Valentina Iemmi, Martin Knapp, David McDaid
“When someone has a mental health crisis, it is distressing and frightening for them as well as the people around them. Urgent and compassionate care in a safe place is essential – a police cell should never need to be used because mental health services are not available. For me, crisis care is the most stark example of the lack of equality between mental and physical health.” (The Rt Hon Norman Lamb MP, Care and Support Minister)
There is a strong moral and economic case for investing in innovative approaches that support people with schizophrenia to live independently in the community. Crisis resolution and home treatment teams and crisis houses can help reduce the need for expensive hospital admissions with some studies suggesting that the costs of care can be reduced by up to 30% through these service models. There is a clear potential for Clinical Commissioning Groups to make better use of their resources by investing in home treatment teams and crisis houses as approaches to crisis resolution.
This was one of the key messages of our report Investing in recovery. Making the business case for effective interventions for people with schizophrenia and psychosis launched at the National Psychosis Summit in London in April. Funded by the Department of Health and Rethink Mental Illness, the report adds further compelling evidence to the work undertaken for the Schizophrenia Commission in 2012. The topic is explored in two sections: Crisis Resolution and Home Treatment teams and Crisis houses.
When do crises occur?
Many people with schizophrenia and psychosis encounter several periods of acute crisis over their lifetime. About 1 in 7 people living with schizophrenia in England are hospitalised each year, one third of them compulsorily.
How costly are hospitalisations?
Not only is admission to hospital distressing, but it is also costly to the NHS. On average, each period of hospitalisation lasts about 5 weeks at a cost of £13,000 per occurrence. Compulsory admissions are longer and more expensive. Potentially, some of these admissions, with all their distress and cost, might be avoided through services provided in the community.
So what are some of the alternatives to hospital care?
Crisis resolution and home treatment teams are multi-disciplinary teams working 24 hours a day, seven days per week. They provide assessment and intensive treatment at home for people experiencing severe, but short term, mental health crises with the aim of avoiding hospitalisation. They can also facilitate earlier discharge of people that have been hospitalised by ensuring that ongoing support can be provided at home. After a few weeks, once the crisis has resolved, responsibility for long-term support is transferred to other community mental-health teams.
Crisis houses are community-based residential alternatives to hospital. They are staffed 24 hours a day, seven days per week, by trained mental-health staff or support workers, helping with treatment planning and day-to-day activities. The term ‘crisis house’ may cover different models of practice using short-term stay outside the hospital: clinical crisis houses, specialist crisis houses, crisis team beds, recovery houses, and other non-clinical alternatives mainly managed by the third sector with a few staff holding professional qualifications.
Do these services lead to better outcomes and are they cost effective?
Crisis resolution and home treatment teams help reduce hospital admissions for people with severe mental health conditions, reducing the impacts on families, improving some clinical outcomes, and increasing both patient and carer satisfaction. The cost of investing in these services can be offset against the costs of hospitalisations, which are avoided.
Crisis houses also seem to help improve symptoms and functioning, and recovery of people suffering from schizophrenia. However, their impact and cost effectiveness is more difficult to capture due to the variety of crisis-house models and service users diagnoses. Some small studies have found that they are preferred by service users, and have outcomes that are at least as good as inpatient care with lower costs.
Time for change!
In February, Norman Lamb launched the Mental Health Crisis Care Concordat setting out four core principles of care for people in mental health crisis: support before the crisis, emergency access to crisis care, treatment when in crisis, and recovery and prevention of future crises. Implementation of the Concordat is based on local commitment and the partnership of health, criminal justice and local authority agencies. Mental Health Crisis Care Concordat has been welcomed as a further step in bridging the gap between mental and physical health.
It’s time for change! People with schizophrenia experiencing a mental health crisis may now take advantage of community-based mental health crisis services. This makes not only moral but also economic sense. The message is out: policy makers are supportive and it’s now time for commissioners and practitioners to take the change on board.
Iemmi V (2014) Crisis Resolution and Home Treatment teams and Iemmi V & McDaid D (2014) Crisis Houses. Both in Knapp M, Andrew A, McDaid D, Iemmi V, McCrone P, Park A, Parsonage M, Boardman J & Shepherd G (2014) Investing in Recovery: Making the Business Case for Effective Interventions for People with Schizophrenia and Psychosis, Rethink Mental Illness, London, UK. Available here.
For additional details, email Valentina Iemmi