The United Kingdom is currently facing a profound mental health crisis, as articulated by the Royal College of Psychiatrists, with an overwhelming surge in demand for mental health services. NHS professionals are sounding the alarm, indicating that the system is struggling to meet this escalating need.
This week, a doctor in training, who is advancing towards a career in psychiatry and is involved in treating mental health patients in various settings, including Accident & Emergency (A&E) and inpatient wards, shared an alarming account of the chaos he encountered during a series of night shifts. Speaking under the pseudonym Adam to safeguard his identity and that of his patients, he reveals the gravity of the situation.
Why I’m worried about the situation in A&E
In emergency departments, we often encounter individuals who have reached such a level of distress that they feel compelled to seek help at a hospital, even in the early hours of the morning. Upon arrival, however, they may find themselves waiting for hours in a crowded area alongside other patients and families, all while grappling with suicidal thoughts. Ideally, a typical night shift in our service includes one doctor and two practitioners dedicated to mental health cases. Unfortunately, there are nights when we have only one doctor available, or even a single practitioner with no doctor at all, due to a lack of staffing and insufficient coverage for absences. On such nights, the workload multiplies, and it becomes increasingly difficult to respond effectively to the needs of our patients. The burden of additional phone calls and requests often detracts from the quality of care we can provide, leaving patients vulnerable.
Some of these individuals have sought help independently, while others may have been discovered after self-harming or after experiencing an overdose. There are also cases where patients arrive for medical reasons, but we learn of their underlying mental health struggles during the assessment. We encounter parents bringing in children suffering from eating disorders, and we must conduct thorough evaluations for each person, which cannot be rushed. We delve into family histories—if there has been a suicide in the family, for instance, it significantly raises the individual’s risk. We also assess social circumstances, as living in unhealthy environments without adequate support systems can heighten risks further. Additionally, we consider any physiological issues that may be present.
If we identify a patient who is severely unwell, they may require admission to a mental health ward. However, I have witnessed patients languish in A&E for days, waiting for a bed to become available. For those in distress, waiting in the chaotic atmosphere of A&E is anything but therapeutic. It’s a situation that should not exist; these individuals need to be in environments specifically designed to care for their needs. It can take an excruciatingly long time—often several days—before they can be moved to the appropriate part of the system. Mental health beds are alarmingly scarce in my region, and this crisis is not solely about the time spent waiting; A&E departments are ill-equipped to provide proper care for patients in mental distress.
Inside our understaffed mental health wards
The challenges within mental health wards can be even more daunting. To those who have never set foot in such a facility, it may invoke images reminiscent of One Flew Over the Cuckoo’s Nest. However, the reality is often far removed from such portrayals, and the atmosphere can significantly vary based on the patients present and the staffing situation. There are moments of calm, at times resembling a more routine environment than one might expect, while at other times, the chaos can be overwhelming. The sheer number of cases I am responsible for concurrently is concerning. On arrival, my first action is to activate my safety alarm, just in case urgent assistance is required. Following this, I meet with the two evening doctors for a handover. After a brief exchange, they wish me good luck, and I take a deep breath, preparing to assess where to direct my attention first.
Even in general non-secure wards, access is controlled via security badges. Patients are legally free to leave unless they have been sectioned, but we are vigilant in monitoring their safety. Within the ward, there is a nurses’ station that oversees communal areas where patients can gather around sofas and a television. Typically, each individual has their own basic bedroom and bathroom, with the freedom to choose when they come and go. Some may feel too overwhelmed to leave their rooms, while others may feel comfortable interacting with the community.
Patient monitoring varies; some individuals are checked every hour, while others require constant supervision. In extreme cases, it might take five staff members to manage one patient. Our guiding principle is one of least restrictive care, aiming to minimize limitations on personal freedom as patients make progress. When relationships between patients and staff are positive, the environment can be quite therapeutic. However, if a few patients are particularly unsettled, it can lead to a collective agitation among others. The ability of the staff to de-escalate crises often hinges on established relationships with patients, cultivated over time, as opposed to relying on agency staff due to chronic understaffing.
We frequently care for individuals dealing with psychotic disorders, where they may become detached from reality, resulting in unpredictable behaviors. For example, a patient might approach holding a jug of water, leaving us to wonder about their intentions. While it is a misconception that individuals with schizophrenia have split personalities, they can experience hallucinations, and paranoia is not uncommon. A person with bipolar disorder might enter the ward during a manic phase, feeling euphoric and believing they possess extraordinary abilities, such as being the smartest person in the country, leading to erratic spending behaviors. Our wards also cater to patients with dementia, who may not typically require hospitalization but can develop challenging behaviors that even specialized care homes struggle to manage. In such cases, we develop tailored combinations of medications and care strategies.
Why working on wards can be so difficult
There exists a constant tension between the ideal care scenario and the actual number of staff available. Resources are often drawn from various units to manage staffing shortages, and it becomes apparent when the number of personnel is insufficient to maintain control over the ward. The harsh truth is that the NHS is critically under-resourced. While we often handle violent incidents, I personally have rarely felt frightened in my role, largely due to the support of nurses when dealing with high-risk patients. The key lies in understanding the underlying causes of agitation and employing effective management strategies. Compassionate communication can often lead to de-escalating tense situations.
Nevertheless, one must remain vigilant, attuned to the patients’ signals while also being aware of exit routes. Although I have never been physically assaulted, I have witnessed instances of violence, including a nurse being bitten. It is crucial to remember that when individuals are psychotic, their perception of reality diverges significantly from ours. Many of our patients come from backgrounds marked by childhood trauma, which can impede their emotional regulation. If society could provide support earlier in life, we might mitigate many of the issues that arise later, yet waiting lists for child mental health services can stretch for years. This is simply unacceptable.
In cases where individuals pose a significant risk to themselves or others, we may resort to rapid tranquilization as a last measure. Contrary to cinematic depictions, this does not render a person unconscious but rather helps to calm them. Trained staff can physically restrain a patient if necessary, and we may place them in a secure room, monitored from the outside. Their behavior is continually reassessed, and they are allowed to leave the secure area as soon as it is safe. However, when operating as the sole doctor across multiple sites, making decisions during a seclusion review at 2 a.m. while a nurse at another location expresses concern about a patient’s physical health can lead to difficult choices.
I’ve witnessed instances of patients attempting to end their own lives, and despite our best efforts, there are times when we cannot prevent them from harming themselves. This reality weighs heavily on all of us, as our primary purpose is to ensure safety. If a patient in a mental health facility dies due to their condition, this is a tragic failure that should not occur. Unfortunately, it sometimes does, and the extent of our resources directly influences our capacity to prevent such outcomes.
My worries about training shortages
One of the first patients I encountered on a recent night was a teenage girl brought in by police from a general hospital to a secure area under the Mental Health Act. She had been expressing suicidal thoughts and had physically harmed herself. My responsibility was to assess her condition. Initially, she was agitated and lashing out in anger, but thanks to the nurses’ exceptional skills, she was able to settle down. During our conversation, she shared her experiences of hearing voices, coupled with anxiety about her personal space being violated.
Although we often deal with volatile patients, we learn to identify the root causes of their distress and manage their situations accordingly. Establishing rapport and validating their feelings is key to de-escalation, typically through compassionate dialogue. I have seldom felt threatened at work, primarily due to the strong support system provided by the nursing staff. Nevertheless, one must remain vigilant and responsive to the signals of those in distress.
While I have yet to experience physical assault myself, I have witnessed incidents where others have been harmed. It is never acceptable for staff to be subjected to violence; however, it is essential to acknowledge that psychotic individuals may not be in touch with the same reality as others. Many of our patients have histories of trauma that hinder their emotional regulation. If society could intervene and support individuals earlier in their lives, it could significantly reduce the prevalence of mental health crises. Unfortunately, child mental health waiting lists can stretch on for years, which is simply inadequate.
During instances of acute risk to themselves or others, we may need to use rapid tranquillisation as a last resort. This method does not induce unconsciousness but rather helps to soothe the individual. Our trained staff can physically restrain a patient if necessary, placing them in a secure area monitored from outside. Their behavior is frequently evaluated, and they are permitted to leave as soon as it is deemed safe. However, when one doctor is responsible for multiple sites and must make seclusion decisions at 2 a.m., while a nurse at another location raises concerns about a patient’s physical health, it creates challenging dilemmas.
I have seen patients attempt to take their own lives, and despite the collective dedication of our team, there are moments when we cannot prevent self-harm. This realization weighs heavily on us, reminding us that our primary goal is to ensure the safety of those we serve. If a patient in a mental health facility dies as a result of their illness, it signifies a failure that should never happen. Regrettably, it does occur, and the level of available resources plays a critical role in our ability to avert such tragedies.
Official responses to concerns
- In response to 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. Hundreds of thousands of individuals with serious mental illnesses are receiving essential health checks annually. However, we recognize that there is still much to be done to ensure those in crisis can access urgent support.”
- They noted that every A&E department in the country “now has a psychiatric liaison team, an increase from two-thirds of sites in 2018. The NHS in England is among the first globally to provide access to specialist mental health support through a universal three-digit number, 111, which alleviates pressure on urgent and emergency care.”
- Furthermore, they added: “We have also expanded the mental health workforce by 40 percent between March 2016 and March 2024, recently reducing nurse vacancy rates by around 5 percentage points over the past two years.”
- A spokesperson for the Department of Health and Social Care acknowledged: “We have witnessed far too many preventable tragedies resulting from mental health service failures, and it is unacceptable that patients have not received the necessary care and treatment to ensure their safety and that of the public.”
- They continued: “This Government has initiated efforts to modernize the Mental Health Act, ensuring that individuals with severe mental health conditions receive improved, personalized treatment tailored to their needs. Recognizing the burnout and demoralization of NHS staff who have been overworked for years, we will recruit 8,500 additional mental health workers. This summer, we will also introduce a refreshed Long Term Workforce Plan to ensure the NHS has the right personnel with the appropriate skills, including psychiatrists, to provide the care that patients require.”
Individuals of all ages who are in crisis, or concerned loved ones, can call 111 at any time to speak with a trained NHS mental health professional—or reach out to Samaritans by calling 116 123 or emailing [email protected].
Connect with me on social media: @robhastings.bsky.social
