Community alternatives to hospital in a mental health crisis
Project Background
Shared Lives has a long history of providing bespoke care in the community to meet various support needs. Since 2019, Shared Lives in Caerphilly has been providing short-term mental health care placements in partnership with Aneurin Bevan University Health Board, enabling more people to access care in the community. Individuals can be placed with an experienced host who supports and includes them in family and community life, whilst receiving medical support from the Crisis Response and Home Treatment Team.
The aim of this Facilitator project is to hear the voices of those with lived experience and of front-line staff as part of understanding experiences of community alternatives to mental health hospitals when someone is experiencing a crisis. Before this project started an evidence review was conducted by IMPACT. This reinforced the lack of representation in current evidence and the need to know more from a wider range of perspectives. Find out more about Shared Lives in the video.
Pre-project Evidence
The evidence review key points are:
- There is a link between a community approach to recovery and improved quality of life in mental health crisis care.
- Informal networks, family and community have been identified as important protective factors to hospital admission in a mental health crisis.
- There is limited data on community-based services due to the diversity and fragmentation of services. There is a need for more research into the effectiveness of different community-based models.
- There are many criteria for exclusion from community mental health care including compulsory detention (sectioning under the mental health act), risk of self-harm or suicide, addiction, violence and unstable housing or homelessness.
- Crisis Resolution and Home Treatment Teams face challenges with providing a rapid response and managing safety and risks.
- There is a lack of support and planning in the high-risk period after hospital discharge.
- ‘Revolving door’ re-admissions account for a large number of hospital admissions for mental health crisis.
- There is a lack of representation of people with lived experience and professionals in the evidence with few studies focusing on race and ethnicity.
Facilitator Engagement
This project is important to our Facilitator, Catherine, who has lived experience of mental health care and recovery in the community. Catherine would like more people have the option of receiving care in the community and for more information to be available about alternative options to hospital in a crisis. She looks forward to reporting back on future engagement as the project evolves over the coming months and on project outcomes in early 2025. In her other role, Catherine works as a Partnership Officer for Environment Platform Wales, an organisation that seeks to bridge gaps between environmental research and policy in Wales.
When Shared Lives South East Wales decided to engage with IMPACT, they were welcoming of the chance for a fresh pair of eyes to come into the organisation. Shared Lives S.E. Wales wants to showcase the work the organisation is carrying out and raise awareness of the project amongst the general public, statutory organisations and the third sector. They are keen to enable the IMPACT Facilitator to explore any area of the service and have committed to providing information, co-ordinating visits and enabling co-production. They would like to see qualitative evidence of the difference it is making to individuals, their families and wider communities and to be able to utilise the evidence base for expansion and improvements. The team is open to receiving constructive feedback and ideas that would help with the development and growth of the service.
Shared Lives S.E. Wales envisage a number of as part of understanding the range community alternatives to hospital in a mental health crisis. This including a lack of understanding and awareness of the Shared Lives scheme amongst individuals, their families and mental health professionals and the ability to successfully match individuals with carers in the community. The team at Shared Lives think a centre like IMPACT is important due to the fact that it is being driven by the implementation of a range of evidence as opposed to conducting research. Whilst an academic researcher can look at data, systems and processes, the IMPACT Facilitator can share practical suggestions of what works elsewhere and of how to implement the evidence gathered to improve the service locally whilst contributing to wider learning. IMPACT is recognised at a Welsh government level so evidence holds weight when Shared Lives are approaching commissioners and presenting business cases.
Community alternatives during a mental health crisis
Residential alternatives to hospital in a mental health crisis
- Residential alternatives to hospital provide a safe, homely space with accommodation for people experiencing crisis. Residents can typically stay from 4 days up to 4 weeks, depending on the project.
- Often residents will have access to support from staff and partner organisations (e.g. CRHTT, Citizens Advice) during the day, and support from staff overnight if required.
- Such projects typically have a small capacity with access usually gatekept by NHS crisis teams.
- Family and friends also sometimes provide an unofficial residential alternative to hospital.
Early discharge and community step-down from psychiatric hospital
- Many residential alternatives to hospital also offer step-down from hospital support, e.g. Shared Lives (SE Wales) and Platfform Crisis Houses.
- There are other projects dedicated to transitioning back to the community after a hospital stay, e.g. Step Down. Some projects offer longer term support for individuals with mental health diagnoses e.g., residents often stay around 18 months at Mind Supported Accommodation.
- Some wards provide inpatient courses on returning to the community, to promote successful re-integration, e.g. Cardiff Recovery and Wellbeing College.
NHS Crisis resolution
- The primary NHS teams to provide support to individuals experiencing a mental health crisis are the Crisis Resolution and Home Treatment Teams (CRHT/CRHTTs).
- Most health boards have a multidisciplinary CRHTT, who work in partnership with other specialist NHS services, general medicine and external organisations.
- CRHTT staff visit patients in the community (whether it be home, at a relative’s house or in a community-based crisis house).
- CRHTT are often the gatekeepers of other services, for example make referrals into a residential alternative to hospital or a referral into hospital if risk levels are too high to be safely managed in the community.
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NHS community mental health teams
- Sometimes, individuals may already be under the care of a different community NHS service (e.g. CMHT, EIS) when they experience a crisis
- As part of care and treatment planning, individuals may have a designated emergency point of contact within the team they are with.
- Community Mental Health Teams (CMHT) provide multidisciplinary support to patients with a variety of mental health diagnoses
- Specialist teams e.g. Early Intervention in Psychosis Teams (EIS/EIP), Eating Disorder Teams provide support to patients with a specific diagnosis, with expertise in a particular area of mental health
- NHS Older Adult Mental Health Teams typically specialize in helping patients >65. Some teams have specific crisis intervention teams for older people, for example the Cardiff and Vale >65 REACT (Response Enhanced Assessment Crisis Treatment) team.
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Community appointment-based schemes
- There are many charities and organisations that provide crisis counselling or listening/signposting appointments, for example, the Suicide Crisis Centre and Student Intervention Teams.
- Such projects often accepts self-referrals, via a phoneline or webform (although some services are gatekept by the CRHTT, e.g. C&V Crisis Recovery Unit (CRU)).
- Often service users prefer appointment-based schemes to drop-ins as an appointment reduces the risk of being recognized in a waiting area.
- Since COVID-19, many schemes have continued to provide the popular option of an appointment over the phone.
Community out-of-hours schemes
- Research found that there was high demand for crisis support outside of working hours and that a 9-5 model was inadequate.
- NHS health boards have commissioned a number of out-of-hours crisis support schemes or ‘Sanctuaries’ e.g. Adferiad Recovery Sanctuary, Second Step Sanctuary/Safe Haven which are typically open 6pm – 3am (sometimes Thursday – Monday only).
- In addition to out-of-hours appointments, sanctuaries provide a welcoming space, good facilities (e.g. lounge, kitchen, quiet room/art room) and practical support (e.g., food parcels).
- Some daytime services have an emergency nightline, with staff on standby out-of-hours.
Community phone lines
- Many services offer the option of a phone call or face-to-face appointment, depending on the individual’s preference / ability to access in-person locations.
- 111 (Option 2) for Mental Health has recently been rolled out across the UK. Upon calling 111 (Option 2) patients will be triaged and referred to the appropriate place to get help. They may be able to speak to a trained mental health professional over the phone.
- 111 (Option 2) was trialed by ABUHB; unfortunately, this meant that funding from the ‘mental health pot’ was diverted from the Cardiff Mind Sanctuary, which closed-down.
- Some services are best known for or operate only on a phoneline basis.
- Some are designed for specific groups e.g. Nightline is specifically for students.
- Other services will have an out-of-hours phone line, for emergencies only.
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Community dop-in center/crisis cafes
- There were limited crisis drop-ins found in the local area, however community projects such as ‘Together Works’ (Caldicot) and ‘Green squirrel’s Railway Gardens’ (Cardiff) and support groups such as that run by ‘Bipolar UK’ (various locations) provide a safe space which can help to prevent deterioration in mental health. Community groups / Mental Health First Aiders can also provide escalation to emergency mental health services where necessary.
Common barriers to accessing services
- Homelessness / no fixed abode
- High risk (risk to individual, staff and other service users)
- Episode of psychosis / severe acute mental health issues
- Drugs and alcohol
- Accessibility i.e., ground floor?
- Outside of geographical area
- Safeguarding concern
- Lack of knowledge of services available in local area
- Fear of being recognized by others (in professional capacity)
- Fitness to practice concerns (NHS)
- Exclusion policies / ‘ideal candidates’
- Referrals gatekept
- Opening hours
- <18 years old
- Risk too high (UK mental health triage system, used by Adferiad)
- Categories A – C excluded:
- A – Emergency
- B – Very high risk of imminent harm to self or others
- C – High risk of harm to self or others and/or high distress, especially in absence of capable supports
- Categories A – C excluded: