The changing terrain of mental health in A&E: specialised care or the same old bottlenecks?

Long waits in A&E for mental health concerns raise issues for patients, clinicians and systems. For patients, long waits can increase agitation and distress, and there is particular concern that this is exacerbated in busy, chaotic A&E departments. Further international evidence suggests that long waits in A&E are associated with increased use of restraint and sedation. In the UK, staff have reported an increased need for security guards in A&E to deal with violence from mentally unwell patients, and expressed concerns over the impact of aggressive patients on other patients and themselves.

The challenge of managing mental health demand in A&E has attracted more attention in recent years. The 10 Year Health Plan has committed to investing up to £120 million to expand specialist mental health crisis centres, co-located with typical emergency departments, over the next decade. Pilots are currently underway in 10 NHS trusts, with hopes that mental health A&Es will reduce waits for patients and improve access to appropriate care. 

In the absence of detailed, large-scale pilot data, this blog uses existing A&E data to explore the mental health care provided currently in A&Es, as well as the gaps and challenges new specialist services will need to overcome to improve care for people in mental health crises.

Mental health demands on A&E have become more complex

Between April 2024 and March 2025, mental health needs made up approximately 2% of attendances. ¹ However, because people with mental health complaints wait longer, they make up a bigger proportion of people in A&E at any given moment – roughly 3%. Furthermore, most mental health presentations in A&E are complex. Of all mental health attendances, 50% involve self-injurious and/or suicidal intent and behaviour, and a further 34% involve complex behaviour and hallucinations. 

The chart below breaks down how the share of mental health attendances to A&E presenting with bizarre behaviour (i.e. the description given when someone presents at A&E displaying unusual or erratic behaviour), hallucinations, and physical aggression has climbed in terms of attendances. These complex complaints have also increased as a share of all mental health complaints from 22.2% to 33.7% over the past six years.

As this chart indicates, the number of mental health attendances per year for bizarre behaviour has risen from approximately 43,000 to 64,000, hallucinations from 12,000 to 20,000, and physical aggression from 14,000 to 21,000 over the past six years.

People with mental health complaints in A&E often require medical treatment

People who attend A&E for mental health complaints are more likely to receive no treatment in A&E or just receive written advice (56%), compared to people with other complaints (44%). However, over 40% of A&E attendees for mental health complaints had a treatment recorded. This indicates that a large percentage of people with a mental health emergency need more than just a safe place to see out a crisis. Among the 44% of mental health attendees who receive treatment, the most common are:

• Cardiac monitoring surveillance: for example, for monitoring overdose, substance abuse and responses to new medication (22% of all mental health attendances)
• Intravenous cannulas: for example, for fluids, electrolytes or sedatives, and other medication (9%)
• Administration of medication: for example, anti-psychotics, sedatives, or for the treatment of overdose (15%). 

In response to the announcement of specific mental health A&Es in the 10 Year Plan, organisations such as the Royal College of Psychiatrists and the Centre for Mental Health have expressed concern over attempts to clearly divide mental and physical health A&E attendances. While fewer than 1% of A&E attendees for non-mental health complaints had a mental health diagnosis flagged in their attendance, 42% of mental health attendees were flagged with a non-mental health diagnosis.

To complicate matters further, the capacity for mental health A&Es to provide physical treatment is often inconsistent and difficult to ascertain. For example, the North London Foundation Trust’s service excludes patients with an “urgent medical need”, whereas the new service in Tooting includes “psychological difficulties in the context of physical illness” but excludes patients with “serious medical conditions”. This not only illustrates the difficulty of drawing a clear line between the mental and physical, but raises concerns for attendees’ ability to identify the most appropriate service for their needs.

In a typical A&E department, much of the work navigating physical and mental health is done by liaison psychiatry services. Liaison psychiatry plays an important role in assessing patients, managing risk and distinguishing physical symptoms from mental. Despite their importance, the share of major (Type 1) A&Es with sufficient mental health staffing has recently fallen to less than two-thirds. Without proper planning and fairly immediate resourcing, it is possible new mental health A&Es could exacerbate this gap in staffing further.

Mental health A&Es could improve waits for some mental health attendees, but systemic drivers of long waits remain

Mental health A&E centres were introduced in May 2025 with the expressed aim to “reduce crowding” and “speed up access to care”. However, in the Emergency Care Dataset, removing waits for mental health complaints from the latest year of data brings the average wait for all A&E attendances down by about three minutes. Despite mental health complaints having very long waits, removing them from A&E will not move the needle much when it comes to meeting A&E targets. However, mental health A&Es could still reduce waits for people with mental health problems in crisis. 

As shown in the chart below, there are three points at which mental health patients wait longer in A&E. On average, people with a mental health complaint wait longer to be seen for treatment. This difference is especially pronounced among non-admitted patients. It is plausible that mental health patients will experience shorter waits for treatment in an environment where staff better understand their needs. Yet this benefit could exclude a substantial proportion of people requiring treatment that mental health A&Es cannot offer. 

Secondly, among admitted patients, people with a mental health complaint wait longer for a decision to admit and, thirdly, they wait longer to eventually be admitted. This discrepancy is driven overwhelmingly by the availability of beds in mental health wards. In turn, the availability of beds in mental health wards is driven by external factors like the housing needs of patients ready for discharge and social care availability. A&E departments (mental health or otherwise) have very limited control over this factor, meaning that mental health A&Es will struggle to bring down overall waits for admitted mental health patients with new emergency departments alone.

Meeting unmet mental health needs in A&E today

So far, this analysis has considered the case for mental health A&E centres on its own terms, with a focus on waits and targets. However, it is also important to consider the additional potential for mental health A&Es to address currently unmet need. 

A recent study found that between April 2019 and March 2020, around 77% of people who died by suicide had no record of an A&E attendance or hospital admission in the 30 days leading up to their death. In other words, most people who died by suicide had no contact with emergency services shortly before their death. If any of these people had attended A&E, they may have had the opportunity for assessment, support, referral or admission, potentially improving the care they received.

Currently, major A&E departments may discourage people in distress from seeking help. Patients have described typical departments as “horrible” and “off-putting” – suggesting that people who need emergency support may not attend at all, and miss out on a crucial opportunity for intervention. Mental health A&Es could prove ineffective at relieving pressures on typical A&E departments, and could even increase overall demand, but could valuably broaden access for support for people who would otherwise remain unseen. 

As pilot data and new urgent and emergency care targets emerge, it is important the real human cost of inadequate mental health care remains a key consideration in the evaluation of mental health A&E services.

Conclusions

Mental health presentations in A&E are increasingly complex, high risk and difficult to manage. Over the past five years, data from the Emergency Care Dataset shows a marked rise in presentations involving aggressive behaviour, bizarre behaviour and hallucinations. This growing complexity adds to the pressures already facing emergency departments, and exacerbates an already existing gap between the demands of mentally ill people in A&E and appropriate environments and staffing.

Despite being pitched as a service to “reduce crowding” and “speed up access to care” in emergency services, mental health A&E centres have limited ability to reduce overall A&E waits and to address key drivers of very long waits, such as a lack of inpatient mental health beds. Without wider investment in community and inpatient services, bottlenecks will persist regardless of where patients are seen.

A significant proportion of people attending mental health A&Es will have physical health diagnoses requiring physical treatment. The extent to which mental and physical health emergencies are often intertwined has not been addressed uniformly by emerging mental health A&E services and will be exacerbated by a lack of liaison psychiatry staffing.

However, moving away from timestamps and targets, mental health A&E centres represent a crucial opportunity to reach vulnerable and suicidal people. Mental health A&Es are a welcome step towards more compassionate crisis care, but to meet their own expressed aims, they require an integrated approach that addresses the workforce, the number of beds available for mental health patients, and the complex intersection of physical and mental health.