distress that they see no alternative but to travel to a hospital in the middle of the night. But when they reach us, often they have to sit in a waiting area with other patients and families, for hours, while feeling suicidal.
On a normal staff night in our service, there’s supposed to be one doctor and two practitioners dealing with mental health cases. But sometimes there’s just one doctor and no practitioners, or even one practitioner and no doctor, because of sickness and no slack in the system for cover.
On those nights, you’re not just doing the work of three people, you’re also doing it less efficiently, because you’re dealing with three times more phone calls and demands that keep pulling you away. Naturally, it’s patients who can suffer.
Sometimes these people have realised independently that they need help. Others are discovered while they’re harming themselves, or have second thoughts after overdosing, or they come in for medical reasons and we learn the reasons behind their injuries. Parents bring in children with eating disorders.
We have to assess everyone fully; it’s not something that can be rushed. We explore people’s family history – if a close relative has completed suicide, for example, then their risk is higher – and their social circumstances, because if they’re living in squalor and don’t have a support network, their risks are significantly higher. We’ll also consider any physiological issues.
If we see someone who is seriously unwell, they might require admission to a mental health ward. But I’ve seen patients stay in A&E for several days while waiting for a bed to become available. If they’re feeling distressed, waiting in the chaotic environment of A&E is the definition of not therapeutic. It shouldn’t happen. They should be in a place designed to look after them.
It can take days – sometimes days and days and days – before someone reaches where they need to go in the system. Mental health beds can be extremely scarce in my area. And it’s not just about the time. A&Es are not designed for looking after people in mental distress, yet they can end up being stuck there.
The challenges we face in mental health wards can be even more difficult.
It probably helps for me to describe what these wards are typically like, for those who’ve never been inside one.
You might picture One Flew Over The Cuckoo’s Nest when you’re imagining these places. The reality is very different, though the atmosphere varies a lot. Sometimes it’s calm and it can be more normal than you probably expect, depending on the patients and the staff capacity to manage them. Alternatively, it can be chaotic, and the number of cases I can be asked to deal with simultaneously worries me. If things don’t go my way, I’m facing a really difficult night.
The first thing I do when I arrive is put my safety alarm on, in case I need to call for urgent help. Then I meet with the two evening doctors for a handover. After half an hour, they say good night and good luck, I take a deep breath, and I work out where to start.
Even at general non-secure wards, where I’m working, you need a security badge to get in or out. Unless they’ve been “sectioned”, patients are legally free to leave, but we monitor them closely for their safety.
Inside, there’s a nurses’ station looking out on communal areas. There, patients share a couple of sofas and a television.
Normally, individuals have their own basic bedroom and bathroom. Patients can choose when they go in or out; some might not feel able to leave their room, others may not want to go in.
Some patients are checked once an hour, others must be in constant eyesight or even within arm’s length. We might need five staff to handle one patient in extreme circumstances. But our fundamental principle is “least restrictive”, reducing limits on people’s liberty as they get better.
“The number of cases I can be asked to deal with simultaneously worries me”
When patients get along with each other and staff, it’s a therapeutic environment. If one or two are really unsettled, however, that can make everyone agitated. The team’s ability to de-escalate situations can depend on whether they’ve built personal relationships with patients over weeks or they’re filling agency shifts because of understaffing.
We see lots of people with psychotic illnesses, where they’ve become detached from reality, and things can be very unpredictable. Someone can walk over holding a jug of water and you wonder if it’ll end up over your head.
It’s a myth that people with schizophrenia have split personalities, but they can suffer from hallucinations, and paranoia is very common. They might think they’re secretly being watched or that people are interfering with their thoughts and even controlling them.
Someone with bipolar disorder who’s been admitted during a manic episode might feel ecstatic, like they’re having the time of their lives, but they’re not their normal selves. They might also believe they have special gifts, such as being the most intelligent person in the country, perhaps writing letters to the Prime Minister. Others spend money like there’s no tomorrow, throwing away life savings on an entire house full of Amazon boxes or an expensive car.
We have dementia wards, too. Most dementia sufferers don’t require treatment in a mental health hospital, but some develop very challenging behaviours, which even specialist care homes can’t handle. They might lose understanding of ordinary bodily functions like eating, drinking or going to the toilet, and they might be angry but not understand why, leading to aggression. We formulate a combination of medications and care options.
There’s constant tension between what you’d do in an ideal scenario and how many staff you actually have. They’re pulled from different places to cope. You definitely notice a change in the control staff have over a ward when it’s low on numbers. But the simple fact is that the NHS is massively under-resourced.
We often deal with violent patients, though I’ve rarely felt scared in my job. Partly that’s because I’m normally well supported by nurses while seeing higher-risk patients. You also learn to recognise why someone is agitated and how to manage things. You listen to what they say, validate the valid and build a rapport. There’s almost always a way to de-escalate through communication. It all has to come from a place of compassion.
Still, you need to be very alert in reading people’s signals and know where your exit is.
Although I’ve never been physically assaulted, I’ve seen a nurse who was bitten. It’s never okay for someone to harm staff. But you have to remember that if someone is psychotic, their reality is different to ours.
Others are violent because of past traumas which mean they can’t regulate emotions. Most patients we see have experienced childhood problems, perhaps from abusive or negligent caregivers. If society could support people earlier in life, it would minimise problems later, but child waiting lists can run into years. It’s not good enough.
“You definitely notice a change in the control staff have over a ward when it’s low on numbers”
If somebody poses a significant risk to themselves and others, we can use rapid-tranquilisation medication as a last resort. It doesn’t knock them out like in films, but it relaxes them. Trained staff can physically hold someone, and we can place people in a secure room monitored from outside.
Their behaviour is re-evaulated frequently and they’re allowed out as soon as it’s safe. But if you’re the only doctor for several sites and you’re doing a seclusion review at 2am when a nurse at another site is worried about a patient’s physical health, you face a difficult decision.
I’ve seen patients trying to end their own lives. Sometimes, despite everyone’s best efforts, you can’t stop them hurting themselves. That impacts us all – knowing you weren’t able to keep somebody safe when it’s the entire purpose of us being there.
If someone in a mental health hospital has died as a consequence of mental illness, that shouldn’t happen. Sadly, sometimes it does – and the level of resourcing impacts how much we can do to prevent it.
Mental health staff try their absolute hardest to provide adequate care. But we’re constantly struggling because of a lack of resources, and the system isn’t working how it should be.
There’s a shortage of staff throughout the system, especially consultant psychiatrists. Lots of resident doctors like me want to become specialists – there are nine applications for every psychiatry training post – but the Government isn’t providing sufficient funding for enough training roles. I’m paying thousands of pounds for my exams, but I don’t know if I’ll be able to continue next year because of the scarcity of training jobs.
The consultant shortage also limits training, but how do you get more of them without more training? It’s a mess.
Working in mental health is a really stressful job that demands a huge amount of you, so morale is important, but often the NHS isn’t a good employer. Once we received a pouch from HR containing a tea bag and a 25p canteen voucher as a wellbeing gift. I’ve kept it in a box to remind myself how it made me feel. In contrast, I have a relative in a Commonwealth country where medics get a free lunchtime buffet including oysters. I’m not saying the NHS should be doing that but there are clear differences abroad.
Doctors are paid much more in Australia. In New Zealand, a doctor can request annual leave with six weeks’ notice and that’s it – whereas in the NHS, it’s your responsibility to swap your shift with someone, and if you can’t find anyone, bad luck.
I want to stay and work in my own country, but I would absolutely consider working elsewhere. It’s more likely than not that I will at some point, unless things change.
People of all ages who are in crisis, or concerned loved ones, can call 111 at any time to speak to a trained NHS mental health professional – or contact Samaritans by calling 116 123 or emailing [email protected]
@robhastings.bsky.social
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