Resolving the psychiatric bed crisis: a critical analysis of policy Abstract
The National Service Framework (NSF) for Mental Health in 1999 was central to the modernisation of mental health services under the New Labour government of 1997. It placed an emphasis on universal clinical standards and set out a vision for service developments over the next 10 years. One such proposal was the development of crisis resolution teams, aimed at reducing the psychiatric admissions rate by providing care at home. This article provides a critical analysis of policies relating to the provision of 24-hour access to mental health services, focusing on the specifications for creating crisis resolution teams, as laid out in the NSF for Mental Health and the NHS Plan. First, it looks at the historical context surrounding the policy, examining the content of the NSF and NHS plan and how policy was disseminated and implemented nationally and locally. Then it examines the effects and changes this policy brought about and, specifically, whether it has achieved its aims of reducing the nationwide acute psychiatric inpatient admission rate. Key words: NHS policy ■ National Service Framework ■ NHS Plan ■ Mental health ■ Crisis resolution teams
W
hen the New Labour government took power in 1997 it heralded a prodigious shift in the focus of health policy for mental health services. It promised to modernise and unify provision for mental health care through the white paper, Modernising Mental Health Services: Safe, sound and supportive (Department of Health (DH), 1998), which highlighted a need for 24-hour access to mental health services. These proposals were later expanded and developed into the National Service Framework (NSF) for Mental Health (DH, 1999) and the NHS Plan (DH, 2000a). With these policies the Labour government sought to strengthen and reform the NHS by standardising the quality and delivery of mental health care countrywide (Klein, 1999; Tyrer, 1999; Fatchett, 2012) based on sound evidence (DH, 2001; Burns and Catty, 2002) and pledged to increase funding significantly to achieve these aims.
Historical context The concept of 24-hour access in mental health care is not new. Since the 1950s there had been widespread dissatisfaction Katie Loader is Community Mental Health Nurse at Gordon Hospital, Bloomburg Street, London Accepted for publication: January 2014
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with long-stay psychiatric institutions (Freshwater and Cahill, 2011). Chronic underfunding and a growing understanding that institutionalisation can be harmful (Claassen and Priebe, 2010) led to many such asylums being closed down. Pharmacological advances led to the development of more effective drugs that could be used to treat patients in a local setting (Sainsbury Centre for Mental Health, 2001a; Caldas de Almeida and Killaspy, 2011). During the 1970s, in the context of a struggling economy and social unrest, the provision of health care was becoming increasingly expensive, and further credence was given to the concept of community care being more financially viable for the NHS. However, it was not until the 1980s—when there were increasing concerns about the quality of care for patients with severe and enduring mental illnesses—that Margaret Thatcher politically pursued community care as a policy agenda. The Griffiths Report (Community Care: Agenda for Action, Department of Health and Social Security (DHSS), 1988) highlighted that, so far, community care had failed due to a lack of clear leadership. This led to a government white paper, Caring for People: Community care in the next decade and beyond (DHSS, 1989) and eventually the Community Care Act 1990. However, psychiatric community care led to many concerns over the perceived and actual risk patients posed to the public. High-profile cases of patients harming members of the public, widely reported in the media, highlighted concerns that patients were slipping through the net, with inadequate follow-up and lack of communication between agencies (Salter and Turner, 2008). The British Medical Association (BMA) (1992) at the time also raised the issue of the ability of local authorities to support mental health patients in the community. The proximity of mentally ill people in the community and the representation of such patients in the media fuelled public concern. This galvanised government response (Avery, 2012), prompting a re-evaluation of mental health policy (Means et al, 2008). In 1998 Frank Dobson, then Health Secretary, remarked that care in the community had been unsuccessful (Warden, 1998), paving the way for an overhaul of mental health legislation. Under the previous government, investing in mental health care had been impeded by the economic situation of the time, leading to contrasting levels of care nationwide (Ham, 2009). The Sainsbury Centre for Mental Health (2001b) found that before implementing the policies governing 24-hour access to care, there were only a small number of practising crisis teams. Minghella et al (1998) identified that these services had been slow to develop due to
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Katie Loader
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MENTAL HEALTH lack of guidance as to how to develop the teams. Klein (1999) believed that services benefited the interests of the NHS as opposed to the needs of the patient.
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NSFs and the NHS Plan The NSF for Mental Health was an ambitious 10-year plan set out by the DH. Its purpose was to set national, evidence-based standards for mental health services. A year later, in July 2000, the NHS Plan was published; it outlined the expectations of what services should deliver. The overall aim was to provide financial investment for a radical reform of the health service, which should pivot around the needs of the patient, providing choice by extending and creating services all based on universal standards of care. Part 14 of the NHS Plan, ‘Clinical priorities’, followed on from the NSF requirement to provide 24-hour access to care by stipulating that within 4 years all patients would have access to crisis resolution team (CRT) services by creating 335 teams nationwide. The objective was to treat around 100 000 patients per year in the community by averting an inpatient admission or facilitating early discharge from hospital and, furthermore, to reduce inpatient admissions by 30%. Bebbington et al (2013) stated that the NSF was created to reduce avoidable inpatient admissions and The Sainsbury Centre for Mental Health (2001a) described the NSF and NHS Plan as an inclusive set of policies, aiming to promote mental health issues, and backed by an increase in available spending. The Government pledged to invest over £300 million to realise its ambitions. However, it was not clear within the plan whether the resources available could meet such progressive targets (Means et al, 2008) and Klein (1999) believed that the Government was intensifying pressure on the NHS by increasing demand and public expectation. Hudson (2005) praised Government efforts to advance mental health care but believed the incentive was to reduce costs rather than improve care. It was also felt that the focus of the policies was what the Government, not the patient, would gain from the investment (Lester and Glasby, 2006) and that if targets were not met it could be politically damaging for the Government (Klein,1999). The NHS Plan was widely welcomed as a vehicle for change, to improve the quality of care delivered within the NHS (Holloway, 2002). Preparation for its publication involved a public consultation, as the vision was for the NHS to reflect the desires of the patients (Overshott et al, 2007) and staff (Dixon and Dewar, 2000). An external reference group that included patients, professionals and carers was set up to advise the Government on the composition of the central policies and core objectives of mental health care, which were to be available when needed and to offer alternatives to admission (Thornicroft, 2000). The professional component researched the evidence base, which formed the foundations of the new policy (Dobson, 1999). In contrast, some researchers (Tyrer, 1999; Alimo-Metcalfe et al, 2007; Tyrer et al, 2010) commented on the lack of clear evidence that 24-hour access to services improves outcomes for patients. Indeed, Minghella et al (1998) reported that if community mental health services were appropriately run, there would be no need for 24-hour provision and that the care needs of patients in crisis could usually be accommodated within
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Box 1. Key policies in the development of 24-hour access to mental health services ■■ Modernising
Mental Health services: Safe, sound, supportive (DH, 1998) Service Framework for Mental Health: Modern standards and service models (DH, 1999) ■■ NHS Plan: A plan for investment, a plan for reform (DH, 2000) ■■ NHS Plan implementation programme (DH, 2000) ■■ Mental health policy implementation guide (DH, 2001) ■■ National
Box 2. Specifications for creating crisis resolution teams from the NSF for mental health (DH, 1999) and NHS Plan (DH, 2000) ■■ Aim
– To provide consistent 24-hour access to mental health services, by providing treatment at home, aimed at those patients with severe and enduring mental health illnesses ■■ Investment – £300 million extra annual investment by 2003/2004 ■■ Services – Create 335 new crisis resolution teams by 2003 ■ 24-hour access to psychiatric care by 2004 ■ Treat 100 000 patients annually ■ Reduce psychiatric inpatient admissions by 30% ■ Reduction in unnecessary out-of-area admissions Core features of a crisis resolution team ■■ Accessible
24 hours a day, 7 days a week patients aged 16–65 with severe mental illness ■■ Cover a population of approximately 150 000 ■■ Carry a caseload of 20–30 patients ■■ 14 members of multidisciplinary staff with 24-hour access to senior psychiatrist ■■ Prompt assessment following referral (recommendations state within 1 hour) ■■ Focused and intensive support while in crisis ■■ Active engagement of service user, families/carers ■■ Assertive involvement ■■ Time-limited, flexible interventions ■■ Remaining involved until the crisis resolves ■■ Signpost to appropriate services ■■ Involvement in planning early discharge when hospitalisation is necessary ■■ Relapse prevention planning ■■ Gate-keeping role ■■ For
(DH, 2001)
daytime hours. Pelosi and Jackson (2000) felt that GP services already played a significant role in providing containment for mental health patients in the community and advocated strengthening established services instead of creating new ones. Burns (2000) agreed with this, believing also that the work of CRTs replicated that of community mental health teams (CMHTs). CRTs have also been criticised for diverting money away from traditional CMHTs (Pelosi and Jackson, 2000; St John-Smith et al, 2009).
Policy implementation and dissemination The key to a policy’s success is a thorough working knowledge of the local population and professional arrangement it will affect (Minghella and Ford, 1997; Kelly et al, 2004). Thornicroft and Reynolds (2007) described the NSF as both requisite and liberal, allowing trusts flexibility in developing services to reflect the framework and local needs. However, there were difficulties in implementing the policies. Harrison et al (2001) found that, although there was an identified need for CRTs to be actualised, information about referral processes
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The clinical outcomes of crisis resolution teams Since their inception, CRTs have achieved widespread changes to the way psychiatric community care is provided and occupy a unique role within the mental health system. They operate as a ward in the community by working with patients who would have traditionally been admitted
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to hospital and managing their treatment, with all its complexities, in a community setting. CRTs are ideally placed to enhance care for patients in crisis by working alongside their regular community care team and, crucially, providing timely responses to changing needs out of hours and at weekends. Within the hospital setting, CRTs provide a gate-keeping role by working alongside bed managers to screen patients presenting for admission and identify those in need of assessment for CRT intervention as an alternative to hospital admission. They also work closely with the inpatient wards to facilitate early discharge from hospital and reduce length of inpatient stay for those assessed as appropriate. It is essential for both inpatient and community systems to assimilate and work cohesively in order to achieve the maximal benefits for patients as well as the service (McCrone et al, 2007). There have been numerous studies into the effectiveness of CRTs in reducing inpatient admission rates (Johnson et al, 2005a; Keown et al, 2007; Jethwa et al, 2007; Barker et al, 2011). Glover et al (2006) found that over a 6-year period, the admissions rate fell by 23% across 226 PCTs, which although clinically relevant, certainly fell short of the Government’s expectation of 30%. However, data from 74 PCTs had to be discounted for being ambiguous or incomplete. Research suggests CRTs are cheaper to run (Burns et al, 1993; McCrone et al, 2009) and able to provide the same treatment as inpatient units (Johnson et al, 2007) leading to comparable treatment outcomes as reported by Smyth and Hoult (2000). They are preferred by patients and relatives (Johnson, 2004; Johnson et al, 2005b; Joy et al, 2006; Barker et al, 2011) and give overall higher staff satisfaction (Minghella et al, 1998; Nelson et al, 2009). Audini et al (1994) found in their study that CRT services facilitated an 80% decrease in the duration of admissions. Furthermore, Hoult (2006) reported evidence that such reductions were sustainable in the long term. Despite these numerous positive outcomes, there is also evidence to the contrary: a study by Jacobs and Barrenho (2011) showed that there was little indication that CRTs reduce admission rates. Tyrer et al (2010) agreed with these findings and found that along with a fall in informal admissions there was a concurrent increase in admissions under detention. A study by Kingsford and Webber (2010) shows that CRTs are associated with a less successful outcome for patients in deprived areas. Uddin and Byrt (2007) stated that CRTs should do more to aid social inclusion and Tyrer et al (2010) found that CRTs fared no better than wards in the areas of patient satisfaction and quality of care. Gilbody et al (2003) concluded that there is an overall need for mental health policy to focus more on improving patients’ functional wellbeing. Johnson et al (2005b) found that clear evidence of the effectiveness of CRTs is limited by the lack of randomised controlled trials (RCTs). However, Slade and Priebe (2012) found that such methods were ineffective within health care, with researchers unable to use them to garner adequate information. Given the complexities of providing treatment to patients with mental illness, conducting research through the use of RCTs may be morally and ethically inappropriate. Joy et al (2006) felt that some of the more negative opinion of
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and patient suitability were lacking. Training provision on how to set up and manage the teams varied nationwide with no consistency of training provider. Onyett et al (2006) found in their national survey of CRTs that formal training was only received by 52% of their respondents, 86 teams, and mostly run by The Sainsbury Centre for Mental Health. The most common training need identified by staff was in the area of crisis-intervention skills. However, as Lakhani (2006) found, the provision of such training proved challenging and its effect on the delivery of care remains uncertain. Therefore a balance must be sought between the rigidity of expectation to conform to national standards and allowing trusts the freedom to develop services that meet local demand. The Sainsbury Centre for Mental Health (2001a) felt that in order for CRTs to be fully functional they must be adequately implemented. The Government set up the NHS modernisation board to supervise implementing the NHS Plan, which highlighted some initial concerns. The first annual report (DH, 2002) found that aims for achieving 24-hour access to care were in jeopardy and interventions might be needed to ensure success. However, a further report in 2003 stated that 62 CRTs had been set up by that point and the aim of creating 335 teams by 2004 was likely to be realised (DH, 2003). The NHS Plan implementation programme (DH, 2000b) was developed to provide guidance and targets on the implementation of the NHS Plan nationally and locally. It advocated a working partnership with staff and service users to create a tailor-made service. There were no explicit targets for implementing CRTs. However, the DH published further advice in 2001, in the form of the Mental Health Policy Implementation Guide. This offered advice to dedicated local implementation teams (LITs) to guide delivery in their own area. It outlined specific features of CRTs and made it clear that these frameworks should be adapted to local population needs. However, this lack of clarity can be seen as a failure. Holloway (2002) found reports that some LITs were financially favouring CRTs over established teams. Several other barriers to successful implementation were identified by Onyett et al (2008), such as staff shortages, absence of support from a psychiatrist and lack of money. Despite these issues the National Audit Office (2007) reported that CRTs were rapidly realised across the country and the NHS Plan target of 335 teams nationwide was achieved by 2005. However, the goal of 100 000 treatment episodes per year was not reached, and at the time of the report the total stood at 95 397. The National Audit Office also found that CRTs were not operating at their optimum due to a number of issues such as management arrangements, limitations in providing 24-hour care, or referrers not understanding the remit of CRTs, and that there was scope to improve facilitating early discharges.
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n In
the 1990s, there were concerns over the perceived and actual risk patients posed to the public by psychiatric community care, leading to government policy focusing on 24-hour access to mental health services
n The
National Service Framework (NFS) for Mental Health and NHS Plan set out ambitious targets for an overhaul of mental health provision
n This
overhaul included targets for access to crisis resolution team (CRT) services, with the aim of averting inpatient admissions or facilitating early discharge from hospital
n It
has now been over a decade since the introduction of the NSF and NHS Plan—measuring the success of these policies, and the CRT model, will depend on which viewpoint is taken
CRTs merely reflected the opposing views of the researchers instead of an objective evaluation of the issues. Another aspect for consideration is whether CRT input fully averted an inpatient stay or merely served to prolong an inevitable admission. Harrison et al (2001) found that 20% of patients accepted to the crisis team were later transferred to an inpatient unit and Johnson et al (2005b) found that 60% were admitted to an inpatient unit following CRT intervention. Kingsford and Webber (2010) hypothesised that if CRTs are unsuccessful, this could lead to the patient’s health declining to the point of needing an assessment under the Mental Health Act. Within the ever-changing landscape of the NHS, it is essential for staff to constantly evolve and adjust in order to continue delivering a high standard of care. However, it is not always easy to change established practices.The introduction of CRTs precipitated a departure from the traditional roles of some professionals, with greater responsibility for decision making being placed on nursing staff. The National Audit Office (2007) hypothesised that risk aversion can influence a decision to use CRT services, as patients stepping down from a ward to the community would receive less supervision. To counteract this, Lester and Glasby (2006) advocate cohesive working between teams with an emphasis on greater understanding.
Contemporary issues It has now been over a decade since the introduction of the NSF and NHS Plan. Measuring the success of these policies will depend on which viewpoint is taken. The Government, clinicians, patients and the many others involved in the realm of mental health will all have different criteria by which to measure positive outcomes. Certainly the introduction of the NSF and NHS Plan has changed the landscape of community mental health care. For patients, the introduction of CRTs has been positive as it has introduced more choice into a system that has traditionally been seen as authoritarian in its approach to treatment. However, Naylor and Bell (2010) identified that there is still an issue of over-use of acute mental health beds, which varies nationally. They concluded that there is still scope to improve further CRT productivity. Hoult (2006) felt that in order to maximise productivity, CRTs must improve their gate-keeping role by assessing all
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patients in need of hospital admission. If achieved, this has the potential to save the NHS £132 million a year (McCrone et al, 2007), though an increase in workload would lead to additional demands on resources at a time when budgets are being tightened. With the current coalition government having ushered in an era of austerity, the NHS has to make around £20 billion in savings. Recent reports show that spending on mental health accounts for 11% of the overall budget (Harker, 2012) and means that services will have to make a significant contribution to the savings target (Naylor and Bell, 2010). The National Survey of Investment in Adult Mental Health Services 2011/12 (Mental Health Strategies, 2012) shows that investment in adult mental health services decreased by 1% during the rated period. Also, for the first time, investment in CRTs has decreased by 4.3%, despite an increase in activity year on year. This translates, on a local level, to reduced services and staffing levels. A recent study by Mind (2012) found only 39% of the trusts surveyed were available to patients 24 hours a day. There are some current concerns regarding GP commissioning, with patients feeling their views are not sought or valued (Rethink Mental Illness, 2013) and GPs often feeling they lack experience with mental health issues (Mental Health Foundation, 2011). With almost 25% of GP contacts relating to mental health issues (Mental Health Strategic Partnership, 2011), the new commissioning boards will need to procure the necessary expertise to ensure this vulnerable area of health is not neglected. These findings have shown that providing cost-effective choices for mental health patients experiencing crises in the community is a complex area of health policy. There are no easy answers and implementing strategies that will work countrywide on such diverse populations is not without its issues. The latest policy No Health Without Mental Health (DH, 2011) shows there is still a need for 24-hour access to care in the least restrictive environment, to provide choice and ensure equality of access. They have also recognised the improvements brought about by specialised community mental health services. Despite some difficulties and inconsistent results overall it is felt that CRT services have been successfully implemented, according to the original Department of Health specifications, and a fall in admission rates has been sustained (Sjølie et al, 2010). Given the continued need for high-quality mental health care on limited resources, it may be prudent for services to focus on identifying the best value interventions without compromising patient care. There may also be the potential to develop other alternatives to hospital admission, such as crisis houses, possibly in conjunction with the private sector initiatives. Whatever the future may hold, CRTs are now fully established as an integral part of the community mental BJN health system. Conflict of interest: none Alimo-Metcalfe B, Alban-Metcalfe J, Samele C et al (2007) The impact of leadership factors in implementing change incomplex health and social care environments: NHS Plan clinical priority for mental health crises resolution teams. http://tinyurl.com/q48ckx6 (accessed 4 Febuary 2014) Audini B, Marks IM, Lawrence RE, Connolly J, Watts V (1994) Home based versus outpatient/in-patient care for people with serious mental illness. Phase
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KEY POINTS
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The National Service Framework (NSF) for Mental Health in 1999 was central to the modernisation of mental health services under the New Labour government of 1997. It placed an emphasis on universal clinical standards and set out a vision for service developments over the next 10 years. One such proposal was the development of crisis resolution teams, aimed at reducing the psychiatric admissions rate by providing care at home. This article provides a critical analysis of policies relating to the provision of 24-hour access to mental health services, focusing on the specifications for creating crisis resolution teams, as laid out in the NSF for Mental Health and the NHS Plan. First, it looks at the historical context surrounding the policy, examining the content of the NSF and NHS plan and how policy was disseminated and implemented nationally and locally. Then it examines the effects and changes this policy brought about and, specifically, whether it has achieved its aims of reducing the nationwide acute psychiatric inpatient admission rate. Key words: NHS policy ■ National Service Framework ■ NHS Plan ■ Mental health ■ Crisis resolution teams
W
hen the New Labour government took power in 1997 it heralded a prodigious shift in the focus of health policy for mental health services. It promised to modernise and unify provision for mental health care through the white paper, Modernising Mental Health Services: Safe, sound and supportive (Department of Health (DH), 1998), which highlighted a need for 24-hour access to mental health services. These proposals were later expanded and developed into the National Service Framework (NSF) for Mental Health (DH, 1999) and the NHS Plan (DH, 2000a). With these policies the Labour government sought to strengthen and reform the NHS by standardising the quality and delivery of mental health care countrywide (Klein, 1999; Tyrer, 1999; Fatchett, 2012) based on sound evidence (DH, 2001; Burns and Catty, 2002) and pledged to increase funding significantly to achieve these aims.
Historical context The concept of 24-hour access in mental health care is not new. Since the 1950s there had been widespread dissatisfaction Katie Loader is Community Mental Health Nurse at Gordon Hospital, Bloomburg Street, London Accepted for publication: January 2014
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with long-stay psychiatric institutions (Freshwater and Cahill, 2011). Chronic underfunding and a growing understanding that institutionalisation can be harmful (Claassen and Priebe, 2010) led to many such asylums being closed down. Pharmacological advances led to the development of more effective drugs that could be used to treat patients in a local setting (Sainsbury Centre for Mental Health, 2001a; Caldas de Almeida and Killaspy, 2011). During the 1970s, in the context of a struggling economy and social unrest, the provision of health care was becoming increasingly expensive, and further credence was given to the concept of community care being more financially viable for the NHS. However, it was not until the 1980s—when there were increasing concerns about the quality of care for patients with severe and enduring mental illnesses—that Margaret Thatcher politically pursued community care as a policy agenda. The Griffiths Report (Community Care: Agenda for Action, Department of Health and Social Security (DHSS), 1988) highlighted that, so far, community care had failed due to a lack of clear leadership. This led to a government white paper, Caring for People: Community care in the next decade and beyond (DHSS, 1989) and eventually the Community Care Act 1990. However, psychiatric community care led to many concerns over the perceived and actual risk patients posed to the public. High-profile cases of patients harming members of the public, widely reported in the media, highlighted concerns that patients were slipping through the net, with inadequate follow-up and lack of communication between agencies (Salter and Turner, 2008). The British Medical Association (BMA) (1992) at the time also raised the issue of the ability of local authorities to support mental health patients in the community. The proximity of mentally ill people in the community and the representation of such patients in the media fuelled public concern. This galvanised government response (Avery, 2012), prompting a re-evaluation of mental health policy (Means et al, 2008). In 1998 Frank Dobson, then Health Secretary, remarked that care in the community had been unsuccessful (Warden, 1998), paving the way for an overhaul of mental health legislation. Under the previous government, investing in mental health care had been impeded by the economic situation of the time, leading to contrasting levels of care nationwide (Ham, 2009). The Sainsbury Centre for Mental Health (2001b) found that before implementing the policies governing 24-hour access to care, there were only a small number of practising crisis teams. Minghella et al (1998) identified that these services had been slow to develop due to
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Katie Loader
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MENTAL HEALTH lack of guidance as to how to develop the teams. Klein (1999) believed that services benefited the interests of the NHS as opposed to the needs of the patient.
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NSFs and the NHS Plan The NSF for Mental Health was an ambitious 10-year plan set out by the DH. Its purpose was to set national, evidence-based standards for mental health services. A year later, in July 2000, the NHS Plan was published; it outlined the expectations of what services should deliver. The overall aim was to provide financial investment for a radical reform of the health service, which should pivot around the needs of the patient, providing choice by extending and creating services all based on universal standards of care. Part 14 of the NHS Plan, ‘Clinical priorities’, followed on from the NSF requirement to provide 24-hour access to care by stipulating that within 4 years all patients would have access to crisis resolution team (CRT) services by creating 335 teams nationwide. The objective was to treat around 100 000 patients per year in the community by averting an inpatient admission or facilitating early discharge from hospital and, furthermore, to reduce inpatient admissions by 30%. Bebbington et al (2013) stated that the NSF was created to reduce avoidable inpatient admissions and The Sainsbury Centre for Mental Health (2001a) described the NSF and NHS Plan as an inclusive set of policies, aiming to promote mental health issues, and backed by an increase in available spending. The Government pledged to invest over £300 million to realise its ambitions. However, it was not clear within the plan whether the resources available could meet such progressive targets (Means et al, 2008) and Klein (1999) believed that the Government was intensifying pressure on the NHS by increasing demand and public expectation. Hudson (2005) praised Government efforts to advance mental health care but believed the incentive was to reduce costs rather than improve care. It was also felt that the focus of the policies was what the Government, not the patient, would gain from the investment (Lester and Glasby, 2006) and that if targets were not met it could be politically damaging for the Government (Klein,1999). The NHS Plan was widely welcomed as a vehicle for change, to improve the quality of care delivered within the NHS (Holloway, 2002). Preparation for its publication involved a public consultation, as the vision was for the NHS to reflect the desires of the patients (Overshott et al, 2007) and staff (Dixon and Dewar, 2000). An external reference group that included patients, professionals and carers was set up to advise the Government on the composition of the central policies and core objectives of mental health care, which were to be available when needed and to offer alternatives to admission (Thornicroft, 2000). The professional component researched the evidence base, which formed the foundations of the new policy (Dobson, 1999). In contrast, some researchers (Tyrer, 1999; Alimo-Metcalfe et al, 2007; Tyrer et al, 2010) commented on the lack of clear evidence that 24-hour access to services improves outcomes for patients. Indeed, Minghella et al (1998) reported that if community mental health services were appropriately run, there would be no need for 24-hour provision and that the care needs of patients in crisis could usually be accommodated within
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Box 1. Key policies in the development of 24-hour access to mental health services ■■ Modernising
Mental Health services: Safe, sound, supportive (DH, 1998) Service Framework for Mental Health: Modern standards and service models (DH, 1999) ■■ NHS Plan: A plan for investment, a plan for reform (DH, 2000) ■■ NHS Plan implementation programme (DH, 2000) ■■ Mental health policy implementation guide (DH, 2001) ■■ National
Box 2. Specifications for creating crisis resolution teams from the NSF for mental health (DH, 1999) and NHS Plan (DH, 2000) ■■ Aim
– To provide consistent 24-hour access to mental health services, by providing treatment at home, aimed at those patients with severe and enduring mental health illnesses ■■ Investment – £300 million extra annual investment by 2003/2004 ■■ Services – Create 335 new crisis resolution teams by 2003 ■ 24-hour access to psychiatric care by 2004 ■ Treat 100 000 patients annually ■ Reduce psychiatric inpatient admissions by 30% ■ Reduction in unnecessary out-of-area admissions Core features of a crisis resolution team ■■ Accessible
24 hours a day, 7 days a week patients aged 16–65 with severe mental illness ■■ Cover a population of approximately 150 000 ■■ Carry a caseload of 20–30 patients ■■ 14 members of multidisciplinary staff with 24-hour access to senior psychiatrist ■■ Prompt assessment following referral (recommendations state within 1 hour) ■■ Focused and intensive support while in crisis ■■ Active engagement of service user, families/carers ■■ Assertive involvement ■■ Time-limited, flexible interventions ■■ Remaining involved until the crisis resolves ■■ Signpost to appropriate services ■■ Involvement in planning early discharge when hospitalisation is necessary ■■ Relapse prevention planning ■■ Gate-keeping role ■■ For
(DH, 2001)
daytime hours. Pelosi and Jackson (2000) felt that GP services already played a significant role in providing containment for mental health patients in the community and advocated strengthening established services instead of creating new ones. Burns (2000) agreed with this, believing also that the work of CRTs replicated that of community mental health teams (CMHTs). CRTs have also been criticised for diverting money away from traditional CMHTs (Pelosi and Jackson, 2000; St John-Smith et al, 2009).
Policy implementation and dissemination The key to a policy’s success is a thorough working knowledge of the local population and professional arrangement it will affect (Minghella and Ford, 1997; Kelly et al, 2004). Thornicroft and Reynolds (2007) described the NSF as both requisite and liberal, allowing trusts flexibility in developing services to reflect the framework and local needs. However, there were difficulties in implementing the policies. Harrison et al (2001) found that, although there was an identified need for CRTs to be actualised, information about referral processes
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The clinical outcomes of crisis resolution teams Since their inception, CRTs have achieved widespread changes to the way psychiatric community care is provided and occupy a unique role within the mental health system. They operate as a ward in the community by working with patients who would have traditionally been admitted
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to hospital and managing their treatment, with all its complexities, in a community setting. CRTs are ideally placed to enhance care for patients in crisis by working alongside their regular community care team and, crucially, providing timely responses to changing needs out of hours and at weekends. Within the hospital setting, CRTs provide a gate-keeping role by working alongside bed managers to screen patients presenting for admission and identify those in need of assessment for CRT intervention as an alternative to hospital admission. They also work closely with the inpatient wards to facilitate early discharge from hospital and reduce length of inpatient stay for those assessed as appropriate. It is essential for both inpatient and community systems to assimilate and work cohesively in order to achieve the maximal benefits for patients as well as the service (McCrone et al, 2007). There have been numerous studies into the effectiveness of CRTs in reducing inpatient admission rates (Johnson et al, 2005a; Keown et al, 2007; Jethwa et al, 2007; Barker et al, 2011). Glover et al (2006) found that over a 6-year period, the admissions rate fell by 23% across 226 PCTs, which although clinically relevant, certainly fell short of the Government’s expectation of 30%. However, data from 74 PCTs had to be discounted for being ambiguous or incomplete. Research suggests CRTs are cheaper to run (Burns et al, 1993; McCrone et al, 2009) and able to provide the same treatment as inpatient units (Johnson et al, 2007) leading to comparable treatment outcomes as reported by Smyth and Hoult (2000). They are preferred by patients and relatives (Johnson, 2004; Johnson et al, 2005b; Joy et al, 2006; Barker et al, 2011) and give overall higher staff satisfaction (Minghella et al, 1998; Nelson et al, 2009). Audini et al (1994) found in their study that CRT services facilitated an 80% decrease in the duration of admissions. Furthermore, Hoult (2006) reported evidence that such reductions were sustainable in the long term. Despite these numerous positive outcomes, there is also evidence to the contrary: a study by Jacobs and Barrenho (2011) showed that there was little indication that CRTs reduce admission rates. Tyrer et al (2010) agreed with these findings and found that along with a fall in informal admissions there was a concurrent increase in admissions under detention. A study by Kingsford and Webber (2010) shows that CRTs are associated with a less successful outcome for patients in deprived areas. Uddin and Byrt (2007) stated that CRTs should do more to aid social inclusion and Tyrer et al (2010) found that CRTs fared no better than wards in the areas of patient satisfaction and quality of care. Gilbody et al (2003) concluded that there is an overall need for mental health policy to focus more on improving patients’ functional wellbeing. Johnson et al (2005b) found that clear evidence of the effectiveness of CRTs is limited by the lack of randomised controlled trials (RCTs). However, Slade and Priebe (2012) found that such methods were ineffective within health care, with researchers unable to use them to garner adequate information. Given the complexities of providing treatment to patients with mental illness, conducting research through the use of RCTs may be morally and ethically inappropriate. Joy et al (2006) felt that some of the more negative opinion of
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and patient suitability were lacking. Training provision on how to set up and manage the teams varied nationwide with no consistency of training provider. Onyett et al (2006) found in their national survey of CRTs that formal training was only received by 52% of their respondents, 86 teams, and mostly run by The Sainsbury Centre for Mental Health. The most common training need identified by staff was in the area of crisis-intervention skills. However, as Lakhani (2006) found, the provision of such training proved challenging and its effect on the delivery of care remains uncertain. Therefore a balance must be sought between the rigidity of expectation to conform to national standards and allowing trusts the freedom to develop services that meet local demand. The Sainsbury Centre for Mental Health (2001a) felt that in order for CRTs to be fully functional they must be adequately implemented. The Government set up the NHS modernisation board to supervise implementing the NHS Plan, which highlighted some initial concerns. The first annual report (DH, 2002) found that aims for achieving 24-hour access to care were in jeopardy and interventions might be needed to ensure success. However, a further report in 2003 stated that 62 CRTs had been set up by that point and the aim of creating 335 teams by 2004 was likely to be realised (DH, 2003). The NHS Plan implementation programme (DH, 2000b) was developed to provide guidance and targets on the implementation of the NHS Plan nationally and locally. It advocated a working partnership with staff and service users to create a tailor-made service. There were no explicit targets for implementing CRTs. However, the DH published further advice in 2001, in the form of the Mental Health Policy Implementation Guide. This offered advice to dedicated local implementation teams (LITs) to guide delivery in their own area. It outlined specific features of CRTs and made it clear that these frameworks should be adapted to local population needs. However, this lack of clarity can be seen as a failure. Holloway (2002) found reports that some LITs were financially favouring CRTs over established teams. Several other barriers to successful implementation were identified by Onyett et al (2008), such as staff shortages, absence of support from a psychiatrist and lack of money. Despite these issues the National Audit Office (2007) reported that CRTs were rapidly realised across the country and the NHS Plan target of 335 teams nationwide was achieved by 2005. However, the goal of 100 000 treatment episodes per year was not reached, and at the time of the report the total stood at 95 397. The National Audit Office also found that CRTs were not operating at their optimum due to a number of issues such as management arrangements, limitations in providing 24-hour care, or referrers not understanding the remit of CRTs, and that there was scope to improve facilitating early discharges.
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n In
the 1990s, there were concerns over the perceived and actual risk patients posed to the public by psychiatric community care, leading to government policy focusing on 24-hour access to mental health services
n The
National Service Framework (NFS) for Mental Health and NHS Plan set out ambitious targets for an overhaul of mental health provision
n This
overhaul included targets for access to crisis resolution team (CRT) services, with the aim of averting inpatient admissions or facilitating early discharge from hospital
n It
has now been over a decade since the introduction of the NSF and NHS Plan—measuring the success of these policies, and the CRT model, will depend on which viewpoint is taken
CRTs merely reflected the opposing views of the researchers instead of an objective evaluation of the issues. Another aspect for consideration is whether CRT input fully averted an inpatient stay or merely served to prolong an inevitable admission. Harrison et al (2001) found that 20% of patients accepted to the crisis team were later transferred to an inpatient unit and Johnson et al (2005b) found that 60% were admitted to an inpatient unit following CRT intervention. Kingsford and Webber (2010) hypothesised that if CRTs are unsuccessful, this could lead to the patient’s health declining to the point of needing an assessment under the Mental Health Act. Within the ever-changing landscape of the NHS, it is essential for staff to constantly evolve and adjust in order to continue delivering a high standard of care. However, it is not always easy to change established practices.The introduction of CRTs precipitated a departure from the traditional roles of some professionals, with greater responsibility for decision making being placed on nursing staff. The National Audit Office (2007) hypothesised that risk aversion can influence a decision to use CRT services, as patients stepping down from a ward to the community would receive less supervision. To counteract this, Lester and Glasby (2006) advocate cohesive working between teams with an emphasis on greater understanding.
Contemporary issues It has now been over a decade since the introduction of the NSF and NHS Plan. Measuring the success of these policies will depend on which viewpoint is taken. The Government, clinicians, patients and the many others involved in the realm of mental health will all have different criteria by which to measure positive outcomes. Certainly the introduction of the NSF and NHS Plan has changed the landscape of community mental health care. For patients, the introduction of CRTs has been positive as it has introduced more choice into a system that has traditionally been seen as authoritarian in its approach to treatment. However, Naylor and Bell (2010) identified that there is still an issue of over-use of acute mental health beds, which varies nationally. They concluded that there is still scope to improve further CRT productivity. Hoult (2006) felt that in order to maximise productivity, CRTs must improve their gate-keeping role by assessing all
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patients in need of hospital admission. If achieved, this has the potential to save the NHS £132 million a year (McCrone et al, 2007), though an increase in workload would lead to additional demands on resources at a time when budgets are being tightened. With the current coalition government having ushered in an era of austerity, the NHS has to make around £20 billion in savings. Recent reports show that spending on mental health accounts for 11% of the overall budget (Harker, 2012) and means that services will have to make a significant contribution to the savings target (Naylor and Bell, 2010). The National Survey of Investment in Adult Mental Health Services 2011/12 (Mental Health Strategies, 2012) shows that investment in adult mental health services decreased by 1% during the rated period. Also, for the first time, investment in CRTs has decreased by 4.3%, despite an increase in activity year on year. This translates, on a local level, to reduced services and staffing levels. A recent study by Mind (2012) found only 39% of the trusts surveyed were available to patients 24 hours a day. There are some current concerns regarding GP commissioning, with patients feeling their views are not sought or valued (Rethink Mental Illness, 2013) and GPs often feeling they lack experience with mental health issues (Mental Health Foundation, 2011). With almost 25% of GP contacts relating to mental health issues (Mental Health Strategic Partnership, 2011), the new commissioning boards will need to procure the necessary expertise to ensure this vulnerable area of health is not neglected. These findings have shown that providing cost-effective choices for mental health patients experiencing crises in the community is a complex area of health policy. There are no easy answers and implementing strategies that will work countrywide on such diverse populations is not without its issues. The latest policy No Health Without Mental Health (DH, 2011) shows there is still a need for 24-hour access to care in the least restrictive environment, to provide choice and ensure equality of access. They have also recognised the improvements brought about by specialised community mental health services. Despite some difficulties and inconsistent results overall it is felt that CRT services have been successfully implemented, according to the original Department of Health specifications, and a fall in admission rates has been sustained (Sjølie et al, 2010). Given the continued need for high-quality mental health care on limited resources, it may be prudent for services to focus on identifying the best value interventions without compromising patient care. There may also be the potential to develop other alternatives to hospital admission, such as crisis houses, possibly in conjunction with the private sector initiatives. Whatever the future may hold, CRTs are now fully established as an integral part of the community mental BJN health system. Conflict of interest: none Alimo-Metcalfe B, Alban-Metcalfe J, Samele C et al (2007) The impact of leadership factors in implementing change incomplex health and social care environments: NHS Plan clinical priority for mental health crises resolution teams. http://tinyurl.com/q48ckx6 (accessed 4 Febuary 2014) Audini B, Marks IM, Lawrence RE, Connolly J, Watts V (1994) Home based versus outpatient/in-patient care for people with serious mental illness. Phase
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KEY POINTS
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