Thematic review of mental health crisis care

Page last updated: 12 May 2022

Our themed programme on mental health crisis care ran from October 2013 until June 2015.

About this themed programme

During this programme, we explored three ways that people are likely to receive emergency mental health care.

We looked at people who have experienced a mental health crisis and who:

  • go to accident and emergency departments (with a particular focus on people who self-harm).
  • require access and support from specialist mental health services.
  • are detained under Section 136 of the Mental Health Act (the power that police officers have to detain people, believed to have a mental disorder, in a public place and to take them to a place of safety for assessment).

We also:

  • assessed the quality of a service’s response to a person experiencing a mental health crisis.
  • looked at how different organisations and agencies work together to provide an effective response within a local area.
  • explored the inequalities and outcomes for particular groups of people experiencing a mental health crisis (such as the inequalities experienced by some black and minority ethnic groups).

What services did we look at?

The themed programme looked at services provided by:

  • NHS acute and mental health trusts.
  • NHS and independent ambulance providers.
  • primary medical services (including GPs).

What did we do?


  • analysed existing national data to build a comprehensive evidence base that details mental health crisis care across England’s local authority areas.
  • ran a call for evidence about the help, care and support available to people experiencing a crisis, which led to more than 1,750 responses from individuals and local groups who wanted to share their personal stories.
  • surveyed NHS mental health trusts about health-based places of safety and produced an online map of their locations and a report on our findings.
  • carried out 15 local area inspections of health and care services. This included two pilot inspections. The inspection reports are published on our website.
  • explored the role of different services in providing help, care and support to people who are experiencing a mental health crisis.
  • published the data we collated in the first phase of the review.
  • published a national report from the review.
    • developing a clear set of measures for our new surveillance model.
    • developing tools and methods that can improve the way we inspect health and care services to ensure they are responding to the needs of people experiencing a mental health crisis.
    • reflecting the views of people who use services and stakeholders in the monitoring and inspection of services and localities.

Improving our approach

The results are being used to develop the way we monitor and inspect services.

Expert advice

This work was supported by a panel of experts with lived experience of a mental health crisis and an external advisory group. You can find out more about the membership and terms of reference of the advisory group below.

Terms of reference: Experiences and outcomes for people experiencing a mental health crisis - themed programme

Find out more

Read Right here, right now, our review of mental health crisis care.

Read our report, A safer place to be.

Download the data we collected in the first phase of the review.