Reducing the burden on Welsh ambulance services and emergency departments: a mental health 999 clinical support desk initiative
Intended for healthcare professionals
Evidence and practice    

Reducing the burden on Welsh ambulance services and emergency departments: a mental health 999 clinical support desk initiative

Mark Jones Consultant mental health nurse, Mental Health, Welsh Ambulance Services NHS Trust, Cwmbran, Wales
Stephen Clarke National clinical lead for mental health, NHS Wales Executive, Cardiff, Wales
Simon Amphlett Clinical lead specialist, Welsh Ambulance Services NHS Trust, Cwmbran, Wales

Why you should read this article:
  • To understand why demand for ambulances has increased in recent years

  • To reflect on why people experiencing mental health issues often contact emergency services

  • To learn how mental health professionals working within 999 call centres can help to reduce demand on emergency services

Demand for ambulances has increased significantly in recent years due, for example, to ongoing public health issues and lack of availability of alternative healthcare services. However, as demand increases, so too do ambulance waiting times, partly due to significant pressures on emergency departments (EDs) resulting in handover delays. People experiencing mental health distress who cannot access the care they need often contact ambulance services or present to the ED. Ambulance trusts across the UK are attempting to address this by employing mental health professionals (MHPs) in various capacities. In this article, the authors explore some of the issues related to mental health-related calls to 999 services. The authors then describe a service improvement initiative in Wales which involves MHPs working in 999 call centre clinical support desk services to improve the quality of care delivered to people with mental health issues and reduce demand on ambulance and ED services.

Emergency Nurse. doi: 10.7748/en.2024.e2195

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

mark.jones34@wales.nhs.uk

Conflict of interest

None declared

Jones M, Clarke S, Amphlett S (2024) Reducing the burden on Welsh ambulance services and emergency departments: a mental health 999 clinical support desk initiative. Emergency Nurse. doi: 10.7748/en.2024.e2195

Published online: 13 February 2024

Wales, like the other UK countries, has been experiencing unprecedented pressure across its health and social care systems, including unscheduled care services such as ambulance services. These pressures are driven by public health issues, such as seasonal influenza and coronavirus disease 2019 (COVID-19) variants, and multiple system challenges, for example inadequate patient flow through acute hospitals and emergency departments (EDs), workforce pressures due to high staff sickness absence rates and recruitment and retention issues, lack of access to primary care services and long waiting times for elective care for patients (Sarsfield and Boyle 2021, Beegan and Jones 2022).

Such issues are no longer confined to the winter period but continue throughout the year, resulting in various adverse effects on ambulance services and on patients who call 999. Demand for ambulances has increased over the past five years, but so too have ambulance waiting times, in part due to delayed hospital handovers in EDs that render ambulance crews unable to respond promptly to new calls (Alarilla et al 2022, Welsh Government 2023a). Such delays result in suboptimal experiences and outcomes for many 999 callers (Alarilla et al 2022).

One reason for increasing demand on ambulance services is the lack of availability of other services. For example, people with mental health issues who cannot access the care they require often call 999 or present at an ED instead (Alarilla et al 2022). In an epidemiological analysis of the outcomes of people attended by an ambulance due to a mental health or self-harm emergency, Duncan et al (2019) noted that around 10% of emergency calls to English and Scottish ambulance services, over one year, were related to mental health. A ‘deep dive’ into mental health demand for Welsh Ambulance Services NHS Trust (WAST) services, undertaken in 2013, revealed a similar figure.

Ambulance trusts across the UK have employed mental health professionals (MHPs) to work alongside paramedic crews on scene and/or in ambulance call centres, to provide triage and support more appropriate care pathways for patients who do not require ED treatment (NHS England 2022). This article explores some of the issues related to mental health-related calls to 999 services and describes a WAST initiative involving recruitment of MHPs to work on the clinical support desks of three 999 call centres in Wales.

Mental health

Over the past five years the prevalence of patients experiencing mental health issues has increased significantly (Royal College of Emergency Medicine 2022). Although these patients account for a small percentage of ED attendances, the discrepancies between capacity and demand, reduced numbers of mental health hospital beds and suboptimal patient flow through acute hospitals means they endure long waits in the ED and are twice as likely to wait 12 hours or more from time of arrival than those without mental health issues (Royal College of Emergency Medicine 2022). Furthermore, while waiting to be seen, patients with mental health issues are often supported in environments that are not conducive to their mental well-being, which may result in exacerbation of their distress (Swires-Hennessy and Hayhurst 2021).

There are around 100,000 crisis care mental health episodes in Wales each year, with WAST receiving higher acuity calls than any other single organisation in Wales. Although primary care services as a whole manage a higher level of mental health crisis demand, only a small proportion of crisis care mental health episodes are managed by specialist mental health crisis care teams (Mills et al 2020). The Welsh National Review of Access to Emergency Services for those Experiencing Mental Health and/or Welfare Concerns (Mills et al 2020) reported that there are around 946 calls, attendances or referrals for mental health or welfare concerns every day, including 73 calls to WAST 999 call centres for emergency or immediate response and around 12 calls to Wales 111 for urgent response services. These figures show that people seek help with mental health issues through multiple routes and that the 999 and 111 services are significant providers of crisis and urgent care. This includes conveyance to the ED, supporting patients to identify the most appropriate pathway and initiating referrals to early intervention services.

Emergency 999 calls involving mental health issues are often complex, take longer to resolve than other health issues and can be challenging to manage for generalist clinical support desk staff (Briggs et al 2021). Emergency 999 call centre clinical support desk staff are healthcare professionals who undertake complex clinical triage by phone, provide assessment and referral to the most appropriate care pathway or provide support while paramedics make their way to the scene. While there are no data available to determine the reasons why people call 999 services for mental health issues, in the authors’ experiences it appears that most callers to WAST 999 services are unknown to, or are reluctant to engage with, mental health services.

There have been initiatives aimed at involving MHPs in lessening the burden on emergency services. For example, an initiative called ‘111 Press 2’ has been rolled out across Wales and aims to provide people with mental health concerns, about themselves or others, with direct access to an MHP by calling 111 and selecting ‘option 2’. Callers are then transferred to a member of a mental health team in their health board area (Welsh Government 2023b). The service includes a needs assessment and phoned-based intervention to reduce distress where appropriate. Service users may be provided with self-care advice, referred to mental health services or signposted to other support.

The overall aim of the 111 Press 2 initiative is to channel requests for mental health services and/or advice – including crisis episodes, new presentations and seeking information about existing referrals – through the Wales 111 service rather than the 999 service. An additional potential benefit would be reduced demand on 999 and ambulance services. However, since the roll-out of the 111 Press 2 service across Wales at the time of writing there had not been a significant reduction in the number of mental health-related 999 calls, as demonstrated in Figure 1.

Figure 1.

Welsh Ambulance Services NHS Trust mental health-related 999 calls

en.2024.e2195_0001.jpg

Key points

  • People experiencing mental health issues who cannot access the care they require often call 999 or present at an emergency department

  • Emergency 999 calls involving mental health issues are often complex, take longer to resolve than other health issues and can be challenging to manage for generalist clinical support desk staff

  • Experts in mental health crisis care were recruited to work on the clinical support desk in three 999 call centres

  • There was a significant increase in the consult and close rate for calls related to mental health issues

Mental health professional clinical support desk initiative

In 2021, WAST internal data showed that when an ambulance was dispatched to a patient who had placed a mental health-related 999 call, around two thirds of these patients were conveyed to an ED. In the authors’ experience, this was partly due to lack of confidence among generalist clinical support desk staff in managing patients experiencing a mental health crisis and their lack of knowledge of local mental health pathways, making it challenging for them to refer patients to the appropriate service. However, given the complexity of mental health presentations, it was felt unlikely that training alone for generalist clinical support desk staff would have a significant effect on the WAST ambulance conveyance rate.

Therefore, a pilot involving two WAST MHPs working alongside generalist colleagues on the clinical support desk was initiated to determine if this would increase ‘consult and close’ rates. Consult and close involves assessing, managing and ‘discharging’ patients from a call, rather than dispatching an ambulance to provide treatment or conveyance to the ED. Data from the pilot demonstrated positive effects on consult and close rates, which resulted in funding and commissioning of the initiative in three WAST 999 call centres.

The overall aim of the initiative was to improve the quality of care delivered to people who call 999 regarding mental health issues and to reduce demand on ambulance and ED services through increasing consult and close rates. In March 2022, six full-time MHPs, five mental health nurses and one mental health social worker who were experts in mental health crisis care, were recruited to work on the clinical support desk in three WAST 999 call centres – St Asaph, Carmarthen and Cwmbran – alongside generalist colleagues. The MHPs underwent a comprehensive training and induction programme, including in WAST’s information technology systems, and were in place by June 2022. The service operates between 1pm and 1am seven days a week – these hours were found to be when the highest number of mental health-related calls were made to WAST 999 call centres.

The main elements of the MHPs’ roles are to engage compassionately with patients with mental health issues, undertake a robust mental health assessment, provide crisis support directly over the phone and/or direct patients to the most appropriate mental health service.

The MHPs also provide advice to ambulance crews on scene with patients experiencing mental health distress or crisis, and provide advice, peer supervision and mental health training to their generalist clinical support desk colleagues. In addition, the MHPs have provided suicide first aid training and mental health awareness training to other WAST staff via webinars. The MHPs receive regular clinical, managerial and professional supervision, which has facilitated team identity building and team cohesion, given that they work in different centres, and they have access to in-house and external training and education, including post-graduate education programmes.

Outcomes of the initiative

Internal WAST data from June 2022 to April 2023 for the hours of operation of the MHP clinical support desk service showed a significant increase in the consult and close rate (including referred on) for calls related to mental health issues. On average, the MHPs were achieving a consult and close rate of 42%, while generalist clinical support desk colleagues were achieving a consult and close rate of 29% for the same category. Figure 2 shows that in 2019, before this initiative was implemented, mental health-related calls to the clinical support desk achieved only a 12% consult and close rate (including referred on), while 88% of calls resulted in ambulance dispatch and/or conveyance to the ED. Figure 3 shows outcomes of mental health-related 999 calls managed by the MHPs between June 2022 and May 2023.

Figure 2.

Mental health-related calls to the clinical support desk in 2019

en.2024.e2195_0002.jpg
Figure 3.

Outcomes of mental health-related 999 calls managed by the mental health professional clinical support desk service (June 2022-May 2023)

en.2024.e2195_0003.jpg

WAST internal data for June 2022 to May 2023 showed that the MHPs and their generalist colleagues had similar rates of arranging alternative transport to the ED, such as taxis or with family and friends (9% of calls (MHPs) compared with 8% of calls (generalist)) and similar rates of referral to secondary mental health services for further psychiatric assessment (4% of calls (MHPs) compared with 3% of calls (generalist)). The authors believe this was partly due to the fact that the MHPs were providing mental health education and peer supervision for their generalist colleagues.

The MHPs have been capturing the acuity of patients via the UK Mental Health Triage Scale (Sands et al 2015, 2016), which they use as part of their decision-making process during calls. The aim of the scale (Sands et al 2015) is to:

  • Promote consistency in decision-making and response.

  • Ensure the service response is appropriate to the person’s level of need and risk.

  • Ensure response times correspond with the urgency of the person’s needs.

  • Support appropriate prioritisation of mental health resources.

  • Provide a systematic method for documenting outcomes of triage assessments.

The UK Mental Health Triage Scale maps patient assessments to seven levels of urgency (Table 1), reflecting different levels of needs, risk and urgency of response. Each level includes a brief description of typical signs and symptoms and appropriate triage responses and actions (Sands et al 2015).

Table 1.

UK Mental Health Triage Scale levels of urgency

Triage code/descriptionResponse type/time to face-to-face contact
A – emergencyImmediate referral – emergency service response
B – very high risk of imminent harm to self or othersWithin four hours – very urgent mental health response
C – high risk of harm to self or others and/or high distress, especially in absence of capable supportsWithin 24 hours – urgent mental health response
D – moderate risk of harm and/or significant distressWithin 72 hours – semi-urgent mental health response
E – low risk of harm in short term or moderate risk with good support/stabilising factorsWithin four weeks – non-urgent mental health response
F – referral not requiring face-to-face response from mental healthReferral or advice to contact alternative provider
G – advice, consultation, informationAdvice or information only OR more information if needed

Figure 4 shows the types of calls managed by the MHPs categorised by the UK Mental Health Triage Scale levels of urgency.

Figure 4.

Types of calls managed by the mental health professional clinical support desk service categorised by the UK Mental Health Triage Scale levels of urgency (June 2022-May 2023)

en.2024.e2195_0004.jpg

The MHPs have also been gathering data on the levels of distress experienced by patients, by using the subjective units of distress scale (SUDS), originally developed in 1969 by Wolpe. The SUDS is presented as a scale ranging from 0-10 (sometimes 0-100), with 0 indicating no distress and 10 (100) indicating the most intense distress the person feels they can experience. The tool, which is also referred to as the SUDS thermometer, is often used in psychological therapies as a benchmark for evaluating distress and the progress of an intervention.

The MHPs ask patients to rate their SUDS during the early part of the call and again at the end of the call. Figure 5 shows a comparison of SUDS scores between those recorded early in the call and those recorded at the end of the call.

Figure 5.

Subjective units of distress scores during calls with clinical support desk mental health professionals (June 2022-May 2023)

en.2024.e2195_0005.jpg

Challenges and future plans

One of the challenges for the new MHP clinical support desk service is that there has been a relatively high staff turnover since its implementation in June 2022, with two of the original six staff leaving and being replaced by new MHPs, which has affected team cohesion. However, it is hoped that such issues will be addressed by the continuing provision of clinical, managerial and professional supervision, ongoing service evaluation and research and provision of education and training for the MHPs in, for example, managing callers with personality disorders, managing children and young people with mental health issues and independent prescribing. There are also plans to expand the service’s operational hours.

Another challenge for the MHPs is undertaking remote triage for patients experiencing mental health distress or crisis, which is not as comprehensive or holistic as a face-to-face assessment. The MHPs believe they could close around 30% more calls if they could attend patients in person to undertake a face-to-face assessment. This might be possible through the introduction of mental health response vehicles, an initiative that has been implemented in some ambulance trusts in England.

Mental health response vehicles

Between 2018 and 2020, London Ambulance Trust piloted a Mental Health Joint Response Car (MHJRC) scheme that involved pairing paramedics and mental health nurses to respond to patients experiencing a mental health crisis or who required a specialist mental health response (NHS England et al 2020). A main finding of the pilot evaluation was a significant reduction in ED conveyance rates, with 80% of patients discharged at the scene compared to a business-as-usual non-conveyance rate of 41%. This finding suggested that the combination of MHPs alongside paramedics had a significantly positive effect on the quality and effectiveness of the care delivered to patients at the scene (NHS England et al 2020).

Feedback from patients showed they had an overall positive experience of the service and they reported that they appreciated the specialist skills and personalised care delivered by the mental health team and being treated in their community rather than being taken to the ED. In addition, the MHJRC team members reported high levels of job satisfaction and said they believed the multidisciplinary approach to care was beneficial for patients (NHS England et al 2020).

Undertaking a similar initiative in Wales could have significant benefits for patients and staff, as it would support face-to-face holistic assessment and management and potentially further reduce the burden on ambulance services and EDs. The WAST mental health team has developed a local mental health response vehicle protocol and at the time of writing was in discussion with Welsh health boards and commissioners to develop this further and secure funding to initiate the service.

Conclusion

A WAST initiative to improve the quality of care delivered to people who call the 999 service regarding mental health issues and to increase consult and close rates has decreased ambulance dispatch and ED conveyance rates, thus reducing the burden on these services. The initiative also appears to be having a positive effect on patients, demonstrated by reduced SUDS scores during a call with the MHPs working on the clinical support desk. Furthermore, the MHPs are providing generalist clinical support desk colleagues with education and peer supervision, which the authors believe has influenced the overall increase in consult and close rates. Despite the effectiveness of this initiative, the MHPs believe they could enhance the service they provide to patients, and further increase consult and close rates, if they could assess and manage patients in person. WAST is therefore considering ways to support this, including exploring the implementation of mental health response vehicles.

References

  1. Alarilla A, Stafford M, Coughlan E et al (2022) Why Have Ambulance Waiting Times Been Getting Worse? The Health Foundation, London.
  2. Beegan A, Jones F (2022) Unscheduled Care in Wales – A System Under Real Pressure. Auditor General for Wales, Cardiff.
  3. Briggs H, Clarke S, Rees N (2021) Mental health assessment and triage in an ambulance clinical contact centre. Journal of Paramedic Practice. 13, 5, 196-203. doi: 10.12968/jpar.2021.13.5.196
  4. Duncan EA, Best C, Dougall N et al (2019) Epidemiology of emergency ambulance service calls related to mental health problems and self harm: a national record linkage study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 27, 1, 34. doi: 10.1186/s13049-019-0611-9
  5. Mills S, Bagshaw R, Watt A (2020) Beyond the Call. National Collaborative Commissioning Unit, Cardiff.
  6. NHS England (2022) NHS Expands Mental Health Crisis Services this Winter. http://www.england.nhs.uk/2022/12/nhs-expands-mental-health-crisis-services-this-winter/ (Last accessed: 24 January 2024.)
  7. NHS England, NHS Improvement, London Ambulance Service (2020) Mental Health Joint Response Car Pilot: Evaluation Report. http://aace.org.uk/wp-content/uploads/2020/08/MHJRC-Review-Final-12082020.pdf (Last accessed: 24 January 2024.)
  8. Royal College of Emergency Medicine (2022) RCEM Acute Insight Series: Mental Health Emergency Care. RCEM, London.
  9. Sands N, Elsom S, Colgate R (2015) UK Mental Health Triage Scale Guidelines, UK Mental Health Triage Scale Project, Wales, 2015. http://ukmentalhealthtriagescaledotorg.files.wordpress.com/2016/01/uk-mhts-guidelines-for-use.pdf (Last accessed: 24 January 2024.)
  10. Sands N, Elsom E, Colgate R et al (2016) Development and interrater reliability of the UK Mental Health Triage Scale. International Journal of Mental Health Nursing. 5, 4, 330-336. doi: 10.1111/inm.12197
  11. Sarsfield K, Boyle A (2021) RCEM Acute Insight Series: What’s Behind the Increase in Demand in Emergency Departments? RCEM, London.
  12. Swires-Hennessy K, Hayhurst C (2021) Mental Health in Emergency Departments. A Toolkit for Improving Care. RCEM, London.
  13. Welsh Government (2023a) NHS Activity and Performance Summary: April and May 2023. http://www.gov.wales/nhs-activity-and-performance-summary-april-and-may-2023-html (Last accessed: 24 January 2024.)
  14. Welsh Government (2023b) NHS ‘111 press 2’ A Big Step Forward for Access to Urgent Mental Health Support. http://www.gov.wales/nhs-111-press-2-big-step-forward-access-urgent-mental-health-support (Last accessed: 24 January 2024.)
  15. Wolpe J (1969) Subjective Units of Distress Scale (SUDS) [Database record]. APA PsycTests. doi: 10.1037/t05183-000

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