More than half a million mental health-related attendances were recorded in EDs in England in 2025-26.
“We should also ask whether they received the right support before reaching crisis”
Helen Macdonald
People experiencing mental health problems are twice as likely as other patients to remain in the emergency department for more than 12 hours.
NHS standards expect liaison mental health teams to respond within one hour of referral for someone presenting at an ED with a mental health need, with the evidence-based treatment pathway setting out assessment, care planning and onward referral, transfer or discharge within four hours.
What the HSSIB report repeatedly shows, and what ED staff will know, is that liaison psychiatry provision is ‘variable’ with ‘poor’ information sharing IT systems.
The report also reiterates that prolonged waits, crowding, overstimulation and a lack of privacy in EDs – that are often ‘not designed nor resourced to provide prolonged therapeutic mental health care’ – can increase distress for people already experiencing a mental health crisis.
For nurses and other staff trying to care for people in these circumstances, the pressures can be immense.
The HSSIB report identifies gaps in specialist skills, trauma-informed care, therapeutic engagement, de-escalation and clinical supervision.
It also highlights burnout, compassion fatigue, moral distress and the potential for moral injury among staff.
The answer to this cannot simply be to expect EDs, or the nurses working within them, to become better at absorbing ever-increasing mental health demand.
This view is reflected in the model NHS England says it wants to deliver. Crisis and acute mental health care should be a coordinated pathway involving emergency departments, liaison psychiatry, community crisis teams, ambulance services and other partners, so that people receive the right care, in the right place, at the right time.
An ED should be one part of that pathway, not the default destination because support elsewhere is unavailable.
Emergency staff of course need training, resources, specialist support and appropriate environments to provide safe and compassionate care when somebody experiencing a mental health crisis seeks their help.
But there is a bigger issue to address. Why do so many reach EDs in mental health crisis in the first place?
EDs have an essential role when somebody is in immediate danger, requires urgent physical healthcare, mental health support or emergency assessment.
They should not, however, become the default entry point into mental health care simply because appropriate help was unavailable elsewhere.
Professionals know that EDs are the most expensive and least therapeutic setting for dealing with someone in mental distress.
This matters because, as the HSSIB showed, the capacity, accessibility, integration and responsiveness of mental health crisis services are varied and are not always able to provide ‘timely or suitable alternatives’ to EDs.
People with complicated needs can fall through gaps in services, leaving ED staff managing demands and filling roles for which they were not intended or fully prepared.
Improving crisis care needs us to look at not the ability of ED staff to manage people in crisis, but at the pathway that ends with somebody arriving at their door.
That means accessible community mental health services, effective crisis teams and clear routes between primary, community, emergency and specialist care.
It should also mean ensuring people can access appropriate evidence-based psychological support before their difficulties escalate to crisis.
Early intervention does not mean every mental health emergency can be prevented and attendance at an ED should not automatically suggest failure of services upstream.
But for some, a crisis comes after a much longer period of deteriorating mental health during which there may have been opportunities to provide effective support.
Psychological therapies have an important part to play. Cognitive behavioural therapies (CBT), for example, are evidence-based treatments recommended by the National Institute for Health and Care Excellence (NICE) for a range of mental health conditions that can be delivered effectively in lower-cost and more therapeutic environments such as community and outpatient settings.
CBT will not be appropriate for every person or every difficulty, but people should have timely access to the evidence-based treatment appropriate to their needs, delivered by accredited and registered practitioners with the necessary training, supervision and professional standards.
The government’s investment in 59 dedicated mental health EDs and 100 community mental health centres is an opportunity to improve this pathway.
Dedicated mental health emergency facilities may provide more appropriate and therapeutic environments than conventional EDs for some people in crisis.
But buildings alone will not solve the problem. The HSSIB’s report repeatedly returns to workforce capacity and capability.
Expanding mental health provision must therefore happen alongside workforce expansion to ensure sufficient appropriately trained professionals are available to deliver care, whether in emergency, specialist or community settings.
There is a distinction between equipping emergency nurses to respond confidently and compassionately to mental health crisis and expecting them to substitute for specialist mental health professionals.
Emergency nurses should, of course, have access to appropriate mental health training and clinical support.
But they also need timely access to specialist professionals, clear assessment and onward care pathways and services capable of accepting people who need specialised support.
Without this, ED teams are being used to manage the consequences of pressures elsewhere in the system.
As the HSSIB’s report makes clear, this is not a failure of one profession or one part of the NHS. It is a whole-system problem.
Making EDs safer and more therapeutic for people experiencing mental health crisis is essential.
But success should not be measured only by how well we manage people once they arrive there.
We should also ask whether they received the right support before reaching crisis, whether evidence-based treatment was available when they needed it, whether services worked together around them and whether there were gaps in the pathway through which they may fall.
EDs will always have an important role in mental health crisis care. But they cannot carry that role alone.
If we want to reduce pressure on emergency nurses while improving care for patients, we must strengthen both ends of the pathway; ensuring excellent, properly resourced crisis care when it is needed while investing in the community and psychological support that can help more people before an emergency department becomes their only remaining option.
Helen Macdonald, senior clinical advisor for the British Association for Behavioural and Cognitive Psychotherapies
