Crisis Resolution and Home Treatment teams
Key elements include:
- Providing 24 hour service, 7 days a week to people within their own homes with a view to resolving the crisis in the context in which it occurred.
- Providing rapid response following referral.
- Ensuring that individuals experiencing severe mental distress are served in the least restrictive environment and as close to home as possible
- Creating a link between referring agencies and inpatient services, actively acting as a gatekeeper to other services for people at the point of crisis.
- Having capacity to provide intensive interventions and support in the early stages of the crisis.
- Working in a time limited way with service users and with sufficient flexibility to respond to differing levels or types of need.
- Providing an emphasis on learning from the crisis with the involvement of the whole social support network.
- Actively involving the service user, family and carers and applying an assertive approach to engagement.
- Remaining involved with the service user until the crisis has resolved and they are linked into on-going care.
- Where hospitalisation is necessary, being actively involved in discharge planning and providing intensive care at home to enable early discharge.
- Working to reduce future vulnerability to crisis59.
Residential crisis services
There are community-based crisis services that offer residential support as described above and include Clinical Crisis Houses, Specialist Crisis Houses, Crisis Team Beds and Non-clinical alternatives but are relatively unusual across the UK.
Hospital based approaches
- People in crisis may require treatment in a hospital setting and these remain a key component of all mental health services across the UK although bed numbers have been reduced substantially.
- However, the quality of inpatient care has often fallen well short of expectations, and at its worst, has been described as ‘unsafe, inhumane and un-therapeutic’59 75. Concerns have been raised that inpatient services are not fit for purpose and do not effectively manage risk with widespread failures being identified76.
- Generally service users do not want to be admitted to hospital as evidenced by the high proportion who are detained under Mental Health legislation and the adverse response provided in surveys77. Many report being bored and feeling unsafe; in particular, women can often feel vulnerable in ward8.
Types of wards available:
- General therapeutic wards and psychiatric intensive care units
Hospital based services that serve a range of diagnostic and demographic groups and are generally either locally based acute admission wards or general wards in private hospitals.
- Assessment wards
These are being introduced by a number of Trusts but remain unusual.
- Wards for specific demographic groups
Mother and baby units and services for people with hearing impairments – small units often associated with specialist community services.
- Therapeutic communities for specific groups
Units which apply a defined therapeutic model but targeted at a specific diagnostic group such as people with early psychosis or severe emotional difficulties (‘borderline personality disorder’).
Reasons for admission vary. These include suicidality and agitation/hostility but in a recent analysis only half of acute in-patients were admitted for these reasons78.
Lengths of stay:
- Often longer than necessary for therapeutic benefit with housing problems frequently impeding discharge79.
- The NHS Benchmarking Club has produced data demonstrating marked changes in bed usage across Trusts which seem not to be explained by demographic differences4.