Dalton-Locke et al. BMC Health Services Research
https://doi.org/10.1186/s12913-021-07181-x
(2021) 21:1174
RESEARCH
Open Access
Emerging models and trends in mental
health crisis care in England: a national
investigation of crisis care systems
Christian Dalton-Locke1*, Sonia Johnson1,2, Jasmine Harju-Seppänen1, Natasha Lyons1, Luke Sheridan Rains1,
Ruth Stuart3, Amelia Campbell4, Jeremy Clark5, Aisling Clifford6, Laura Courtney1, Ceri Dare4, Kelly Kathleen7,
Chris Lynch4, Paul McCrone8, Shilpa Nairi2, Karen Newbigging9, Patrick Nyikavaranda4, David Osborn1,2,
Karen Persaud4, Martin Stefan10 and Brynmor Lloyd-Evans1
Abstract
Background: Inpatient psychiatric care is unpopular and expensive, and development and evaluation of
alternatives is a long-standing policy and research priority around the world. In England, the three main models
documented over the past fifty years (teams offering crisis assessment and treatment at home; acute day units; and
residential crisis services in the community) have recently been augmented by several new service models. These
are intended to enhance choice and flexibility within catchment area acute care systems, but remain largely
undocumented in the research literature. We therefore aimed to describe the types and distribution of crisis care
models across England through a national survey.
Methods: We carried out comprehensive mapping of crisis resolution teams (CRTs) using previous surveys,
websites and multiple official data sources. Managers of CRTs were invited to participate as key informants who
were familiar with the provision and organisation of crisis care services within their catchment area. The survey
could be completed online or via telephone interview with a researcher, and elicited details about types of crisis
care delivered in the local catchment area.
Results: We mapped a total of 200 adult CRTs and completed the survey with 184 (92%). Of the 200 mapped adult
CRTs, there was a local (i.e., within the adult CRT catchment area) children and young persons CRT for 84 (42%), and
an older adults CRT for 73 (37%). While all but one health region in England provided CRTs for working age adults,
there was high variability regarding provision of all other community crisis service models and system
configurations. Crisis cafes, street triage teams and separate crisis assessment services have all proliferated since a
similar survey in 2016, while provision of acute day units has reduced.
* Correspondence: c.dalton-locke@ucl.ac.uk
1
NIHR Mental Health Policy Research Unit, Division of Psychiatry, University
College London, London, UK
Full list of author information is available at the end of the article
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Conclusions: The composition of catchment area crisis systems varies greatly across England and popularity of
models seems unrelated to strength of evidence. A group of emerging crisis care models with varying functions
within service systems are increasingly prevalent: they have potential to offer greater choice and flexibility in
managing crises, but an evidence base regarding impact on service user experiences and outcomes is yet to be
established.
Keywords: Mental health, Crisis, Care, Systems, Emerging, Models, Survey
Background
Developing and implementing alternatives to acute hospital admission has for several decades been a highly salient aim in mental health service development,
endorsed by policy makers, service planners and service
users [1]. Inpatient care is costly, and potential harms include loss of rights and freedoms, stigma, institutionalisation and development of unhelpful coping strategies
[2]. Although inpatient care is sometimes the most appropriate option, most service users prefer services
which are less institutional [3].
Three main alternatives to an acute inpatient admission have developed since the mid-twentieth century, each giving rise to a substantial research
literature [4]. Crisis resolution teams (CRTs) are
multidisciplinary teams that provide rapid assessment
and intensive home treatment for a limited period
during a crisis, and have become almost universal in
England since being mandated in the NHS Plan in
2000 [5]. CRTs have also been widely implemented in
Norway [6] and Germany [7]. Trials suggest CRTs
can help reduce admissions and improve satisfaction
with acute care [8], although little is known about the
critical components of CRT care [9]. The second alternative, acute day units (ADUs) (traditionally known
as acute day hospitals), provide a structured
programme of activities and support on a group and
individual basis for a time-limited period during a crisis. A review in 2011 found that for some service
users, ADUs were a viable alternative to inpatient admission with similar rates of readmission [10]. More
recent studies carried out in England found that
people supported by ADUs had a positive experience
[11] and similar readmission rates to service users of
CRTs [12]. Although ADUs can be found across Europe [13], in England they are much less widely implemented than CRTs [14]. The third alternative, crisis
houses, are residential services which provide short-term
intensive support in the community [15]. Crisis houses
may be cheaper than inpatient care and service user satisfaction tends to be high [15], with comparable rates of readmission despite shorter length of stay than inpatient
wards [16]. As is the case for ADUs, we are unaware of
national policies to implement the crisis house model in
any country.
Despite the provision of CRTs and sporadic availability of ADUs and crisis houses in England, there
has been widespread dissatisfaction with crisis care. A
national survey conducted by the Care Quality Commission in 2014 found that only 14% of respondents
felt they received appropriate support in a mental
health crisis [17]. The share of mental health budgets
dedicated to acute hospital care remains high, and the
nationwide implementation of CRTs does not seem to
have resulted in consistent reductions in admission
rates as envisaged when they were originally mandated [18], in high quality community crisis care being available and readily accessed [19], or in a
reduction in overall rates of detention or ethnic inequalities regarding who is detained [20].
Dissatisfaction with access to and quality of crisis care
in England has been a driver for a national service improvement programme, with a Crisis Care Concordat introduced in 2014 [21]. The aim of the Concordat was to
facilitate local innovation, which was already occurring
in some areas as a response to identified gaps in service
provision [22]. A national survey by our group in 2016
revealed wide variations in the provision of crisis services, and the emergence of several new models across
the country [23]. Grey literature [21, 24–27], including
policy documents and voluntary sector reports, have
documented some of these new models including “crisis
cafés” (also often referred to as “safe havens” or “recovery cafés”): walk-in services allowing informal assessment; stand-alone community crisis assessment teams;
and 24-h crisis lines established to improve access and
care provision.
Given the high priority attached to reductions in hospital admissions, especially involuntary, and improving
mental health crisis care in England and internationally,
there is considerable interest in these emerging models
of crisis care [1]. Therefore, while descriptions and/or
preliminary evaluations of some new models of mental
health crisis care can be found in the literature, e.g. for
police street triage teams [28] and psychiatric decision
units (PDUs) [29], it is striking that several new models
remain almost undocumented in the peer-reviewed research literature, and little is known about the extent
and variation of their implementation in England. In
general, they have developed according to a need, rather
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than via the process of theory building and iterative testing advocated in guidance such as the Medical Research
Council (MRC) framework [30]. If new models are to be
recommended across England and beyond, clear definitions of their purposes and key components is required
as a prelude to acquiring evidence on their effectiveness
and cost-effectiveness.
We conducted a national survey of mental health community crisis care services for all age groups in England
in 2019, to identify and describe these emerging crisis
service models. In this paper, we focus on the survey
data regarding crisis care for adults of working age or all
ages. The research questions were:
I. What are the characteristics of the new models of
crisis care in England?
II. How widely disseminated are these new models of
crisis care, and can trends over time be discerned
when comparisons are made with a 2016 survey in
which some preliminary information about these
models was acquired?
Methods
Design and participants
From April to December 2019, we conducted a crosssectional national survey of crisis care in England. The
basic unit for our data collection was the catchment area
of CRTs. Following government mandates, almost every
area in England is served by such a team, with most
mental health Trust catchment areas sub-divided by several CRTs [23]. Our first choice of participant for each
area was the CRT manager, as staff in this role are normally required to have a very good familiarity with crisis
services in their local catchment areas. We asked participants to complete each question regarding local service
provision on 31 March 2019. As a first step in carrying
out the survey, we identified and mapped all CRTs in
England, including CRTs specialising in children and
young people, adults of working age or all ages, and
older adults and people with dementia. We defined a
CRT as a service which provides time-limited (usually
up to around a month) acute care to people in their
homes who are experiencing a mental health crisis, with
the aim of averting hospital admission. We excluded
generic services in which an acute response was one of
several service functions, for example, a general children
and young people's mental health service that also provides enhanced care to their service users when in crisis.
Measures
Development of the survey was led by experts in crisis
care research with relevant experience in the development of data collection tools (SJ and BLE [23, 31, 32])
and was informed by iterative feedback from a working
group set-up specifically for this study. This working
group included people with relevant lived experience of
using services or supporting those who do, senior practitioners and managers currently or recently working in
CRTs, relevant policy officials, and other academic researchers with expertise in acute care from a range of
disciplinary backgrounds. The survey was delivered via
UCL Opinio, a tool for designing and hosting surveys
online. The survey was designed so that it could be completed online by the participant or via telephone with a
researcher. It was tested by the working group and then
piloted with managers from three separate CRTs.
The survey included structured and free text questions
regarding the CRT the participant managed, and other
local community crisis care services available in the
CRT’s catchment area. These included the types of service identified as emerging innovative models in our preliminary 2016 survey ( [23]), as well as from the grey
literature including policy documents, and the authors’
and working group’s personal knowledge. Table 1 shows
the models included, and the operational definitions
used to determine whether services met inclusion criteria for the survey.
Participants were thus asked between 69 and 292
questions, depending on what services were provided locally. Each question included a ‘Not sure’ or ‘Don’t
know’ response to avoid the participant guessing at answers. The survey took around 45 minutes to complete:
a copy is included in the Supplementary Information.
Mapping
An initial list of CRTs in England serving all age groups
was generated from four sources: i) a crisis care survey
carried out by the research team in 2016 [23], ii) a separate survey carried out by NHS England in 2018–2019, iii)
Freedom of Information requests sent to NHS Clinical
Commissioning Groups (in the UK, under the Freedom of
Information Act 2000 [33], members of the public have
the right to request information held by public authorities); and iv) NHS Trust websites. Mapped CRT services
were then contacted to confirm eligibility (i.e., that the primary remit of the service was to provide brief, intensive
home treatment to people experiencing acute mental
health problems, and the service was operational on 31
March 2019), contact details of the service manager or a
senior member of staff which the survey invitation should
be sent to, and to check details of other local CRTs.
Potential participants were sent an information sheet
and a letter of support from the Department of Health
and Social Care. The survey was completed by consenting participants online or via telephone interview with a
researcher (CDL, JHS, LSR, NL and RS). Alternative respondents were sought where the person originally invited declined or did not respond.
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Table 1 Models of crisis care and their definitions
Crisis service
Definition
Acute day unit (ADU; traditionally known as
acute day hospital)
A non-residential day hospital / crisis day service providing support, activity and therapeutic groups,
for people in mental health crisis.
Crisis assessment service
A service which provides rapid response crisis assessment in a community setting but does not
also provide home treatment for acute mental health problems.
Crisis telephone service
A service which provides crisis response and triage via telephone only, without face-to-face
contact.
Crisis house
A time-limited non-hospital residential service for people in mental health crisis.
Crisis café (often referred to as safe havens or
sanctuaries)
A community-based service which provides out of hours assessment and immediate support for
people in mental health crisis, intended to reduce pressure on Accident and Emergency
departments.
Police and/or ambulance street triage team
A team where mental health staff work jointly with police and/or ambulance services to arrange
appropriate assessment and support for people with mental health problems who come to the
attention of the police and/or ambulance service, and provide alternatives to using Section 136 of
the Mental Health Act 1983 where possible.
Psychiatric decision unit (PDU; often referred to
as clinical decision units)
A dedicated space (separate from an Accident and Emergency department / psychiatric ward /
psychiatric liaison team) in which assessment can be conducted and treatment plans developed
for patients in mental health crisis who are accessing emergency services. People may typically stay
for up to 24–48 h.
Triage ward
Inpatient psychiatric wards that admit patients for briefer stays than are usual on acute psychiatric
wards. Usually these do not admit people compulsorily detained under mental health legislation,
and they work closely with local community crisis services to avoid the need to transfer to an
acute psychiatric ward.
Crisis family placements service
A service involving families offering short-term crisis foster placements in their family home for
people in mental health crisis, supported by local crisis services.
Data validation and cleaning
Where there was missing data, second respondents
nominated by our initial respondent were contacted and
asked to complete these questions. Researchers (BLE,
CDL, LC and RS) then checked remaining gaps and inconsistencies in the data, with reference to available
public information including Trust websites and a directory of voluntary sector crisis services provided from a
recently completed study [22]. All participants and NHS
Trust Chief Executives were then contacted by the study
team and invited to check and correct any remaining inaccuracies. Where information could not be confirmed
or discrepancies resolved, data was treated as missing.
Data analysis
This study reports descriptive results using Microsoft
Excel and compares data from the current survey with a
similar survey carried out in 2016 [23].
Ethics
Our survey, commissioned by national policy-makers to
understand current service provision, met national
guidelines [34] for a service evaluation which did not require review from an ethics committee nor did it require
participants to provide informed consent. We did however provide staff invited to take part in this survey with
a participant information sheet (see Supplementary
Materials). We consulted Noclor, the research support
service overseeing research governance for several NHS
Trusts in North London to check this.
Results
We mapped 200 CRTs serving working age adults or
adults of all ages provided by 59 NHS Trusts and one independent health care provider. The survey opened 1
April 2019 and closed 18 December 2019. It used 31
March 2019 as the reference point for all questions. 184
of the 200 adult CRHTTs in England (92%), completed
the survey. Completion was defined as having answered
questions relating to the CRHTT and crisis assessment
and telephone services. Only one NHS Mental Health
Trust did not provide an adult CRT, compared to two in
2016 [23]: this Trust is not included in this study. We
also mapped 39 children and young people CRTs and 49
older adults/dementia CRTs.
Table 2 shows the types of crisis service available to
the public for each adult CRT catchment area where
there was a response to the survey, and compares this to
data collected in the 2016 survey [23]. A single crisis service may serve more than one adult CRT catchment
area, and there may be more than one crisis service of
each type in a local CRT catchment area. Therefore, this
table does not show the total number of different crisis
services in the country.
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Table 2 Total mapped CRTs and the availability of other types of crisis service in 2016 and 2019
Crisis service
N (%) of adult CRTs with access to other crisis service models
2016 survey
(198 mapped adult CRTs)
2019 survey
(200 mapped adult CRTs)
Children and young people CRT
91/182 (50%)
84/200 (42%)
Older adult/ dementia CRT
77/183 (42%)
73/200 (37%)
A separate crisis assessment service
59/184 (32%)
71/185 (38%)
A separate crisis telephone service
132/184 (72%)
115/184 (63%)
Psychiatric decision unit (PDU)
Data not available
30/182 (16%)
Triage ward
Data not available
7/174 (4%)
Crisis house
85/185 (46%)
85/180 (47%)
Acute day unit (ADU)
40/185 (22%)
20/182 (11%)
Crisis family placement scheme
Data not available
5/174 (3%)
Crisis café
28/185 (15%)
52/180 (29%)
Police and/or ambulance street triage
106/184 (58%)
118/182 (65%)
Table 2 illustrates that the level of provision of crisis
houses in England has remained constant since 2016,
with almost half of CRTs having access to this form of
crisis care. Access to ADUs has declined since 2016,
while trends towards more widespread provision of
other crisis care models can be observed: crisis assessment teams, crisis cafés and police and ambulance street
triage teams. Other crisis models not included in the
2016 survey are also available in a minority of areas:
PDUs, inpatient triage wards and crisis family placement
schemes.
In the section below, we use our survey results to provide a structured summary of the core characteristics of
each of these service models and variations in how they
are organised. We also provide a case example of each
model, using publicly available information. Further detail about the characteristics of each model is provided
in the Supplementary Materials (Tables 1 to 8).
Crisis assessment services
In 38% of CRT catchment areas, a separate crisis assessment team has been established, providing rapid assessment and referral on to other acute mental health
services where appropriate. Whereas the original CRT
model in England involves delivery of both rapid crisis
assessment and intensive home treatment by the same
team, in areas with crisis assessment services, these two
functions are now provided by separate crisis assessment
and crisis home treatment teams. Around two-thirds of
crisis assessment services were operating 24-h (48/70,
69%) and three-quarters accepted self-referrals from any
member of the public as well as from professionals (53/
71, 75%).
The First Response Service provided by Cambridge
and Peterborough NHS Trust is an example of such a
service [35]. The service offers responsive, face-to-face
crisis assessment in the community throughout their
catchment area. It is open 24/7 and people can self-refer
via NHS 111 option 2 (a national healthcare telephone
triage service). They also accept referrals from anyone
acting on behalf of the person in crisis, such as carers,
GPs, and ambulance and police staff. The introduction
of the First Response Service has been supported by the
development of two crisis cafés, provided by a voluntary
sector organisation and offering a range of support, including peer support.
Crisis telephone services
A majority of CRTs had a separate dedicated crisis telephone service providing a response within their catchment area and triaging to other services in 2019 (115/
184, 63%) but access to this type of crisis service had reduced since 2016 (132/184, 72%), possibly reflecting the
increase of crisis assessment teams offering open access
to face-to-face assessment. Most crisis telephone services
were provided by the NHS (103/115, 91%), accessible by
any member of the public seeking help within their
catchment area (92/115, 80%) and available 24hr (83/
114, 73%).
The Single Point of Access service for Central and
North West London NHS Trust [36] is available 24/7
via telephone and email. It can be accessed by the
person in crisis or by someone on their behalf, including family, carers and other healthcare professionals such as GPs. Staff assess the urgency of the
presented mental health problem and triage appropriately, which can include making appointments with
other mental health services. Anyone who has concern for someone can also contact the service for advice and signposting.
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Crisis houses
Almost half of adult CRTs had access to a local crisis
house (85/180, 47%), a 24hr staffed community premises
where people in crisis could go for a short stay. Just over
half of CRTs who told us there was access to a local crisis house reported they had exclusive referral rights to
the service so that all access was via this route (46/85,
54%). A minority reported the crisis house accepted selfreferrals (14/85, 16%). Almost all CRTs in areas with crisis houses could ‘always’ or ‘usually’ access a crisis house
bed when needed (74/83, 89%), and 43% told us they
could arrange an admission within 4 hours (35/82).
Lowther Street Crisis House in Cumbria [37] is provided by the Richmond Fellowship, a national mental
health charity. It is the only crisis house in Cumbria and
accepts referrals 24/7 from other healthcare services.
They have six places and a minimum of two staff on
duty at all times, with a nurse available on call. The service aim is to provide an alternative to an acute hospital
admission, in a homely, community setting.
The Drayton Park Women’s Crisis House, provided by
Camden and Islington NHS Foundation Trust, is another example of a crisis house [38]. They have 12 places
available to women, including rooms where mothers can
be admitted with their children. The service accepts selfreferrals, and the staff, who are all women, are trained to
work with women who may have experienced or are
currently experiencing trauma such as sexual, physical
or emotional abuse. The length of stay is initially 7 days,
but this can be extended up to a maximum of 4 weeks.
Past and current residents are also invited to a weekly
support group.
Crisis cafés
The main remit of a crisis café is to provide a place
other than hospital emergency departments where
people in crisis can go to for support and signposting to
other crisis services. They are often referred to as ‘safe
havens’ or ‘recovery cafés’ and are typically provided by
voluntary sector organisations. Such a service was available in around a third of adult CRT catchment areas in
2019 (52/180, 29%), up from 15% in 2016 (28/185). In
most catchment areas, at least one of the crisis cafés was
provided by the voluntary sector (40/48, 83%) and had a
crisis café open 7 days a week for at least 4 hours each
day (32/48, 67%), typically during out-of-office hours
(i.e. 5pm to 9am). Most allowed members of the public
to attend without an appointment (32/47, 68%), and
around a fifth were service user led (7/36, 19%).
The Bexley Crisis Café is provided by the mental
health charity, Mind, and is located in south-east
London [39]. They are open 6-10pm 7 days a week and
adults over 18 can drop-in without an appointment to
access mental health support and advice, including
signposting to appropriate services. They aim to provide
an environment which feels safe and welcoming for
people in distress, and to help people feel less isolated.
Dial House in Leeds is provided by a partnership between Leeds Survivor-Led Crisis Service and Touchstone, offering a place of sanctuary in a homely
environment [40]. It is open 6pm-2am on Mondays,
Wednesdays, Fridays, Saturdays, and Sundays, and
people in crisis can access the service by calling on the
day that they wish to visit. They provide transport to
and from the service and have a family room so parents
can visit with their children.
Acute day units (ADUs)
Only 20 (11%) CRTs had access to an ADU, a day service where people in crisis could be admitted for a
programme involving a mixture of therapies, activities
and social contact. Seven CRTs (35%) told us they had
exclusive referral rights to the ADU. Eight (40%) could
‘always’ access a place when needed and another 11
(55%) could usually access a place. Most CRTs could arrange a place within 24 hours (12/20, 60%).
The Fennell Acute Day Treatment Service in Coventry
is provided by Coventry and Warwickshire Partnership
NHS Trust [41]. The service aims to provide an alternative to hospital admission and support early discharge
from hospital, with a focus on crisis resolution and recovery. They provide individual and group focussed support including physical health assessments, signposting
and vocational groups such as gardening and sewing.
Police and/or ambulance street triage
Street triage services are available in about two thirds of
CRT catchment areas (118/182, 65%). At least three different models of street triage have been implemented in
England: i) two-fifths operated as a mobile unit with a
mental health worker and a police officer or paramedic
(44/109, 40%), attending calls where there was a suspected mental health element; ii) around one-fifth had a
mental health worker stationed at a call centre who
could go out with a police officer or paramedic to calls
when required (23/109, 21%); iii) just under a fifth told
us that a mental health worker was stationed at the call
centre and could provide phone advice only (19/109,
17%). The remainder selected ‘other’ (23/109, 21%). A
quarter of CRTs who told us there was a local street triage team reported it was a 24hr service (23/93, 25%).
The Teeside Street Triage, a partnership between
Tees, Esk, and Wear Valley NHS Foundation Trust and
Cleveland Police, is available daily from 4pm until midnight [42]. When a police officer encounters someone
they think may have a mental health need, they contact
a team of mental health nurses who arrive at the location and carry out an assessment. The aim of the service
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was to reduce admissions under Section 136 of the Mental Health Act 1983, and provide people with mental
health problems with more appropriate support. The
team of nurses also provides training to Cleveland Police
officers to increase mental health awareness.
Psychiatric decision units (PDUs)
PDUs are dedicated spaces co-located with or accessed
via a general hospital emergency department where a
mental health assessment can be conducted and a support plan put in place for people who are in crisis. The
majority of CRTs with a local PDU told us this unit was
based in a psychiatric hospital (21/30, 70%), almost all
were 24hr (27/28, 96%), and around four-fifths provided
reclining seats rather than beds (23/28, 82%).
The Sheffield Decision Unit, provided by Sheffield
Health and Social Care NHS Foundation Trust, aims to
offer a safe and comfortable place for people in crisis to
be assessed [43]. It is located near, but is separate from,
the Northern General Hospital Accident and Emergency
department. It is designed for short stays with a maximum stay of 48 hours. There are male and female
lounge areas with recliners, no beds, and private assessment rooms.
Triage wards
Triage wards are assessment wards with shorter stays
than acute wards and work closely with community crisis services with the aim avoiding referral to an acute
ward. They usually do not admit patients detained under
the Mental Health Act 1983. In 2019, only seven out of
174 (4%) CRTs had access to a local triage ward. The
median maximum length of stay was 72 hours and the
median number of beds on the ward was 18.
The Swift Assessment for the Immediate Resolution of
Emergencies (SAFIRE) Unit in Manchester, provided by
Greater Manchester Mental Health NHS Foundation
Trust, offers rapid assessments of people in mental
health crisis with the aim of identifying the most appropriate form of support [44]. Although this may entail
transfer to an acute inpatient ward, the intention is to
find an alternative to inpatient admission, which will
usually mean a transfer to the CRT or to the community
mental health team. The unit has nine beds and is available 24/7.
Crisis family placement schemes
Crisis family placement schemes provide people in crisis
with a trained and supported host family. Only five out
of 174 CRTs (3%), all in the same NHS Trust, had access
to a crisis family placement scheme for adults in 2019.
This was an NHS-run service. The CRTs reported they
could usually access a place when needed, and that
placements could typically be arranged within 24 hours.
A typical length of stay with the host family was just
under 4 weeks.
The Hertfordshire Host Families Scheme, provided by
Hertfordshire Partnership University NHS Foundation
Trust, is intended to offer a welcoming family environment for a person in crisis as an alternative to hospital
admission or to support an early discharge [45]. Guests
are encouraged to take part in daily life such as cooking
meals and walking the dog. Host families and guests are
supported by the local CRT and the families receive a
payment to cover the costs of having a guest. Guests
usually stay for between 3 to 6 weeks.
Crisis care systems
As Table 2 illustrates, there is wide variation in the local
provision of different crisis care models, this leads to
variation between local crisis care systems. Table 3 presents three examples of local crisis care systems, at the
NHS Trust level. These do not represent defined types
of system, but illustrate the extent and nature of variation within local crisis care systems.
Discussion
New models of crisis care have become widespread in
England, but there is wide variation in local provision
meaning some people have access to many alternative
forms of community crisis care whilst others have access
to just the crisis resolution teams that have been standard in the UK over the past 20 years, offering assessment, and where feasible, home treatment. The national
implementation of CRTs following the NHS Plan (2000)
[5] provided a local dedicated service whereby people
acutely unwell could be assessed and treated in the community and in their own homes. However, gaps and
shortfalls in quality have continued to be identified in
Table 3 Crisis care system examples
Example 1: NHS Trust in South England, serving a large mixed urban
and rural area
This Trust was divided into four catchment areas, each with its own CRT.
The whole area covered by the Trust had a crisis telephone service
separate from the CRT, one crisis house, one ADU, and one PDU. There
were no crisis cafés, triage wards or street triage teams.
Example 2: NHS Trust in North England, serving a predominantly urban
area
There were two CRTs provided by this Trust, each serving their own
catchment area, with a single crisis assessment service working
separately but in partnership with both CRTs. There was also a crisis café
and a police street triage service but there were no crisis houses, ADUs,
PDUs or triage wards.
Example 3: NHS Trust in South-West England, serving a small, mainly
rural area
In this Trust, crisis assessment and home treatment functions were all
provided by the local CRT. There were none of the emerging crisis care
service models described in this paper.
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the acute care system despite this national implementation, resulting in the past 10 years in the proliferation of
specialised crisis care models documented in our study.
This has potential to provide greater choice, flexibility
and role clarity but may also come with risks of discontinuity in care, greater complexity and difficulty in navigating systems. Whole-system evaluation may be
required to fully understand the impact of this change.
Furthermore, there does not appear to be a link between the extent of evidence and adoption of new
models of crisis care. For example, crisis cafés have increased the most rapidly between 2016 and 2019 of all
the emerging models but there is minimal evidence regarding their effectiveness, whereas ADUs have a substantial body of evidence [10–12, 14] but have declined
over the same period. This is inconsistent with aspirations that policy should be rooted in evidence in order
to make best use of resources and maximise safety, acceptability and effectiveness of services. Thus, evidence
now needs to be acquired regarding impacts of previously untested crisis care models’ safety, service users’
experiences and outcomes, and their impact on resource
use in the system as a whole. Availability of a greater
range of models and pathways in crisis care systems has
potential to increase choice and the range of needs that
can be successfully addressed, but we now need to
understand which models work best for whom and
under what circumstances, and whether any significant
risks or unintended harms are involved.
For example, stand-alone crisis assessment services
may be able to respond more quickly and flexibly to initial help-seeking than a traditional CRT which provides
both assessment and home treatment, and are especially
attractive in areas where there is a range of crisis care alternatives. However, a separate assessment team may
take resource away from the home treatment team and
reduce flexibility by allowing for less sharing of resource
between crisis assessment and home treatment. It is also
unclear how it affects the experience of the person in
crisis. One of the criticisms levelled at the traditional
CRT model is that the service user may be seen by several different healthcare clinicians during their brief time
with the CRT, hampering the continuity of care and the
formation of therapeutic relationships [46]. This may be
more likely if the person is assessed and treated by two
different teams. Evaluation of this model is needed to
better understand its impact on the system and service
users. Crisis cafés which offer non-clinical forms of support in a less formal setting than a hospital emergency
department may facilitate earlier help-seeking, for example for people who may be at risk of harming themselves if they become severely distressed. However, they
may be less well equipped than hospital settings to provide swift access to physical tests or treatment or a full
clinical assessment, with potential safety risks if widely
used as a first point of crisis support. Psychiatric decision units may reduce pressure on emergency departments, but have also been criticised as holding distressed
service users for extended periods in uncomfortable surroundings, for example with reclining seats rather than
beds [47]. Thus, it cannot be assumed that no unintended negative consequences result from new models.
For example, the Serenity Integrated Mentoring (SIM)
model which aims to facilitate joint working by mental
health care services and the police to better support
people who frequently use emergency services [48], has
been deployed by around half of NHS Trusts in England
without a robust evidence base and has faced widespread
criticism. In addition to a lack of evidence, the criticism
has been mainly focused on the ethics of police involvement in mental health care. The criticism has led to a
coalition including people with relevant lived experience,
clinicians and policy makers, protesting against the
model’s deployment [49–51], resulting in policy makers
requiring Trusts urgently to review its further use.
Limitations
This survey was carried out in 2019, and as the changes
since 2016 indicate, this is an area of health care which
changes quickly and so may not provide an accurate picture of current provision. Our survey also focused on
the provision of distinct service models, rather than how
services or staff were coordinated at the system level.
This survey therefore did not capture the implementation of the SIM model described above. Furthermore,
the COVID-19 pandemic and its wide-reaching impact
on mental health care is likely to have further accelerated changes in crisis care, with reports of new crisis assessment services being rapidly introduced [52, 53]. This
study does however illustrate how crisis care systems
have continued to change since the implementation of
CRTs. Our focus is only on England, so no conclusions
can be drawn about whether new models described are
also found internationally.
Primary respondents in this survey were usually the
manager of the CRT, who despite their signposting and
triage role may not have a fully comprehensive knowledge of local crisis care. Although wide-ranging, our
survey may have failed to elicit information about unusual local crisis services which we did not ask about
directly – for example, a chaplaincy team which patrols
a local area well known for suicide attempts and tries to
dissuade people from their planned course of action
[54]. We did however apply rigorous methods to ensure
the accuracy of the data, including having ‘Not sure’ or
‘Don’t know’ response options to all survey questions to
avoid participants guessing at answers, checking data
with nominated second respondents where possible, and
Dalton-Locke et al. BMC Health Services Research
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checking the data against a directory of voluntary care
services [22].
Finally, the survey asked only about organisation and
not about content of care in crisis care services. We provided brief operational definitions, and so there should
be core features which are common within the different
service models. However, there may still be considerable
variation within these models. For example, a national
survey of PDUs in England found wide variety in how
these services are structured and what activities they
provide [29].
Research implications
Several directions for further research are suggested by
our findings. First, evaluations are needed of emerging
crisis care models, including new services implemented
during the COVID-19 pandemic. These evaluations
should focus on service user outcomes and experiences,
and consider the potential of unintentional harm caused
by the model. For example, crisis cafés provide great potential but it is currently unknown whether this usually
non-professional setting is appropriate for managing
mental health crises. Also, economic analyses are needed
to ensure that models make effective and efficient use of
limited resources. Second, we did not investigate the role
of service users and carers in developing and providing
leadership in crisis services, although there are examples
where this is reported to work well (e.g. Dial House in
Leeds, England [40]). Future research which helps better
understand the role of people with lived experience in
the commissioning, development, and delivery (as peer
support workers), of emerging crisis care services will
help inform future planning of services. Furthermore, research of new crisis care services or models should involve researchers with lived experience to ensure that
such studies are addressing issues that are relevant to
people using these services. Third, well-established crisis
care models such as crisis houses and acute day services
have been described and evaluated in a range of higher
income countries. A task for further research is to establish whether the emerging models described in the
current paper have also developed in other countries,
how they fit into different crisis care systems if so, and
what outcomes, service user experiences and risks may
be associated with them in other contexts. Fourth, it is
unclear whether there are any geographical or socioeconomic factors associated with the current provision
of innovative crisis care service models. It is important
that if these new service types do provide favourable
outcomes that certain areas are not left behind, potentially exacerbating social and health inequalities. Fifth,
research should explore the possibility of developing a
typology of crisis care systems, and if different definable
systems do exist, they should also be evaluated. Crisis
care systems are likely to be complex and vary greatly
but a broader understanding of the wider system is
needed to fully understand the role and impact of individual services and the contexts in which they perform
best.
Implications for policy and practice
Unlike the NHS Plan 2000 which provided a very prescriptive, top-down national overhaul of mental health
crisis care, recent service developments have been locally
driven and varied, usually without robust evaluation.
This creates a challenge for national policymakers and
local commissioners to know what best to promote and
provide. However, we identify four implications for policy and practice from our study. First, there is no obvious justification for the apparent decline in the provision
of evidence-based community crisis services such as
ADUs. We suggest policy makers and service planners
should prioritise providing models such as ADUs and
crisis houses where there is substantial evidence of benefit, and also that models can be safely implemented. Second, development of new models of care may divert
attention from improving quality and service user experiences in existing services, such as CRTs. Kindness and
compassion, attributes that are both highly valued by
people in crisis, are often lacking in mental health crisis
care [17]. Furthermore, in a recent study of 75 CRTs,
none was found to be operating at high fidelity to the
service model [19], but improvement initiatives can increase model fidelity and improve service outcomes [55].
It is important that innovation in service models does
not divert all resources and attention from efforts to
maintain and improve the quality of care delivered
within existing services. Third, our survey illustrates high
levels of innovation and variation in local community
crisis care systems. This is likely to have increased during the COVID-19 pandemic, which has caused widespread changes to mental health care [52]. Given the
lack of a robust evidence base regarding many of the
emerging models described in our study, and the high
levels of service user dissatisfaction with crisis care, there
is a clear case for any further restructuring of crisis care
to be co-produced from the start in order to meet service users’ needs in a local context. Fourth, the variation
in service provision may reflect a lack of prescriptive
policy directives (beyond providing CRT [5]) and initiatives like the Crisis Care Concordat [21] which explicitly
encourage local innovation. This may be appropriate
given the widely recognised need to improve mental
health crisis care and lack of evidence to support many
emerging models, but it risks creating unwarranted variation and post code lotteries in what types of care are
available in any given area. Some variation in crisis care
provision between local areas is necessary and
Dalton-Locke et al. BMC Health Services Research
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appropriate, for example, there are different challenges
to providing crisis care in densely populated urban areas
compared to large sparsely populated rural areas. However, there should still be core components which remain the same in order to avoid differences in access
and quality of crisis care between localities. In the absence of sufficient evidence to guide policy clearly, national and local commissioners should diligently audit
the impact of new services and changes to local crisis
care systems, which will in turn increase the evidence
base and inform subsequent decision-making.
Conclusions
Crisis care in England has continued to evolve since the
nationwide implementation of crisis resolution teams in
2000, with a trend toward specialisation seemingly borne
out of local need and creating substantial regional variation. There are new and emerging crisis care models
with great potential to improve access and service user
satisfaction, but the evidence base for some of these
models is lacking, and we do not yet know how introducing these new models affects the broader local crisis
care system. Research evaluating these models and the
adaptations made since the start of the COVID-19 pandemic is needed urgently to inform future crisis care
provision.
Lived experience commentary
Chris Lynch and Karen Persaud.
Crisis Care Services (CCS) for users and carers are
often considered the most traumatising and dehumanising aspect of Mental Health Services so we are pleased
to see this research into emerging new models. From
personal experience what happens when someone is at
crisis point and what response they receive can dramatically affect the rest of their lives. A kind, compassionate,
caring, and effective response followed by the right support can transform lives for the better.
The research highlights the massive variety that is offered, much of which seems to be built around what has
historically been available, what funding has been obtained and which direction commissioners have taken
recently. It still very much feels like a system built up
around things being done to people and for people rather than things done with people and the scope did not
capture details of treatments provided (e.g., psychosocial elements and whether crisis planning played a role
in any aspect). Also missing from the picture was the
role of carers despite being a critical element of the
cycle. These aspects need further exploration for impact
and efficacy.
Co-production was touched on but no mention of
whether patients/service users and carers had a role in
the development. Given the ambition is creating a more
inclusive and responsive service, service users and carers
are a critical element of the development of CCS and
this involvement must be measured as part of the whole
picture. It is concerning (but not surprising) that evidence suggests CRTs sometimes do not work effectively
to reduce admission rates. We need to know why. Customer feedback and satisfaction surveys would be a useful element of future data gathering exercises.
We want to see more around the quality of services
and outcomes, ideally co-evaluated by people that have
used them or cared for people that have. We think it’s
important that the research is co-produced in the future
and services co-delivered, otherwise, we’ll keep getting
what we’ve always got.
We support the paper’s recommendation for a new
body of research to delve further into these emerging
models and would advocate for inclusion of services outside the NHS and for any future work to seek to better
understand what CCS means for marginalised groups
(e.g., Afro-Caribbean males).
Abbreviations
ADU: Acute Day Unit; CCS: Crisis Care Services; CRT: Crisis Resolution Team;
PDU: Psychiatric Decision Unit
Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12913-021-07181-x.
Additional file 1. NIHR Mental Health Policy Research Unit 2019 Crisis
Care Survey.
Additional file 2: Supplementary Table 1. Crisis assessment services.
Supplementary Table 2. Crisis telephone services. Supplementary
Table 3. Crisis houses. Supplementary Table 4. Crisis cafés.
Supplementary Table 5. Acute day units (ADU). Supplementary
Table 6. Police and/or ambulance street triage. Supplementary
Table 7. Psychiatric decision units (PDU). Supplementary Table 8.
Triage wards.
Additional file 3. Participant Information Sheet.
Acknowledgements
The authors would like to thank the participants for responding to our
invitations and taking the time to complete the survey. We are grateful to
mental health policy colleagues in the Department of Health and Social Care
and NHS England for their help in planning this survey and with mapping
and approaching CRTs to take part.
Authors’ contributions
SJ and BLE made the initial plan for the study. All authors contributed to
protocol development. SJ drafted the survey, all authors commented, and
CDL developed the online version for UCL Opinio. CDL and BLE led on
mapping services and data collection. CDL, JHS, NL, LSR and RS mapped
services, invited managers to complete the survey, and conducting
telephone interviews with participants. Data cleaning was led by CDL and
performed by CDL, BLE and LC. CDL prepared and finalised the results
Tables. CDL, BLE and SJ drafted, and all authors contributed to and approved
the final manuscript.
Funding
This paper presents independent research commissioned and funded by the
National Institute for Health Research (NIHR) Policy Research Programme,
conducted by the NIHR Policy Research Unit (PRU) in Mental Health. The
Dalton-Locke et al. BMC Health Services Research
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views expressed are those of the authors and not necessarily those of the
NIHR, the Department of Health and Social Care or its arm’s length bodies,
or other government departments.
8.
9.
Availability of data and materials
The dataset used and analysed during the current study are available from
the corresponding author on reasonable request.
10.
Declarations
Ethics approval and consent to participate
The study was reviewed and approved as a service evaluation by Noclor, the
research support service overseeing research governance for several NHS
Trusts in North London. As a service evaluation rather than research in which
no personal data were collected, the survey did not require review and
approval from a research ethics committee nor did it require participants to
provide informed consent. We did however provide staff invited to take part
in this survey with a participant information sheet (see Supplementary
Materials). Wherever participants directed us to local R&D or audit
committees, we followed Trusts’ local governance procedures.
Consent for publication
Not applicable. Our plans to publish findings from this study was explained
to participants in the Introduction to the survey. This text can be viewed in
the copy of the survey included in the supplementary materials.
11.
12.
13.
14.
Competing interests
The authors declare that they have no competing interests.
15.
Author details
NIHR Mental Health Policy Research Unit, Division of Psychiatry, University
College London, London, UK. 2Camden and Islington NHS Foundation Trust,
London, UK. 3NIHR Mental Health Policy Research Unit, King’s College
London, Institute of Psychiatry, Psychology & Neuroscience, London, UK.
4
NIHR Mental Health Policy Research Unit Co-Production Group, Division of
Psychiatry, University College London, London, UK. 5Mental Health Policy
Branch, Department of Health and Social Care, London, UK. 6Oxleas NHS
Foundation Trust, London, UK. 7Oxford Health NHS Foundation Trust, Oxford,
UK. 8Faculty of Education, Health and Human Sciences, University of
Greenwich, London, UK. 9Health Services Management Centre, School of
Social Policy, University of Birmingham, Birmingham, UK. 10Southern District
Health Board, Southern Health, Dunedin, New Zealand.
16.
1
17.
18.
19.
20.
Received: 6 July 2021 Accepted: 15 October 2021
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