Sample characteristics
17 in-depth interviews were conducted, nine with LMHS users and eight with healthcare professionals. Service user participants consisted of 3 men and 6 women with varying age ranges (Table 1). Presenting problems included self-harm, psychosis, mania, long-term physical health problems and medically unexplained symptoms. The interviewed professionals were mental health liaison nurses (n = 3), consultant liaison psychiatrists (n = 2), general nurses (n = 2) and one consultant in emergency medicine.
Table 1
Demographic characteristics and presenting health problems of service user participants.
Gender | Age range | Ethnicity | Physical and mental health problems |
Male | 50–59 | White-British | Long term physical and mental health problems |
Female | 20–29 | White-British | Unexplained physical symptoms |
Female | 30–39 | White-British | Multiple complaints-frequent user of emergency services |
Male | 60–69 | Afro-Caribbean heritage /British | Renal failure |
Male | 30–39 | White British | Long term physical condition |
Female | 40–49 | White British | Severe mental illness |
Female | 50–59 | African | Long term physical condition and mental health problems |
Female | 30–39 | White British | Frequent self-harm |
Female | 40–49 | White British | Severe mental illness |
Main findings
Participants discussed a range of topics surrounding the provision and experience of mental healthcare in general hospitals. They illustrated the complexity involved in meeting mental health needs in this setting. Below we outline our findings in terms of themes and sub-themes that emerged from the interviews; the four themes and their constituent subthemes are summarised in Table 2. The staff topic guide included specific questions about Core-24 that were not included in the service users’ topic guide, so most of the sub-themes around the Core-24 service standard are only relevant to staff participants.
Table 2
Themes and sub-themes from framework analysis of interview transcripts.
Theme | Subtheme |
The emergency department (ED) | ED staff |
| Physical environment (service users only) |
| Appropriateness for mental health problems |
| Desired characteristics |
Liaison mental health services (LMHS) | LMHS staff |
| Barriers to contact |
| Desired characteristics |
Core-24 service standard | 1-hour wait |
| Perceived benefits (staff only) |
| Unintended consequences (staff only) |
| Policymaker detachment (staff only) |
Stigma of mental illness | Discrimination |
| Mental-physical dichotomy |
Theme One: The emergency department (ED)
Healthcare professionals and service users discussed their views of the ED as a site for mental healthcare provision. The content of their discourse comprised the sub-themes of ED staff, physical environment, appropriateness for mental health problems and desired characteristics.
i) ED staff
Service users recounted highly variable experiences of ED staff when seeking help for their mental health problems. Some were described as kind and compassionate people who acknowledged distress and evoked feelings of validation:
“They recognised I wasn’t putting things on, that I did feel acutely suicidal as I was saying” – Participant 1
Others disclosed negative views of ED staff, describing them as unpleasant and harsh. Three participants reported that ED staff withheld treatment that they thought was needed. Others reported that staff did not allow the service user to speak and failed to provide any guidance or support on discharge.
“The GP referred me to A&E and when I arrived there, they were very very harsh” – Participant 6
LMHS professionals generally had negative perceptions of ED staff, reporting that they had poor psychiatric knowledge and skills. Several felt that ED staff did not appreciate the role of LMHS and frequently made inappropriate referrals. Some suggested that ED staff had little interest in mental health problems:
“I think sometimes they don’t ask more questions about mental health, and I don’t know if that is because they don’t feel confident to, or they just don’t want to” – Participant 13
ii) Physical environment
The ED environment was discussed exclusively by service users, and their opinions were overwhelmingly negative. Common issues were that the assessment room was uncomfortable and small:
“You’re brought into this really small room with no windows, it was tiny, it was also not necessarily painted, it was very scruffy” – Participant 5
A lack of provision of refreshments contributed to a sense of discomfort. The privacy of the assessment environment varied; two individuals reported that they were assessed in a private space, and one was not:
“In the department with just a curtain pulled around, so it wasn’t very private” – Participant 1
iii) Appropriateness for mental health problems
Both service users and providers questioned the appropriateness of the ED for people with mental health needs. No participants felt that the ED was an appropriate place for these needs.
“A lot of them are quite vulnerable, and more at risk of accidental self-harm or sort of vulnerable from other people in the department and it’s A&E isn’t it, I wouldn’t it consider a very nice environment for people that are experiencing psychosis” – Participant 13
Service users described their experiences of seeking care in the ED as anxiety-provoking and lonely. They acknowledged that attending the department was an undesirable last resort, only done when other services and professionals could not be accessed in the community.
“It’s not the best solution by any stretch of the imagination but, but it’s the only place that’s available” – Participant 8
iv) Desired characteristics
Participants suggested ways that the ED could be improved to better care for those with mental health needs. These included a more comfortable environment, the option to wait outside, better communication of next steps and knowledge of community-based support. One participant suggested the provision of company while awaiting input from the mental health team.
“I don’t know what else they could do apart from have somebody sit with you all the time until the psychiatrist came or somebody to assess you” – Participant 7
Liaison practitioners also felt that the ED could be improved by providing more staff training in mental health assessments and improving referrals to the LMHS. This could reduce the volume of referrals and facilitate referral triage while reducing wait times for service users.
“If you upskill the ED people to even basic then liaison psychiatry should be able to turn down referrals… And we have to remember in the middle of all of this is a patient” – Participant 15
Theme Two: Liaison mental health services (LMHS)
The second theme refers to participants’ views and experiences of liaison mental health services (LMHS). There are three sub-themes: experiences of LMHS, barriers to contact and desired characteristics.
i) LMHS staff
Service users described variable experiences of the help they received from LMHS. Contact with LMHS helped some individuals to feel more comfortable and to understand the next steps. Some described a therapeutic benefit of talking in depth about their issues:
“It helps me mental health, being able to talk about it and stuff” – Participant 3
Others voiced that LMHS were either unhelpful or contributed to them feeling worse. This was related to the feeling of not being listened to and the perception that no tangible help or support was offered.
“I’ve not got time for them as they do nothing for me” – Participant 9
Some service users held the view that LMHS complete little more than a “box-ticking” exercise that offers little benefit to the service user. This was echoed by one of the physical healthcare professionals.
Common problems were that the professionals seemed rushed and incompetent. Three participants shared the view that LMHS staff were dismissive or disinterested. This led them to feel guilty and as though they had wasted the professional’s time.
“Sometimes the mental health staff can be very dismissive and treat me like I’ve just wasted everybody’s time, and I should have just looked after myself at home” – Participant 8
Others described LMHS staff in a more positive light, reflecting that they allowed them to speak freely while listening carefully and acknowledging their needs. In some interviews, LMHS staff were described as caring and comforting. One participant felt that LMHS staff are underappreciated:
“I know with my experiences with liaison psychiatry that they do a lot more than people may think” – Participant 4
Generally, interviewed professionals were complimentary towards LMHS staff, describing them as hard-working, knowledgeable, experienced, accessible, and committed to high-quality patient care. Participants had conflicting views on whether LMHS staff have a good relationship with the ward teams and whether they meet their expectations, although this was often attributed to a rise in demand for the service.
ii) Barriers to contact
Participants discussed barriers to accessing LMHS. Some service users recounted how input from LMHS was postponed or withheld because they were under the care of a community mental health team. This sometimes resulted in interactions with a “diversion team”, which was described as a frustrating, obstructive experience.
“You just can’t get past diversion because they’ve been put in place to stop people like me who are known to the system… They’re basically there to go, ‘there, there, you’re ok, you go home and speak to your care coordinator tomorrow.’” – Participant 8
Staff felt that significant barriers to contact with LMHS included insufficient staffing levels, particularly out of hours, and a seemingly excessive amount of time completing documentation.
“The [LMHS] team spend a long time writing things up and reporting… If we do make a referral for later in the evening or overnight, I don’t work nights, but they’re often told, ‘oh we can’t come and see the patient because we’re writing up our reports!’” – Participant 12
iii) Desired characteristics
Service users outlined factors that would improve their experience of receiving care from LMHS. Several participants described dissatisfaction with being discharged without a clear treatment plan and called for the provision of aftercare and more information about third sector organisations.
“If someone’s self-harming or whatever they shouldn’t just be discharged. They need aftercare and everything. It should be in their care plan.” – Participant 2
Some described desirable characteristics of LMHS staff, which included compassion, knowledge, and clearer communication of delays and anticipated next steps. Service users expressed a desire to be treated as an individual and to be listened to attentively.
“You need front-line staff who have the personal interactive skills to acknowledge, to offer comfort and explain what is going to happen, not front-line staff who make you more agitated or that they are confused” – Participant 5
Other desirable characteristics of the service identified include universal service provision across the country, a switch of focus from medications to psychosocial interventions, and a separate service for those who do not meet the criteria for admission but who feel unsafe to return home. Some service users voiced support for an acute mental health service separate from the ED.
Theme Three: Core-24 service standard
This theme encapsulates views towards the Core-24 service standard and the subthemes are the 1-hour wait, perceived benefits, unintended consequences, and policymaker detachment.
i) 1-hour wait
Although professionals acknowledged the importance of targets, many felt that the one-hour target was unattainable, particularly for those with complex presentations or substance issues. Some felt that it was inappropriate to assume that service users’ needs are constant throughout the day. There was a consensus that immediacy was prioritised over clinical importance, which manifests as brief introductions within the hour instead of careful, comprehensive assessments.
“It’s not about how quickly you are seen, it’s about the quality of the interaction and I think if you are having to respond to patients in an hour that can sometimes compromise the quality” – Participant 16
In contrast, service users almost universally expressed a wish to receive contact from the LMHS as soon as possible, and even a one hour wait felt too long to wait if someone was very distressed.
“When you are thinking of taking your own life, an hour is a lifetime” – Participant 1
ii) Perceived benefits (staff only)
The most salient benefit reported by the healthcare professionals was investment in the LMHS. They described more financial investment into the service, and the creation of staff posts to expand the workforce, contributing to feelings of reassurance and comfort. Although participants acknowledged the associated challenges of training new staff, overall, this change was perceived as positive.
“The investment within the services has enabled us to, erm you know, to broaden out what we do” – Participant 17
Generally, professionals explained that the service standard improved patient flow. They felt that one-hour reviews were conducive to faster discharges and the prevention of unnecessary hospital admissions. They also reported a greater focus on the service user experience and acknowledged the target as an opportunity to improve the service further.
“I think that’s been a huge positive for the team because it’s made them think, actually, okay, we need to do this. How are we going to do it in the best way possible to get the service users experience and the standard of care for them as best as we can?” – Participant 14
iii) Unintended consequences (staff only)
Professionals also reported numerous undesired sequelae to the Core-24 one hour target. The first was that the target acted as an incentive for people to use the ED for their mental health needs in the knowledge that they would be seen quickly. This contributed to a rise in the clinical workload for both ED and LMHS staff.
“It was an odd thing to do when you’re trying to decrease attendances, it’s like a bit of an incentive to [attend the ED]” – Participant 11
Some explained that the target had a detrimental impact on servicing providing ward cover, as LMHS staff are diverted from wards to the ED for initial reviews for new presentations. This results in delays on the wards and subsequently prolongs admissions.
“They used to see people who were in the beds before the parvolex (a treatment following a paracetamol overdose) ended, but they’re just unable to do that now because of the amount of people in A&E to be seen” – Participant 10
The target has also had ramifications on working hours, with some participants reporting that their shifts were extended from eight to twelve hours, resulting in more lone working and reduced staff morale. This was identified as the reason for some staff members deciding to leave their jobs.
iv) Policymaker detachment (staff only)
Generally, professionals felt that Core-24 was implemented poorly by policymakers and commissioners who were disconnected from the service. They described that no attempts were made to seek the views of clinicians, and that it was delivered as a compulsory change.
“The way that this change was brought in was very top-down, there was very little engagement with the team” – Participant 16
One professional reported that they were informed with little notice that older people would be included in the remit of LMHS following the standard, and they received no formal training for this. The disconnect between policymakers and clinicians resulted in resentment among staff.
Service users echoed this idea by suggesting that policymakers were detached from the views and priorities of those seeking care. Some mentioned that these should be incorporated into decisions about LMHS provision:
“I think that the service should get more involvement from the service user's experience” – Participant 6
Theme Four: Stigma of mental illness
The final theme describes the stigma associated with mental health problems. The subthemes were discrimination and the mental-physical dichotomy.
i) Discrimination
Service users commonly felt discriminated against for having mental health problems. They described being treated differently to those with physical health problems, with their issues not being taken as seriously. Some recalled being dismissed and feeling guilty for accessing services.
“If you’re physically ill that counts, it’s given a higher priority over mental illness” – Participant 4
Professionals also acknowledged the discrimination against those with mental health problems in the general hospital setting. They commented that service users with mental health needs are generally perceived as problematic and unwanted in the ED.
“Patients with mental health difficulties in the emergency department are the difficult ones, the bad ones, the ones that upset the data, or the ones that don’t move out quick enough” – Participant 15
ii) The mental-physical dichotomy
This subtheme describes the clear delineation between physical and mental health in the context of healthcare services. Both professionals and service users commented that mental health needs are frequently neglected in physical healthcare settings. This is attributed to a perceived unwillingness to enquire about psychiatric symptoms and a tendency to ignore biopsychosocial determinants of health.
“If I was to mention mental state, your consultants turn their faces away from me” – Participant 9
“The traditional method of dealing with a lack of liaison psychiatry in the general hospital is to ignore the problem and just pretend it’s not there, to not notice that the patient is sad, not notice that they are anxious, to blame the patient, to discharge them early, to not take care of the wider side of psychosis difficulties that have prompted this admission” – Participant 15
Clinicians also perceived a divide between mental and physical healthcare professionals. Some LMHS staff felt that ED clinicians had poor psychiatric knowledge and skills, that they often made inappropriate referrals with minimal information, and that their service was not understood or appreciated.
“I don’t think mental health is respected within the A&E department as a proper profession” – Participant 13
Final analysis
The final stage of analysis is summarised in Table 3, which shows comparisons across the service user and staff groups whilst also reflecting the strength of the signals from the data (determined by the proportion of participants who voiced these opinions). It shows some striking differences in patterns but also several areas of agreement. The one-hour access target is seen differently by service users and staff whilst issues related to stigma are perceived as important by both groups.
Table 3
Data intensity mapping for key framework components and sub-components.
| Service Users | Staff |
The emergency department (ED) | ED staff are helpful and caring | * | - |
ED staff are unhelpful and dismissive | ** | ** (perception of non-ED staff) |
ED environment is stressful | *** | * |
ED environment is not appropriate for people with mental health problems | *** | *** |
ED environment could be improved for people with mental health problems | ** | ** |
Liaison mental health services (LMHS) | LMHS staff are helping and understanding | * | *** (perception of non-LMHS staff) |
LMHS staff are dismissive | ** | - |
It is difficult to access LMHS | * | ** (perception of non-LMHS staff) |
There are ways LMHS could be improved | ** | ** |
Core-24 service standard | The one-hour access standard is the maximum time a person with mental health problems should wait in ED | *** | * |
The one-hour access standard prioritises immediacy over clinical need and has unintended consequences for other parts of the liaison service | - | *** |
Policymakers are detached from clinical services which results in poor implementation | - | ** |
Stigma of mental illness | People with mental health problems who attend the ED experience discrimination | ** | ** |
There is a mental-physical dichotomy in the acute hospital which prioritises physical health over mental health | ** | ** |
*** indicates high intensity sub-component. ** indicates medium intensity sub-component |
* Indicates low intensity sub-component. – indicates no data present for this sub-component |
Table 3. Data intensity mapping for key framework components and sub-components.