Background
Methods
Governance
Settings
Participants
Service users and carers
Practitioners
CRT developers
Measures
Procedures
Data analysis
Results
Sample characteristics
Service users N = 42 |
N (%) | Carers N = 20 |
N (%) | |
---|---|---|---|---|
Gender | Male | 14 (33%) | Male | 8 (40%) |
Female | 28 (67%) | Female | 12 (60%) | |
Age | 16–24 | 5 (12%) | 16–24 | 0 |
25–34 | 11 (26%) | 25–34 | 2 (10%) | |
35–44 | 13 (31%) | 35–44 | 3 (15%) | |
45–54 | 8 (19%) | 45–54 | 7 (35%) | |
55–64 | 5 (12%) | 55–64 | 5 (25%) | |
65+ | 0 | 65+ | 3 (15%) | |
Ethnicity | White British | 30 (71%) | White British | 16 (80%) |
White Irish | 1 (2%) | White Irish | 1 (5%) | |
White Other | 2 (5%) | White Other | 0 | |
Black Caribbean | 3 (7%) | Black Caribbean | 0 | |
Black African | 1 (2%) | Black African | 0 | |
Indian | 1 (2%) | Indian | 0 | |
Asian Other | 2 (5%) | Asian Other | 0 | |
Mixed White/Asian | 0 | Mixed White/Asian | 1 (5%) | |
Other mixed ethnicity | 0 | Other mixed ethnicity | 1 (5%) | |
Other ethnic group | 2 (5%) | Other ethnic group | 1 (5%) | |
Relationship to service user | N/A | Partner | 11 (55%) | |
Parent | 9 (45%) | |||
Lives with service user | N/A | Yes | 15 (75%) | |
No | 5 (25%) | |||
Number of times service user used a CRT | Once | 17 (41%) | Once | 10 (50%) |
2–5 times | 18 (43%) | 2–5 times | 7 (35%) | |
6–10 times | 7 (17%) | 6–10 times | 2 (10%) | |
> 10 times | 0 | > 10 times | 1 (5%) | |
Most recent service user contact with CRT ended | Still receiving CRT support | 7 (17%) | Still receiving CRT support | 5 (25%) |
< 1 month ago | 21 (50%) | < 1 month ago | 6 (30%) | |
1 to 3 months ago | 10 (24%) | 1 to 3 months ago | 5 (23%) | |
> 3 months ago | 4 (10%) | > 3 months ago | 4 (20%) | |
Previous service user in-patient admission | Yes | 32 (76%) | Yes | 16 (80%) |
No | 10 (24%) | No | 4 (20%) | |
Most recent hospital discharge | < 3 months ago | 15 (36%) | < 3 months ago | 5 (25%) |
3–12 months ago | 9 (21%) | 3–12 months ago | 5 (25%) | |
1–5 years ago | 5 (12%) | 1–5 years ago | 3 (15%) | |
> 5 years ago | 3 (7%) | > 5 years ago | 3 (15%) | |
N/A | 10 (24%) | N/A | 4 (20%) | |
Service user has care co-ordinator | Yes | 22 (52%) | Yes | 11 (55%) |
No | 14 (33%) | No | 6 (30%) | |
Not sure | 6 (14%) | Not sure | 3 (15%) | |
Diagnosis (reported by service user / carer) | Affective Disorder | 21 (50%) | Affective Disorder | 10 (50%) |
Psychotic Disorder | 11 (26%) | Psychotic Disorder | 5 (25%) | |
Personality Disorder | 3 (7%) | Personality Disorder | 2 (10%) | |
Unknown | 7 (17%) | Unknown | 3 (15%) |
Subgroups |
N (Total = 147) | Percent | |
---|---|---|---|
Data collection | CRT staff (10 focus groups) | 61 | 42% |
Senior staff (7 focus groups, 1 interview) | 39 | 27% | |
Referrer to CRTs (8 focus groups, 1 interview) | 33 | 22% | |
Senior managers (1 focus group, 7 interviews) | 14 | 10% | |
Service | CRT | 88 | 60% |
Community mental health team/equivalent | 17 | 12% | |
In-patient service | 5 | 3% | |
Senior management | 15 | 10% | |
Early intervention service | 2 | 1% | |
General practice | 2 | 1% | |
Liaison psychiatry | 2 | 1% | |
Other | 3 | 2% | |
Not specified | 13 | 9% | |
Role | Nursing | 45 | 31% |
Senior nursing | 6 | 4% | |
Team leader/manager | 23 | 16% | |
Senior NHS manager | 16 | 11% | |
Consultant psychiatrist | 11 | 8% | |
Other psychiatrist | 9 | 6% | |
Support time and recovery worker | 11 | 8% | |
Social worker | 8 | 5% | |
Occupational therapist/activity co-ordinator | 4 | 3% | |
G.P. | 2 | 1% | |
Psychologist/therapist | 3 | 2% | |
Pharmacist | 1 | 1% | |
Not specified | 8 | 5% | |
Years worked in NHS: mean (s.d.) (n = 121) | 15.8 (9.2) | ||
Years worked in CRT: mean (s.d.) (n = 99) | 5.1 (3.5) | ||
Years at current service: mean (s.d.) (n = 116) | 5.8 (4.4) | ||
Gender | Male | 71 | 48% |
Female | 75 | 51% | |
Unknown | 1 | 1% | |
Age group | 16–24 | 2 | 1% |
25–34 | 26 | 18% | |
35–44 | 42 | 29% | |
44–54 | 54 | 37% | |
55–64 | 14 | 10% | |
65+ | 1 | 1% | |
Unknown | 8 | 5% | |
Ethnicity | White British | 97 | 66% |
White Irish | 4 | 3% | |
White Other | 5 | 3% | |
Black Caribbean | 5 | 3% | |
Black African | 6 | 4% | |
Black Other | 1 | 1% | |
Indian | 7 | 5% | |
Pakistani | 1 | 1% | |
Asian Other | 5 | 3% | |
Mixed White / Black African | 1 | 1% | |
Mixed White / Asian | 2 | 1% | |
Other Mixed | 1 | 1% | |
Other ethnic group | 4 | 3% | |
Unknown | 8 | 5% |
Qualitative findings
The organisation of CRT care
At least a same-day response was advocated by service users and carers. CRT staff also stressed the importance of rapid responses, seeing service users in person soon after a referral and setting target response times (e.g. within 4 h of a referral), although the pressures this places on CRTs were acknowledged. For clients previously on the caseload, CRT staff and developers reported that self-referrals (not via health professionals) were usually appropriate, and users and carers with experience of this valued it highly. For clients not known to services, a majority view was that CRTs should assess and accept referrals 24/7. Practitioners’ comments reflected implementation tensions between maximising accessibility, and concerns about large volumes of potentially inappropriate self-referrals if no filtering process was in place.“One of the things that first strikes me is the availability and the immediacy of it…So the fact that the crisis team are so accessible at the point when you’re actually in crisis is just almost... it feels like a miracle at the time. I remember the first time it ever happened I couldn’t believe how sudden it was and how they could offer something that was so supportive in terms of an everyday contact. So I think that that really is the primary plus point about it”. (SU281)
For both new referrals and existing clients, there was also agreement across all groups about the need for a 24/7 service offering at least rapid telephone access to clinical advice. Around a third of service users and carers described experiencing this as reassuring, although a small minority of both groups described negative impacts of being unable to successfully make phone contact, or feeling let down by a phone-only overnight service. Staff and CRT developers acknowledged that providing a more substantial 24/7 service has significant resource implications.“I know it’s a bit of a broad brush statement, but there’s lot of referrals that take place in A&E where people have maybe had a bit too much to drink and have taken an overdose, the hospital are reluctant to discharge them without a psychiatric assessment, so the team go out or this one person goes to A&E, does an assessment, ends up saying actually you don’t need any follow up from psychiatric services.” (Practitioner group 32, CRT referrers)
For the most part, services appeared to be successfully providing regular contact, although a few service users said that infrequent contact had been the least helpful aspect of their care. While practitioners also viewed regularity as important, this was more because it enabled them to monitor risk and clinical changes. Service users and carers also described reliability and clear communication as helpful to forming trusting therapeutic relationships, and a small minority of both groups described large negative impacts when staff were not reliable (e.g. they did not visit at agreed times, or failed or were slow to do things they had agreed to).I: What would you say was the most helpful thing about the crisis team?SU07: It was the daily support, definitely; knowing that, when I got up each morning, if I was frightened or upset, I knew that someone was coming to see me.
Similarly, clear communication from the CRT at every stage of care was important. Some service users and carers identified lack of clarity as the least helpful aspect of their CRT experience, and scope for improvements was identified across all groups. Information about the CRT’s remit and contact details at the start of care, medication, and written discharge plans at the end of care were areas where practice often fell short of ideals. However, the majority of service users and carers reported clear communication about the timing and staffing of home visits, and plans for ending CRT support. A small number of carers identified confidentiality as a barrier to clear communication between themselves, the CRT and the person they cared for.“They were supposed to come here one day, and it was the first time he felt comfortable enough to be on his own with them, and I went to work, and I rang him, just to make sure he was up out of bed, and I think I rang him to see how it had gone, and they just hadn’t turned up.” … “I think the fact that they forgot to come to see him, really, he was… I think he was at the point where he was just getting to trust them, and thinking that they might be able to help him, and then for them not to come…” (C10)
Significant minorities of both carers and service users felt these problems were exacerbated by poor communication between staff, and described receiving inconsistent advice, or having to repeat their story or correct staff about their diagnosis or medication. Many service users and carers would have preferred a single allocated CRT worker or a smaller team of visiting staff. Only three service users had not minded a variety of CRT staff visiting them. These people described staff as up-to-date and well-informed, and were told who would be visiting next, thus ensuring support was as seamless as possible.“The least helpful thing, for me, was not knowing the person that’s coming through the door. It was hard for me to talk to a total stranger. It was almost like, I don’t really know why you’re here, because I don’t know you, I’m not going to talk to you, because of the person that I am… Unfamiliarity to me, it’s quite difficult ... when I’m in a bad situation. … When I’m at the point where I need the crisis team I prefer to have somebody who’s familiar that I can have that continuity with.” (SU08)
While the mix of staff types was important to some service users, especially the availability of support workers, psychologists, social workers and occupational therapists, for others this was less important than being visited regularly. Views on “peer workers” with personal experience of mental health problems also varied: whilst some service users and carers valued talking to someone with experiential knowledge, others preferred to see a team member with more ‘traditional’ qualifications.“Well, they’re responsive, but also they’re professional. The trouble with being a parent is you’re so emotionally involved, and I have no medical expertise. And also, to an outsider and a professional skilled outsider, the person who’s ill can say things, particularly negative things about the family that you can’t say to your parents.” (C04)
However, only a minority of CRT staff groups described their own teams as multidisciplinary. Some described practitioners other than nurses or psychiatrists as part of, or linked to the CRT, but often thought they had insufficient time allocated to CRT work. Practitioners often described current overall staffing levels as stretched or inadequate. A mix of staff on each shift across both disciplines and seniority was seen as important, for example nurses qualified to dispense medication, and experienced senior staff to conduct initial assessments, formulate risk and care plans, and take risk-related decisions, allowing less experienced staff to deliver care. Practitioners saw CRT-specific training as essential [see Additional file 2].“I think it’s good if a team is as multi-disciplinary as possible with OTs and with social workers. We used to have a psychologist who did a lot of family work and also supported the rest of the team in doing that. That post was cut unfortunately a few years ago, and as a result a lot of the family work we used to do has just disappeared because people don’t feel… they lost their skill and it just fell by the wayside”. (Senior CRT clinicians focus group 35)
The content of CRT work
In comparison, whole family involvement was discussed less by practitioners, who described initial home-based assessments informed by family members as valuable in developing a holistic view of the crisis, and deciding on the suitability of home treatment. Only a minority of practitioners and CRT developers thought CRTs should provide interventions to support the family’s needs, usually in the form of respite for primary carers, through extended visits or access to crisis beds. A more common view was that CRTs should signpost carers to support groups, counselling, family therapy, or advice on carers’ entitlements. Some practitioners acknowledged that carers’ views and support needs were often not considered adequately, and saw some barriers to family involvement, including the time-limited nature of CRT work, a focus on medication over social aspects of crises, lack of skills in social systems working, and resource limitations that impacted on length and frequency of visits, and duration of CRT care. Carers wanted to be involved in and informed of service users’ treatment and discharge decisions, but often described this not happening.“Who are the key people involved in that service user who can help us understand what’s going on, and how can they help in managing this crisis? What’s the ramifications of this crisis and what do we… what are we going to need to fix him in the social context, what can we start with that now? I think they’re the good principles of it.” (CRT developer 02)
Carers often felt their views had not been considered, for example, in deciding on CRT discharge dates, and most had not experienced CRT interventions involving the whole family or addressing social aspects of the crisis. However when specific carers’ support was provided, it was described positively. Carers valued having time with CRT staff without the service user, so they could relay any concerns privately, and being asked about their own wellbeing. Only a minority of service users spoke about family involvement, describing family members being involved only if they happened to be at home when CRT staff visited, although noting that this had been useful.“They didn’t listen to us as carers. We know the person we’re caring for.” (C20)
In comparison, emotional support and relationship development were discussed less by professionals, although they recognised that their personal style in relating to service users and families was important. CRT staff in particular identified excellent interpersonal skills as important to developing good relationships with clients and families. A combination of skills similar to those identified by service users and carers was identified: being caring, friendly, supportive, a good listener, respectful, non-judgemental and courteous. Factors that facilitated or impeded emotional support were discussed by all stakeholders. Among facilitating features, trust was central and was often related to features described in section 1 (rapid responses, staff continuity, reliability and regularity). Lack of staff continuity, brief visits, and a focus on medication were seen to compromise emotional support, although there were some reports that if previously unknown staff were friendly and well-informed by colleagues, these limitations could be overcome [see Additional file 2 for further details].“Just listening as well, listening to you going on. And becoming somebody that you could trust, because you were telling them an awful lot about yourself and they’re not judging you. And like I say they never made you feel as though it was you being stupid, or they never made you feel little … you weren’t taking their time up and wasting their time.” (SU22)
Some practitioners attributed this to lack of resources or time, so that staff sometimes delivered medication in very brief home visits. Some service users complained that CRT staff were unresponsive to concerns about medication side-effects, and a small number of carers found communication and organisation surrounding medication problematic.“They pop in for no more than 4 minutes to make them take their meds […] and every now and then ask a question. […] But it’s a pointless visit in my mind, because, other than delivering meds, how are you delivering care?” (C03)
Across all stakeholder groups there was a general view that the social or practical issues underlying a mental health crisis should be addressed by practical interventions provided by CRTs [see Additional file 2 for details]. Only a minority of practitioners felt it was not appropriate or feasible for CRTs to provide practical support given their time and resource limitations. Some were critical of a trend towards CRTs increasingly signposting and referring to other services, rather than providing support themselves.“I think a lot of the crisis work that we do is about empowering the individuals to take control of their own lives, rather than going into hospital where it’s all sorted out for them”. (Practitioner group 20; senior staff)
Role of CRTs within the care system
A physical presence on acute in-patient wards and at assessments was thought to be necessary for effective gate-keeping. Tensions between CRT staff and consultants and ward staff regarding admission decisions were identified as potential barriers.“I think it impacts on their ability to be able to function because I think the majority of their time should be spent gatekeeping those people who might need inpatient care, and delivering home treatment. And the greatest proportion of the time should be delivering home treatment as a functional alternative to hospital admission.” (CRT developer 04)
Service users also valued greater privacy, feeling safer than in stressful acute in-patient wards, and more equal relationships with staff. A small number of carers commented that, at times, they would have preferred their family member to be hospitalised for their safety, but most still believed home-based care was preferable. A concern about whether home treatment was based on clinical need or a requirement to reduce and shorten hospital admissions was expressed across stakeholder groups. A few service users said that their preferences for admission were not considered, and attributed this to reduced availability of hospital beds. Some practitioners thought that a primary aim should be to extend choice rather than reduce admissions.“I think that could be why I got better quicker, because I was in my familiar surroundings, and not locked away, not under a regime. […] It’s more relaxing at home, I can see my kids, I couldn’t see them in there, and that hurts. I think it helps in getting better quicker.” (SU20)
Joint working at the point of CRT discharge was considered particularly important to ensuring continuity of care, for example informing GPs and other mental health services about medication changes, and ensuring physical health monitoring and interventions are coordinated. Again problems in inter-agency communication were reported across stakeholders (although not universally), associated with service gaps, delays in receiving community support, and confusion. A number of strategies were suggested to help facilitate or improve communication, continuity and working relationships with other services [see Additional file 2].“Do community mental health teams really know what home treatment is, and what it can offer, and how it adds value? Do inpatient services really know what the difference is from an inpatient service, apart from the four walls around it? And what crisis home treatments do. I think that’s a huge issue for the services, and I would imagine it’s incredibly confusing for those out in primary care to know what on earth any of us are trying to do.” (Practitioner focus group 23; senior managers)