STAND BY YOUR BEDS

Published: 15/09/2005, Volume II5, No. 5973 Page 29 31

Crisis resolution teams were meant to be a means of reducing bed use in mental health, but they are under great pressure to perform - or face extinction. Emma Forrest reports

When a new look for mental health services was outlined in the NHS plan and the national service framework for mental health, the emphasis on community teams was clear.

Among the newcomers were crisis resolution teams. Also known as home treatment teams, they were set up for one purpose: to treat people who did not need to be in hospital in another setting, preferably their home.

This national emphasis came about after a clutch of pioneer teams found the approach reduced bed use and gained the approval of service users. The government wanted 335 teams to be set up by the end of last year.

Unfortunately, new figures show conflicting results. The Department of Health says 343 teams were established by the end of 2004, but Durham Mapping Service, which tracks mental health services across the country, says there are 267.

Durham says one reason for this discrepancy may be how the teams are being measured. The DoH's mental health policy implementation guide set out guidelines for team numbers; if a team is especially well staffed it may be counted as the equivalent of two teams.

But one thing is certain: team managers say staffing a crisis team can be difficult, despite claims that crisis staff are regularly poached from inpatient units.

'The biggest issue for me has been recruitment, ' says Bob Bowers, manager of Bedfordshire and Luton Community trust's crisis team, which was set up late last year with an initial staff of three. 'There are 300 teams all fishing for the same number of experienced people, ' he adds. Managers say recruitment can be particularly difficult when a neighbouring trust or patch is setting up its own teams because of the small pool of relevant candidates.

Crisis resolution teams work in a way that is still relatively new. Their mantra is 'hospitalisation is the last option'.

Before going out to assess a potential client, the team will gather as much information as possible and aim to identify what the client wants from the service and what their needs are. Clients should receive an assessment visit from staff working as a pair within a matter of hours.

'We can see people at home, or we can pick them up from accident and emergency, GP surgeries and police stations, ' says Tim Colman, manager of Leicestershire Partnership trust's Leicester City crisis team.

After an initial assessment a client may be visited up to three times a day, seven days a week if they are thought unwell enough.

Team members will carry out a mixture of interventions, including work on helping the client recognise the potential for future crises. They will also help with personal and social issues, such as making sure there is food in the fridge and that bills have been paid. If someone is having housing problems, for example, staff can make representations to the housing department with them.

This level of intensity can last for days or weeks, with the number of visits gradually being reduced.

The whole crisis team will meet daily, usually at every shift change, to discuss every client.

'We offer the care they could have in hospital without being in hospital, ' says Mr Bowers. 'We have managed to keep some very unwell people out of hospital.' Seeing someone in their own surroundings is far more natural for clients than a hospital environment. And if their home is considered unsuitable, the team will arrange for the client to stay with friends, relatives or in respite accommodation. Teams may even place someone in a hotel or bed and breakfast for a few days, funding permitting, if a lack of any other suitable accommodation would result in clients being admitted to hospital.

Another key issue for crisis resolution is the decision about whether someone should be admitted is shouldered by the whole team, regardless of background. This is in contrast to medical staff making the decision in inpatient care.

'My only concern when looking at staff is if they are going to be comfortable with the way we work, ' says Mr Bowers. 'They have to feel confident in making their own decisions and living with those decisions.' Mersey Care trust crisis teams project manager Peter Walmsley admits that having to adopt a new way of working can be difficult. 'It sounds an easy concept, but to work differently is challenging. Ways of communicating and shift patterns have to be different, ' he says.

The teams also have to deal with organisational challenges - negotiations with other community services, which are often concerned that their work is being taken away, or with clinicians accustomed to making their own decisions over whether someone should be admitted.

NIMHE eastern region programme manager for community teams Martin Flowers says it is important for teams to learn about managing risk outside traditional environments. 'They need to get away from the automatic response that when someone presents a risk they should be in hospital. It needs confidence. It is probably the hardest part of the job, ' he says.

It is no surprise, then, that gatekeeping of acute admissions has emerged as one of the biggest issues for new teams. It is something they cannot shy away from, says Sainsbury Centre for Mental Health lead on community teams Pat McGlynn.

'There is not enough evidence around to say that gatekeeping is essential, but efficient teams would say it is crucial, ' says Mr McGlynn. 'To have any impact, crisis teams must be involved in all admissions. But gatekeeping is not universal.' One manager, who does not want to be named, says: 'Gatekeeping is difficult because of the politics around who can access the beds.' Referrers must be educated about the process. GPs need to refer acute cases for assessment, while they, community teams and A&E mental health liaison services must not expect crisis teams to mop up all their non-acute as well as acute clients.

Another key issue is whether a service is available 24 hours a day, seven days a week. 'There is an even split across the country on teams having someone in the office at night or not. Some areas feel there is not sufficient demand for it but we feel we do, and it does help with response times, ' says Leicester City crisis team's Mr Colman. The decision to have team staff in place overnight was taken after admission patterns for local wards showed that two-thirds were being made outside standard working hours.

'Users need to be entitled to a service if they go into crisis after 9pm. If you are offering an alternative to hospitalisation, there is a need for round-the-clock access, ' says Mr Flowers.

However, financial constraints may render this impossible. At Bedford, for example, the team will start to provide 24-hour cover after 1 October, but will work on an on-call system, with staff based at home.

It seems that while trusts have responded to the call to set up teams, there are too many variations in the model suggested by the DoH (see box below).

Dr John Hoult is a consultant psychiatrist at North Essex Partnership trust, who also works for the National Institute for Mental Health in England, where he advises eastern region trusts on crisis teams. Dr Hoult believes half the country's teams are not following the model, with teams in some areas adhering to it in as little as 20 per cent of cases.

'It can be difficult to get people to understand some of the more important features of crisis teams and in getting newer teams to follow the model, ' he says. 'There are problems with funding and staffing that can mean teams are not working 24 hours. A lack of staff can also mean they cannot do it. But you have to make the extra effort and work with a patient until the problem is resolved, ' he adds. He fears some teams are not allowing time to get to know the client and their family, or do not see clients often enough.

It is also felt that some teams have been set up too quickly and are unable or unwilling to meet model requirements, says Mr McGlynn. 'Because of the target there has been pressure around establishing new teams but with clear differences in how they operate, ' he says. 'It sometimes feels as if they have been set up because they have to be, but with a feeling that it does not matter much what they look like.' Yet if teams continue to work inefficiently they will fail to meet one of the key requirements of a crisis team: reduced bed use. If that happens there is growing concern that trusts may start to pull the plug on funding.

'People will say it was just a fad and does not work in practice, ' says Dr Hoult. 'But bed use has been reduced by as much as 50 per cent in some areas; there is no reason why it should not be an effective way of working. If we can get at least half the teams across the country making some kind of impact, that will help get the message across.' A national audit of crisis teams, funded by the DoH, will shed light on the levels of good and bad practice. The results, expected early next year, should help to create pressure for change in teams not toeing the line on core issues such as 24-hour access and gatekeeping. They could also pinpoint areas for change.

'The current guidelines are based on an urban model, which may not suit rural areas and may exclude a number of people who do not fit the criteria, but who could benefit from these services. There could be arguments for changing some aspects of the guidelines, ' says Mr McGlynn.

'We need to ask if fidelity to a model stops people from innovating.' NIMHE is also planning to set up a national crisis forum for managers, and hold conferences to promote idea-swapping and build on the success of some local crisis forums.

In spite of arguably patchy performance, the new teams are far from a crisis of their own. 'It seems like common sense, ' says Mr Colman. 'I worked in inpatient wards for a long time and we used to say that what we needed was more out-ofhours community services. This should have been done years ago.' .

NEW WAYS OF WORKING IN NORFOLK

Although adherence to many parts of the crisis team model is considered essential, it is accepted that local adaptation is equally important.

In King's Lynn, West Norfolk primary care trust has established a crisis resolution service that combines community teams, an inpatient ward, home treatment, day services, social workers, accident and emergency assessment and a helpline. A single case co-ordinator looks after all of a client's care.

'The nature of the problems in this area meant a standalone home treatment did not make sense, ' says service manager Kay Ingram. The community team is at the centre and the crisis service is brought in if support is needed 'We wanted to make a difference to services, not just tick the box.' Bed numbers, bed use and length of stay have all been reduced since the service began in mid2004.

'We are picking people up sooner and are able to give greater support, ' adds Ms Ingram, who says that the support of lead clinician Dr Luke Ho and PCT director of mental health Jim Keown was key to helping staff feel they had ownership of the changes.

Staff working together across services is also a feature of Norfolk and Waveney Mental Health Partnership trust's Norwich City crisis resolution team, which has been integrated with two inpatient wards. In addition to taking referrals from the community, the crisis team also works with inpatients to see if they are suitable for home treatment.

Staff are often seconded from one area to the other and at night crisis team staff are based in the ward. At one point earlier this year one of the wards was closed because there was no need for it.

'At assessment stage we consider if someone needs acute services at all, and if offering home treatment is possible, ' says integrated acute services manager Pete Williams.

'Gatekeeping is the first step of implanting our work with the ward, ' adds crisis resolution manager Andrew Mack.

If the person is known to services their community team care co-ordinator is involved in all decisions. This is crucial to ensure nonurgent cases are not referred to the crisis resolution team, and in maintaining smooth handover of care back to the community.

The PCT is also considering other changes - for example, extending the local A&E liaison service to prevent unnecessary referrals. Another is to provide funds for respite accommodation for clients to stay in hotels or with other families.

'Without doing what we are doing we would not be able to think creatively like that, ' says Mr Williams. 'Practices do have to be shifted but staff are engaged because this helps patient recovery.'

CRISIS RESOLUTION TEAMS WHAT THEY SHOULD PROVIDE

The Department of Health's mental health policy implementation guide suggests that they should:

Act as a 'gatekeeper' to mental health services.

Be available 24 hours a day, seven days a week. Mobility is essential.

Respond rapidly following referral.

Provide treatment in the home or something close to home.

Provide intensive support in the early stages of a crisis.

Actively involve the service user, friends and family.

Help service users learn from the crisis.