Right on time

Early intervention and crisis resolution work with psychiatric patients are increasingly seen as ways to prevent unnecessary hospital stays - and they can prevent conditions becoming worse than they need to be, says Emma Forrest

The national service framework for mental health announced wholesale modernisation of services.A key part was an emphasis on providing care in a community setting and avoiding admission to hospital.

Two models which strongly adhere to this ethos are early intervention and crisis resolution teams. Both have targets for the numbers of teams to be in place by the end of this year: 50 early intervention services, each serving a population of 1 million, and 330 crisis resolution teams.

Concerns that neither target will be met have already been voiced (news focus, page 12, 23 October 2003; mental health, page 36, 26 February), yet trusts across the country are putting into place intensive and convention-challenging services.

'Early intervention teams mean you have to start thinking differently about how to manage young people with psychosis, ' says Northern Centre for Mental Health former chief executive Professor Martin Brown.

'It is often that people only access services after diagnosis, which can lead to them becoming more ill than they could have been.

'It is also key to look at the service as a whole to stop mental health becoming a secondary service that takes referrals from GPs. Conventionally, by the time someone accesses mental health services it is likely that they will have a fairly well-formed psychosis, ' he adds.

Those working in the service echo his views. 'We work from symptoms, not diagnosis. If a diagnosis has been made longer than 12 months ago we will not take them on because the chances are they will have been kicking around in the system for some time before that, ' says Ruth Marriott, deputy director of Plymouth's youth access service, which includes an early intervention team.

The team, in common with others around the country, was set up after research alerted the local mental health trust to patients, likely to be aged 18-25, who were failing to link up with mental health services.

Max Birchwood, professor of mental health at Birmingham University and director of the Birmingham and Solihull early intervention team - which set the model for the Department of Health's policy implementation guide on early intervention - explains: 'Incidence of psychosis is often at around 16 years old, just the age where the transition between child and adolescent services to adult services takes place, and so people slip between them. The early years are critical. Psychosis does not have to be a long-term deteriorating condition. The outcome after two or three years can predict the outcome after 10 or 15 years.

'Historically, this is a group that has consumed vast amounts of resources, is prone to self-harm and has a high rate of readmission. Prevention of suicide and readmission is a high priority. This is about them accessing the right part of the service.'

Early intervention services are often far removed from a traditional mental health model. Accessibility is key.

Ms Marriott says: 'It was decided to locate the [early intervention] service in the youth enquiry service because at that point it had been set up for 10 years and was well known in the city.'

'We work with the client for two years. It is a holistic, psycho-social and developmental youth approach.'

If a client has practical problems, such as housing, the service will deal with them too.

At Hull and East Riding community trust, early intervention project lead Kate Macdonald explains that the team looks at the context in which an individual is experiencing psychotic symptoms, 'not just what is going on in their head'.

The team has a joint post with youth service Connexions, and is working with schools and colleges to train teachers to help young people who may be exhibiting early signs of psychosis.

Active health promotion around psychosis is planned.

Meanwhile, Ms Macdonald is using her contacts as a part-time snowboarding coach to gain clients free snowboarding lessons at a local ski centre.

'It means they are not smoking or drinking and are getting some exercise and interacting socially. It also gives us a chance to see how they interact with others and if their medication has affected their movements.'

Criteria for diagnosis at Birmingham and Solihull are broad, as psychosis 'does not present itself in neat packages', says Professor Birchwood. 'You have to be flexible. Some clients we try to stabilise and improve the quality of life, some we try to prevent getting any worse.'

All advocates of early intervention teams champion the psycho-social model, which as well as more unusual exploits like the snowboarding may simply involve going out for a pizza with a client. Professor Brown emphasises that psycho-social models of care are carefully designed and that their impact on the user and carers cannot be underestimated: 'There are lots of things of things that can reduce the number of people needing long-term care and treatment. It is about having the human contact, just having someone to talk to so they do not have to cope on their own.'

As yet, enough evidence to support the belief that early intervention will prevent future admissions is not available in the UK, although studies are under way and Professor Brown is confident this will be proven.

'Looking at a recovery model is one of the aims of early intervention.One-third of clients will only have one episode and we refer a lot of our clients straight back to their GP.We do not want young people and their families giving up on their hopes and dreams. There are few positive stories around diagnoses of schizophrenia but if long-term access to services is needed then they should feel OK about it, ' says Ms Marriott.

Nurse consultant Stephen Niemiec is assistant director of nursing for Newcastle, North Tyneside and Northumberland Mental Health trust and runs the trust's crisis team.He is adamant that crisis services should adhere to the following principles: 'They should operate 24/7 and be in an urban situation, consist of a multidisciplinary team and gate-keep the inpatient beds. Teams also need to be mobile; do not expect people to come to you. And the team should stay involved until the crisis is over.'

Although the teams from both Newcastle, North Tyneside and Northumberland and North Birmingham trusts are frequently imitated, services vary according to size and needs of population, but one thing is clear: crisis teams must offer an alternative to hospital admission. Referrals to Mr Niemiec's team come from a number of sources: 'anyone capable of making a cursory assessment', according to Mr Niemiec, such as GPs, the police, social workers and community mental health teams. They are divided equally between clients with a history of accessing mental health services, and those that are new to them.

The Newcastle model of care is an intensive one. 'We might see people three times a day, ' says Mr Niemiec. 'It can be as simple as getting the gas turned on or getting some food in.We may help them get out of bed and ready for the day, or be there when they take their medication. They will be spending hours at a time with an experienced clinician; quite different to being in an inpatient ward.'

Although he acknowledges that the evidence base is not as substantial as it could be, Sainsbury Centre for Mental Health crisis lead Pat McGlynn argues that reduction in bed use at trusts with established crisis teams should not be underestimated. Reductions of up to 50 per cent have been recorded.At Newcastle, inpatient bed use has reduced by 40 per cent.

The large population served by Mr Niemie's team means that it provides a referral service.As Mr Niemiec explains, one person's idea of a crisis varies from another's, and the service would be overwhelmed if clients were able to walk in.On average, a client will remain with the team for five or six weeks, although they have been on the books for as long as three months.

'We want to restore people to their pre-crisis levels of functioning.We also want to see if we can improve resistance to any future crisis by improving their coping capacity and developing a coping style.'

But Mr McGlynn has concerns that crisis teams may be stretched by other responsibilities.

'In areas without accident and emergency liaison teams, they may become wrapped up in working with people in accident and emergency who may not be the most needy. Crisis teams should not spend all their time making diagnoses. It is about working with those that are at most risk of hospitalisation. Not necessarily today, but next week or in three weeks.'

He also has doubts about crisis teams that do not offer a 24/7 service. 'Resources may mean your service is limited to overnight on-call duties, rather than a series of shifts, and a cost-effective decision has to be made. But you can't provide a true gatekeeping role unless you are 24/7.Once someone has been admitted to hospital, it is difficult to get them out. It is much better to stop them being admitted in the first place.'

Further information

Mental health policy implementation guide www. publications. doh. gov. uk/mentalhealth/imp lementation guide. htm

Key points

Early intervention and crisis teams aim to prevent admission to inpatient services.

Early intervention is often far removed from the traditional mental health model - accessibility is key.

Crisis teams should be mobile, multidisciplinary and remain in contact with users until the crisis is resolved.