Someone experiencing a mental health crisis needs immediate professional advice and assessment. Their mental, physical and/or social problems can be extreme, and they need appropriate care to prevent catastrophic outcomes such as suicide.
"those who do reach crisis state... should receive an appropriate level and intensity of care in a timely manner. Such care should be delivered in ways that are shown to be the most effective, making the best use of available resources and the most up to date evidence."
Getting it Right First Time report: Mental Health - Adult Crisis and Acute Care, 2021
Community services for people in mental health crisis provide an alternative to emergency departments or inpatient psychiatric admission. They include helplines, GPs, ambulance services, crisis resolution and home treatment teams, and day treatment services. They are usually delivered by a variety of agencies, including the NHS, the voluntary sector and local government. But people can find services difficult to navigate, which can delay their access to the right care.
NIHR Evidence held a webinar in May 2024 on care for adults in mental health crisis. The webinar shared research findings on:
- what works in community crisis care
- how acute day units compare to crisis resolution teams
- whether peer-supported self-management can reduce acute readmissions.
This Collection summarises the 3 research projects presented at the webinar. It includes video clips from the speakers and incorporates quotes from the day. The information will be useful for anyone involved in commissioning or delivering mental health crisis services.
Background
Recent years have seen investment in community-based crisis care to better support people experiencing mental health crises. Building on the Five Year Forward View for Mental Health, the NHS Long Term Plan aims to expand and improve access to crisis services. Recent service developments include community alternatives to hospital care, mental health ambulances, and changes to the role of police so people in mental health crises are seen by the most appropriate service.
The demand for crisis care is growing, according to the Department of Health and Social Care. Crisis resolution and home treatment teams received more than 520,000 referrals between 2018-2019, and an NHS call line dedicated to mental health crises received around 3 million calls between 2020 and 2021 (during the COVID-19 pandemic). The first presentation explored this complex landscape.
1. What works in community crisis care services?
Nicola Clibbens, Associate Professor of Mental Health Nursing, Northumbria University and Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust presented findings from a study published in the NIHR Journals Library, September 2023.
At the webinar, Nicola Clibbens described her team’s work: a realist evidence synthesis involving iterative literature reviewing, an expert stakeholder group of 15 that included policy experts, mental health staff, crisis services managers, voluntary sector workers and six people with lived experience, and interviews with 19 professionals, including police and ambulance personnel, and people with lived experience. The researchers aimed to understand what works, who it works for and in what circumstances in community crisis services.
Community services for people in mental health crisis have grown and diversified in recent years, resulting in a complex system that varies across the country.
“Service provision in the NHS is innovating ahead of the evidence base… the evidence takes a little while sometimes to catch up.”
Nicola Clibbens
People in crisis valued reliability, easy access and shared decision-making
The research found that people in crisis who believed a service was certain to respond had a reduced sense of urgency, and felt safer. They were more likely to tolerate waiting for care and less likely to attend A&E.
People sought easy access to the right support. Walk-in services, and those with open referral and peer support provide a sense of safety, belonging and being understood.
Shared decision-making with professionals increased people’s trust in services and their personal control. They felt valued, believed in and respected when staff were compassionate. People who had a positive experience of crisis care often expressed a desire to give back by, for example, working in crisis care services themselves in future.
Staff valued clear roles, collaboration and compassion
Staff need defined roles and responsibilities, collaboration across boundaries, belief in the service. A shared language between different agencies ensured more integrated care and minimised delays in providing care.
When staff delivered compassionate care, not only did this improve services it increased staff members’ job satisfaction. Staff who received immediate support and supervision while caring for fraught and distressed people also became less fearful of seeking support, which in turn reduced stress.
Improved relationships between agencies, and compassionate leaders who worked close to the front-line, increased staff members’ confidence in the decisions made.
Commissioners and leaders can promote training and compassion
If commissioners can provide clarity on service and role boundaries, for instance how people are moved around the service and how services link together, then relationships between staff in different crisis services improves, reducing disputes and delays and ultimately improving the experience of people experiencing a crisis. To sustain staff in their roles, training and supervision time needs to be built in.
Service leaders need to be visible and buffer external demands (for instance about resourcing and service structure); they need to model compassion. Leadership across agencies gives staff a better understanding of where they fit in the system and a shared sense of compassionate values.
The researchers concluded service users want crisis care that is easy to access and that they can trust. They need to feel safe and cared for. Staff who are cared for by leaders are more able to care compassionately for service users in the longer term. Interagency working takes effort, but it can create systems that engage staff and provide valuable services.
“... trust develops respect, safety, and people feel a degree of personal control that isn't always associated directly with choice. It means that people have… agency… [They] feel that they're part of the journey through the service, and they're not just being provided [for].”
Nicola Clibbens
2. How do acute day units help?
Crisis resolution teams are established in every NHS trust. They help people manage a crisis without admission to hospital; teams typically visit people at home, ideally once or multiple times per day (although this can vary by service). In some parts of the country, people experiencing a mental health crisis can visit an acute day unit where they receive peer support and spend more time with staff than crisis resolution teams can provide.
Danielle Lamb, Senior Research Fellow, University College London presented findings from an original study published in the NIHR Journals Library, October 2021. The study explored acute day units in a 3-part mixed-methods study. At the webinar, she presented readmission rates among people who attended acute day units compared with those under the care of crisis resolution teams.
The study included 744 service users, over half of whom (431) had used acute day units. During a 6 month period, a similar proportion of both groups were readmitted to mental health services (21% of people who had attended acute day units; 23% of those cared for by crisis resolution teams). Results varied greatly between trusts. During the Q&A, Danielle Lamb said this could be linked with how well established the units were in each trust, and how well they worked with other services.
Acute day units were valued by service users and staff
People who attended acute day units reported better satisfaction and wellbeing scores, and lower depression scores, than those cared for by crisis resolution teams.
The researchers explored care in acute day units through interviews with 21 service users, 3 carers and 12 members of staff. Both staff and service users valued acute day units. Service users appreciated the contact time with staff, staff continuity, peer support and structure. Staff valued being able to provide continuity, build strong therapeutic relationships and offer flexible, personalised support.
“Continuity of staffing [in acute day units] was really important both for service users, but also for staff… Patients got to know staff, and that was really beneficial for everyone.”
Danielle Lamb
The researchers concluded acute day units could reduce pressure on other services, avoid or reduce the length of inpatient stays and complement the work of crisis resolution teams.
During the Q&A, Danielle Lamb said that when the study was carried out, only 17 out of 58 trusts ran acute day units, partly because provision was not mandatory. Acute day units do not appear in national data sets. They lack a clear specification for the best model of practice, and the model varies across trusts. Future research could support a clearer service specification and implementation.
3. Can peer-support reduce readmission to acute care?
The resources available to crisis resolution teams often do not match demand and staff are stretched. People may experience care from these teams that ends too quickly, or a gap before ongoing care is in place.
Bryn Lloyd-Evans, Professor of Mental Health and Social Inclusion, University College London, and a team led by Sonia Johnson, Professor of Social and Community Psychiatry, carried out a 2-part study that examined what best practice in crisis resolution teams looks like, and whether a self-management recovery plan delivered by peer support workers could reduce relapse following crisis resolution team support. The research was published in the NIHR Journals Library, April 2019. At the webinar, Bryn Lloyd-Evans presented the findings of the second part.
“When we were planning the CORE study… it seemed evident that there was a… need for some extra support to help people with ..the process of leaving community crisis care from a crisis resolution team, to … promote recovery, and reduce the risk of being readmitted and coming back to crisis care quite soon.”
Bryn Lloyd-Evans
The trial included 441 people who had just been discharged from the crisis resolution team service. They all received a self-management recovery plan, which was co-produced with service users, and included sections on moving on after a crisis, managing ups and downs, keeping well and goals and dreams. Half the participants (221) were offered up to 10 sessions with a peer support worker (with personal experience of mental health services), to help them complete the recovery plan. The others (220) were sent a copy of the plan by post, with no further encouragement to engage with it.
Fewer people (29%) in the peer support group were readmitted to acute care over the following year, compared with the group who were mailed the plan (38%). People in the peer support group had longer before their first readmission and were more satisfied with their care at 4 months. The study found that the peer support programme was good value for money.
Where do peer support workers fit in?
Peer support workers are a growing part of the NHS mental health workforce and NHS England has outlined an expansion in their numbers. But their role is not yet defined clearly. These findings provide evidence that structured self-management, supported by peer support workers, can help people stay well after a crisis.
“It's a bit of a category error to talk about peer support as an intervention. Peer workers are a group of people who can deliver care … we need.. specified ways of working, and values to which they work.”
Bryn Lloyd-Evans
During the Q&A, Bryn Lloyd-Evans said that peer support workers received training and supervision from a clinician and another peer support worker. Peer support workers benefited from being seen as part of crisis teams and receiving wraparound support from them.
Most of the trusts in the trial valued the peer support workers and continued to employ them after the trial had finished.
Conclusion
Care for someone experiencing a mental health crisis can mean the difference between living and dying. But the many different models of care and the resulting complex web can be difficult to navigate. People need crisis care that is easy to access and that they can trust. They need to feel safe and cared for. Staff who are well supported by leaders are more able to care compassionately for service users in the longer term. Interagency working takes effort, but it can create systems that engage staff and provide valuable services.
At the end of the webinar, presenters were asked what one thing they would do to improve services. One suggestion was a single point of access to help people find the right service for them. However, there is a lack of evidence that this approach reduces hospital admissions. They also argued for services that are values driven, and increased numbers of staff. Lastly, they called for more support for structured self-management, practical help and social support.
If you need help
Information about your local urgent NHS mental health helpline can be found on the NHS website.
If you are struggling to cope, the Samaritans website contains help and information.
How to cite this Collection: NIHR Evidence; Mental health crises: how to improve care; July 2024; doi: 10.3310/nihrevidence_63937
Disclaimer: This Collection is based on research which is funded or supported by the NIHR. It is not a substitute for professional healthcare advice. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
NIHR Evidence is covered by the creative commons, CC-BY licence. Written content and infographics may be freely reproduced provided that suitable acknowledgement is made. Note, this licence excludes comments and images made by third parties, audiovisual content, and linked content on other websites.
