Mental health is often spoken about as though it’s one cohesive, neatly-packaged topic, in the same way that a physical illness like “breathing difficulties” might be. When mental health and ambulance services end up on the news, the common refrain is that “mental health calls to 999 are on the rise”. Which… is not wrong, but it’s like saying “calls to 999 for medical conditions are on the rise” — it’s not specific enough to talk about such a broad topic. What kind of medical conditions? What kind of mental health conditions?

That being said, calls to 999 for mental health conditions and crises are on the rise, and have been for some years. The stigma around mental health has fallen — don’t get me wrong, mental health is still stigmatised, but nowhere near as much as it used to be — and as it has, people have felt more confident to call for help when they’re in a mental health crisis. Which is a great start, but what hasn’t yet caught up is the support services that aren’t 999 — what’s the equivalent of an urgent care centre for mental health? Can you name your nearest?

What is an Emergency?

Many of these calls end up coming to 999 because it’s free, it’s easy to access, and because it’s one of the relatively few places that will do something today to help, instead of deferring it — referring you elsewhere, or making an appointment for a later date, etc. The problem is that 999 is there for emergencies, and given the breadth of mental health issues, many situations either aren’t immediate emergencies, or aren’t seen as emergencies.

A medical or traumatic emergency is comparatively easy to define. We have vast amounts of experience to draw on, and it’s relatively well-known what’s life-threatening and what’s not. Asthma attack? Check. Hypoglycaemia? Check. STEMI? Check. Nosebleed? Nope.

A mental health emergency is much less easily defined. Given the relatively recent de-stigmatisation and recognition of mental health issues, we have far less experience to draw on collectively, and what’s life-threatening — and when it’s life-threatening — evades easy definition. The only real way to do it is to ask the patient.

That’s where we hit another wall: disbelief. Recall I said mental health is still stigmatised to an extent? This is where we see it. Both the public and healthcare professionals can be reluctant to believe a mental health patient about their own condition. We’d believe someone if they were talking about how their diabetes affects their day-to-day life, but not if they’re talking about how their depression affects their day-to-day life. It’s still sometimes seen as attention-seeking or self-involved. That stigma isn’t gone yet.

Breadth & Depth

My trust uses MPDS to triage calls. For the uninitiated, that means that I have a selection of 33 protocols at my disposal to categorise and triage an incoming call. When someone calls for a physical health problem, I’ll assess what it is they’re calling about or what the primary symptom is, and pick the relevant protocol — for difficulty breathing, Protocol 6; for chest pain, Protocol 10. There’s a protocol to address most physical health and emergency complaints, even if it’s just a generic Protocol 26 – Sick Person.

When someone calls in for a mental health problem, I have exactly one protocol to choose from: Protocol 25 – Psychiatric / Suicide Attempt. Think about that. Mental health problems are as broad a category as physical health problems, if not broader, but where I have 32 protocols for physical health I have one for mental health. The questions it asks are suitable for a limited set of mental health situations, but not for many others — is the patient violent or likely to hurt an ambulance crew? Is the patient trying to commit suicide, or thinking about it?

Take, for example, someone having an anxiety-induced panic attack. Panic attacks are horrible things — terrifying, suffocating, choking for the person experiencing it, and panicking and overwhelming for anyone witnessing it. They’re not life-threatening: in the worst case you’ll hyperventilate yourself unconscious, at which point your reflexes kick in and reset things to normal. The cause, though, is a mental health problem. Is the patient violent?

Then you have someone’s sweet 92-year-old mother with dementia. Dementia is also a horrible thing, especially for those caring for someone with dementia. Is it an emergency? No, but that doesn’t mean we don’t still get calls from folks who feel completely unable to care for someone because of it. We can’t ignore that call for help, but right now we also don’t have a good way of handling it. Is the patient suicidal?

The Public Eye

I’m going to generalise summarily here: mental health is still seen, in the eyes of the public, as not as important as physical health. That’s not just the UK, that’s across most of the world — there are places where that’s less so and places where it’s more so, but as a general rule it holds true almost everywhere.

That fact alone puts pressures and complications on how healthcare agencies the world over respond to mental health. In the UK, one of the major limits on how the NHS responds to mental health is down to funding, which is in turn down to politics. The government of the day gets to set the NHS budget, and then it’s up to the NHS how it’s spent. We don’t have a choice about physical healthcare: that’s our mandate, our raison d’être — the public in the UK would (rightly or wrongly) be outraged if physical healthcare was cut to allocate more funding to mental healthcare. That leaves mental health in a sticky spot, having to make do with the scraps and the leftovers. Supporting mental health doesn’t win you elections.

Post-Crisis Support

Funding is really the big problem that mental healthcare faces: lower public and political support means lower funding, means lower staffing, lower availability, lower everything. That’s not to say it’s the only problem: one of the particular problems for 999 is being one of the few available services. As I’ve already noted, we’re not well-equipped to handle many mental health crises, but where else will?

A lot of mental health support services rely on volunteer or charity services — who do wonderful work, but usually can’t handle lots of volume, and can’t handle long-term needs. This is where the NHS really falls down on mental healthcare: in a crisis, the ambulance service, hospitals, and mental health professionals will get you help to deal with the crisis. Past that, you’re often on your own, or waiting on ever-increasing waitlists for appointments with overworked staff.

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Is all of this fixable? Sure. But fixing it relies on having everything fall into place at the same time: societal attitudes, political support, funding, staffing — the works. I’d love to see it happen, and I’d love to be able to support people much better — but we’re not there yet.