news focus: Community-based crisis services can keep psychiatric patients out of hospital and reduce feelings of stigma. Paul Smith looks at their progress to date

Published: 28/02/2002, Volume II2, No. 5794 Page 18

Patient involvement is a buzz phrase in today's NHS. The structural shifts taking place are meant to offer new opportunities to tailor services based on patient need. And no-one - so the argument goes - is better at defining that need than patients themselves.

The philosophy is gradually being made flesh across selected parts of the service.

But nowhere does it seem more relevant than in mental health.

In a new report, Being There in a Crisis, the Mental Health Foundation and the Sainsbury Centre for Mental Health have been looking at the development of the crisis programme the Mental Health Foundation launched in 1996. It focuses on three crisis houses: the Nile Centre and the Highbury Centre in London, and Anam Cara in north Birmingham. User-led, they each offer crisis services as an alternative to hospital admission.

The attractions for the NHS are obvious - dealing with problems before they reach crisis point takes pressure off overstretched acute psychiatric wards.

The report highlights the fear, dread and alarm that many people with mental health problems face when they end up in hospital. It emphasises their desperation for alternatives that give them greater emotional support, less focus on drug therapy and more face-to-face contact with staff.

'While the evidence does not suggest that all traditional elements of acute hospital care would be voluntarily rejected by those in crisis, it clearly shows that many service users reject the model on offer.

They want more control over their crisis, for personal coping strategies to be recognised, and respected crisis care centres are seen as an attractive alternative.'

One of the authors, Alison Faulkner, is head of service user initiatives at the Mental Health Foundation. She says: 'There is a real concern among users about acute services.

There are variations, but from my own experience I know they are not widely liked.

Service users frequently report feeling punished by acute services which focus on medication and containment, rather than the need to talk to somebody and develop positive coping strategies.

'The report demonstrates that alternative community-based crisis services can meet people's needs effectively and can work in collaboration with mainstream services to avoid unnecessary hospital admissions.'

While not offering a simplistic and unqualified endorsement, the report judges the pilots a success and a model for future services.

The Sainsbury Centre made crude calculations around their financial benefits and found the cost per day for each client for Anam Cara was£66.88, the Nile Centre£97.27 and Highbury Grove£113.81.

It says that while it is difficult to compare the costs of crisis houses fulfilling different functions for different people in different areas, the cost appears to fall within a broad range 'somewhere between the voluntary sector, residential care and NHS inpatient care'.

While supportive of the projects, the report points out that none offers a quick fix to the usual headaches dogging mental health services. Development work in all the projects assessed took time.

One difficulty lay in resistance from mainstream providers, particularly when crisis houses found themselves dealing with increasing numbers of severely ill clients.

A Highbury Grove staff member said: 'With the very limited information we have, we are providing an acute service via the voluntary sector without information, clinical support for the team and at the same staffing levels.'

Highbury Grove was forced to depart from its initial blueprint.When it offered a drop-in centre as well as crisis support, it was abused and began to resemble what was called 'a night-club facility with music and drug dealing'.

'It quickly became apparent that a combined service was not effective and even potentially dangerous and unmanageable.'

Changes were made, shifting the philosophy from a user-led project to one more in line with statutory provision.

At the Nile Centre, a locality manager said: 'In the beginning, there were difficulties.' There had been no clarity of roles, responsibilities and functions.Nor had there been criteria regarding the people they were going to take. Also there was no review mechanism.'

It is the tension between the need for users to see crisis houses as independent and the need for them to offer high-level care properly integrated in mainstream services that may need to be resolved.

Ms Faulkner says: 'It is important to realise that the involvement of users is important and that the independence is recognised. That does not mean that the management is inexperienced and not up to doing the job. Support is needed, and training, if these services are to be a success, but that should not be seen as an impossible barrier.

She herself has experienced life at the sharp end: 'I was in hospital for seven months.The staff sit and read newspapers and dish out medication; you are not allowed out.

'It really does not compare: here you get your own life back; people help to pick up pieces.'

Being There in a Crisis .The Mental Health Foundation, 020-7802 0300.£22.50.