Examples of whole system approaches to mental health specialist care
“You can develop as many whizzy new services or amend services that exist, but until you address how people work together you are never going to address the service change you want”
Rapid synthesis of available models of care
A 2016 rapid synthesis of evidence used the crisis concordat 4 stages of care to structure an examination of how well different services work to improve outcomes for people in mental health crisis. The four stages of care are: 1 Access to support before crisis point, 2 Urgent and emergency access to crisis care, 3 Quality treatment and care in crisis, 4 Promoting recovery/preventing future crises. One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. A limitation found across the stages was quality of evidence with a general lack of rigorous randomised and cluster randomised trials evaluating models of mental health crisis care. The authors note ‘further high-quality trials conducted in the UK would have a considerable impact on reducing uncertainty regarding what are the most effective models of care for people experiencing mental health crisis’.
Reported implications for practice included the below:
- Access to support before crisis point: Services should ensure that people at risk of mental health crisis receive care with minimum delay, receive quick referral (either through self-referral or building links between services) and that there is equality of access to such care.
- Urgent and emergency access to crisis care: Although there is evidence of benefits for liaison psychiatry teams in improving waiting times and reducing readmission this is largely based on uncontrolled studies and a lack of data from the UK.
- Quality treatment and care in crisis: Crisis resolution teams (CRTs) are more effective than inpatient care for a range of outcomes, although implementation of this model of care varies across the UK with few teams meeting all evidence-based criteria for good practice. Crisis houses and acute day hospitals appear as clinically effective as inpatient treatment but are associated with increased service user satisfaction.
- Promoting recovery/preventing future crises: Effective service models include early intervention services for people with psychosis and other serious mental illnesses, and collaborative care for depression (particularly for people with chronic physical health problems). Effective individual-level strengths-based interventions include self-management and supported employment. There is also some evidence for benefit for peer support (but this needs further high-quality research to validate these findings).
Examples of whole system approaches
Lambeth Living Well Collaborative
In 2019 Nesta reported on their website an example of transformation in mental health services in Lambeth in London. The director of commissioning and colleagues wanted to change the system from being crisis-dominated to focusing on prevention, early intervention and enablement.
The Lambeth Living Well Collaborative was established, which includes people who use services as well as clinicians, carers, secondary mental health services, voluntary sector providers, primary care practices, and public health and commissioners to radically improve the way mental health services work. They credit regular ‘breakfast meetings’ where everyone comes together to solve problems as a group as being a key element of ‘an ethos of collaborative working and a collective reframing of what the challenges are’.
They created new initiatives such as more empowered Community Mental Health Teams, a structured programme of peer support, time-banking, a Community Options Team and networks between GPs, social care and mental health primary care. They are now supporting up to 500 people a month, before they reach crisis point, and have seen a 43 per cent reduction in referrals to secondary care, which has reduced waiting times.
A 2017 report on lessons from the vanguard sites in England, relating to mental health and new models of care, from The King’s Fund and the Royal College of Psychiatrists drew on recent research, in particular interviews with leaders, expert groups and key stakeholders. Findings included that local professionals viewed new models of care which aimed to remove the barriers between mental health and other parts of the health system as being highly valuable in improving care for patients and service users. It was emphasised that there was still much more to do to fully embed mental health into integrated care teams, primary care, urgent and emergency care pathways, and population health work.
Nine principles for success were developed which were designed to reflect the approach to integrated mental health that key stakeholder groups would like to see implemented through new models of care:
- The commissioning, design and implementation of new models of care should be consistent with the requirement to deliver parity of esteem.
- Mental health should be considered from the initial design stages of new models of care.
- New care models should address and measure outcomes that are important to patients and service users, identified through a process of co-design.
- New care models should take a whole-person approach spanning an individual’s physical, mental and social needs.
- New models of care should extend beyond NHS services to include all organisations that may impact on people’s health and wellbeing.
- Invest in building relationships and networks between mental and physical health care professionals.
- New models of care should enhance the provision of upstream, preventive interventions to improve mental health and wellbeing.
- Every clinical interaction should be seen as an opportunity to promote mental and physical wellbeing.
- All frontline staff should receive appropriate training in mental health, regardless of the setting in which they work.
Emerging lessons for local system leaders included: Incorporate mental health expertise into integrated care teams, broaden the scope of mental health, focus on prevention as well as care, develop the workforce, build the right relationships that span system boundaries, co-design and public involvement as a pre-requisite, starting small and learn from experience, test and adapt.
A systematic review of effectiveness of current policing-related mental health interventions (such as liaison and diversion, street triage, specialist staff embedded in police contact control rooms) concluded that overall, rather than finding that one approach is more effective than another, the evidence suggests the need for a multi-faceted approach within a structured and integrated model, such as the Crisis Intervention Team model, and that policy makers, service commissioners and providers may wish to review future options.
Understanding variation in compulsory admission rates
A 2017 cross-classified, multilevel analysis quantified the extent to which patient, local-area, and service-setting characteristics accounted for variation in compulsory psychiatric inpatient admission in England. The authors examined data available for 1,238,188 patients and found that, after adjusting for confounders, black patients were almost three times more likely to be admitted compulsorily than white patients, and compulsory admission was greater in more deprived areas and in areas with more non-white residents. Their interpretation of these findings were that ‘rates of compulsory admission to inpatient psychiatric beds vary significantly between local areas and services, independent of patient, area, and service characteristics. Compulsory admission rates seem to reflect local factors, especially socioeconomic and ethnic population composition. Understanding how these factors condition access to, and use of, mental health care is likely to be important for developing interventions to reduce compulsion.’ Whilst we appreciate this level of analysis may not be feasible we have included this evidence to illustrate the importance and value of examining local data and local factors when considering local interventions.
Example of crisis service approach
24/7 Crisis Service
A 2016 paper in the Ulster Medical Journal describes the outcomes of a new Mental Health Crisis Service in a health and social care trust in Northern Ireland covering five council areas. A 24/7 crisis service was required to provide alternatives to inpatient admission, with over occupancy of acute psychiatric inpatient beds and a move to a new unit meaning a reduction of 30 beds compared to 44.
A multimodal, multi-disciplinary service was developed incorporating a high fidelity Crisis Response Home Treatment Team (CRHTT), Acute Day Care (ADC) facility and two inpatient wards. The aim was to provide alternatives to inpatient admission. The medical staff is consistent during the crisis period (inpatient, ADC and CHRTT phases). There was flexibility in placement and step down and respite support for carers.
The CRHTT role is to enhance the person's skills and improve resilience by replicating hospital care in their own home. Functions include:
- Undertake crisis assessments, manage risk and assess level of containment required
- ‘Gatekeep’ the inpatient beds
- Collaboratively establish management plans
- Increasing support
- Short term prescribing (meds initiation and review)
- Frequent review during crisis (therapeutic intervention, monitoring of progress, carer support)
- Timely discharge
The ADC role is to support the assessment and management of patients in the crisis service. Functions include:
- Inpatients and outpatients observed in a variety of settings
- Close monitoring
- Less restrictive environment
- Interventions (structured activity, psychoeducation, skills training, signposting to community services)
The authors report that data was collected on a monthly basis and the inpatient occupancy rate, total number of admissions and total length of stay decreased. The average inpatient occupancy rate before the new service was 106.6%, admission rate was 48 patients per month and total length of stay was 23.4 days. After introducing the inpatient consultant hospital model, the average occupancy rate was 90%, admissions 43 per month and total length of stay 22 days. After CRHTT initiation they report it decreased further to 83% occupancy, 32 admissions per month and total length of stay 12 days. The authors caution that the Crisis Service still requires evaluation but the model has provided safe alternatives to inpatient care, and involvement is maximised with patients, carers and multidisciplinary teams to improve the quality and safety of care. Innovative ideas are described such as a structured weekly timetable and improved communication through regular interface meetings.
Example of ward approaches
Safewards is an evidence-based model formulated specifically for use on inpatient mental health wards. It was developed on the basis of research that showed up to tenfold variation in incidents of violence, restraint and seclusion between different acute mental health wards with similar patient populations. Six domains underpin the model: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. In a randomised controlled trial on 31 mental health wards at 15 hospitals in nine NHS Trusts within 100 km of central London. Fifteen wards trialled Safewards and sixteen used a different programme. Wards using Safewards reduced conflict by 15% (95% CI 5.7-23.7%) and containment by 23.2% (95% CI 9.9-35.5%) compared with controls. The authors concluded ‘simple interventions aiming to improve staff relationships with patients can reduce the frequency of conflict and containment’.
Improving inpatient discharge to the community
A 2019 systematic review investigated interventions to improve discharge from acute adult mental health inpatient care to the community. Whilst the different interventions and outcomes reported in the literature made drawing overall conclusions challenging, the authors suggest that interventions that aim to reduce people experiencing homelessness are generally effective where they either provide resources or psychosocial and/or therapeutic support in securing accommodation. Similarly, with interventions that aim to improve treatment adherence, there seems to be some success in introducing a co-ordinating agent (assigned nurse, social worker or pharmacist) or technology enhanced contact methods. The most successful interventions in reducing readmission aim to bridge boundaries between hospital and community, with community staff on the ward, or ward staff in the community, increasing continuity of care or increasing knowledge of service users and families. Examples include Community-Based Discharge Planning and the Transitional Discharge Model. The authors note a systems-level approach is more successful than a single intervention (such as a new role) in accelerating discharge. Educational interventions appear to be highly successful in increasing knowledge in both service-users and care-givers and appear to affect readmission, symptom reduction and treatment adherence outcomes.