By December 2004, all patients must be discharged from an accident and emergency (A&E) department within 4 hours of arrival (Department of Health, 2001). We sought to identify what factors contributed to the long waiting times experienced by some patients referred to psychiatry by our local A&E department.

Over a 2-month period in 2004, we identified 23 patients who breached the 4-hour target. More than half were patients who had self-harmed. Alcohol intoxication and awaiting the results of investigations following an overdose were common reasons for a delay. In more than a fifth of cases, a prolonged psychiatric assessment was required, including one Mental Health Act 1983 assessment. In 40% of cases, there was more than an hour's delay between referral and psychiatric assessment.

A rapid response is unlikely to reduce attendance to below 4 hours in all cases. If a psychiatrist can attend within 1 hour, and their assessment takes no more than another hour, then patients should be referred within 2 hours of attendance to achieve the 4-hour target. This occurred in only one-quarter of cases reviewed.

Striving to achieve rapid throughput for patients with psychiatric as well as physical problems may not always be possible or advisable (Psychiatric Bulletin, December 2003, 27, 81-82). Obtaining background information is often a crucial but time-consuming part of an assessment. Is the drive for a rapid discharge from A&E, evidence of a sway towards ‘ fast psychiatry’ (Psychiatric Bulletin, July 2004, 28, 265-266) that runs counter to good clinical care?