In many parts of England, a person experiencing a mental health crisis today has more options than ever before. They might call NHS 111 and speak to a mental health clinician, be directed to a crisis café or voluntary sector service, seen by a crisis team at home, or assessed in an emergency department or specialist unit.
During the pandemic, locally run crisis lines were already handling around 200,000 calls a month, a level of demand since absorbed into a national NHS 111 mental health offer. On paper, this looks like progress: more choice, earlier support, a system trying to respond more flexibly to people in distress.
However, for the people moving through it, and for the staff trying to hold it together, the picture is more complicated. More options can mean more confusion. Different areas offer different pathways. And when support does not arrive early enough, those same individuals often still find themselves at the sharpest end of the system, one where pressure has not eased.
Few people have seen that shift play out as closely as Helen Embleton, who is an Urgent Care Pathways Lead at an NHS Trust, Clinical Lead for Acute Pathway at NHS England: North East and Yorkshire Regional Mental Health Team and a clinical associate with the Getting it Right First time Urgent and Emergency Care (MH) Team. Having worked across crisis teams, liaison services and now urgent care pathway development, she has watched the system evolve from a largely single NHS offer into something broader, more collaborative and more complex.
More choice, but not always more clarity
When Embleton first worked in crisis services, the NHS was effectively the only offer. That is no longer the case. Over time, the system has widened its front door, bringing in crisis houses, cafés, voluntary sector provision and, more recently, national access through 111.
“You’ve got more options and more choice,” she explained, and in principle that is exactly what people need. Yet that expansion has also introduced a new kind of complexity, felt most acutely by the people trying to navigate it.
“Where do I go, who do I see?” is how Embleton characterises the experience for many. The answer depends not just on need, but on geography. What is available in one area may not exist in another, shaped by local commissioning decisions, historical service development and the capacity of place-based systems.
For a reform agenda built on treating the person as an individual, that inconsistency matters. Personalised care cannot depend on where someone happens to live. Ensuring equity in service provision means not just expanding access, but addressing the uneven foundations on which that access has been built.
Why pressure has not eased
If the front door to crisis care has widened, the expectation might be that pressure on the most mental health services would begin to fall. Instead, the opposite has happened. Urgent referrals to adult mental health crisis teams more than doubled in England, from around 1,400 in April 2023 to over 3,000 by March 2024.
One of the clearest indicators of sustained pressure sits within emergency departments. Recent Nuffield Trust analysis shows mental health-related presentations account for around 2% of A&E attendances, appearing relatively small, but representing closer to 3% of people physically in departments at any given time because these patients tend to stay longer. Around half of those presentations involve self-harm or suicidal intent, with a further third involving complex behavioural disturbance or hallucinations. Mental health accounts for a disproportionate share of time, resource and clinical complexity within urgent care.
For Embleton, the reasons are not confined to service design. They are rooted in a broader shift in context. Individuals are presenting with a wider mix of needs, including alcohol use, substance misuse, and the cumulative impact of financial, social and relational pressures. Community support structures feel weaker and primary care has changed, with less continuity between GPs and patients.
That is why she returned to a point that reframes how success should be understood: “A measure of our success is that we shouldn’t need crisis teams if we’re getting this right.” She is not suggesting crisis care will disappear. There will always be people who need urgent intervention. But if the system is truly delivering on its principles, fewer people should be reaching that point. At present, too many still do.
Crisis care is a whole-pathway problem
One of the most consistent themes in Embleton’s account is that crisis care cannot be understood as a single service or offer. “It’s a journey,” she reflected, and that framing matters because it shifts focus away from individual services and towards how they connect.
Ambulance crews, police, emergency departments, crisis teams, GPs and voluntary sector organisations all play a role, often within a short window of time. The quality of care is shaped not just by what happens within one organisation, but by how effectively handovers are managed. Different parts of the system are measured differently, operate under different pressures and do not always share the same priorities.
Even so, Embleton is clear that no single service can meet patient need in isolation. “You can’t just go off and do your own little thing,” she said, reflecting on the shift required across the system. Services need to work collaboratively, recognising that each part of the pathway sees only one part of a much bigger picture.
When that shift towards collective thinking happens, the question moves away from organisational responsibility and back towards the person: what does this individual need next, and how can the system respond without delay, duplication or unnecessary escalation.
What good looks like and the limits of certainty
For someone closely involved in national standards and peer review through her work with the Royal College of Psychiatrists, as well as wider improvement initiatives such as Getting It Right First Time, Embleton’s definition of quality is notably grounded. Evidence-based practice, accreditation and shared learning matter because they create a common understanding of what good looks like and help services learn from one another.
But she resists reducing quality to frameworks alone. In her view, improvement also depends on how services involve the people who use them, with patients and carers playing a central role in shaping how care is delivered and improved over time.
“It’s about being listened to, it’s being validated and it’s treating people with care and compassion.” In a crisis, how someone is treated shapes not only their immediate experience, but their willingness to seek help again.
On least restrictive practice, she is realistic. There has been progress, particularly in how police and mental health services work together. But detention will always have a role. The challenge is reducing how often it becomes necessary, which depends on what happens much earlier in the pathway.
On information, she is similarly clear-eyed. Professionals are often faced with making decisions with incomplete pictures “It’s a bit like being a detective, isn’t it?” she suggested. Even when history is available, it does not remove uncertainty. Risk can be mitigated but never fully eliminated.
What progress would actually look like
Embleton’s definition of progress is both straightforward and demanding: fewer people reaching crisis point because support arrived earlier; services less pressured and better able to spend time with individuals; a stronger evidence base for what works, and the confidence to stop what does not. The theme of the workforce remains central throughout.
Mental health crisis care has undoubtedly evolved, broader, more connected and more responsive than two decades ago — yet the central challenge remains unchanged. Until fewer people are reaching crisis in the first place, the system will continue to carry the greatest weight at its most acute point. It is there that the success or failure of reform will be most clearly felt.
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