Adam understood from the outset that a career in NHS mental health services would present significant challenges. His role as a psychiatry doctor involves navigating some of the most complex and distressing situations in healthcare, from attempting to calm patients experiencing psychosis to supporting those battling severe depression who have self-harmed. For Adam, these challenging encounters are not deterrents; rather, they are motivating factors that drive him to provide care. He considers it a profound privilege to assist individuals when they are at their most vulnerable.
Yet, even with this sense of purpose, Adam occasionally finds himself questioning, “Why am I doing this?” These moments of doubt seldom arise from the patients themselves; instead, they are predominantly the result of “failures in the system.” With the NHS facing overwhelming pressure, stories about “corridor care” have become commonplace, highlighting the plight of sick patients languishing in A&E while ambulances remain stranded outside. The struggle to secure a dentist appointment or a GP visit is all too familiar, as is the exasperation of waiting years for surgical procedures. Unlike physical health crises, mental health issues do not often ignite public outcry, except when severe incidents, such as the 2023 Nottingham attacks, expose systemic failings. Following these tragic events, reviews revealed that significant “errors, omissions, and misjudgements” within NHS services contributed to allowing Valdo Calocane—who was suffering from paranoid delusions—to commit acts of violence that claimed three lives.
This month, a comprehensive review of the failures in NHS mental health services that treated Calocane found that he was not compelled to take anti-psychotic medication, partly due to his aversion to needles. With nearly one in seven NHS mental health positions unfilled, experts warn that serious challenges are pervasive throughout the system. The problems begin in A&E, where over 80,000 individuals presenting with suspected mental health concerns endured waits of more than 12 hours in 2023/4. This staggering figure represents over a third of all mental health-related cases, with 26,000 individuals waiting 24 hours or more for care.
These issues also extend to specialized inpatient wards. Last year saw the number of mental health beds plummet to its lowest level since records began in 2010, resulting in further delays and necessitating that some patients travel hundreds of miles for treatment. Adam, who has been given a pseudonym to protect the anonymity of himself and his patients, faces both facets of this healthcare crisis during demanding 12.5-hour night shifts for an NHS trust in an English city. As a resident doctor— the new designation for junior doctors—Adam is several years into his psychiatry training. His regular hours are spent in community-based care, seeing patients in their homes or clinics from 9 am to 5 pm. However, several nights each month, he is assigned to the psychiatric services of an A&E unit, and other nights, he oversees specialized mental health wards. Frequently, he alternates roles from one night to the next, often amid two exhausting weeks of his regular responsibilities. In A&E, he is typically the sole psychiatry doctor on duty overnight. In his other role, he is the only physician responsible for more than a dozen mental health wards that are dispersed across several sites, each a mere 15-minute drive apart. He describes this single-handed oversight as sometimes feeling “absurd.”
Dr. Andrew Molodynski, a consultant psychiatrist and the mental health lead at the British Medical Association, states that the challenges Adam faces are widespread, attributing them to a system that is “crumbling” and in dire need of additional funding. “Demand has increased dramatically, and funding has not kept pace,” Molodynski explains. “Doctors are forced to make impossible decisions about who to prioritize, meaning many patients are not receiving adequate care and some fall through the gaps completely.” Matthew Taylor, chief executive of the NHS Confederation, has labeled the situation a “national emergency.” To illuminate how these systemic issues impact patients at their lowest points and contribute to staff burnout, Adam spoke with The i Paper each morning following four recent night shifts.
Night one, A&E: Helping patients at their lowest
Upon starting my shift, I was met with approximately 90 patients waiting to be seen in A&E. While most were there for physical health issues, my focus was on individuals arriving with mental health challenges, particularly those feeling suicidal. For many, finding the courage to seek help in such a chaotic environment can be an arduous task, especially when A&E is bustling with activity. This chaotic atmosphere has become the new normal—a stark reflection of the current state of the NHS. However, those who seek our assistance are doing the right thing, and we strive to help them in any way possible.
I work alongside a couple of mental health practitioners, whose backgrounds may include nursing, social work, or occupational therapy, and together we assess patients. Tonight, we saw seven or eight individuals as a team. Among them was a young woman experiencing increasingly suicidal thoughts over the past week, following her therapist’s advice to seek hospital care. Accompanied by a loved one, she waited a couple of hours in a corridor, sitting next to patients with various ailments, including nosebleeds, and across from others on trolleys. She appeared tearful—overwhelmed, sad, and very low. I spoke with her in a private cubicle, albeit with the curtain drawn, as A&E is notoriously noisy and not the ideal setting for these discussions. We conducted a thorough exploration of her situation, delving into her thoughts and feelings. Many patients appreciate the opportunity to articulate their experiences.
I assessed whether she required admission to a mental health ward for psychiatric care or could be discharged home with a follow-up plan. If a patient is not well enough to consent to admission and poses a safety risk, we evaluate whether they may need to be detained under the Mental Health Act, always aiming to follow the least restrictive course of action. After over an hour of discussion, we developed a safety plan that she felt comfortable with. Following some administrative tasks, a crisis team will follow up with her within the next 24 to 48 hours. She was able to leave around midnight, feeling heard and with a clear path forward. I am confident that she will be seen promptly for that first follow-up meeting. However, waiting lists for community services can be excruciatingly long. Many individuals struggling with depression and anxiety would greatly benefit from talking therapies, such as Cognitive Behavioral Therapy, but these resources are severely overstretched.
The second patient I encountered was a young woman who had attempted suicide and was receiving medical treatment in a bed. She arrived alone, feeling hopeless, but her ability to sleep indicated we could take a more gradual approach. By the time I wrapped up her paperwork, it was already 3 am. As the first night shift of what would be a grueling fortnight, I felt the fatigue settling in, akin to experiencing jet lag. I was scheduled to be in A&E another night that week, but there was currently no doctor assigned to the local mental health wards. They were in search of a locum, but if they couldn’t find one, I would be reassigned there. I hoped this wouldn’t be the case, as those shifts are even more exhausting on top of an already demanding schedule.
I finished at 9 am and returned home by 9:30. I had prepared soup for the week, so I enjoyed a bowl with some toast before heading to bed.
Night two, A&E: Managing alcohol issues
On this night, a young man presented with intrusive suicidal thoughts but was intoxicated. I opted to wait for him to sober up before attempting a more productive conversation. Another patient with suicidal ideation had developed an unhealthy long-term relationship with alcohol, using it to cope with his distress, which ultimately exacerbated his situation. The police also brought in a teenage girl who had been drinking; she lived with carers but had gone missing. Our assessment revealed that while she might have some mental health challenges, her immediate situation was more a result of behavioral issues rather than mental illness. She expressed no inclination to harm herself, so we requested social services to follow up on her case.
If police officers suspect that someone has a mental disorder and believe that individual may be at risk of harm or mistreatment, they can transport them to a “place of safety” for evaluation. These facilities can be located in psychiatric hospitals or police stations. While one might picture a padded room, that’s not entirely accurate; these spaces are designed to be as safe as possible, with no sharp corners, exposed pipes, or loose wires. Tonight, it seemed a young person might need to come to A&E due to the unavailability of places of safety, but fortunately, it worked out in the end. The scarcity of such facilities is a recurring issue.
Tonight, a doctor picked up the locum shift to cover the wards, allowing me to remain in A&E, but this has been a frequent concern. There’s a vacant doctor shift this evening that I could fill at double the normal pay. However, taking on additional shifts without exceeding my limits would be unwise. We are facing challenges filling shifts because many doctors are exhausted and overworked, further compounding the problem.
Night three, on the wards: Coping with violent patients
During the daytime, mental health wards have their own doctors working regular hours to care for patients, review their cases, and manage prescriptions. In the evening, there are typically two resident doctors on call for all the mental health wards in our area, which is already a stretch. At 10 pm, I become the only doctor on duty until the morning, responsible for multiple sites, each with several wards. This situation can quickly escalate into a state of chaos.
The first patient I saw tonight was a teenage girl who had been brought in by the police under the Mental Health Act from a general hospital. She had expressed suicidal thoughts and had self-harmed. The Mental Health Act dictates when we should detain patients who pose a significant risk to themselves or others. Navigating this terrain can be tricky, and the Government is currently modernizing the law to ensure it’s applied fairly. Continuous reviews are important for maintaining standards.
I needed to assess her condition. Initially, she had been exhibiting anger and lashing out, but the nurses had done an excellent job of helping her calm down. She was hearing voices, and we discussed her concerns regarding her personal space being violated. Another patient came in after a Mental Health Act assessment at a general hospital, where it was determined that his altered behavior was due to a psychotic illness. A third patient was admitted under similar circumstances, but they were asleep when I arrived, so I simply checked that they were safe and attended to the necessary paperwork.
It can be challenging to stay alert during these shifts. Proper breaks can make a significant difference, but tonight, I could only take half of mine. Finding time for a break is nearly impossible when you’re the sole doctor on duty. There was simply no opportunity for a proper meal, so I quickly consumed a meal-replacement drink in my car.
Night four, on the wards: Exhaustion from difficult decisions
This night started with three competing priorities across different sites. I needed to evaluate a patient who hadn’t eaten for weeks and was deteriorating to determine if they required immediate hospitalization or could wait until morning. At the same time, I had to review blood results for another patient and assess an elderly gentleman who had fallen. I began with the case of disordered eating, but they were stable, so I proceeded to the elderly patient. He was fine, but then we had an urgent new admission on a dementia ward. This patient was experiencing a psychotic episode and was in significant distress. I also noticed a potential skin infection, which a subsequent blood test confirmed. Severe infections can lead to delirium.
While I was assessing this woman, a nurse rushed out from another room, alerting me that her patient had fallen and sustained a head injury. In situations involving dementia patients who have fallen, distinguishing between symptoms of confusion and signs of a serious head injury can be incredibly difficult. The nursing staff were hesitant to send this patient to a medical hospital unless absolutely necessary because a team member must accompany them, leaving the ward dangerously understaffed—a substantial risk if complications arise.
I contacted a medical registrar for guidance and was fortunate to connect quickly. Sometimes, you can spend up to 20 minutes waiting on the phone because there’s only one registrar available for the area. I also consulted my direct senior, the psychiatric registrar, and we decided to transfer the patient to the hospital to rule out any potential bleeding on the brain. However, this decision left the ward significantly understaffed. I then had to attend to another site, only to realize that a second patient also required hospitalization. We agreed to defer that decision until morning, implementing an appropriate care plan in the interim.
At the next ward, police brought in a woman who had been suicidal at a train station. I ensured she had not sustained any injuries and arranged for further assessment the next day. Meanwhile, I received calls regarding two additional cases needing evaluation, but I simply wouldn’t be able to see them. Instead, I provided guidance over the phone to ensure they could safely wait until morning when more staff would be available. A patient who had assaulted a family member during a psychotic episode needed admission to a secure facility, but such beds are extremely limited. As a result, they had to wait in our ward’s place of safety. I intended to conduct a thorough assessment, but it quickly became apparent that there was a risk of violence, so we decided to wait for a more opportune moment.
I finally made it home at 9:30 am. After a quick snack of toast, I headed straight to bed. It had been a draining night, leaving me utterly spent. I felt the weight of fatigue from all the decisions I had to make. I couldn’t shake the worry of whether I had made the right choices or overlooked critical factors. The lack of overnight staff to prepare us for potential crises is disheartening.
Official responses to concerns
- In addressing Adam’s concerns, an NHS England spokesperson stated: “Staff are working extremely hard to meet an increase in demand following the pandemic—with mental health services treating a million more people a year compared to six years ago—and hundreds of thousands of individuals with serious mental illnesses receive physical health check-ups annually. However, we recognize there is more to be done to ensure those in crisis can gain urgent access to support.”
- They further noted that every A&E in the country “now has a psychiatric liaison team, up from two-thirds of sites in 2018, and the NHS in England is one of the first in the world to provide access to specialist mental health support through a universal three-digit number, 111, which alleviates pressure on urgent and emergency care.”
- The spokesperson added: “We have also increased the mental health workforce by 40 percent between March 2016 and March 2024 and recently reduced nurse vacancy rates by approximately five percentage points over the last two years.”
- A Department of Health and Social Care representative acknowledged: “We have witnessed far too many preventable tragedies resulting from failings in mental health services, and it is unacceptable that patients have not been receiving the care and treatment necessary to ensure their safety and that of the wider public.”
- They continued, stating: “This Government has already initiated steps to modernize the Mental Health Act, ensuring that individuals with severe mental health conditions receive improved, personalized treatment tailored to their needs. To combat burnout among NHS staff, we plan to recruit 8,500 more mental health workers. This summer, we will also unveil a refreshed Long Term Workforce Plan to guarantee the NHS has the right personnel with the appropriate skills, including psychiatrists, to provide the necessary care to patients.”
- Last year, NHS England accepted all recommendations from the Care Quality Commission’s review of the Valdo Calocane case, which includes mandates for every mental health service provider to review the care provided to individuals with severe mental illnesses.
Individuals of all ages in crisis, or those concerned for their loved ones, can call 111 at any time to speak with a trained NHS mental health professional, or contact Samaritans at 116 123 or via email at [email protected].
@robhastings.bsky.social
