Redesigning Paediatric Emergency Care for Mental Health: A realist, mixed-methods evaluation of a new model of integrated care (Best For You)

In the chaotic, brightly lit corridors of a hospital emergency room, the standard rhythm is one of physical crisis: a broken bone, a high fever, a sudden accident. For decades, the system was built to fix the body quickly and send the patient home. But a different kind of emergency has been growing in silence, one that does not show up on an X-ray. It is the crisis of the mind, striking teenagers who arrive at the emergency department in a state of severe emotional distress, often with nowhere else to go. When these young people arrive, they frequently find themselves in spaces designed for physical trauma, surrounded by hard surfaces, loud noises, and staff who are experts in saving lives but may not have the specific training or tools to calm a spiraling mind. This mismatch creates a dangerous loop where a child in crisis waits for days in a place that feels unsafe, often leading to longer hospital stays and a higher chance of returning in a worse state. The question facing modern healthcare is not just how to treat these emergencies, but how to redesign the very environment and the way care is delivered so that a young person in a mental health crisis receives the same dignity, safety, and speed of care as someone with a broken leg.

A team of researchers in Northwest London set out to answer this question by watching, listening, and helping to build a new way of working. They focused on a specific project called "Best For You," an attempt to transform how a large urban hospital cares for children and teenagers experiencing mental health emergencies. The researchers did not just look at the final result; they followed the entire journey from the first idea to the opening of the new service. They sat in on dozens of planning meetings, interviewed the doctors, nurses, and charity workers trying to make it happen, and spoke with the families who had suffered through the old system. Their goal was to understand not just what the new model was, but exactly how it was built, what obstacles stood in its way, and how the people involved managed to overcome them to create something that actually works.

The story of this project began with a single conversation. A parent, whose child had been through a terrifying mental health emergency in the hospital, spoke with a doctor about how unsuitable the facilities were. The parent described a lack of privacy, disturbing noise, and a feeling that the environment was unsafe for a child in crisis. This conversation sparked a movement. A group of people, including doctors, nurses, policy experts, and a healthcare innovation charity, came together to design a solution. Their initial vision was ambitious: to build a brand new, separate unit dedicated entirely to adolescent mental health emergencies. They imagined a place with private rooms, calm spaces, and staff trained specifically to handle these complex situations. However, the reality of the hospital's physical space made this dream impossible. There was simply no room to build a new building without displacing other essential services.

Instead of giving up, the team adapted. They realized that the solution did not have to be a new building, but rather a new way of using the existing one. They decided to reconfigure two parts of the hospital that were already there: the main emergency department and an acute pediatric ward. They transformed specific rooms into what they called "flexi-rooms." These were spaces that could be used for general medical care but were also designed to be safe and secure for a child in a mental health crisis. They removed ligature points—areas where a child could hang themselves—installed soundproofing to reduce noise, and created quiet, private areas where a young person could de-escalate without feeling trapped. This was a significant shift in thinking. It meant that the hospital did not need to be a mental health trust to provide mental health care; it just needed to be flexible enough to adapt its existing spaces to meet the needs of the moment.

The path to opening these new spaces was not smooth. The team faced a series of hurdles that threatened to stop the project entirely. One major barrier was the way the hospital system is funded. In the UK, money for physical health and money for mental health often come from different pots, managed by different groups. This made it incredibly difficult to agree on who would pay for the staff needed to run the new service. If the mental health trust paid for the nurses, the physical health trust might feel they were losing out, and vice versa. This financial tug-of-war caused long delays. Another significant obstacle was the pandemic. When the virus hit, the hospital staff were stretched to their limits, and many of the people leading the project had to focus on saving lives in the emergency room, leaving the planning meetings to be postponed or held online. The pandemic also delayed construction, as building work in clinical areas was paused to ensure safety.

Despite these setbacks, the project moved forward because of the sheer determination of the people involved. The researchers noted that the team had a shared vision that was stronger than the obstacles. They were driven by a common belief that the current system was failing young people and that they had the expertise to fix it. The healthcare innovation charity played a crucial role, acting as a bridge between the different groups and raising the money needed to pay for the physical changes, which cost £2.8 million. They also brought in the voices of young people and families who had lived experience of the crisis. These families were consulted on the design, telling the team exactly what they needed: private spaces to talk, quiet areas to calm down, and a sense of safety. Their input ensured that the new rooms were not just clinically safe, but also human and welcoming.

The researchers found that the success of the project relied heavily on how the team worked together. They did not just follow a rigid plan; they constantly adjusted their approach as new challenges arose. When the initial plan for a new building was rejected, they quickly pivoted to redesigning existing rooms. When funding was unclear, they found creative ways to secure resources. When the pandemic hit, they adapted their meetings to be virtual. This flexibility was key. The team also realized that the physical changes were only half the battle. They had to train the staff. Every nurse and doctor in the emergency department received new training on how to recognize the signs of a mental health crisis, how to de-escalate a situation without using force, and how to prioritize patients based on their mental health needs. This training was not a one-time event; it became part of the routine for new staff joining the hospital.

The data collected by the researchers showed that the need for such a service was urgent. They looked at hospital records from the years leading up to the project and found that while the number of physical health emergencies dropped during the pandemic, the number of mental health emergencies remained stubbornly high. In fact, admissions for eating disorders and drug or alcohol intoxication increased significantly. The data also revealed a stark difference in how these young people were treated compared to those with physical injuries. Children with mental health crises stayed in the hospital much longer, were transferred to other hospitals more often, and were less likely to get follow-up care from a doctor after they left. This confirmed that the system was not just inefficient; it was actively failing to provide the right kind of care at the right time.

The final result was a service that was ready to open, even though it looked different from the original blueprint. The "Best For You" model was not a single, isolated unit, but a network of improved spaces and trained staff working together across the hospital. The researchers concluded that achieving this level of change required a rare combination of factors: a clear vision shared by everyone involved, the willingness to adapt when things did not go according to plan, and the persistence to keep pushing forward despite financial and logistical barriers. They found that the most important ingredient was not the money or the new equipment, but the people. The doctors, nurses, charity workers, and families who refused to accept the status quo were the ones who made the change possible.

This study offers a clear lesson for other hospitals and policymakers who are trying to improve care for young people in crisis. It shows that you do not always need to build something new to create something better. Sometimes, the solution lies in reimagining what you already have, training your staff to think differently, and listening to the people who have been let down by the system. The researchers emphasized that while the path was difficult and the timeline was long, the effort was worth it. They provided a detailed map of the barriers and the facilitators, showing that with the right leadership and a commitment to integrated care, it is possible to create an emergency department where a young person in a mental health crisis can find safety, dignity, and the care they need. The project did not solve every problem in the system, but it proved that a better way is possible, and it gave other hospitals a practical guide on how to start building it themselves.